Introduction
Pathophysiology of post-stroke urinary incontinence
Current policy and evidence to guide the management of post-stroke urinary incontinence
Nurse-led assessment and systematic voiding programmes for managing post-stroke urinary incontinence
Transcutaneous electrical nerve stimulation
Pelvic floor muscle training
Post-stroke urinary incontinence service development
Conclusion
References

Introduction

Urinary incontinence (UI) is defined as 'the complaint of any involuntary loss of urine…that may also be considered a social or hygienic problem'.1 UI is a common complication of stroke affecting up to two thirds of patients and while the prevalence of post-stroke UI does decrease over time, 10% of all patients will remain incontinent two years after its onset.2-3 Post-stroke UI is associated with both increased patient mortality and morbidity and can be used as an independent predictor for increased hospital length of stay when compared with patients who remain continent over the same time period.4,5,6

It is also associated with depression7 and a diminished quality-of-life,8 whilst placing a significant burden on carers, many of whom feel socially isolated and/or physically and mentally drained due to the responsibilities attributed to the caring of a person with post-stroke UI.9,10 It is therefore of significant importance that multidisciplinary teams (MDTs) aspire to manage post-stroke UI effectively and mitigate the negative impact the condition has on stroke survivors.

Pathophysiology of post-stroke urinary incontinence  

During bladder filling low intensity afferent signals pass through the pelvic nerves to the spinal cord, which results in inhibition of parasympathetic innervation of the detrusor muscle of the bladder.11-13  This process also stimulates sympathetic outflow in the hypogastric nerve contracting the bladder outlet and pudendal outflow via neurons in Onuf’s nucleus contracting the external urethral sphincter. These spinal reflexes are known collectively as the ‘guarding reflex’ and promote continence. Additionally, a region in the lateral pons known as the ‘pontine storage area’ may contribute by stimulating striated urethral sphincter activity.11, 13 

At a critical level of bladder distension, afferent signals, via the pelvic nerves to the spinal cord are relayed to the pontine micturition centre (PMC) of the brain.11, 13 Excitation of the PMC activates descending pathways, which leads to inhibition of sympathetic and pudendal outflow to the urethral outlet resulting in urethral relaxation and stimulation of parasympathetic outflow to the bladder resulting in detrusor contraction. The voiding pathway is under strict voluntary control by higher brain centres11, 13 and any damage to the cortical or sub-cortical areas of the brain involved in its management can have a significant impact on a patient’s ability to maintain their continence post-stroke.

There are several types of post-stroke UI. The symptoms and pathophysiological causes are outlined below:

  • Urge incontinence – an involuntary leakage of urine, frequency and/or nocturia caused by direct damage to the neuro-micturition pathways.11,12
  • Overflow incontinence – associated with acute/chronic urinary retention, poor stream and straining whilst voiding that is caused by a loss of bladder tone in the acute phase of stroke, although the pathological cause of this is not readily understood.11,12
  • Reflex incontinence – a reduced awareness of bladder fullness that follows a normal voiding pattern that may present in patients with total or partial anterior circulatory strokes.11,12
  • Functional incontinence – despite the bladder functioning normally, incontinence occurs as an indirect cause of cognitive and/or motor disabilities.11,12

It is important to note that not all episodes of UI are attributable to stroke and consideration must be had for likely reversible causes including faecal impaction, pharmacologically induced UI, urinary tract infections, delirium and atrophic vaginitis. Patients may also present with stress incontinence and although not caused by stroke, it may be exacerbated by it.11

Current policy and evidence to guide the management of post-stroke urinary incontinence

The importance of effective continence management is recognised within national stroke guidelines14 that recommend:

  • Ensuring staff are trained in the use of a standardised assessment and management protocol for post-stroke UI.
  • Treating the identified cause of incontinence and reassessing/designing a treatment plan that may include referral to specialist continence services and/or supplying adequate supplies of continence aids for patients who remain incontinent two weeks after onset.
  • Training the person affected by the stroke and/or their carers in the management of UI.
  • Offering behavioural interventions such as prompted/timed voiding, bladder retraining, PFMT, and where appropriate external equipment.

Nurse-led assessment and systematic voiding programmes for managing post-stroke urinary incontinence

Several studies have analysed the effects of structured assessments and treatment protocols in the management of post-stroke UI. Herr-Wilbert et al. evaluated the impact of therapeutic interventions for UI management, based on a structured process of interdisciplinary caregiving, in 21 of 44 screened stroke patients deemed to have UI as a direct result of their stroke.15 Nursing interventions included distinction of stress or urge UI and the assessment of different forms of UI; the latter intervention being based on the functional independence measure (FIM) Item G-bladder management, the protocol of micturition, urine dipstick and ultrasound measurement of post-void residual urine (PVR).

Interventions which also consisted of standards for prompted voiding, timed voiding and habit training were applied according to the recommendations of the 3rd International Consultation on Incontinence. An algorithm of the interdisciplinary process was implemented and the nursing staff received specific education regarding the interventions. At 30 days, 52% (n=11) of participants had achieved an independent level of continence.15

A subsequent quasi-experimental study of implementing comprehensive bladder assessment, PFMT and a prompted/timed voiding regime in 35 female stroke patients also provided supportive evidence for adoption of a structured approach to screen, assess and plan interventions to manage post-stroke UI.16 Cournan et al. demonstrated that utilisation of such behavioural interventions significantly improved patient FIM Item-G scores (treatment arm mean (SD) 2.83 (2.23) vs control arm mean (SD) 1.6 (2.17); p< 0.05).16 

More recently, a multi-centre, cluster randomised control trial (RCT) recruited 413 participants from 12 stroke-rehabilitation units to conduct a preliminary evaluation of the benefits of using a systematic voiding programme (SVP) to manage post-stroke UI.17 Participants allocated to two treatment arms received a nurse-led continence assessment, a three-day bladder diary and a subsequent personalised prompted voiding programme for those that were cognitively impaired or a bladder retraining/timed voiding programme for those whose cognition remained intact. One treatment arm received additional support from external facilitators to embed the new programme into practice. Participants allocated to a control group received usual care, including the use of containment techniques and a non-specific toileting schedule.

The primary outcome of this study was to assess for the presence or absence of UI at 12 weeks post-stroke. The results suggested that participants were no more likely to be continent at 12 weeks in either treatment arm. However, there was evidence to suggest that participants experiencing urge incontinence achieved a better level of continence in both treatment arms compared with usual care and, after excluding patients with anterior circulatory infarcts in sub-group analyses, it was demonstrated that participants were more likely to be continent at 12 weeks in both treatment arms when assessed using the ICIQ-UI-SF (International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form).17

While the results of these studies would appear to indicate a benefit of using a structured nurse-led assessment and tailored treatment programme to manage post-stroke UI,15,16,17 they should be viewed cautiously due to the use of purposive sampling and the small sample sizes used.

Transcutaneous electrical nerve stimulation (TENS)

The use of TENS therapy to treat urge incontinence in the non-stroke population has a growing body of evidence to support it.18,19 There have, however, only been two small RCTs that have reported on its use in stroke survivors.21,22 Guo et al. randomised 61 participants to 30 minutes of TENS therapy at 75Hz once daily for 60 days or usual therapy. The results demonstrated a positive impact in favour of the treatment arm in all three primary outcomes of improved pre-/post-overactive bladder symptom score, Barthel Index of activities of daily living (ADL) score and urodynamic values.

The statistically significant results also suggested improved bladder capacity for those in the treatment arm.21 The second RCT in 81 participants aimed to study what effects TENS therapy at two different frequencies (20Hz and 75Hz) had on post-stroke UI.22 A group receiving basic rehabilitation and no TENS therapy was used as a control. The study protocol maintained that both treatment arms received 30 minutes of TENS therapy a day for 90 days at their respective frequencies. Primary outcomes were identified as pre-/post-overactive bladder symptom scores, Barthel Index of ADL scores and urodynamic values as well as the number of UI episodes within a 24-hour period. The results again demonstrated statistically significant improvements in all primary outcomes in favour of both treatment arms when compared with control.

In addition, the results supported the use of 20 Hz frequency rather than 75Hz. It is important to note that there was a spontaneous improvement in the number of UI episodes in a 24-hour period within the control group but this was not statistically significant.22 Given the positive results attained in both RCTs, TENS therapy has the potential to be used as effective treatment for post-stroke UI but before TENS can be widely recommended, larger multi-centre studies are warranted.21,22

Pelvic floor muscle training

PFMT is recommended as an intervention to manage post-stroke UI14 with RCT evidence confirming its importance within the female population.23 Shin et al. randomised 35 female participants to either an experimental group (n=18) or control (n=17). The experimental group received 50 minutes of PFMT, three times per week for six weeks, while the control group only received basic education around the pathophysiology of UI and the function of the pelvic floor muscles. Both groups were assessed using pre-/post-maximum vaginal squeeze pressure (MSVP), pelvic floor muscle activity (PFMA) and the Bristol Female Urinary Questionnaire (BFUQ) to ascertain the inconvenience of lower urinary tract symptoms on their ADLs. In all outcome measures, results significantly favoured the intervention over the control group (post-MSVP results: 17.81 mmHg (SD 5.39) vs 8.83 mmHg (SD 3.60); post-PFMA: 12.09 µV (SD 2.24) vs 9.33 µV (SD 3.40); post-BFUQ results: 15.92 (SD 6.85) vs 0.08 (SD 1.50).23

Post-stroke urinary incontinence service development

After considering the current evidence base, we undertook a review of the practices used to manage post-stroke UI on the 28-bedded stroke unit at St Thomas’ Hospital, London and checked compliance with national stroke guidelines. It was considered that practice leaned towards the use of containment techniques with little emphasis placed on active bladder rehabilitation. In response, a "Plan, Do, Study, Act (PDSA)" methodology was used to develop and implement a quality improvement project (QIP) incorporating a nurse-led continence algorithm. Formal educational sessions were provided to the MDT to explain the rationale for the QIP and how it was to be implemented. These education sessions were continued throughout the process including when new staff joined the ward and/or after each audit cycle. Audits of compliance were undertaken pre-intervention and then at four and eight months after the intervention with calculation of the percentage of patients completing urinalysis, bladder diaries and SVP use (Table 1). 

 

Table 1. Summary of results of QIP

 

Audit 1

(Pre-intervention)

 

Audit 2

(4-months post-intervention)

 

Audit 3

(8-months post-intervention)

 

Completion of urinalysis

31% of patients

43% of patients

88% of patients

Completion of 3-day bladder diary

15% of patients

43% of patients

43% of patients

Assigned to patient -centred SVP

15% of patients

29% of patients

43% of patients

 

These findings suggest that using a PDSA methodology to improve post-stroke UI management may lead to a trend in adherence to national stroke guidelines. Although these results were not powered to demonstrate the effectiveness of the intervention, given the negative impact post-UI has on patients,7,8,9,10 and the growing body of evidence supporting the use of structured assessments and assignment to specific voiding programmes,15,16,17 its continued use its warranted.

Conclusion

In conclusion, UI is a common complication of stroke that is primarily managed conservatively. This includes using PFMT and structured nurse-led assessments to determine the type of incontinence and tailor interventions to an individual’s needs. To ensure adherence to current national stroke guidelines, a PDSA cycle is one methodology that can be used to achieve this aim. Although not currently recommended within national guidelines, there is some evidence to suggest that TENS therapy can have a positive impact on the management post-stroke UI and therefore, larger, multi-centre studies are warranted to determine its efficacy.

 


Jonathan Hayton, Deputy Ward Manager, Stroke and Neuro-Rehabilitation,  Stroke Unit, St Thomas’ Hospital, London

Ajay Bhalla, Consultant in Stroke Medicine, Geriatrics and General Medicine,  Stroke Unit, St Thomas’ Hospital, London

Jonathan Birns, Consultant in Stroke Medicine, Geriatrics and General Medicine, Stroke Unit, St Thomas’ Hospital, London

jonathan.hayton@nhs.net


 

References

  1. Abrams p, Anderson KE, Birder L, et al the Members of the Committees. Fourth international consultation on incontinence recommendations of the international scientific committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurology and Urodynamics 2010; 29: 213-240
  2. Thomas LH, Cross S, Barret J, et al. Treatment of urinary incontinence after stroke in adults. The Cochrane Library 2008; 1: 1-40
  3. Matthews M. Causes and rehabilitation of urinary incontinence after stroke: a literature review. Nursing & Residential Care 2010; 12: 474-480.
  4. Sommerfield DK, Johansson H, Jönsson AL, et al. Rivermead mobility index can be used to predict length of stay for elderly persons, 5 days after stroke onset. Journal of Geriatric & Physical Therapy 2011; 34: 64-71
  5. Wit LD, Putman K, Devos H, et al. Five-year mortality and related prognostic factors after inpatient stroke rehabilitation: A European multi-centre study. Journal of Rehabilitation medicine 2012; 44: 547-552
  6. van Almenkerk S, Smalbrugge M, Depla MFIA, et al. What predicts a poor outcome in older stroke survivors? A systematic review of the literature. Disability and Rehabilitation 2013; 35: 1774-1782
  7. Dugan E, Cohen SJ, Bland DR, Preisser JS, et al The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatric Society 2000; 48: 413-416
  8. Edwards DF, Hahn M, Dromerick A. Post-stroke urinary loss, incontinence and life satisfaction: When does post-stroke urinary loss become incontinence? Neurology and Urodynamics 2006; 25: 39-45
  9. Brittain KR, Shaw C. The social consequences of living with and dealing with incontinence – A carers perspective. Social Science & Medicine 2007; 65: 1274-1283.
  10. Tseng CN, Huang GS, Yu PJ, Lou MF. A qualitative study of family caregiver experiences of managing incontinence in stroke survivor. PLoS ONE 2015; 10: 1-12
  11. Mehdi Z, Birns J, Bhalla A. Post-stroke urinary incontinence. International Journal of Clinical Practice 2012; 67: 1128-1137
  12. Woodward S. Managing urinary incontinence after stroke. British Journal of Neuroscience Nursing 2014; 10: 25-31
  13. Fowler CJ, Griffiths D, De Groat WC. The neural control of micturition. Nature Reviews Neuroscience 2008; 9: 453-466
  14. Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 2016 https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx (accessed 16 January 2019).
  15. Herr-Wilbert IS, Imhof L, Hund-Georggiadis M, Wilbert DM. Assessment-guided therapy of urinary incontinence after stroke. Rehabilitation Nursing 2010; 35: 248-253
  16. Cournan M. Bladder management in female stroke survivors: Translating research into practice. Rehabilitation Nursing 2012; 37: 220-230
  17. Thomas LH, French B, Sutton CJ, et al. Identifying continence options after stroke (ICONS): An evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care. Programme Grants for Applied Research 2015; 3: 1-644
  18. Burton C, Sajja A, Latthe PM. Effectiveness of percutaneous posterior tibial nerve stimulation for overactive bladder: A systematic review and meta-analysis. Neurourology and Urodynamics 2012; 31: 1206-1216
  19. Gross T, Schneider MP, Bachmann LM, et al. Transcutaneous electrical nerve stimulation for treating neurogenic lower urinary tract dysfunction: A systematic review. European Urology 2016; 69: 1102-1111
  20. Booth J, Connelly L, Dickson S, Duncan F, Lawrence M. The effectiveness of transcutaneous tibial nerve stimulation (TTNS) for adults with overactive bladder syndrome: A systematic review. Neurourology and Urodynamics 2018; 37: 528-541
  21. Guo ZF, Liu Y, Hu GH, Liu H, Xu YF. Transcutaneous electrical nerve stimulation in the treatment of patients with post-stroke urinary incontinence. Clinical Interventions in Aging 2014; 9: 851-856.
  22. Liu Y, Xu G, Luo M, Teng HF. Effects of transcutaneous electrical nerve stimulation at two frequencies on urinary incontinence in post-stroke patients. A randomized control trial. American Journal of Physical Medicine & Rehabilitation 2016; 95: 183-193
  23. Shin DC, Shin SH, Lee MM, et al. Pelvic floor muscle training for urinary incontinence in female stroke patients: A randomised controlled and blinded trial. Clinical Rehabilitation 2016; 30: 259-267