Patient Assessment: Overactive Bladder
Introduction
Case Study: AB is fifty-eight and has taught 5th grade in the Philadelphia public school system for the past thirty years. She is very distressed. She has lived with urinary urgency and frequency for more than six years, but it has been getting worse since her doctor prescribed a diuretic for her high blood pressure. Lately, the urge is so strong she feels she won't make it to the toilet unless she runs.
When teaching, she is unable to leave her classroom and frequently doesn't
have enough time between classes to go to the bathroom. The other day, AB actually
had a "urinary accident." Driving home from school, she got a strong
urge. She parked the car in the garage, grabbed her shopping bags, and rushed
to the door. She fumbled with her keys, couldn't get them in the lock, and the
urge was so strong that she completely "lost it." AB wet through her
pants. She was so glad she was home and not at school. She has started wearing
an ultra thick pad in her underwear as a safeguard against unexpected episodes.
During her last routine visit with her doctor, she was asked about her blood
pressure, but not about possible bladder problems and she didn't bring up the
subject.
Patients with overactive bladder (OAB) tend not to tell their health care providers about their symptoms and "episodes" and their health care providers do not ask about urinary control problems, at least as a matter of routine or as part of an overall health assessment. OAB is quite common but only one out of four women (13% to 54%) with symptoms of OAB with urinary incontinence (UI) seeks clinical help.1,2,3 OAB is both under-diagnosed and under-treated, partly due to the "stigma" attached to bladder control problems and partly due to the rampant misconceptions that exist among patients that inhibit them from seeking care. 4 Women are especially hesitant to bring up the subject and prefer that their health care providers initiate a conversation about OAB. Consequently, health care providers need good information about the best methods for assessing patients for OAB and for communicating with their patients about urinary symptoms.
Assessment and Screening
The widespread stigma around patients discussing urinary incontinence places
a greater burden on nurses to introduce the topic of bladder control. Nurses
understand the best ways to initiate a dialogue with patients, put them at ease,
and encourage them to talk about symptoms, related issues and lifestyle changes.
They can offer significant help to their patients in overcoming their reluctance
to discuss such bladder control problems as OAB. After all, in a recent poll,
nurses were named the health care professionals most trusted by the public.
.
As part of a routine general health assessment, nurses should include questions
about OAB, bladder control and voiding habits. A minimal investment of time
is required by the health care provider when they use a screener or questionnaire
that is appropriate in most clinical settings.5 Most such questionnaires
are self-administered and can be completed in the waiting room prior to a medical
visit. Office nurses, medical technicians or assistants can be trained to distribute
and help patients fill in the questionnaires as part of the intake procedure.
Table 1 lists commonly asked questions to help providers determine
symptoms of OAB. 6
Patient History
A good place to begin any assessment of patients suspected of having OAB is
to determine which symptom(s) are most bothersome to the patient. This information
will guide the provider in recommending a therapy and measuring the patient's
response to it. Focusing on symptoms allows the provider to bypass invasive
and costly tests that often must be done by a specialist or by a teriary medical
center and that can be stressful for patients.
The patient history should include details about all OAB symptoms including when they began, their duration, specific characteristics and how they have progessed. When questioned, many patients can recount the specific situations that "triggered" their wetting episodes and describe them in detail similar to our case study above.7 Triggers can be auditory or visual and some common triggers are running water, seeing a bathroom sign, having hands in water as when washing dishes, stress or anxiety, sudden exposure to cold when exiting from a warm environment and "key in the lock" or "garage door syndrome", all of which can bring about a sudden feeling of urgency with leakage of urine. Other problems may include urinary frequency, lower urinary tract symptoms (LUTS) including post void dribbling, nocturnal enuresis, hesitancy or weak stream and straining while voiding.8
As part of the patient history, the intake protocol should include questions
about self-care, which ways a patient might hide or accommodate his symptoms
and whether the patient has altered her lifestyle in response to bladder control
problems.7 For example, some patients memorize the locations of available toilets
and plan their route or daily activities so they are always near facilities,
a practice known as "toilet mapping".
In addition, patients should be asked about any medical problems or illnesses
that may precipitate an episode of OAB or transient urinary incontinence (See
Table 2.) This should be accompanied by a discussion of any
drugs the patient may be taking, both prescription and over the counter varieties
(OTC). See Table 3.
Bowel function can also play a role in OAB, especially constipation that causes fecal straining, and should be part of the patient history. Any other associated medical conditions should also be noted; for example, neurologic diseases, BPH, previous pelvic injury or such surgeries as hysterectomy or those for stress UI, and any previous pelvic trauma or radiation therapy. If the patient has already received treatments for OAB, these should be noted along with outcomes.9
Physical examination of the patient
A physical exam to investigate OAB symptoms includes four components:
- General
- Abdominal
- Genital
- Pelvic in women and rectal in men
General Exam
The clinician should evaluate the patient in a general way for such problems
as lower extremity edema that may contribute to increased renal perfusion when
the patient is lying down. This alone may explain symptoms of nocturia and nocturnal
enuresis.
Abdominal Exam
Palpation of the abdomen can help detect bowel sounds, mases and suprapubic
fullness.8 Decreased bowel sounds (fewer than three per minute) indicate
decreased motility while prolonged gurgling sounds may indicate diarrhea. In
elderly patients, abdominal masses may be an indication of hard stool in the
colon and possible fecal impaction. It may be possible to palpate the bladder
if it distends above symphysis pubis or contains more than 150 ml of urine but
there are better methods than palpation for determining an abnormal post-void
residual (PVR).8
Genital Exam
It is important to make a careful inspection of the skin in the perineal and
gluteal areas and assess its integrity since OAB and urinary incontinence may
cause dermatitis and a bacteria or fungal rash. Also, urine leakage may cause
the clothing to be damp or wet and give off a characteristic odor of urine.
These signs and any actual urine leakage from the perineum are important to
note.
Constant wetness creates special problems for women. Excoriations and macerations
of the vulva may occur and should be noted. At the same time, the vulva should
be examined for signs of hypoestrogenism and of urogenital atrophy, especially
atrophy of the vulvar skin, agglutination of the labia minora or a urethral
caruncle. Vulvar atrophy appears as shrunken areas with dry, pale, inflamed
mucosa or with red, petechial and ecchymotic areas that bleed easily.
A genital exam in men is done to evaluate the condition of the external perineal
skin and to detect any abnormalities in the glans penis or foreskin. Phimosis
can occur in uncircumcised men when the orifice of the foreskin is too narrow
to allow retraction of the foreskin over the glans. Palpation of each testis
and epididymis is done to rule out masses and the size, shape, consistency,
and tenderness of any found should be noted.
Female Pelvic Exam
The pelvic exam is done to determine the presence of pelvic organ prolapse (POP),
other vaginal abnormalities, and the condition of the pelvic floor muscle (PFM)5.
POP may include:
- Urethrocele, the descent of the lower urethra into the vagina
- Cystocele, the descent of the anterior vaginal wall and bladder into the vagina
- Uterine prolapse when the uterus and cervix descend into the vagina
- Vaginal vault prolapse when the walls of the vagina descend and fall out of the vagina
- Rectocele, the protrusion of the posterior vaginal wall and rectum into
the vagina.8
A helpful system for grading prolapse is the "Baden-Walker Halfway" categories:
Grade 0: no prolapse
Grade 1: vaginal segment descends halfway to the hymen
Grade 2: vaginal segment descends to the hymen
Grade 3: vaginal segment descends halfway outside the hymen
Grade 4: pelvic organs protrude completely outside the body without Valsalva (referred to as a procendentia).
The pelvic exam should include a strength assessment of the PFM, specifically the muscular attachments along the pubic arch and the insertion of the levator ani (just superior to the hymeneal ring) and coccygeus muscles.8,10 Ask the patient to pull her vaginal muscles in and upward in short, fast contractions ("flicks") and in long, sustained contractions. The observer notes which other muscles contract at the same time, specifically the gluteal, abdominal or thigh muscles. There are several rating scales for PFM assessment.11-15 This author has developed a scale that includes various components of PFM assessment (pressure, duration and alteration in position) and provides documentation for insurance requirements (See Table 4).
Anorectal Exam
The clinician does a rectal exam to assess for rectal sphincter tone and sensation,
and to determine the presence of fecal impaction. Begin with visual inspection
of the perianal area and note any ulcers, inflammation, rashes, excoriations
or lumps. Inspect the anus for external hemorrhoids and fecal staining. Have
the patient relax and contract the anal sphincter and "bear down"
as if having a bowel movement. This allows assessment of the anus for tone,
strength and symmetry of the anal sphincter and identification of any defects
in the sphincter mechanism.10 An evaluation of anal sphincter contraction
and tone can also provide an opportunity to assess the PFM, and both men and
women can learn PFM exercises during this part of the rectal exam. The distal
external sphincter can be felt just inside the anal canal while the puborectalis
portion of the levator ani muscle is palpated 2.5 to 4 centimeters past the
anal verge.10
A digital rectal exam (DRE) in men includes palpation of the prostate and notation
of its size, consistency (typically "rubbery") and contour.
Neurologic Exam
Four components comprise a focused neurological examination8,9,10:
- Mental Status
- Sensory function
- Motor function
- Reflex Integrity
Observe the patient while rising from a chair and walking into the exam room as a measure of mobility. The way a patient manipulates clothing is a good measure of fine motor skills and manual dexterity. During conversation, the patient's mood, affect, orientation, speech pattern, memory and comprehension can provide clues to his mental status. Stimulation of the anal reflex (S2-5) and bulbocavernosus (S2-4) can be used to evaluate the sacral nerve root reflexes. Relevant dermatomes include L1 (labia majora), L1-2 (labia minora), and S3-5 (perineum and perianal skin).
Patient Bladder diary
An important part of intial screening for OAB is the patient's three day bladder
diary. This simple and practical method of daily self-monitoring is the best
way to obtain information on voiding behavior.16 The bladder diary should be
examined for voiding patterns including daytime and nighttime patterns, frequency
of urination, the association between leakage and urgency or the ingestion of
caffeinated beverages, when incontinent episodes occur and their circumstances
(during the night, cold temperature or on the way to the bathroom) and the type
and amount of liquids ingested previously. In addition, the diary may show that
the patient is making trips to the bathroom before feeling the need as a way
to head off incontinence episodes ("defensive voiding").
Measurement of the urine volume is helpful in assessing the functional and maximal capacity of the bladder; both daytime and nocturnal urine volumes should be recorded as part of a Frequency Volume Record. It may also be helpful in quantifying urine leakage to have the patient record the type and quantity of absorbent incontinence pads used in a specified period of time.8 An actual "pad test" is an accurate way to determine the amount of urine leakage and can provide a more objective result.
Besides being useful for assessment, a bladder diary can be therapeutic for
the patient and the act of keeping it can constitute a "behavioral intervention".
Unfortunately, patient compliance is often low in spite of its value. Younger
patients with families and full time jobs are less likely to take the time to
keep a diary but older, retired men and women with more severe symptoms may
have more time and motivation to comply.
Urologic Testing
Urinary tract infections are one of the transient causes of OAB and a Dipstick
urinalysis is the easiest way to measure nitrites, leukocytes, red blood cells
and glucose.5 Obtaining a post-void residual urine volume (PVR) is
the best way to measure incomplete bladder emptying but is necessary only in
patients that have experienced recurrent urinary tract infections (UTIs), have
severe POP, prostate nodules or history of BPH, or in those who report difficulty
emptying the bladder. A normal residual urine volume is 50-75 cc but in patients
older than sixty-five, anything over 200 cc should probably be considered abnormal.
When to refer patients to a specialist for testing
The need for further testing with urodynamics should be related to the severity
and duration of the patient's symptoms and the clinical setting. Complex urodynamics
tests such as cystoscopy, cystometrogram (CMG), uroflow, urethral pressure profile
(UPP), voiding pressures and electromygram can help ensure a correct diagnosis
and provide a more accurate functional assessment of the urinary bladder and
urethra. The CMG is a test that measures bladder capacity and can assess the
stability of the detrusor muscle, instability of which is common in patients
with OAB and urge UI. The UPP is used to measure urethral sphincter damage and
the uroflow is useful in ruling out bladder outlet obstruction in men.
Patients should be referred to a specialist under the following conditions:
- Uncertain diagnosis, especially if unable to develop a successful management plan.
- Failure to respond to conservative treatments after a reasonable trial period.
- Hematuria when no infection is found.
- POP beyond the hymen (Grade 3 or higher).
- Abnormal post-void residual volume.
- Prostate nodule or enlargement.
- Any neurologic condition that may cause neurogenic bladder.
Conclusion
Nurse providers can play an important role in helping patients obtain OAB treatments
by learning symptom-based OAB assessment and detection that includes patient
history and examination.
References
- Herzog AR, Fultz NH, Normolle DP, Brock BM, Diokno AC. Methods used to manage urinary incontinence by older adults in the community. J Am Geriatrics Society. 1998;37(4):339-47.
- Kinchen, KS, Burgio, K, Diokno, AC, Fultz, NH, Bump, R, Obenchain, R. Factors associated with women's decisions to seek treatment for urinary incontinence. Journal Women's Health.2003;12(7):687-697.
- Roberts, RO, Jacobsen, SJ, Rhodes, T, et al. Urinary incontinence in a community based cohort: prevalence and healthcare-seeking behavior. J Am Geriatrics Society 1998; 46:467-472.
- Garcia, JA, Crocker, J, and Wyman, JF. Breaking the cycle of stigmatization. J Wound Ostomy Continence Nurs. 2005;32(1):38-52.
- Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Continence Program for Women Research Group. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131-9.
- Coyne K, Revick, D, Hunt, T, et al. Psychometric validation of an overactive bladder symptoms and health related quality of life questionnaire: The OAB-q. Qual Life Res. 2002; 11:563-574.
- Newman, DK, and Wein, AJ. Overcoming Overactive Bladder. Los Angeles, California: New Harbinger, 2004.
- Newman, DK. and Wein, AJ. Managing and Treating Urinary Incontinence. 2nd Edition; Baltimore, Maryland: Health Professions Press, 2008.
- Newman DK, and Giovannini D. The overactive bladder: a nursing perspective. Am J Nurs 2002; 102(6):36-45.
- Newman, DK. Pelvic Muscle Rehabilitation, Clinical Manual. The Prometheus Group: Dover, NH, 2003.
- Bo, K, Finckenhagen, H. Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility and comparison between palpation and vaginal squeeze pressure. Acta Obst Gynecol Scand. 2001; 80:883-887.
- Brink, CA, Sampselle, CM, Wells, TJ, Diokno, AC, Gillis, GL. A digital test for pelvic muscle strength in older women with urinary incontinence. Nursing Research, 1989; 38(4), July/August: 196-199.
- Brink, CA, Wells, J, Sampselle, CM, et al. Digital test for pelvic muscle strength in women with urinary incontinence Nursing Research 1994; 43:352-356.
- Laycock J and Jerwood D. 2001.(?????) Pelvic floor assessment; the PERFECT scheme. Physiotherapy. 2001; 12: 631-642.
- Worth, AM., Doughery, MC, McKey, PL. Development and testing of the circumvaginal muscles rating scale. Nursing Research. 1986; 35(3):166-168.
- Sampselle, CM. Teaching women to use a voiding diary. Am J Nurs. 2003;103:62-64.
Table 1: Symptom assessment chart9
|
| General | Metabolic conditions |
|
|
|
Medication
|
Effect
|
| ACEI (Captopril, Lisinopril, Enalapril) |
Increased cough leading to stress UI |
| Alpha-adrenergic agonists | Increase urethral resistance causing post-void dribbling, straining, hesitancy in urione flow |
| Alpha-receptor agonists (pseudoephreine, ephedrine) | Urethral constriction, urinary retention (male) |
| Alpha-receptor antagonists (prazosin, terazosin, doxazocin) | Urethral relaxation and decreases urethral resistance causing stress UI (females) with UI with cough, sneeze, or other activity |
| Anticholinergics (H1 antihistamines, antiparkinsonian agents) | Urinary retention with symptoms of post-void dribbling, straining, hesitancy in urine flow, overflow incontinence, fecal impaction |
| Antidepressants, tricyclic | Anticholinergic effect, alpha-receptor antagonist effect causing post-void dribbling, straining, hesitancy in urine flow |
| Antipsychotics, sedatives | Act as sedative causing confusion, may relax destrusor muscle leading to urinary retention |
| Beta-receptor antagonists (propranolol, Metoprolol, Atenolol) | Urinary retention |
| Calcium channel blockers (Verapamil, dilitiazem, nifedipine) | Urinary retention, fecal impaction |
| Diuretics | Increases urine production (plolyuroia) and volume leading to urgency and frequency |
| Methylxanthines (caffeine, Theophylline) | Polyuria, bladder irritation |
| Neuroleptics (thioridazine, chlorpromazine) | Anticholinergic effect, sedation |
| Other (caffeine and alcohol) | Other (caffeine and alcohol) Act as diuretic leading to urgency and frequency, induces sedation |
| Opiods | Urinary retention, fecal impaction, sedation, delirium |
| Sedative-hypnotics | Sedation effect may relax detrusor muscle |
| CHECK ONE | VAGINAL EXAM ϖ RECTAL EXAM ϖ | |
| Scale | Grade | Description |
| None | 0 | No duration (number of seconds) of muscle contraction, pressure or strength, displacement |
| Trace | 1/5 | Slight but instant contraction: < 1 second |
| Weak | 2/5 | Weak contraction: with or without posterior elevation of fingers,
held for > 1 second but < 3 seconds |
| Moderate | 3/5 | Moderate contraction: with or without posterior elevation of fingers, held for at least 4-6 seconds, repeated 3 times |
| Good | 4/5 | Strong contraction: with posterior elevation of fingers, held for at least 7-9 seconds, repeated 4-5 times |
| Strong | 5/5 | Unmistakably strong contraction with posterior elevation of fingers, held for at least 10 seconds, repeated 4-5 times |
| Abdominal |
ϖ Yes
|
ϖ No
|
||
| Gluteal |
ϖ Yes
|
ϖ No
|
||
| Thigh/Abdutor |
ϖ Yes
|
ϖ No
|
| Circle One: |
0
|
No pressure or pain associated with exam |
|
1
|
Comfortable pressure associated with exam | |
|
2
|
Uncomfortable pressure associated with exam | |
|
3
|
Moderate pain associated with exam, intensifies with contraction | |
|
4
|
Severe pain associated with exam, unable to perform muscle contraction due to pain |
Posted June 2008