Urinary Incontinence and the Role of the Midwife

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Before addressing the role of the midwife in urinary incontinence, a brief review of kinds, causes, and risk factors is introduced. The role of the midwife, references, and four appendices follow.

There are several forms of urinary incontinence, but the principal ones are stress incontinence, urgency incontinence, and overflow incontinence. Stress incontinence occurs when bladder pressure exceeds urinary resistance. Urgency (urge) incontinence comes from neurologic pathology, bladder abnormality, or disturbance of sensory pathways such as in fecal impaction. Overflow incontinence is characterized by continuous leakage and incomplete emptying of the bladder (Bickley, Szilagy, & Hoffman, 2017; Bond, McCool, & Brucker, 2019; Madsen & Kriebs, 2017; Screening for urinary incontinence, 2017).

Causes of incontinence vary by type. Stress incontinence usually occurs from urinary sphincter, levator ani, and external anal sphincter impairment (see Appendix 1), but may also be due to detrusor muscle over-activity (see Appendix 2). In urgency incontinence, the detrusor fails to perform correctly, though reasons for this are unclear. In addition, a cystocele causing a kinked urethra, the weakened muscle volume in aging, and the physiological changes of childbirth and subsequent detachment of the levator ani all contribute to incontinence (Bickley et al., 2017; Sheng & Miller, 2017).

Risks increase over time. Aging, hysterectomy, urinary tract infections, chronic cough, straining, cognitive impairment, depression, neurologic disability, stroke, diabetes, and, especially, obesity add to the potential for developing incontinence. It is most prevalent in menopause when estrogen levels have declined. Between various metabolic states and comorbidities the risks multiply. In addition, several genes have been associated with urge incontinence (Bond et al., 2019; Screening, 2017; Sheng & Miller, 2017).

While there has not been much research concerning differences in prevalence by racial and ethnic categories, Thom, Van den Eeden, and Ragins, et al. found that Caucasians had higher rates of stress incontinence and African Americans higher in urgency incontinence (2006). However, a study by Kraus, Markland, and Chai, et al., did not find racial or ethnic differences in stress incontinence (2007).

Since women do not readily seek help, the midwife should question them about this subject (Madsen & Kriebs, 2017). Thoroughly examining general and lifestyle history and asking more explicitly about urination symptoms, even intermittent ones, is an important focus (Madsen & Kriebs, 2017). Assessing and treating incontinence can also be accomplished through consultation and collaboration (Bond et al., 2019).

The midwife should do a complete pelvic exam, noting prolapse, atrophy, and masses, and add a neurologic exam if called for. Blood chemistry, kidney function, and urinalysis should be ordered, along with a urine culture to rule out infection. A bladder stress test can be performed to ascertain stress incontinence. Lifestyle counseling, pelvic floor exercises, a voiding diary, bladder training for urge incontinence and topical estrogen for postmenopausal women are within the midwife’s scope, as are treatment for constipation and urinary infection. Of these measures, pelvic floor exercises and weight loss have been shown to be the most beneficial (Madsen & Kriebs, 2017). Many other tests can be performed by a uro-gynecological specialist. Bear in mind that consultation and referral are always recommended, but the midwife can begin the initial discussion.

The midwife can evaluate the pelvic floor muscles directly during the bimanual exam. After assessing the cervix, uterus, and each ovary, the midwife should withdraw the fingers just past the cervix and spread them against the sides of the vagina; the patient should try to squeeze them. Healthy musculature will compress the fingers upward and inward. Tenderness, relaxation, and endurance are determined through all quadrants. The midwife can note urinary leakage after the patient coughs and observe for over-recruitment of the abdominals, adductors, or gluteal muscles (Bickley et al., 2017).

The type of incontinence can be gauged. Stress incontinence is characterized by momentary leakage when coughing, sneezing, or laughing; it will not be accompanied by the urge to urinate. This will be demonstrable when the patient is in a standing position before voiding. Urge incontinence will be apparent by one of two signs: non-detection of the small bladder on palpation or the presence of nervous system disease and/or mental deficits. Local signs of pelvic problems or fecal impaction may also be present. Urge incontinence is characterized by an urge to void followed by a moderate amount of urine passed involuntarily. Atrophic vaginitis may be evident during the vaginal exam (Bickley et al., 2017).

The midwife should discover the full scope of the problem when presented with a patient with incontinence. Frequency, severity, bother, and impact on quality of life are important parameters. Previous treatment, comorbidities as precipitating issues, medications, and obstetric and gynecologic history will contribute to the picture. The state of physical impairment, social lifestyle, environmental history, and current coping measures should be elicited. A leakage index questionnaire (see Appendix 3) can aid with the history. Women can also keep a three-day voiding diary that details times, amounts voided, description of episodes, and kind and amount of beverages (Sheng & Miller, 2017).

Not just “urinary incontinence” but the specific type should be diagnosed, which will help in correcting causative pathology and directing referral. Stress-, urgency-, postural-, nocturnal-, missed-, continuous-, insensible-, and coital incontinence are defined by the International Uro-Gynecological Association /International Continence Society for female pelvic floor dysfunction (Sheng & Miller, 2017).

There is much the midwife can do before referral to specialized management. After history-taking, the clinical assessment involving general appraisal, symptoms, quality of life, urinalysis and/or culture, estrogen status, power of the pelvic floor, and post-void residual measurement, with presumed diagnosis, should be done. Management can then be set in motion: lifestyle interventions such as a diary and elimination of caffeine, artificial sweeteners, and alcohol, muscle training of the pelvic floor (see Appendix 4), bladder training, suppressing urge sensation using the Kegel and Knack techniques, and void intervals of three to five hours when awake. Reverse bladder training may be needed by women who have urge incontinence that is only experienced as late signaling and detrusor underactivity. Medications such as Duloxetine (off-label for treating neurogenic pain and urinary incontinence) or anti-muscarinic agents are other options within the midwife’s scope. Adjuncts such as electrical stimulation, vaginal devices, or urethral inserts can also be prescribed. In a nutshell, management reduces factors that allow bladder pressure to exceed urethral pressure (Sheng & Miller, 2017).

Submitted by:
Lina Wong, SNM
Shenandoah University/George Washington University
Collaborative Nurse-Midwifery Program

References

Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (Guest Ed.). (2017). Female genitalia. In Bates’guide to physical examination and history taking. (12 Ed. pp. 592, 462-463). Philadelphia: Wolters Kluwer.

Bond, S., McCool, W., Brucker, M. (2019). Gynecologic disorders. In King, T., Brucker, M.,Osborne, K., Jevitt, C. Varney’s Midwifery (6th ed., pp. 404-405). Burlington, MA: Jones and Bartlett.

Bradley, C., Rahn, D., Nygaard, E. (2010). Questionnaire for urinary incontinence: Validity and responsiveness to change in women undergoing non-surgical therapies for treatment of predominant urinary incontinence. Neurourology and urodynamics. 29 (5): 727-734 doi: 10.1002/nau.20818. retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891326/

Kraus, S., Markland, A., Chai, T., Stoddard, A., FitzGerald, M., Leng, W., Mallett, V., Tennstedt, S. (2007, July). Race and ethnicity do not contribute to differences in preoperative urinary incontinence severity or symptom bother in women who undergo stress incontinence surgery. American journal of obstetrics and gynecology. 197 (1). Pp. 92. e1-92. e6. DOI:10.1016/j.ajog.2007.03.072 Retrieved from https://www.ajog.org/article/S0002-9378(07)00440-1/fulltext

Madsen, M., Kriebs, J. (2017). Urinary system. In Hackley, B. and Kriebs, J. Primary Care of Women (2nd ed., pp. 812-815). Burlington, MA: Jones and Bartlett.

Metro Books. (2015). Human anatomy coloring book. London: Amber Books Ltd.

Screening for urinary incontinence: Recommendations to the health resources and services administration. (2017, December). WPSI: Women’s preventative services initiative. Retrieved from https://www.womenspreventivehealth.org/wp-content/uploads/Screening-for-Urinary-Incontinence_FINAL.pdf

Sheng, Y., Miller, J. (2017). Urinary incontinence. In Schuilling, K. and Likis, F. Women’s Gynecologic Health (3rd ed., pp. 525-543). Burlington, MA: Jones and Bartlett.

Stein, Amy. (2009). Heal pelvic pain: A Proven stretching, strengthening, and nutrition program for relieving pain, incontinence, IBS, and other symptoms without surgery. (Pp. 39, 42, 43, 47, 57, 60, 62, 82, 86). New York: McGraw Hill.

Thom, D., Van Den Eeden, S., Ragins, A., Wassel-Fyr, C., Vittinghof, E., Subak, L., Brown, J. (2006). Differences in prevalence of urinary incontinence by race/ethnicity. Journal of urology. 175 (1). Pp. 259-264. doi: 10.1016/S0022-5347(05)00039-X. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557354/

Appendices (click to open PDF)