Self monitoring for management of urinary incontinence
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Self-Monitoring for Management of Urinary Incontinence. Molly C. Dougherty, PhD, RN Professor Jean Kincade, PhD, RN Research Associate Professor John R. Carlson, MS Assistant Professor The University of North Carolina at Chapel Hill Chapel Hill, NC, USA. Goal of Presentation.

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Self-Monitoring for Management of Urinary Incontinence

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Self monitoring for management of urinary incontinence

Self-Monitoring for Management of Urinary Incontinence

Molly C. Dougherty, PhD, RNProfessor

Jean Kincade, PhD, RNResearch Associate Professor

John R. Carlson, MSAssistant Professor

The University of North Carolina at Chapel HillChapel Hill, NC, USA


Goal of presentation

Goal of Presentation

  • Discuss a single idea

  • Based on clinical observation

  • Idea was tested through research

  • Results: Evidence-based recommendations

  • For women with urinary incontinence (UI)


A metaphor for the presentation

A Metaphor for the Presentation

  • A metaphor is a figure of speech containing an implied comparison.

  • Here, the development of research in urinary incontinence (UI) is compared to running a relay.


Ui research as a relay race

UI Research As a Relay Race

Think about runners, coaches, handing off the baton.

Think about running towards the finish line.


The approach handing off the baton

The Approach:Handing Off the Baton

  • Chronological over 20 years

  • Sequential

  • Results build


Original idea

Original Idea

Among women with UI, simple steps result in large improvement for some women.


Ui studies in the mid 1980s stretching our muscles

UI Studies in the Mid-1980s:Stretching Our Muscles

  • Included simple steps

  • Within other behavioral interventions

  • Consequence

  • Simple steps contributed to error variance and affected the experimental outcome


Manage measurement error stay on track

Manage Measurement Error:Stay on Track

  • Control for simple steps

  • Place simple steps first in protocol

  • Measure baseline after simple steps and before randomization into Randomized Controlled Trial (RCT)


Trust clinical observation

Trust Clinical Observation

  • Simple steps are important on their own.

  • Simple steps should be tested in an RCT.


Both approaches we have run it both ways

Both Approaches:We Have Run It Both Ways

  • Meritorious

  • Provide important results


Multiple studies mid 1980 s more early winners

Multiple Studies Mid-1980s:More Early Winners

  • A whole century ago!

  • Behavioral management for UI research growing

  • Research funding available

  • Publications, new knowledge


Several studies showed

Several Studies Showed

Regardless of behavioral intervention studied, intervention and control group improved.


Keeping a bladder diary

Keeping a Bladder Diary

  • Self-monitoring

  • Changed urinary patterns

  • Improved UI


Simple steps runner one leaves the block dougherty et al 1993

Simple Steps:Runner One Leaves the BlockDougherty et al., 1993


Overview of first study

Overview of First Study

  • Pelvic Floor Muscle Exercise (PFME)

  • Intervention for Stress Urinary Incontinence (SUI)

  • Results supported use of PFME


Changes in urine loss variables at baseline after the control period and at pme levels 2 and 4

Changes in Urine Loss Variables at Baseline, After the Control Period, and at PME Levels 2 and 4


Primary outcome variable

Primary Outcome Variable

  • Grams of urine loss in 24 hours

  • Measured by pad test


Secondary outcome variable

Secondary Outcome Variable

  • Episodes of urine loss in 24 hours

  • Measured by bladder diary

  • Self-report of episodes


Simple steps

Simple Steps

  • Keep a bladder diary

  • Maintain fluid intake

  • Limit caffeine ingestion

  • Discuss effect of over-the-counter medications on UI


Bladder diary

Bladder Diary

  • Cornerstone of UI research

  • Episodes of UI – primary variable

  • Literature support reliability and validity

  • Clinical observation, logic support

  • Diligence decreases in many with diary keeping over time – during an intervention


Bladder diary1

Bladder Diary

  • Many forms

  • One form each 24-hour period

  • Hourly time blocks

  • Simple to complex


Simple bladder diaries

Simple Bladder Diaries

  • Hourly time blocks

  • Woman checks beside hour each time she has a urine loss episode

  • Needed for elderly and disabled participants


Complex bladder diaries

Complex Bladder Diaries

  • Hourly time blocks

  • Woman records:

    • Episodes of urine loss

    • Amount and type of fluid intake

    • Voluntary voids

    • Other information


Control period

Control Period

  • Careful instruction on keeping bladder diary

  • General instructions on fluid intake and caffeine

  • Review of over-the-counter medication

  • Discussion of their effect

  • No specific instruction about medications given


Control period results

Control Period Results

  • Keeping a bladder diary had an effect

  • Related to

    • Quality of counseling

    • Learning from bladder diary

  • Effect not statistically significant

  • Could be important

    • Controlling error

    • As intervention


Community based rct study hand off the baton to runner two dougherty et al 2002

Community-Based, RCT Study:Hand Off the Baton to Runner TwoDougherty et al., 2002


Overview of rct study

Overview of RCT Study

  • Intervention – Behavioral Management for Continence (BMC)

  • Three phases

    • Self-monitoring (simple steps)

    • Bladder training

    • PFME with biofeedback


Self monitoring phase 1 criteria

Self-Monitoring:Phase 1, Criteria

  • Caffeine intake: 2+ cups or glasses/day

  • Fluid intake: <1,500 or >4,000 cc/day

  • Excessive voiding interval: average 4+ hours

  • Constipation: self-reported

  • If did not meet any criterion, advance to Phase 2


Self monitoring phase 1 goals

Self-Monitoring:Phase 1, Goals

  • Reduce caffeine gradually to no more than 2 caffeinated beverages/day

  • Increase (<1,500 cc) or decrease (>4,000 cc) fluid intake gradually, to 1,800-2,400 cc/day

  • Reduce voiding interval to 2-3 hours during waking hours

  • Increase fiber


Bladder training phase 2

Bladder Training:Phase 2

  • Protocol – Wyman and Fantl (1991)

  • Guided women to:

    • Void at scheduled time intervals

    • Gradually increase the voiding interval


Pfme with biofeedback phase 3

PFME with Biofeedback:Phase 3

  • Biofeedback with surface electromyography (EMG)

  • Observe and modify quality of pelvic floor muscle contractions

  • PFME

    • Goal: 45 contractions per day

    • Three times a week for 12 weeks


Outcome measures

Outcome Measures

  • Primary – grams of urine loss in 24 hours

  • Secondary – episodes of urine loss in 24 hours


Analysis plan

Analysis Plan

  • Intervention (BMC) evaluated as a whole

  • Results supported the efficacy of BMC

  • Significant reductions in grams of urine loss

  • Also in episodes of urine loss

  • Results sustained over 2 years


Mean grams loss per 24 hr at baseline and four follow ups in bmc and control groups

Mean Grams Loss per 24 hr at Baseline and Four Follow-ups in BMC and Control Groups


Bmc group looking inside the intervention

BMC Group: Looking Inside the Intervention


Bmc group looking inside the intervention1

BMC Group: Looking Inside the Intervention


Bmc group looking inside the intervention2

BMC Group: Looking Inside the Intervention

Tomlinson et al., 1997


Analysis caffeine intake

Analysis:Caffeine Intake

  • Linear regression

  • Decrease in caffeine intake

  • Decrease in episodes of urine loss

  • Approached statistical significance (p = .07)


Analysis change in fluid intake

Analysis:Change in Fluid Intake

  • Increase in fluid intake

  • Increase in volume of urine voided (p = .05)


Analysis daytime voids

Analysis:Daytime Voids

  • Fewer daytime voids of intervals greater than 4 hours

  • Increase in volume of urine voided (p = .04)

  • No change in urine loss


Results indicate

Results Indicate

  • Simple steps merit more attention

  • Need for RCT on simple steps


Weakness of self monitoring

Weakness of Self-Monitoring

  • Cannot be applied to all women with UI

  • One or more criterion does not apply to all

  • Drink too much or too little, too much caffeine, etc.


Design issues

Design Issues

  • Bladder diary

  • Promotes improvement in UI

    • Bladder diary alone

    • No significant improvement

  • Competitive funding not likely


Simple steps design issue

Simple Steps Design Issue

  • Caffeine reduction

  • Fluid intake modification

  • Long voiding interval

  • Alleviation of constipation

  • Improvement in UI

    • Promising

    • Not clearly significant

  • All women with UI do not need simple steps


Rct research

RCT Research

  • Participants assigned to a condition

  • Experience that condition


The knack number three runs ahead miller aston miller delancey 1996

The Knack:Number Three Runs AheadMiller, Aston-Miller, DeLancey (1996)


What is the knack

What Is The Knack?

  • Precisely timed pelvic floor muscle contraction

  • Practice in clinic to reinforce learning

  • Used before activities that result in urine loss

  • Significantly reduces urine loss

  • Women with stress urinary incontinence


Knack quick kegel

Knack = Quick Kegel

  • Simple step

  • Appropriate to all women with UI

  • Important addition to simple steps


Using quick kegel

Using Quick Kegel

  • Most women probably use it

  • Nearly all women can use it


Rct on self monitoring runner four comes around the bend kincade dougherty carlson 2000 2006

RCT on Self-Monitoring: Runner Four Comes Around the BendKincade, Dougherty & Carlson, 2000-2006


Study design

Study Design

  • Random assignment

    • Self-monitoring

    • Wait-list group

  • Bladder diary and pad tests

    • Baseline

    • Follow-up


The intervention

The Intervention

  • Counseling and instruction

  • Simple steps

    • Caffeine 12 oz or more caffeinated beverages/day

    • Fluid intake

      • 50 oz or less total fluids

      • 133 oz or more total fluids

    • Constipation one or more bowel symptoms (Kincade et al., 2005)

    • Quick Kegel: all participants


Outcome measure

Outcome Measure

  • Pad tests

  • Grams of urine loss in 24 hours


Results

Results


Conclusions simple steps significant improvement

Conclusions:Simple Steps, Significant Improvement

  • Urine loss (gm)

  • Women with stress and mixed UI


Implications the ideal training schedule

Implications:The Ideal Training Schedule

  • Simple steps should be first steps

  • Management of stress and mixed UI

  • Use bladder diary

  • Counsel women

  • Follow up on progress

  • Add Quick Kegel instruction


Summary

Summary


Overall implications

Overall Implications

  • Women should be screened in all clinical settings for bladder control problems.

  • Women should be offered evidence-based counseling.

  • Sampselle et al., 1997


Review

Review

  • Follow-up on one clinical observation

  • Use results from one study

  • Build rationale for next

  • Support importance of simple steps

  • Any nurse can implement


Keep running to the finish line

Keep Running to the Finish Line


Self monitoring for management of urinary incontinence

The University of North Carolina at Chapel Hill ~ NC, USA


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