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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

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 Control Period, and at PME Levels 2 and 4

  • Grams of urine loss in 24 hours

  • Measured by pad test


Secondary outcome variable
Secondary Outcome Variable Control Period, and at PME Levels 2 and 4

  • Episodes of urine loss in 24 hours

  • Measured by bladder diary

  • Self-report of episodes


Simple steps
Simple Steps Control Period, and at PME Levels 2 and 4

  • Keep a bladder diary

  • Maintain fluid intake

  • Limit caffeine ingestion

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


Bladder diary
Bladder Diary Control Period, and at PME Levels 2 and 4

  • 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 Control Period, and at PME Levels 2 and 4

  • Many forms

  • One form each 24-hour period

  • Hourly time blocks

  • Simple to complex


Simple bladder diaries
Simple Bladder Diaries Control Period, and at PME Levels 2 and 4

  • 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 Control Period, and at PME Levels 2 and 4

  • Hourly time blocks

  • Woman records:

    • Episodes of urine loss

    • Amount and type of fluid intake

    • Voluntary voids

    • Other information


Control period
Control Period Control Period, and at PME Levels 2 and 4

  • 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 Control Period, and at PME Levels 2 and 4

  • 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: Control Period, and at PME Levels 2 and 4Hand Off the Baton to Runner TwoDougherty et al., 2002


Overview of rct study
Overview of RCT Study Control Period, and at PME Levels 2 and 4

  • Intervention – Behavioral Management for Continence (BMC)

  • Three phases

    • Self-monitoring (simple steps)

    • Bladder training

    • PFME with biofeedback


Self monitoring phase 1 criteria
Self-Monitoring: Control Period, and at PME Levels 2 and 4Phase 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: Control Period, and at PME Levels 2 and 4Phase 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: Control Period, and at PME Levels 2 and 4Phase 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: Control Period, and at PME Levels 2 and 4Phase 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 Control Period, and at PME Levels 2 and 4

  • Primary – grams of urine loss in 24 hours

  • Secondary – episodes of urine loss in 24 hours


Analysis plan
Analysis Plan Control Period, and at PME Levels 2 and 4

  • 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



Bmc group looking inside the intervention
BMC Group: BMC and Control GroupsLooking Inside the Intervention


Bmc group looking inside the intervention1
BMC Group: BMC and Control GroupsLooking Inside the Intervention


Bmc group looking inside the intervention2
BMC Group: BMC and Control GroupsLooking Inside the Intervention

Tomlinson et al., 1997


Analysis caffeine intake
Analysis: BMC and Control GroupsCaffeine Intake

  • Linear regression

  • Decrease in caffeine intake

  • Decrease in episodes of urine loss

  • Approached statistical significance (p = .07)


Analysis change in fluid intake
Analysis: BMC and Control GroupsChange in Fluid Intake

  • Increase in fluid intake

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


Analysis daytime voids
Analysis: BMC and Control GroupsDaytime 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 BMC and Control Groups

  • Simple steps merit more attention

  • Need for RCT on simple steps


Weakness of self monitoring
Weakness of Self-Monitoring BMC and Control Groups

  • 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 BMC and Control Groups

  • Bladder diary

  • Promotes improvement in UI

    • Bladder diary alone

    • No significant improvement

  • Competitive funding not likely


Simple steps design issue
Simple Steps Design Issue BMC and Control Groups

  • 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 BMC and Control Groups

  • Participants assigned to a condition

  • Experience that condition


The knack number three runs ahead miller aston miller delancey 1996
The Knack: BMC and Control GroupsNumber Three Runs AheadMiller, Aston-Miller, DeLancey (1996)


What is the knack
What Is The Knack? BMC and Control Groups

  • 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 = BMC and Control GroupsQuick Kegel

  • Simple step

  • Appropriate to all women with UI

  • Important addition to simple steps


Using quick kegel
Using Quick Kegel BMC and Control Groups

  • 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 BMC and Control Groups: Runner Four Comes Around the BendKincade, Dougherty & Carlson, 2000-2006


Study design
Study Design BMC and Control Groups

  • Random assignment

    • Self-monitoring

    • Wait-list group

  • Bladder diary and pad tests

    • Baseline

    • Follow-up


The intervention
The Intervention BMC and Control Groups

  • 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 BMC and Control Groups

  • Pad tests

  • Grams of urine loss in 24 hours


Results
Results BMC and Control Groups


Conclusions simple steps significant improvement
Conclusions: BMC and Control GroupsSimple Steps, Significant Improvement

  • Urine loss (gm)

  • Women with stress and mixed UI


Implications the ideal training schedule
Implications: BMC and Control GroupsThe 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 BMC and Control Groups


Overall implications
Overall Implications BMC and Control Groups

  • 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 BMC and Control Groups

  • 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 BMC and Control Groups



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