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n most long-term care facilities, urinary incontinence is a prevalent condition. An average of greater than 50 percent of nursing home residents have loss of bladder control. Costs to the institution include absorbent products, laundry, increased staff workload, and sequelae, such as falls and hospital stays. Surveyors may note the prevalence of bladder incontinence in relation to pressure ulcers and urinary tract infections. In these days of over-extended staff and administration and limited resources, a comprehensive continence program may seem difficult if not impossible to implement. But this is not the case. A simple cost-effective program is possible using the Minimum Data Set (MDS) as the identification tool and the Resident Assessment Protocol (RAP) as a tool for diagnosis of transient causes or exacerbating factors.1
       Omnibus Budget Reconciliation Act (OBRA) regulation F316 states, "A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible." The MDS has specific definitions for the level of bladder incontinence noted. Residents who trigger under the MDS section for bladder incontinence are then expected to receive an assessment based on the RAP. The following criteria are listed as the mandated assessment for residents with bladder incontinence.
       The medical and genitourinary history is reviewed for conditions that may cause increased urine production (congestive heart failure treatment, elevated glucose, or calcium); decreased urine production (abnormal blood urea nitrogen or creatinine); or decreased bladder emptying (recent stroke or decreased Vitamin B12 level). Medication review is suggested for the same reason, which is to look for medications that may affect the ability of the bladder to empty or store.
       The RAP goes on to ask about other reversible conditions that cause or exacerbate urinary incontinence. Fecal impaction can impair bladder emptying. Delirium and depression can decrease the resident's ability to recognize the need to void and/or ask for assistance to toilet. Functional status must be evaluated to determine if the resident can access an appropriate toileting device. A pelvic exam is also included in the mandated assessment to assess for signs of atrophic vaginitis. This condition caused by estrogen deficiency of the vaginal canal can cause genitourinary complaints, such as frequency, urgency, and nocturia. The RAP suggests a prostate exam for incontinent male patients to rule out prostatic disease and especially prostatic nodules. Symptomatic urinary tract infection is a reversible cause of incontinence not outlined by the RAP but one that should be ruled out.
       Finally, the two diagnostic procedures outlined by the RAP are provocative stress test and post-void residual urine. The first is done during the physical exam where the resident is asked to cough forcefully with a full bladder. If urine leakage occurs during cough, the test is considered positive and is indicative of stress incontinence and pelvic muscle weakness.
       The second procedure is paramount to ascertaining if urinary incontinence is a failure to store (stress or urge incontinence) or failure to empty (overflow incontinence).
       A true post-void residual measures the amount of urine left in the bladder immediately after voiding. The amount can be measured by straight catheterization or portable bladder ultrasound, but abdominal palpation is not sufficient. Less than 100cc of urine left in the bladder after voiding is considered a normal post-void residual.
       Once reversible causes have been identified and are being treated, the differential diagnosis of incontinence type will drive the treatment plan.3 Table 1 summarizes common symptoms for each type of incontinence along with expected lab results and general treatment options. Although impaired cognitive status may limit treatment choices, a prompted voiding trial should be attempted with most residents.
       An individualized toileting plan is the most important intervention in a successful bladder retraining program. Caregivers who schedule toileting to match the individual's habits are doing much more than "toileting every two to four hours." Providing prompts and praise can motivate cognitively impaired individuals, while scheduled voiding with systemic delays can assist individuals to successfully retrain their bladder to hold more urine.
       Once an individual's voiding patterns are established and symptoms continue, a medication trial may be indicated. There are currently limited pharmacological treatment choices for patients with stress incontinence. A patient with overflow incontinence may have improved symptoms once the cause of obstruction is treated (e.g., a patient with benign prostatic hypertrophy is treated with an alpha-adrenergic drug). For urge incontinence and overactive bladder symptoms, anticholinergic drugs are the most common medications used (see Table 2). Differential diagnosis is important to ensure the right medication for the right type of incontinence.
       Criteria for referral to a specialist have been established by the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality or AHRQ).2 The guidelines outline safe and effective treatment for clinical staff while highlighting which individuals should be considered for referral to a specialist. Continence care specialists are available in some areas to assist long-term care staff at the bedside.
       A comprehensive continence program consisting of toileting based on individualized patterns, dietary modifications (limiting caffeine and alcohol), and in some cases adding medications is an attainable goal. Long-term care residents affected by incontinence deserve the noninvasive evaluation and treatment to regain and maintain as much normal bladder function as possible.