Mrs.Giovanni who admits that she has problems with urine leakage when laughing and coughing, and a strong urge to void on hearing the sound of running water. At night, her urge to void is so strong that she often cannot reach the bathroom in time. Mrs. Giovanni denies ahistory of UTIs,neurologic disorders, or difficulty with her bowels.
She had a hysterectomy at age 52 and was on hormone replacement therapy for about 10 years afterward. She is taking digoxin 0.125 mg daily, furosemide 40 mg twice daily, and potassium chloride 20 mEq 3 times daily for mild heart failure.
Physical assessment reveals a moderate cystourethrocele and atrophy of vaginal and vulvar tissues.Moderate perineal dermatitis is noted.Pelvic floor strength is weak.Urinalysis is within normal limits, and postvoiding residual urine is 5 mL.
Analysis of Mrs.Giovanni’s voiding diary shows moderate consumption of tea and juices throughout the day, nine daytime voidings and four night voidings with an average volume of about 250 mL per void. She notices urine leakage most often in the late afternoon and at night.Ms.Oberle identifies a diagnoses of stress incontinence with an urgency component and decides to try a conservative approach before referring Mrs. Giovanni for further testing and possible cystourethrocele repair. She prescribes estrogen cream, tolterodine (Detrol), and a barrier cream to treat Mrs.Giovanni’s vulvitis.
Stress urinary incontinence related to weak pelvic floor musculature and tissue atrophy
• Urge urinary incontinence related to excess intake of caffeine and citrus juices
• Impaired skin integrity related to constant contact of urine with perineal tissues
• Ineffective coping related to inability to control urine leakage
The expected outcomes are that Mrs. Giovanni will:
• Remain dry between voidings and at night.
• Demonstrate improved perineal muscle strength.
• Regain and maintain perineal skin integrity.
• Return to her previous level of social activity.
PLANNING AND IMPLEMENTATION
Ms. Oberle and the clinic staff plan and implement the following
interventions with Mrs. Giovanni and her daughter.
• Teach how to identify pelvic floor muscles and how to perform Kegel exercises.
• Suggest drinking decaffeinated tea and noncitrus fruit juices (grape, apple, and cranberry).
• Encourage to minimize fluid intake after evening meal.
• Change afternoon dose of furosemide from 9:00 P.M. to 3:00 P.M.
• Instruct to void by the clock, gradually increasing intervals from every 45 to 60 minutes to every 2 to 2.5 hours.Advise to maintain shorter voiding intervals for 2 to 3 hours after furosemide doses.
• Teach to cleanse perineal area,wiping front to back, after each voiding or incident of urine leakage.
• Introduce commercial products available for clothing and furniture protection, encouraging experimentation to identify the most helpful product(s).
• Provide a commode for bedside at night and adequate lighting to prevent injury.
• Schedule follow-up visits and evaluations to reinforce teaching.
Three months after her initial visit, Mrs. Giovanni states that she is doing very well, experiencing occasional leakage of small amounts of urine,primarily when sneezing,coughing,or laughing.
She finds a minipad adequate for protection and is often able to remain dry all day. She has had no further problems with enuresis since changing her evening furosemide dose to late afternoon and limiting her fluids after dinner. She can make it to the bathroom and no longer needs the bedside commode. Her perineal tissue is intact, and she demonstrates improved muscle strength.
Anna’s daughter says her mother is beginning to resume her normal social activities, and that she is no longer worried about her mother’s ability to care for herself independently.