Nursing Interventions in Patients with Urinary Incontinence Evidence-Based Practices: A Systematic Review

 

Yesim Bagci1*, Gulcin Avsar1

 

1Department of Medical Services and Techniques, Erzincan Binali Yıldırım University, Erzincan, Turkey

 

*Correspondence to: Yesim Bagci, Department of Medical Services and Techniques, Erzincan Binali Yıldırım University-Yalnızbag Campus, Rectorate Building, Erzincan 24002,Turkey; Email: yesim.bagci@erzincan.edu.tr

 

DOI: 10.53964/jmnpr.2022013

 

Abstract

Objective: Urinary incontinence (UI) causes compromised quality of life and social relations of patients. The present study was to examine the evidence levels of nursing interventions in patients with UI.

 

Methods: An electronic search on the databases of Cochrane, PubMed, and Google Scholar was performed using the keywords “UI”, “evidence-based practices”, and “nursing practices” with the searching language of Turkish and English from 1999 and 2020. A total of 19 studies were recruited between June 1 and September 1, 2021.

 

Results: The studies examined in this systematic review were examined in three groups, namely, "Lifestyle Changes", "Behavioral Treatment Methods" and "Pelvic Floor Muscle Exercises Training". Behavioral treatment approaches (bladder training) and regular application of pelvic floor muscle exercises reduced UI symptoms. Different levels of evidence-based nursing interventions are available for the management of UI.

 

Conclusion: In these nursing interventions, UI risk and existing UI symptoms can be minimized by adopting bladder training and pelvic floor muscle exercises.

 

Keywords: urinary incontinence, evidence-based practices, nursing practices

 

1 INTRODUCTION

According to the definition of the International Continence Society, urinary incontinence (UI) is involuntary urinary incontinence that compromises the quality of life of patients and causes social and hygienic issues[1]. Moreover, it may result in multiple psychological issues in patients, disrupts skin integrity, and causes various infections and hospitalizations[2,3].

 

The estimated number of UI cases worldwide is 200 million[4]. UI can be found across any age group, with a higher prevalence in women versus men[5-8]. Previous studies on the prevalence of UI mainly included female participants for analyses[5,6,8]. There may be differences in the prevalence of UI due to differences in study methods, measurement intervals, study populations, and samples. In a review of UI prevalence studies conducted in Europe, the prevalence ranged from 16.1% to 68.8% in women[5] and was 20.9%[9], 23.9%[10], and 46.3%[11] in studies conducted in different regions and at different times in Turkey. A review examining 16 descriptive/cross-sectional studies indicated the prevalence of UI was between 16.4% and 49.7%[12].

 

Risk factors for UI include age[6,13-16], high body mass index[6,16,17], heavy physical activity[18], pregnancy and childbirth[6,16], diabetes[6,14], chronic constipation[6,16,19], genetic differences, recurrent resistant urinary infections, neurological diseases, menopause[6,14], coughing, gynecological operation[6,19], smoking[6,15], short urethra neck in women, hormonal status, birth trauma, caffeine, alcohol, sedentary life, peripheral vascular insufficiency, lung diseases and congestive heart failure[6]. There are also other types of incontinence, such as stress, urge, reflex, functional, mixed, postural and total incontinence[1]. It has been reported that 42.9% of Turkish women had stress type, 29.8% had a mixed type and 27.3% had an impingement type[20].

 

The goal in the treatment of UI is to prevent incontinence[13]. UI treatment mainly includes non-pharmacological, pharmacological, and surgical interventions. Non-pharmacological methods can alleviate the symptoms of UI, and pharmacological and surgical treatments are adopted for patients with unsatisfactory outcomes after non-pharmacological interventions. Non-pharmacological interventions feature low medical costs, effective outcomes, easy operation, and no side effects and enhance the quality of life of patients[13].

 

Nursing care should be performed as per the most valid scientific knowledge available. Accordingly, mastery and awareness of the importance of evidence-based practices are essential for the nursing staff to deliver better nursing[21]. The use of evidence-based practices enables the scientificity of nursing practices and the improvement of care outcomes by increasing the quality of nursing[22]. Nurses have important responsibilities in the implementation of interventions aimed at preventing UI, reducing symptoms, care and treatment, and increasing the quality of life by reducing the complaints of the patient[23]. The familiarity of nurses who provide health services to UI patients with treatment and care methods positively influences the outcome of care[24].

 

1.1 Aim

UI causes compromised quality of life and social relations of patients. The present study was to examine the evidence levels of nursing interventions in patients with UI.

 

1.2 Ethical Considerations

This systematic review followed the international research standards of the World Medical Association Helsinki Declaration (2008). Due to the nature of the study (systematic review), ethics committee approval was not required.

 

2 MATERIALS AND METHODS

2.1 Design

Studies that met the inclusion criteria between 1999 and 2020 were searched using the "Cochrane", "PubMed" and "Google Scholar" databases. An electronic search on the databases of Cochrane, PubMed, and Google Scholar was performed using the keywords “UI”, “evidence-based practices”, and “nursing practices” with the searching language of Turkish and English from 1999 and 2020. A total of 19 studies were recruited between June 1 and September 1, 2021. The study was methodologically organized according to the PRISMA 2020 notification checklist (Figure 1).

 

Figure 1. PRISMA Flow Diagram.

 

The search resulted in 9106 data. Data containing one or more keywords in the title and abstract were examined, and articles or other publications, such as compilations, books, and conference proceedings books, that were not relevant to the study population were excluded. The remaining 28 studies were reassessed for eligibility, and 19 studies were determined to be eligible for the systematic review.

 

2.2 Data Sources and Search Strategies

In this review, “Cochrane”, “PubMed”, and “Google Scholar” databases were used. In the search, studies with the keywords “Based nursing practice, Incontinence, Nursing, Nursing care, Practice evidence, Systematic Review, Treatment” and published between 1999-2020 were examined between June and September 2021.

 

2.3 Inclusion and Exclusion Criteria

Inclusion criteria: quasi-experimental studies, meta-analysis studies, randomized controlled studies conducted between 1999 and 2020 with samples of patients with UI examining the effects of non-pharmacological care approaches (lifestyle changes, behavioral treatment approaches, and pelvic floor muscle exercise (PFME) training) on patients with UI, systematic reviews, randomized single-blind controlled trials, prospective randomized controlled trials (all the trails were published in Turkish and English). Exclusion criteria: studies with UI risk factors; with inaccessible full text; with questionnaires at the time of study attempt (intervention). The search resulted in 19 eligible studies.

 

2.4 Evaluation of Methodological Quality

The methodological quality of the evaluated articles was evaluated by two authors according to the classification of evidence levels accepted by the Joanna Briggs Institute[25] (Table 1).

 

Table 1. Joanna Briggs Institute Evidence Level Classification

 

3 RESULTS

Of the studies included in the systematic review, there was 1 quasi-experiment, 3 meta-analyses, 10 randomized controlled trials (1 prospective randomized controlled trial, 1 randomized single-blind controlled trial), and 5 systematic research designs. There were 3 published in 2008, 3 in 2012, 3 in 2019…, and the others were carried out in 1999, 2000, 2007, 2010, 2015, and 2018.

 

The studies examined in this systematic review were divided into three groups “Lifestyle Changes” (Table 2), “Behavioral Treatment Methods” (Table 3), and “PFME Training” (Table 4).

 

Table 2. Studies on Lifestyle Changes (n=6)

 

Table 3. Studies on Behavioral Treatment Methods (n=3)

 

Table 4. Studies on Pelvic Floor Muscle Exercise Training (n=10)

 

4 DISCUSSION

Education about lifestyle changes for patients can prevent UI and minimize the symptoms of UI, with low medical costs, easy operation, and few side effects[14].

 

Under lifestyle changes to alleviate UI, there are recommendations such as weight loss, diet modification, constipation prevention, exercise, smoking prevention, and regulation of fluid and caffeine consumption. In the book published by the European Association of Urology in 2019, especially for adults, it is stated that for bowel management in UI patients, weight loss in overweight and obese patients, reduction of caffeine intake, and smoking cessation in smokers is a strong recommendation, but regulation of the type and amount of fluid intake is considered ineffective to prevent UI[45].

 

Studies on lifestyle changes (Table 2) suggested that weight loss contributes to the alleviation of UI[27-30]. Obesity is one of the important risk factors for UI. Every five unit increase in body-mass index increases the risk of UI by 20-70%[17]. Studies have indicated that the intra-abdominal pressure increases with weight gain, and the intra-bladder pressure increases with its effect, possibly resulting in involuntary UI. High daily intake of caffeine has been reported to increase the risk and symptoms of UI, but increased fluid consumption produces no change in the duration of UI[26,31]. Adequate and balanced food consumption contributes to preventing or reducing UI given that weight gain is a risk factor for UI. A study with a high level of evidence reported that short-term physical exercise reduces UI, while heavy physical exercise increases the risk of UI[29]. It is known that behaviors such as heavy physical exercise and heavy lifting exert pressure on the pelvic floor by increasing intra-abdominal pressure and therefore cause insufficiency of the pelvic floor muscles[46]. Balanced and controlled exercise can reduce the risk of UI, as it strengthens the muscles, especially the pelvic floor muscles and bladder muscles.

 

Bladder training is another method to prevent UI and reduce its symptoms. Bladder training is a training program that allows individuals to learn independent voiding behaviors, especially in the treatment of impulsive and mixed-type UI[20]. The aim of bladder training is to reduce overactive bladder by controlling urinary urgency and decreasing the frequency of voiding, thereby preventing UI by increasing bladder capacity[47]. The European Association of Urology, in its book published especially for adults in 2019, stated that teaching timed voiding and urgency to UI patients with cognitive impairment, and recommending bladder exercise as a first-line treatment to patients with mixed type UI are considered strong recommendations[45]. Three studies on this topic were examined (Table 3), and two concluded that bladder training initiates the desire to void and the desire to void decreases UI over time[35,36]. However, a meta-analysis study by Roe et al.[34] suggested limited evidence of bladder training. Two of the studies mentioned that bladder training is effective in the prevention and treatment of UI.

 

PFME is an exercise that increases the urethral closure pressure by causing voluntary contraction of the muscle groups in the pelvis (periurethral and perivaginal muscles) and enhances the support of the pelvic visceral structures[46,48,49]. Pelvic floor muscle exercise enables the pelvic floor muscle groups to strengthen and perform better functions[20,50]. Pelvic floor muscle exercise has been proven to reduce symptoms and improve quality of life in patients with stress and mixed UI[36,42]. It has been stated in a document published by the European Association of Urology in 2019 that women with stress or mixed type UI (including the elderly and those who gave birth) should be offered supervised intensive PFME for at least three months as a first-line treatment[45]. Ten studies on PFME training were reviewed (Table 4), and it was concluded that the controlled and supervised PFME performed by health professionals was more effective in the management of UI than others[40], and PFME increased the pelvic muscle strength of the patients[37,41,44] with high treatment efficiency in the treatment of UI[36,37,41,42] and increased individuals’ quality of life[36,42]. In addition, studies have reported that PFME during pregnancy contributes to the treatment of UI both during pregnancy[35,37,38,41,43,44] and in the postpartum period[37,39,43,44]. As a result, PFME plays a great role in the prevention and treatment of UI.

 

5 CONCLUSION

Nurses play an important role in the prevention and reduction of UI. There are evidence-based nursing interventions with different levels of evidence that are available in the treatment of UI. The level of evidence for the practices and interventions reviewed in this article is high, and UI symptoms are mostly reduced with lifestyle changes. Further investigations are needed for the results of these applications compared to other treatment methods (medical and surgical). These methods (lifestyle changes, behavioral treatment methods, and PFME training) are strongly encouraged for patients given their features of low costs, easy operations, no side effects, and well-established treatment efficiency.

 

5.1 Strengths and Limitations of the Study

The strengths of the study are its broad screening and the selection of quasi-experimental, randomized controlled and meta-analytic studies. The limitations of the study were that only three databases were searched and only two language studies were attained.

 

Acknowledgements

Not applicable.

 

Ethical Statement

Not applicable.

 

Conflicts of Interest

No conflict of interest was declared between the authors.

 

Data Availability

All data generated or analyzed during this study are included in this published article.

 

Copyright Permissions

Copyright © 2022 The Author(s). Published by Innovation Forever Publishing Group Limited. This open-access article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, sharing, adaptation, distribution, and reproduction in any medium, provided the original work is properly cited.

 

Author Contribution

Bagci Y contributed to literature search. Bagci Y and Avsar G both contributed to study design, manuscript writing, article evaluation, study supervision, and critical revisions for important intellectual content

 

Abbreviation List

PFME, Pelvic floor muscle exercise

UI, Urinary incontinence

 

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