Survey And Intervention Study On Stroke Inpatients With Urinary Incontinence In Guangzhou City

BackgroundStroke, also known as cerebrovascular accident, is a chronic non-communicable disease with high rate of morbidity, mortality and recurrence. According to the China2011report of cardiovascular disease, more than200million patients diagnosis with stroke discharged in2008, and nearly increased at an annual rate of9%. Urinary incontinence (UI) is one of the most common and severe complications after stroke. Foreign studies showed that incidence of urinary incontinence in stroke acute period was up to32%to79%, the domestic research showed that incontinence rate in stroke recovery period was38%to60%. Post-stroke urinary incontinence is one of neuropathic urinary incontinence, which means urine flow through the urethra caused by uncontrolled nervous system lesions.Some scholars believe that neuropathic urinary incontinence can be divided into: motor urge urinary incontinence, mixed urge/stress incontinence, overflow urinary incontinence, unstable urethra, reflective urinary incontinence and completely incompetent of urethral closure mechanism. In2005, the third international incontinence advisory committee classified incontinence caused by pons on brain lesions (e.g. stroke) as reflex incontinence, which means bladder sensation cannot be transmitted to the brain, showed lower micturition center of the sacral reflex, often appears spontaneous leakage of urine in the case of lack urinate, the patient generally had no urination feeling. However, some studies reported that the most common abnormal urodynamic in patients with post-stroke urinary incontinence was detrusor hyperreflexia and urethral sphincter no inhibitory relaxation, expressed as urge incontinence. However, detrusor hyperreflexia does not explain all symptoms of post-stroke urinary incontinence. Pettersen’s studies have reported that some stroke patients had no will to urine before urination, therefore, he put forward the concept: impaired awareness of the need to void urinary incontinence (IA-UI), which defined as UI with reduced ability to be aware of bladder signals before leakage, to take notice of eventual leakage, or both. So far, there has no consensus on the classification of post-stroke urinary incontinence.The causes of post-stroke urinary incontinence are complex and diverse, mainly including:lesions direct damaged to the link between the micturition center, voiding reflex arc was loss of inhibition of the cortical micturition center leading to voiding dysfunction, aphasia (cannot express to urine), or limb movement disorder (affecting the speed of going to the toilet) or cognitive impairment (dementia), disturbance of consciousness. They can cause incontinence alone or coexist. Different factors affecting incidence of urinary incontinence due to different inclusion criteria, enrollment time and the study methods. Meanwhile, some studies have shown that factors susceptibility to post-stroke urinary incontinence including age, obesity, stroke type, stroke location, social and psychological factors, aphasia, smoking history and so on.Abroad, treatment guidelines of urinary incontinence recommended conservative strategies, including:record voiding diary, lifestyle interventions, using incontinence appliances, bladder retraining and pelvic floor muscle exercise. In our country, Rehabilitation Nursing Professional Committee developed a Guide (2011Edition) of neurogenic bladder, and also provided effective guidelines for the care of patients with post-stroke urinary incontinence.Post-stroke urinary incontinence affects not only the survival and prognosis of patients, but also seriously affects the quality of life of patients, bringing a heavy burden to families and society. At present, there is few studies of post-stroke urinary incontinence, and lack of analysis of the clinical data and bladder management of these patients. The study aims to further explore the incidence of inpatients with post-stroke urinary incontinence and clinical bladder management status quo and improve the attention of the medical workers of such patients. Reference the findings, taking conventional care, bladder retraining and electrical stimulation therapy to the subgroup of inpatients, to evaluate different nursing intervention of urinary voiding and quality of life to provide a reference for clinical care.Objectives1. To know about basic information, medical history, voiding, bladder management, as well as cognition of patients with post-stroke urinary incontinence in Guangzhou City.2. To investigate the influencing factors of post-stroke urinary incontinence, simultaneously analyze bladder management status and cognitive function of these inpatients, to provide a reference for proposing more effective bladder management measures.3. Post-stroke urinary incontinence inpatients who met the inclusion criteria of subjects were randomly divided into three groups, respectively, in the conventional care group (control group), bladder retraining group, and electrical stimulation treatment group. To evaluate different nursing interventions of voiding and the quality of life on inpatients with post-stroke urinary incontinence.Methods Part ⅠTo know about the basic information, medical history, voiding, bladder management, as well as cognition through questionnaires of inpatients with post-stroke urinary incontinence from in10hospitals in Guangzhou City. Also to investigate the influencing factors of post-stroke urinary incontinence, simultaneously analyze bladder management status and cognitive function of these inpatients, to provide a reference for proposing more effective bladder management measures.1.1Inclusion criteria(1) Inpatients with conventional treatment of cerebrovascular disease which didn’t use any spasmolytic and anticholinergic drugs;(2) Inpatients or caregivers cooperate with the investigation;1.2Exclusion criteria(1) A history of urinary incontinence before stroke;(2) Awareness of disabilities;(3)Suffering from other brain diseases and spinal cord diseases such as Parkinson’s disease, multiple system degeneration, senile dementia, etc.;(4) Failed to cooperate.2. Research methods:questionnaire and interview method. The questionnaire included:2.1General data Including gender, age, country of origin, education background, marital status, medical expenses, long-term caregivers, stroke history and body mass index.2.2Voiding data Including daytime frequency of urination, urinary frequency at night, the occurrence of leakage of urine frequency, urine leakage amount, whether catheterization, whether done urodynamic studies.2.3Bladder management Including the use of incontinence appliances, record the voiding diary, the implementation of the water intake scheme, the bladder retraining, health education and pelvic floor muscle exercise.2.4Past history2.5The cognitive function Mini-mental state examination.Part ⅡDifferent nursing interventions were given to37inpatients with post-stroke urinary incontinence that was enrolled in November2011to March2012, from a stroke unit of tertiary general hospital in Guangzhou City.1.1Inclusion criteria:(1) Aged from18to80, male or female;(2)Diagnosis of urinary incontinence by the International Consultation Committee on Incontinence Questionnaire Short Form;(3) No previous history of urinary tract surgery;(4) Stable vital signs, no severe mental retardation;(5) All patients informed consent, and voluntarily joined this research project.1.2Exclusion criteria:(1) Disturbance of consciousness, mental disorder;(2) Urinary incontinence before the stroke onset;(3) The following diseases:Merge serious heart, liver, kidney and other organ dysfunction; suffering from other brain diseases and spinal cord diseases such as Parkinson’s disease, multiple system degeneration and senile dementia; lower urinary tract obstruction (bladder stones or tumors);(4) Pregnant women;(5) Obvious physical defects;(6) Selected before other clinical trials may affect the results of those.2. The research content The research object were randomly divided into three groups by using random number table, respectively was conventional care group (control group), bladder and training group and percutaneous electrical stimulation treatment group.3. The evaluation method3.1Main evaluation index3.1.1Voiding Diary3.1.2International Consultation Committee on Incontinence Questionnaire Short Form3.1.3Effect assessment3.2Secondary evaluation index Incontinence Quality of Life3. Data analysisAll statistical data were analyzed by using statistical software SPSS13.0. Measurement Data was expressed as Mean±S.D. Statistical significance was determined in a multiple comparisons among different groups of data if homogeneity of variance using One-way ANOVA, group multiple comparisons using the LSD method. Among the three groups after the intervention of the ICI-Q-SF score, I-QOL in scores were compared by using ANCOVA, determine the efficacy of rank conversion of non-parametric tests (the Kruskal-Wallis H test). P value<0.05was considered to be significant.Results1. The overall incidence rate of post-stroke urinary incontinence was44.4%.And the incidence of urinary incontinence was34.6%in stroke acute phase,50.9%in recovering period, and54.5%in sequelae.2. Multivariate analysis showed that:compared with stroke inpatients, inpatients with post-stroke urinary incontinence had the statistical significance (P<0.05) in marital status, long-term care by the nursing workers, the stroke period, type of stroke, parietal lobe lesions, chronic cough, reproductive factors, aphasia/dysarthria and post-stroke depression, while there was no significant statistical significance (P>0.05) in gender, country of origin, educational background, stroke frequency and caregivers. Married (OR=0.403,95%CI0.225～0.724) was protective factor of post-stroke urinary incontinence. Long-term care by the nursing workers (OR=3.768,95%CI1.704～8.333), stroke sequelae (OR=1.761,95%CI1.174～2.642), cerebral hemorrhage (OR=2.022,95%CI1.233～3.317), cerebral hemorrhage and infarction (OR=3.005,95%CI1.199～7.531), parietal lobe lesions (OR=1.549,95%CI1.005～2.386), chronic cough (OR=2.025,95%CI1.265～3.242), postmenopausal women combined vaginal birth history (OR=1.748,95%CI1.179～2.592), history of prostate hyperplasia (OR=2.590,95%CI1.508～4.449), aphasia/dysarthria (OR=3.848,95%CI2.497-5.931), post-stroke depression (OR=3.378,95%CI1.902-6.000) were risk factors of post-stroke urinary incontinence.3. A total of321cases with post-stroke urinary incontinence, of which68(21.2%) indwelling catheter,218(67.9%) of urinary leakage several times a day and a large number of urinary leakage for176cases (54.8%). Only2cases (0.6%) did the urodynamic examination.4. To bladder management analysis found that37.1%of inpatients with post-stroke urinary incontinence did not record voiding diary,51.7%of whom never executive water intake plan,48.6%of whom never did bladder retraining,14.0%of who never accepted medical personnel health education,67.3%of patients never did pelvic floor muscles exercise.5. In the evaluation of cognitive function, patients with incontinence were more severe compared with non-incontinence group,63.0%of the severe cognitive impairment and57.0%of moderate cognitive impairment were with incontinence. Especially in the patient’s orientation (P<0.001), attention and calculation of force (P <0.001), recall (P<0.001), repeat (P=0.028), three-step instructions (P=0.009), expression (P<0.001) and drawing (P=0.002) had statistically significant differences.6. In the implementation of the intervention, the ICI-Q-SF scores of group A (6.28±1.30) and group B (8.80±1.21) were lower than the control group (11.67±1.17) by ANCOVA test with statistically significant differences (F=4.413, P=0.020). Kruskal-Wallis H test results showed that compared with the control group, group A and group B had statistically significant differences (F=12.926,P=0.002). The efficient of the control group was42.86%, and91.67%of group A,83.33%of group B. I-QOL among the three groups after the intervention didn’t have statistically significant differences (P>0.05). After the intervention, quality of life score (I-QOL scores) in each group of patients with urinary incontinence were higher than before the intervention (P<0.001), but there was no statistically significant differences (P=0.298) among the three groups.Conclusions1. The overall incidence rate of post-stroke urinary incontinence was44.4%. And the incidence of urinary incontinence was34.6%in stroke acute phase,50.9%in recovering period, and54.5%in sequelae.2. The risk factors of urinary incontinence included:long-term care by the nursing workers, stroke sequelae, cerebral hemorrhage, cerebral hemorrhage and infarction, parietal lobe lesions, chronic cough, postmenopausal women combined vaginal birth history, history of prostate hyperplasia, aphasia/dysarthria, post-stroke depression. Married was protective factor of post-stroke urinary incontinence.3. Bladder management of inpatients with post-stroke urinary incontinence remains to be strengthened and improved. From the survey results could be seen, many patients did not implement the drinking water program, bladder training, pelvic floor muscle exercise and other measures, suggesting that the health education and management should not be superficial, but timely dynamic assessment and tracking the implementation of management measures. At the same time, health care workers should be concerned about the patient’s mental state, to reduce the burden on the patient’s thinking, as much as possible to obtain the support of patients and their families with as soon as possible to carry out targeted rehabilitation training.4. Compared to non-UI group, the UI group had poorer cognitive function. Suggest inpatients with post-stroke urinary incontinence do MMSE before bladder management, if of cognitive impairment, or aphasia/dysarthria, or post-stroke depression, medical staff should strengthen the health education and make the families and the nursing workers to obtain the cooperation and support the treatment.5. To some extent, compared with conventional care, bladder retraining and transcutaneous electrical nerve stimulation therapy reduced the symptoms of urinary incontinence with better outcomes.