Nurses pursuing WOC certification practice in a variety of settings and roles. Patients seeking this type of specialty care, regardless of the setting, may have multiple comorbid conditions including urinary or fecal incontinence. Choosing to certify in continence may be the single most impactful way that a WOC nurse can affect patient outcomes. In 2000, US $19.5 billion were being spent annually on the management of urinary incontinence, with the majority of that money paying for continence products. The disparity of funds spent on containment in comparison to diagnosis and treatment is thought to be related to the perception that "nothing can be done."1 Overall costs associated with incontinence continue to rise with the aging population. Data from 2007 indicated a national cost of $65.9 billion, with projected costs of $82.6 billion by 2020.2 Patients with urinary and fecal incontinence suffer reduced health-related quality of life.3 Incontinence has been linked to increased caregiver stress as well as other significant conditions such as depression and greater risk of falls.4 Patients with incontinence are also at risk for incontinence-associated dermatitis (IAD), which affects 5.6% to 46% of patients depending upon the practice setting.5 Key examples of how a certified WOC nurse impacts patient and facility outcomes are through an accurate continence assessment and implementation of strategies to reduce conditions such as IAD, pressure injury, and catheter-associated urinary tract infections.
For the nurse who chooses to pursue continence certification, whether CCCN or CCCN-AP, knowledge of assessment is a key competency. Performing a comprehensive continence assessment is fundamental to the art and science of nursing to identify the type of incontinence, act on any findings that require referral for additional evaluation, and establish, with the patient, the goals of treatment. The 4 components of the continence assessment are obtaining a current health history, conducting a physical examination, reviewing/selecting laboratory tests, and synthesizing these to determine the type of incontinence and develop an individualized plan for the patient.1 Familiarity with effective assessment components influencing continence can improve a candidate's success at certification. Medication review, bladder diary, and physical exam findings are essential elements to inform the treatment plan. Diagnostic studies such urinalysis, culture, and/or postvoid residuals (PVRs) can be used to help determine next steps for evaluation by the WOC nurse.1 By effectively conducting the assessment, reviewing laboratory findings, and working with the patient, the certified continence nurse will positively impact patient and caregiver outcomes, reduce costs, and improve outcomes at their institutions.2,6
1. Nelles KK. Primary assessment of patients with urinary incontinence and voiding dysfunction. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:44-41. [Context Link]
2. Coyne KS, Wein A, Nicholson S, Kvasz M, Chen C-I, Milsom I. Economic burden of urgency urinary incontinence in the United States: a systematic review. J Manag Care Pharm. 2014;20(2):130-140. doi:10.18553/jmcp.2014.20.2.130. [Context Link]
3. Gorina Y, Schappert S, Bercovitz A, Elgaddal N, Kramarow E. Prevalence of incontinence among older Americans. In: Vital & Health Statistics. Series 3, Analytical and Epidemiological Studies. https://www.ncbi.nlm.nih.gov/pubmed/24964267. Published June 2014. Accessed February 10, 2020. [Context Link]
4. Lawrence KG, Bauer CA, Jacobson TM, Scardillo J, Slachta PA, Bonham PA. Wound, ostomy, and continence nursing: scope and standards of WOC practice, 2nd edition. J Wound Ostomy Continence Nurs. 2018;45(4):369-387. doi:10.1097/won.0000000000000438. [Context Link]
5. Kayser S, Phipps L, VanGlider C, Lachenbruch C. Examining prevalence and risk factors of incontinence-associated dermatitis using the International Pressure Ulcer Prevalence Survey. J Wound Ostomy Continence Nurs. 2019;46(4):285-290. [Context Link]
6. Franken MG, Ramos IC, Los J, Al MJ. The increasing importance of a continence nurse specialist to improve outcomes and save costs of urinary incontinence care: an analysis of future policy scenarios. BMC Fam Pract. 2018;19(1):1-11. doi:10.1186/s12875-018-0714-9. [Context Link]
PRACTICE QUESTIONS
1. What would the continence nurse expect to find when interpreting the bladder diary of a female patient with suspected stress urinary incontinence?
A. Bladder leakage when sneezing
B. Recordings of 2 days of symptoms including voiding frequency, fluid intake, leakage, and activity
C. Bladder leakage following a sudden urge to void
D. Recordings of 12 days of symptoms including voiding frequency, fluid intake, leakage, and activity
Content outline: 030102
Cognitive level: Application
ANSWER: A
Rationale: Stress urinary incontinence occurs when activity, such as sneezing, causes involuntary loss of urine. Bladder leakage that occurs, followed by a sudden, strong urge to void, would be descriptive of urge incontinence. A bladder diary is intended to capture a patient's subjective data regarding incontinence symptoms. Experts agree that a minimum of 3 days of data should be collected; some research shows benefit of a 7-day diary for patients who are willing to track symptoms for this period of time. Asking a patient to collect a diary longer than 7 days has been shown to increase patient burden and leads to decreased sensitivity and specificity of results.
1. Engberg S. Urinary incontinence/voiding dysfunction in the female. In: Doughty DB, Moore KN, eds. Wound Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:155-179.
2. Doughty D, Moore K. Overview of urinary incontinence and voiding dysfunction. In: Doughty DB, Moore KN, eds. Wound Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:15-23.
2. The continence nurse reviewed PVR results for patient who is at risk for incomplete bladder emptying and may consider referral for:
A. one-time PVR of greater than 200 mL.
B. recurrent PVR of greater than 200 mL over 6 months.
C. one-time PVR of greater than 300 mL.
D. recurrent PVR of greater than 300 mL over 6 months.
Content outline: 030103
Cognitive level: Application
ANSWER: D
Rationale: Patients with signs of incomplete bladder emptying include bladder distension on exam, sensation of incomplete emptying, hesitancy or straining with voiding, poor stream, and postvoid dribbling. Conditions associated with incomplete bladder emptying include recurrent urinary tract infections, benign prostatic hypertrophy, pelvic organ prolapse, neurologic disorders, endocrine disorders, stool impaction, and use of certain medications. Postvoid residual can be assessed with ultrasound scan or catheterization after voiding. Current guidelines state that a PVR of more than 300 mL that has persisted for at least 6 months and is documented on 2 or more separate occasions may warrant additional evaluation. Hydronephrosis and chronic renal failure are complications associated with obstruction of the urinary tract and urinary retention.
1. American Urological Association. Non-neurogenic chronic urinary retention: consensus definition, management strategies, and future opportunities. https://www.auanet.org/guidelines/chronic-urinary-retention. Published 2016. Accessed April 27, 2020.
2. Nelles KK. Primary assessment of patients with urinary incontinence and voiding dysfunction. In: Doughty DB, Moore KN, eds. Wound Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:24-41.
3. Pandian SK, Drake MJ. Retention of urine. In: Doughty DB, Moore KN, eds. Wound Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:144.
3. Which patient should the advanced practice continence nurse refer for urodynamic diagnostic studies?
A. 39-year old woman with stress incontinence following 3 months childbirth
B. 52-year old woman with urge incontinence and a history of heart failure
C. 49-year old woman with mixed urinary incontinence seeking surgical management
D. 2-year-old girl who has been unsuccessful with toilet training
Content outline: 030105
Cognitive level: Analysis
ANSWER: C
Rationale: Urodynamic testing is a broad term for tests that include measuring the flow of urine, bladder pressure and ability to store urine, abdominal pressure, and bladder contractility. These tests are not recommended with initial assessment of urinary incontinence. Stress incontinence and urge incontinence should first be managed with behavioral modifications and exercise. A 49-year old woman with type 1 diabetes is likely to have complex urinary incontinence and is at risk for neurogenic bladder and should be referred for urodynamic testing prior to surgical management. Time for expected toilet training is impacted by the child's functional ability and interest in toileting, which generally occurs between 18 and 28 months of age.
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