Contributor: Kristen S. Krum, CNM,MSN

As a certified nurse midwife, I have had the honor of being with clients during some of their most intimate moments. From childbirth, sexual dissatisfaction, loss, infidelity, infertility, and mental health – I was with my patients and their families. Despite the sacredness of these moments and conversations, I often find the one topic my clients were not sharing with me is experiences of urinary incontinence. In my practice, the prevalence of this condition was consistent with the literature, which estimates that nearly two out of three adult women had or were experiencing urinary incontinence (Lee et al., 2021). Noting what I witnessed in my practice, I sought a source for this disconnect and a resolution.

In seeking rationales for why urinary incontinence is not being discussed or treated, I have found three prevailing themes I have summarized in Figure 1. Barriers to Care Model. I identified two significant patient barriers to seeking care. First, when asking why my patients did not come to me with their concerns, they often reported a deep sense of embarrassment as they felt this was too personal even to share or that it was not medically significant, which is echoed in numerous studies investigating urinary incontinence (Asklund et al., 2019; Jarbøl et al., 2021; Kocates et al., 2021; Pintos-Díaz et al., 2019; Suchithra et al., 2020; Tomar & Sharma, 2021; Toye & Barker, 2020; Yagmur & Gul, 2020). Next, many falsely believe that this is an unavoidable fate that comes with aging (Asklund et al., 2019; Kocates et al., 2021; Tomar & Sharma, 2021; Toye & Barker, 2020; Yagmur & Gul, 2020). When investigating the literature, I found three primary types of provider barriers in managing urinary incontinence that all stem from the same source. The problem begins with a lack of knowledge competency in urinary incontinence, with students’ assessed knowledge ranging from 34-90% (Witkoś & Hartman-Petrycka, 2020). Many midwifery schools do not train students to evaluate and begin treatment for urinary incontinence (Butterfield et al., 2007). As a result of this lack of knowledge, providers fail to assess, treat, and refer this condition. The last barrier, but no less significant, is the financial barrier. Urinary incontinence treatment requires accessibility to resources, financial ability to afford healthcare-related fees, and transportation.

Given what I learned from why these barriers to treating urinary incontinence are occurring, I sought to identify supportive solutions to address this deficit. Herein laid the foundation for why Orem’s (1991) Self-Care Deficit Nursing Theory (SCDNT) provided the critical step in laying the framework for a solution. The initial treatment option for urinary incontinence is pelvic floor muscle training. The success of pelvic floor muscle training depends on the client’s engagement in performing the exercises regularly. This inherently makes the treatment of urinary incontinence a self-reliant care modality. For persons experiencing urinary incontinence, this is a deviation from their universal requisite self-care practices (Orem, 2001). I constructed the situation-specific Theory of Self-Care Deficit in Urinary Incontinence through Orem’s grand nursing theory.

Figure 1. Barriers to Care Model

Figure 2. Theory of Self-Care Deficit in Urinary Incontinence

Four key features are noted in the Theory of Self-Care Deficit in Urinary Incontinence, as shown in Figure 2. First, there is Self-Care in Urinary Incontinence, which Orem (2001) denotes self-care as the ability to autonomously meet one’s needs from a whole person, holistic viewpoint to include physical, psychological, and spiritual needs. The focal point of self-care is meeting the universal requisites of self-care elimination. In meeting these self-care elimination needs, clients will have a positive correlation with a return to well-being in their physical, psychological, social, and professional relationships. The empowerment to manage and treat your health condition also empowers the client to restore their positive body imagery. The underlying Nursing Agency identified in this situation-specific theory relies on the nurse’s educative and supportive role. To address the provider barriers to diagnosis of urinary incontinence, having a validated questionnaire to diagnose urinary incontinence using a self-reporting tool, such as the Questionnaire for Urinary Incontinence Diagnosis (Bradley et al., 2005), would allow for mutually beneficial diagnostic methods. Clients would feel empowered as their concerns were listened to, and midwives would feel empowered to identify urinary incontinence.

The nurse should provide a comprehensive pelvic floor and urinary incontinence educational training session that offers visual aids and written and auditory discussions. Last is imparting a biofeedback device with instructions for use in auditory, visual, and written formats. After completing the educational interventions, nurses must comprehensively re-evaluate the effectiveness of the treatment through questionnaires, physical evaluations, and patient reports. The Self-Care Agency obstacle of motivation to complete is noted whenever a new additional task is being asked of someone. Hence, finding novel ways to reduce the client’s burden and increase their enjoyment is integral. As nurses encourage, direct access to the task and flexibility in performing pelvic floor muscle training enhance the activity’s performance. Loohuis et al. (2021) demonstrated that smartphone applications are an excellent technology to address issues with accessibility, decrease healthcare costs, reduce transportation demands, improve time conservation, and increase privacy. The application of smartphone programs for pelvic floor muscle training increases accessibility to self-care agencies in the management of urinary incontinence.

To address concerns with motivation, Anglès-Acedo et al. (2021) found in an exploratory study that gamifying pelvic floor muscle training improves motivation to complete exercises. Self-care demands require clients to know their healthcare needs and how to perform the tasks required to treat them. However, over half of clients may not be aware of their pelvic or reproductive anatomy, as Reid et al. (2017) noted. Next, when performing pelvic floor muscle training exercises, nearly three out of four clients’ often express that they do not know if they are executing the activity properly (Díaz-Álvarez et al., 2022). Applying Orem’s (1991) Supportive-Educative System, nurse educators should provide comprehensive pelvic floor muscle training and relevant anatomy with auditory, visual, and written information. Assistive devices, such as pelvic floor biofeedback tools, can provide clients with a visual indicator of whether they perform the exercises correctly.

References

Anglès-Acedo, S., López-Frías, L., Soler, V., Alonso, J. F., Kastelein, A. W., Graaf, B. C., Vodegel, E. V., Tervo, J., Baban, A., Espuña-Pons, M., & on behalf of the Women-Up Consortium. (2021). The WOMEN-UP solution, a patient-centered innovative e-health tool for pelvic floor muscle training: Qualitative and usability study during early-stage development. International Journal of Environmental Research and Public Health, 18(15), 7800. https://doi.org/10.3390/ijerph18157800

Asklund, I., Samuelsson, E., Hamberg, K., Umefjord, G., & Sjöström, M. (2019). User experience of an app-based treatment for stress urinary incontinence: Qualitative interview study. Journal of Medical Internet Research, 21(3), e11296. https://doi.org/10.2196/11296

Bradley, C. S., Rovner, E. S., Morgan, M. A., Berlin, M., Novi, J. M., Shea, J. A., & Arya, L. A. (2005). A new questionnaire for urinary incontinence diagnosis in women: Development and testing. American Journal of Obstetrics and Gynecology, 192(1), 66–73. https://doi.org/10.1016/j.ajog.2004.07.037

Butterfield, Y. C., O’Connell, B., & Phillips, D. (2007). Peripartum urinary incontinence: A study of midwives’ knowledge and practices. Women and Birth: Journal of the Australian College of Midwives, 20(2), 65–69. https://doi.org/10.1016/j.wombi.2007.04.001

Díaz-Álvarez, L., Lorenzo-Gallego, L., Romay-Barrero, H., Prieto-Gómez, V., Torres-Lacomba, M., & Navarro-Brazález, B. (2022). Does the contractile capability of pelvic floor muscles improve with knowledge acquisition and verbal instructions in healthy women? A systematic review. International Journal of Environmental Research and Public Health, 19(15), 9308. https://doi.org/10.3390/ijerph19159308

Jarbøl, D. E., Haastrup, P. F., Rasmussen, S., Søndergaaard, J., & Balasubramaniam, K. (2021). Women’s barriers for contacting their general practitioner when bothered by urinary incontinence: A population-based cross-sectional study. BMC Urology, 21(1), 99. https://doi.org/10.1186/s12894-021-00864-x

Kocates, S., Demirel, G., & Erbas, N. (2021). Qualitative analysis of urinary incontinence affectedness and coping statis in women in their menopausal period. International Journal of Caring Sciences, 14(1), 354-361.

Lee, U. J., Feinstein, L., Ward, J. B., Kirkali, Z., Martinez-Miller, E. E., Matlaga, B. R., & Kobashi, K. C. (2021). Prevalence of urinary incontinence among a nationally representative sample of women, 2005-2016: Findings from the urologic diseases in America project. The Journal of Urology, 205(6), 1718–1724.
https://doi.org/10.1097/JU.0000000000001634

Loohuis, A., Wessels, N. J., Dekker, J. H., van Merode, N., Slieker-Ten Hove, M., Kollen, B. J., Berger, M. Y., van der Worp, H., & Blanker, M. H. (2021). App-based treatment in primary care for urinary incontinence: A pragmatic, randomized controlled trial. Annals of Family Medicine, 19(2), 102–109. https://doi.org/10.1370/afm.2585

Orem, D. E. (1991). Nursing concepts of practice (4th ed.). Mosby.

Orem D. E. (2001). Nursing concepts of practice (6th ed.). Mosby.

Pintos-Díaz, M. Z., Alonso-Blanco, C., Parás-Bravo, P., Fernández-de-Las-Peñas, C., Paz-Zulueta, M., Fradejas-Sastre, V., & Palacios-Ceña, D. (2019). Living with urinary incontinence: Potential risks of women’s health? A qualitative study on the perspectives of female patients seeking care for the first time in a specialized center. International Journal of Environmental Research and Public Health, 16(19), 3781. https://doi.org/10.3390/ijerph16193781

Reid, J. A., Templeman, C. L., Groneberg, D. A., Brueggmann, D., & Jaque, J. M. (2017). Patients’ knowledge of female pelvic health and related educational preferences. Journal of Community health, 42(1), 147–154. https://doi.org/10.1007/s10900-016-0241-3

Suchithra, B., Dsilva, F., & Rajeev, T. (2020). Enhancing knowledge of women on urinary incontinence – A pre and post interventional study. Journal of Clinical & Diagnostic Research, 14(11), 17-19. https://doi.org/10.7860/JCDR/2020/46298.14226

Tomar, S., & Sharma, J. B. (2021). Management of stress urinary incontinence. Indian Obstetrics & Gynaecology, 11(1), 51-57.

Toye, F., & Barker, K. L. (2020). A meta-ethnography to understand the experience of living with urinary incontinence: “Is it just part and parcel of life?” BMC Urology, 20(1), 1-25. https://doi.org/10.1186/s12894-019-0555-4

Witkoś, J., Hartman-Petrycka, M. Do future healthcare professionals have adequate knowledge about risk factors for stress urinary incontinence in women?. BMC Women’s Health 20, 254 (2020). https://doi.org/10.1186/s12905-020-01124-0

Yagmur, Y., & Gul, S. (2021). Urinary incontinence in women aged 40 and older: Its prevalence, risk factors, and effect on quality of life. Nigerian Journal of Clinical Practice, 24(2), 186–192. https://doi.org/10.4103/njcp.njcp_626_18

About Kristen S. Krum

I am an Assistant Professor of Nursing at Linfield University. I am a Certified Nurse Midwife who has been working in women’s health since 2003. I am presently enrolled in Ph.D. in Nursing Science, Texas Woman’s University. My clinical experiences extend from various practice settings (home birth to regional medical centers), contrasting community settings (Amish to Military), and diverse populations (LGBTQIA and neurodiverse). I am a United States Army veteran. I am always excited to learn new things, teach in different styles, and bring awareness to complex issues.