Managing Post-Stroke Incontinence

Post-stroke incontinence occurs when the forebrain is damaged - the forebrain is the largest part of the brain.

According to the Stroke Association, about half of all stroke survivors admitted to the hospital experience incontinence. Incontinence after stroke alters the survivor’s ability to control their bladder and bowel functions. Incontinence severity varies from light leakage to complete bowel and bladder control loss. An interdisciplinary team approach can help patients improve continence.

Causes and risk factors of incontinence

Post-stroke incontinence occurs when the forebrain is damaged. The forebrain is the largest part of the brain and contains the hypothalamus, thalamus, and cerebrum. Although the forebrain controls continence, damage to the brain areas that control communication and body movements can increase the risk factors for incontinence.

Recommended course: Clinical Effects and Considerations of Stroke Based on the Affected Region of the Brain

Risk factors for post-stroke incontinence include:

• Communication difficulties that make it challenging for survivors to request bathroom use when needed
• Impaired cognition that limits a survivor’s ability to sequence the steps to get to the bathroom safely
• Impaired arm function that makes it difficult for a survivor to remove clothing
• Impaired mobility that reduces the survivor’s ability to safely and independently access the bathroom by walking or using a wheelchair
• Constipation causes the colon to swell, putting pressure on the bladder and causing leakage

Impacts of incontinence

Post-stroke incontinence can have a negative psychosocial impact on the patient. They may refrain from socializing to avoid the embarrassment of others knowing they are incontinent. Self-esteem and self-confidence may be impacted because of the incontinence as well.

Incontinence management

• Dietary changes such as drinking more water and less caffeine. Caffeine is a diuretic and can cause the urge to urinate frequently. Eating fiber-rich foods and decreasing the number of processed foods eaten can reduce constipation.
• Prescribed medications to help reduce the amount of urine production.

Speech-language therapy interventions

Speech Language Therapists (SLPs) are vital for providing the patient with a way to communicate their needs. The SLP is skilled at determining the augmentative and alternative communication (AAC) device that is a good fit for a patient’s unique needs. The SLP also can provide training for the patient and caregivers regarding AAC use.

Occupational therapy interventions

Modifications to the environment and routines decrease barriers to continence. Occupational therapists (OTs) are skilled at identifying environmental and person factors that can contribute to incontinence. Recommendations to reduce continence barriers include:

• Increasing bathroom safety and accessibility with raised toilet seats and wall-mounted grab bars
• Using a bedside commode or urinal reduces the time needed to get to the bathroom
• Using clothing without fasteners to make clothing management for toileting easier
• Using undergarments or pads designed for incontinence
• Using a bell or other sound alert so the survivor does not have to rely on words to request to go to the bathroom
• Incorporating Kegel exercises and a bowel and bladder program into a survivor’s daily schedule
• Increasing interoception for understanding when the patient needs to go to the bathroom
• Providing a home exercise or intervention program to improve the patient’s strength, coordination, and activity tolerance

Physical therapy interventions

Physical therapists (PTs) hold expertise in accessing mobility to the bathroom areas. PTs determine the appropriate mobility device to facilitate safe transport to desired locations. PTs can also address the underlying factors that are barriers to mobility, such as:

• Impaired balance
• Decreased activity tolerance
• Decrease strength
• Decrease coordination in the lower body

Recommended course: Current Concepts in Fall Prevention and Balance Reeducation for the Geriatric Population

Incontinence-focused therapy

Occupational therapists and physical therapists can also specialize in pelvic floor treatments that address the issues limiting control of bowel and bladder functions. Pelvic floor specialists can also assist with facilitating the following interventions:

• Urgency control uses deep breathing techniques or complex mental tasks like counting down from 100 to help the survivor ignore the urgent need to urinate. Urgency control is an effective long-term treatment that can help rewire the brain to decrease incontinence.

• A bowel and bladder program involves following a schedule to stimulate bowel and bladder movements instead of waiting for the urge to use the toilet. Training requires setting specific times to empty the bowel and bladder. The time between each trip to the restroom is gradually extended until the survivor regains control over bowel and bladder function.
• Pelvic floor strengthening (i.e., Kegel exercises) can strengthen the muscles that support the bladder, small intestine, and rectum. Kegels require squeezing the muscles used to stop urination. Ten repetitions of alternating a 3-second squeeze with a 10-20-second relaxation period can be done initially. One second can be added to each rep as tolerated. Research shows that pelvic floor training can be combined with the professional application of biofeedback to improve results. Kegel exercises can also complement bowel and bladder training.

Conclusion

Incontinence is a common effect of stroke that occurs when the brain area that controls continence is damaged. Damage to areas of the brain that control speech and motor function can also put a stroke survivor at higher risk for incontinence. Incontinence can resolve spontaneously or with a treatment regimen that consists of lifestyle changes, exercises, and environmental modifications.