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Evaluation of a Patient Education Tool to Reduce the Incidence of Incontinence Post-Prostate Surgery

Posted on: Saturday, 30 October 2004, 03:00 CDT

A pelvic floor muscle exercise program can reduce the incidence of incontinence post-prostate surgery. The purpose of this study was to validate a new education tool, a refrigerator magnet, in comparison to a paper copy with the same information, to determine if patient compliance with the exercises increased.

Urinary incontinence is me of the major complications identified by men following prostatectomy. Studies by Gunthorpe, Brown, and Redman, (2000) and Bales et al. (2000) have shown that conservative treatment with a pelvic floor muscle exercise (PFME) program reduces the incidence of urinary incontinence.

Literature Review

Joseph and Chang (2000) suggested that urinary incontinence is one potential complication of surgical interventions such as transurethral resection of the prostate (TURP) and radical prostatectomy. MathewsonChapman (1997) found that men experience urinary incontinence for 1 to 80 or more days after radical prostatectomy, and they are highly motivated following surgery to perform interventions to reduce incontinence. Many other recent studies have shown that a pelvic floor exercise program is a conservative, effective way to reduce the incidence of urinary incontinence.

* Gunthorpe et al. (2000) suggested that this type of exercise program would suit the major types of incontinence (stress and urge) that present postoperatively for these men.

* Porru et al. (2001), in a study of 58 patients who underwent TURP, suggested that PFME provide quick improvement of urinary symptoms and quality of life in patients after TURP. Its early practice reduces urinary incontinence and postmicturition dribbling in the first postoperative weeks.

* Kampen et al. (2000) studied 102 incontinent patients who had undergone a radical retropubic prostatectomy and found that the treatment group who had a training program which involved active PFME and biofeedback had a greater rate of continence than the control group who had placebo electrostimulation. These researchers recommended pelvic floor reeducation should be considered as a first- line option in curing incontinence after radical prostatectomy.

Figure 1.

The Continence Magnet

* Sueppel, Kreder, and see (2001) found that starting biofeedback sessions with PFME prior to radical prostatectomy improved patient outcomes. The group who received instructions on PFME and biofeedback before surgery showed improvement of their urinary incontinence over the group who received instructions after surgery.

* Bales et al. (2000) measured the effect of preoperative biofeedback and pelvic floor training on continence in 100 men undergoing radical prostatectomy. After 6 months, there was no difference in the rate of return of continence between the group who had PFME training with biofeedback and the group who received written and verbal information.

* Moore, Griffiths, and Hughton (1999) studied 63 men 8 weeks post-radical prostatectomy. The control group received only verbal and written instructions in pelvic floor exercises, the second group received additional physiotherapy, and the third group received physiotherapy and electrostimulation of the pelvic floor muscles. There was no difference in rates of continence among the three groups, with all groups improving from their baseline.

Both the Bales et al. (2000) and Moore et al. (1999) studies demonstrated verbal and written information on the pelvic floor muscles alone was almost as effective in reducing incontinence in these groups of men as the more sophisticated adjuncts. The findings of these studies concluded that verbal and written information on PFME is an effective way to reduce the incidence of urinary incontinence among patients who have undergone prostate surgery.

Bo (2001) recommended that a PFME maintenance program should include three series of 812 slow contractions, 2 to 3 days per week, for 5 months

Researchers in the current study realized that doing PFMEs six sessions per day is a gruelling routine which may affect compliance, but anticipated that most men would probably practice half of the amount requested.

Purpose

This research study was undertaken to compare the effectiveness of a new education tool for PFME, in the form of a refrigerator magnet (see Figure 1), to a black and white paper copy of the same written material. Although researchers always encouraged patients to perform pelvic floor muscle exercises by distributing educational handouts, they were faced with poor compliance. In addition, this project aimed to:

* Educate patients in correct technique.

* Encourage them to develop good bladder habits.

* Provide support to patients and encourage active participation in reduction of their incontinence through pelvic floor muscle exercises.

* Supply contact details if additional education, support, or followup is required.

Female patients referred to the unit for treatment of urologie problems may also benefit from pelvic floor muscle education and treatment programs. It was the researchers' intention to design a simple, easy-to-understand education tool that promotes continence within the broader community, also encompassing clients of nonEnglish speaking backgrounds (NESB).

Development of the Refrigerator Magnet

Planning/consultation. During the initial planning stage, all ward staff were invited to participate. A series of meetings were held to plan the project and identify participants and their relevant duties. Suggestions on design, wording, and questions were sought. The idea of the magnet as an educational tool was suggested by an urogynecology research fellow; as the magnet would be put on the refrigerator, it would be visible and constantly reminding the participants to do the exercises. Each member of the team was allocated tasks that included the design and augmentation of the magnet. Team members included the urology clinical nurse consultant (CNC), continence clinical nurse specialist (CNS), and four urology CNSs. A project outline was available for all team members to make comments and modify as necessary.

The initial meeting was held to develop a simple, concise plan for bladder health issues and pelvic floor muscle exercises. It was noted that the current educational handout was not meeting patient needs as it was difficult to understand. It also presented a problem for clients of NESB, as the translated article was even more difficult to understand.

At the same time, researchers wanted to promote regular prostate checks for men over 50 years of age in the community. It was the researchers' experience with patients in the urology ward that many men were neither aware of nor concerned about the need for regular screening for early detection of prostate cancer. Content validation was provided from the head of the urology department.

Enlisting support. The nursing unit manager (NUM) of the urology ward was charged with staff allocating to the pre-admission clinic and fostering communication with medical staff. Project roles were assigned; encouragement and support for the project were seen from the staff.

An outline regarding this exploratory project was disseminated to all six consultant urologists and the current urology registrar, with each consultant urologist receiving 50 magnets to distribute to patients. Community validation was gained by distributing the magnets to members of the local community to elicit preliminary feedback. Initial feedback was positive from patients and the community who noted that having the information readily available via a refrigerator magnet would help promote compliance with pelvic floor muscle exercises.

On an organizational level, the St. George Hospital Public Relations Department gave approval for project material to include both the hospital logo and acknowledgment of the sponsor. Financial support was made available by a pharmaceutical company generously sponsoring this project by printing the magnets. A draft was submitted to the sponsor for approval and as this met company guidelines and government regulations regarding acknowledgments to the company for sponsorship, funding was provided.

Methodology

Sample, A target group of 100 men from an English-speaking background were recruited. These men were randomized by convenience sampling. They were either given a paper copy of the refrigerator magnet or the actual refrigerator magnet, regardless of whether they were undergoing transurethral resection of prostate (TURP) or radical prostatectomy (RRP) so that the magnet (M) group and the paper (P) group would include patients of both types of surgeries. Both groups received identical information on bladder habits and pelvic floor exercises, the only varying factor being the presentation of the information. One group received a paper handout and the other a magnet-backed handout which could be placed on the recipient's refrigerator (see Figure 1).

Initial assessment took place at the pre-admission clinic where the patient's continence status and knowledge of pelvic floor muscle activity were surveyed. Patients were asked to fill in a one-page survey form (see Figure 2). These results were followed up via telephone survey at intervals of 2 weeks and 3 months postoperatively; these calls were made by senior nursing staff.

Tool or instrument. After consultation with the senior research fellow in urogynecology at the St. George Hospital Pelvic Floor Physi\ology Unit, a simple one-page survey form was designed to identify incontinence and impaired pelvic floor integrity in the target group. The information given to patients was clear and defined urge and stress incontinence in simplified terminology. Scoring was based on the validated Blackwell, Yoong, and Moore (2004) St. George Urinary Incontinence Score (see Table 1).

A one-page information handout (see Figure 3) was given to the patients outlining the project and what was required of them. The total time required to complete the relevant documentation was approximately 5 minutes.

Procedure. Patients were recruited in the pre-admission clinic and given the information sheet, incontinence score sheet, pelvic floor exercise information, and questions. They were only required to mark one appropriate column and the project coordinator scored them out of a total of 20. After discharge from the hospital, followup was made by senior nursing staff with a phone call (phone survey) at intervals of 2 weeks and 3 months, using the same questions asked in the preadmission clinic survey form to ensure accuracy.

Figure 2.

Patient Survey Form

At 2 weeks, researchers could identify any patients with incontinence and refer them to the nursing continence service if necessary. The men would then have an opportunity to voice any concern post discharge such as wound care and hematuria.

The American College of Sports Medicine (1990) recommends an exercise period of at least 15 to 20 weeks. Improvements in the first 6 to 8 weeks are the result of neural adaptation, with the increased frequency of excitation leading to the development of more effective motor units. Although muscle hypertrophy takes longer, any benefit of the PFMEs would be evident at 3 months. At the 3-month phone survey, researchers would provide additional support especially to those who had had an RRP. The prostate cancer support group information would also be offered at this time, as most men had recovered from the surgery.

A project logbook was used to record all patient data, including name, phone number, group details [M(agnet) or P(aper)], incontinence assessment, urinary incontinence score, and pelvic floor exercise activity. Weekly meetings were held to allow discussions with pre-admission clinic staff. The project coordinator assigned various roles to the team members and a monthly audit of the logbook was maintained to ensure all data were up to date. Patients identified as experiencing problems with persistent incontinence were referred to the nursing continence service.

Monitoring. Meetings were held regularly with the urology CNC, NUM of the urology ward, and urology CNSs to identify patient and staff needs. Week 1 of the project only yielded one English- speaking client and three from NESB were identified but could not be included. Following this, all patients of a NESB were given handouts on pelvic floor exercises as stock allowed.

Data analysis. To measure the outcome of the project, recruited patients completed a validated questionnaire using St. George Urinary Incontinence Scoring system (see Table 1). This assessed the incontinence status of the patient prior to hospital admission for prostatic surgery. Based on this system, the results ranged from 0/ 20 to 20/20. This pre-admission incontinence score was compared to the scores at the intervals of 2 weeks and 3 months postoperatively when patients were being surveyed over the phone with the same questions.

Results

Paper (P) group. At preadmission, only one patient from the paper group was identified as performing PFMEs and six others were not despite the fact that two patients had knowledge about the exercises (see Table 2). Two men were not incontinent, one had an indwelling catheter, and four men had mild incontinence with scores 2-4/20 (see Table 3).

At 2 weeks post discharge, four men were performing PFMEs and one was not (see Table 2). Four reported no incontinence while one man complained of severe incontinence, with a 16/20 score. Two men were lost to followup as it was during the Christmas period (see Table 3) at 3 months post discharge. Six men were doing PFMEs and one was not (see Table 2). Five reported no incontinence; one man had 1/20 score while the man with a previous score of 16/20 had improved and now scored 9/20 (see Table 3). It was noted that three of the seven men had lost the paper copy of the information regarding PFMEs and bladder health.

Magnet (M) group. At preadmission, none of the patients were doing PFMEs (see Table 2) although two men had heard about it. Four men were not incontinent, three had an incontinence score 1-3/20, and two men had an indwelling catheter (see Table 3).

At 2 weeks post discharge, six men were doing PFMEs while three men were not (see Table 2). Four reported no incontinence, four had mild incontinence with a score 1-3/20, and one man had an indwelling catheter (see Table 3).

At 3 months post discharge, six men were doing the exercises while the remaining three were not (see Table 2). Six of the nine patients reported no incontinence (this included one man who had a radical prostatectomy) while the other three had a mild incontinence score 1-3/20 (see Table 3). It was noted only one man had lost the magnet copy.

Discussion

Researchers had intended to recruit the 100 patients over a 12month period but only 16 patients were recruited for this study. The project was called off prematurely as there had been a restructure of nursing staff in the pre-admission clinic, and staff were no longer required to provide preoperative education. Time constraints and other issues were due to the workload of the staff involved in all the areas and the high acuity of inpatients during the winter months. This limited the resources of suitable personnel and the number of NESB patients at that time.

Figure 3.

Patient Information Form

Table 1.

St. George Urinary Incontinence Scoring System

Only one out of 16 patients was doing PFMEs at time of preadmission although four (including the single patient doing the PFME) of the 16 patients were aware of the exercises. Most men were doing the exercises at 2 weeks and 3 months after their operations. Incontinence scores were improved in both the TURP and prostatectomy groups.

In the TURP group, only one patient in the magnet group had mild incontinence at 3 months and all patients in the paper group had no problem with incontinence. In the radical prostatectomy group, incontinence score was improved significantly, although three men in the magnet group had mild incontinence (score 1-3/20) at 2 weeks but one was continent at 3 months. Between the two men in the paper group, one had improved from a score of 16/20 at 2 weeks to a score of 9/20 at 3 months while the other had lost his paper copy but claimed to be mildly incontinent (score 1-2/20).

It was noted that none had an indwelling catheter at 3 months between both groups. The reasons for not doing PFMEs ranged from "not necessary" as not incontinent, and being forgetful or "lazy." All radical prostatectomy patients were offered information regarding the St. George Prostate Cancer Support Group, while incontinent patients at 3 months were referred to the nursing continence service.

Table 2.

Compliance with Pelvic Floor Muscles Exercises

Table 3

Incontinence Score

To date, the project data are inconclusive, as the researchers were unable to recruit the targeted 100 patients over a 12-month period, or a large enough sample size. It was disappointing for those involved in this project when it was terminated prematurely. Researchers found that patients did benefit from the exercises and reduced the severity of their incontinence, although we were unable to conclude whether or not the magnet is a superior educational tool when compared with the paper copy.

If the paper copy of the magnet was equally as successful as the actual magnet, it would be more cost effective to use the paper handout, as the paper handout cost 5 cents and the magnet cost 60 cents (economy of scale would be applied if a larger quantity of magnets were produced). Given the fact that three out of seven men in the paper group had lost their paper copies of the information, the claim of six men still doing PFMEs at 3 months postoperative is doubtful, although perhaps these men knew the exercises so well that they did not need to refer to the instructions.

Researchers believe behavioral factors contributed to the success of a project, as human nature lends to the fact that patient compliance was increased with inclusion in a project such as the refrigerator magnet. The magnet seemed to be more favorable, as it is more attractive to the eye and acts as a constant reminder to reinforce the information. An education tool such as this is a constant reminder regarding good bladder habits and pelvic floor exercises. Patients in the magnet group commented it was an excellent idea, and the study group found the information content easy to understand. One man even took it away with him while overseas.

Nursing Implications

This study supports the findings of the studies in the literature review that PFMEs do provide improvement of urinary incontinence post-prostate surgery. Nurses should provide education on these exercises preoperatively and as soon as possible after removal of an indwelling catheter. It was important to have a nurse involved with all aspects of the project as nurses had the most contacts with patients. With a rapport established, patients are more likely to cooperate.

Conclusion

To date, over 1,000 magnets have been given out to the community and other patients of the urology clinic; however, it was not feasible to include them in this evaluation. Researchers aim to extend the magnet production to include other languages. Although the findings of this project were inconclusive, the magnet is much friendlier than other handouts currently available.

All men statedthey appreciated the phone call to encourage and support them. It gave them an opportunity to voice their concerns about the surgery and the postoperative complication of incontinence. Researchers will endeavor to provide postdischarge support as an ongoing process.

Researchers also identified factors for the success of any health promotion project, including:

* Verbal as well as written instructions are more beneficial, in addition to receiving the education handout. Patient comments reflected the impression that they would benefit from verbal instruction and support to carry out the exercise program successfully.

* Motivation and encouragement to take responsibility for one's own health leads to success. Some men were not performing the exercises until they received phone calls from researchers. Foliowup via phone can certainly improve compliance.

* Monitoring progress continually also increases compliance, and provides the opportunity for feedback and changing strategies to suit an individual's needs.

Introduction

Compliance with pelvic floor muscle exercises can be difficult to encourage in patients, as the schedule for the exercises itself can be grueling. A refrigerator magnet was investigated as a way to provide a visual reinforcement and a reminder for the exercises.

Objective

To investigate the benefits of a visual reminder, a refrigerator magnet, as compared with a paper reminder, to prompt patients about pelvic floor muscle exercises.

Method

Male patients undergoing either a radical prostatectomy or transurethral resection of the prostate were recruited. Study participants were divided into two groups: one received the magnet and one received a paper copy of the same information. Followup on compliance with the regimen was via phone call.

Results

Men in the magnet group had a higher rate of compliance with the regimen than did those who received the paper copy. They also reported that the visual reminder was a tremendous help in adhering to the pelvic floor exercise regimen.

Conclusions

Both the magnet and followup phone call had a significant impact on the patients who received both, despite the small sample size, and contributed to a reported decrease in incontinence postoperatively. The magnet is now distributed widely and is printed in Chinese language as well.

References

American College of Sports Medicine. (1990). The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Medicine and Science in Sports and Exercise, 22(2), 265-274.

Bales, G.T., Gerber, G.S., Miuor, T.X., Mhoon, D.A., Mcfarland, J.M., Kim, F.L., & Brendler, C.B. (2000). Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. Urology, 56(4), 627-630.

Blackwell, A.L., Yoong, W., & Moore, K.H. (2004). Criterion validity, test-retest reliability and sensitivity to change of the St. George urinary incontinence. BJU International, 93, 331-335.

Bo, K. (2001). Pelvic floor rehabilitation (Keynote Address). Continence Foundation of Australia Conference (8/12/2001), Melbourne, Australia.

Gunthorpe, WJ., Brown, W., & Redman S. (2000). A randomised trial of incontinence treatment and complianceaiding strategies for females in the primary care setting. Australia Continence Journal, 6(3), 3-10.

Joseph, A.C., & Chang, M.C. (2000). Comparison of behaviour therapy methods for urinary incontinence following prostate surgery: A pilot study. Urologic Nursing, 20(3), 203.

Kampen, M.V., Weerdt, W.D., Poppel, H.V., Ridder, D.D., Keys, H., & Baert, L. (2000). Effect of pelvic-floor reeducation on duration and degree of incontinence after radical prostatectomy: A randomised controlled trial. The Lancet, 355, 98-102.

Mathewson-Chapman, M. (1997). Pelvic muscle exercise/biofeedback for urinary incontinence after prostatoctomy: An education program. Journal of Cancer Education, 22(4), 218-223.

Moore, K.M., Griffiths, D., & Hughton, A. (1999). Urinary incontinence after radical prostatectomy: A randomized control trial comparing pelvic muscle exercise with and without electrical stimulation. British Journal of Urology, 83(1), 57-65.

Porru, D., Campus, G., Caria, A., Madedu, G., Cucchi, A., Rovereto, B., Scarpa, R.M., Pili, P., & Usai, E. (2001). Impact of early pelvic floor rehabilitation after transurethral resection of the prostate. Neurourology and Urodynamics, 20, 53-59.

Sueppel, C., Kreder, K., & See, W. (2001). Improved continence outcomes with preoperative pelvic floor muscle strengthening exercises. Urologic Nursing, 21(3),201-210.

Virginia Ip, RN, is a Clinical Nurse Specialist in Urology/ Continence, St. George Hospital, Sydney, Australia.

Acknowledgment: The author will like to thank CSL Pharmaceuticals for paying the cost of producing the magnet, and contributions by J. Werda, S. /Woran, C. Munro, A. Fung, and the St. George Hospital Nursing Research Council.

Copyright Anthony J. Jannetti, Inc. Oct 2004

Source: Urologic Nursing

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