*3.1.4 Characteristics of post-stroke urinary incontinence*

Cerebellar stroke patients' urodynamically more frequently reported signs of detrusor overactivity (53–77%), external detrusor sphincter dyssinergy (40%), and inability to relax the urinary sphincter (47%) [1]. Urge incontinence is characterized by a person who has a strong urge to urinate suddenly followed by involuntary urination (wetting the bed), the frequency of urinating more than 8 times a day, including at night. Stress incontinence is characterized by urine leaking out when there is pressure on the bladder, for example when coughing, sneezing, or laughing. Stress incontinence often precedes stroke symptoms but is usually exacerbated after stroke with recurrent coughing associated with dysphagia and aspiration [15]. Functional incontinence usually occurs in patients who are aware of the need to urinate but have functional limitations to reach the toilet [1].

## *3.1.5 Assessment of post-stroke urinary incontinence*

The assessment can be started with identifying the patient's health condition, including identifying the patient's performance status using the Karnofsky scale, and monitoring the patient's incontinence status using the Bladder diary format for three days (72 hours). Physical assessment and history-taking, including identification of urological problems before the stroke occurred such as bladder outlet obstruction or stress incontinence [16]. Physical assessment also including pain, haematuria, history of recurrent urinary tract infection (UTI), pelvic surgery, and UI associated with known abnormality of the urinary tract [17]. Careful abdominal examination should be performed, an abdominal mass can contribute to stress incontinence and occasionally can cause urinary obstruction with resultant overflow incontinence. The cough test should be performed with the full bladder comfortably in a standing position and it may reveal SUI. In neurologic patients, evaluation of lower extremity strength, reflexes and perineal sensation is necessary. Unilateral weakness or hyperreflexia of the lower extremities may identify an upper motor lesion [17].

In addition, it is also necessary to assessment onset and duration of symptoms, urgency, dribbling, symptoms related to a specific activity such as coughing, sneezing. Assessment of pre-existing incontinence, associated bowel symptoms, medication such as diuretic, anticholinergic, oestrogens, sedatives, and antidepressants. Assessment about fluid intake; medical history related to diabetes, recurrent urinary tract infections and dementia; cognitive ability; and functional capacity: dexterity, mobility, and aids [10].

### *3.1.6 Management of post-stroke urinary incontinence*

There are several successful options for controlling UI, including: nursing interventions in the form of behavioral therapy, pharmacological agents, and surgical treatments [18]. Behavioral treatments are recommended as the first therapy for UI management [1, 19]. It is also recommended by the Intercollegiate Stroke Working Party (2012) and the National Institute for Health and Care Excellence

(2012). Based on the recommendations of the Agency for Health Policy and Research Guidelines (APCHR) and the International Consultation on Incontinence that UI intervention is at least invasive, behavioral management should be initiated early [15].

Behavioral treatment (include bladder retraining and pelvic floor muscle training) can improve bladder control by changing urinary habits experienced by UI patients and teach skills to prevent urine leakage [20]. Several studies mention that the effectiveness of bladder retraining and pelvic floor muscle training in treating UI. There are several advantages of behavioral intervention, including the absence of side effects, comfort, and patient satisfaction [20].

These behavioral interventions need to be taught by nurses to post-stroke UI patients. Families as caregivers also need to be involved in the care of post-stroke UI patients. Management of post-stroke UI needs support family and friends [21]. Families can provide support in the form of emotional and instrumental support by motivating and facilitating patients in providing the necessary equipment such as walking aids and supporting patient healing, including physical support in the form of providing time to assist patients in the management of post-stroke UI. Support from friends can help reduce feeling of isolation and fear, where support from friends who have also experienced in the same diseases can be done by sharing experiences and providing information about necessary health services [22]. Patients are also involved in daily activities so that they can improve the patient's ability and reduce anxiety, where anxiety can also affect UI. Anxiety can directly affect bladder function, this leads to changes in bladder pressure [23]. Changes in bladder pressure can be characterized by abnormal function and condition of the lower urinary tract due to over activity of the bladder wall muscles that cause a sudden urge to urinate [24].

Previous research has shown that supportive care in cancer patients can improve their mood, reduce anxiety, and reduce depression in patients [25]. Supportive interventions also provide ongoing benefits in reducing depressive symptoms in dementia patients [26]. Supportive interventions increase patient satisfaction, significantly reduce depressive symptoms, and improve quality of life [27]. Peer support can help reduce feeling of isolation and fear, where peer support can be done by sharing experiences and providing information about necessary health services [22].
