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The overall goal of treatment is to help the patient manage with a socially acceptable level of bladder function while minimizing the risk of urinary tract infections. Toileting every 2 to 4 hours during the day and fluid restriction after dinner may prevent incontinence in a majority of patients. External catheters may decrease the incidence of enuresis (involuntary discharge of urine, usually at night while sleeping). Intermittent or indwelling catheterization may be indicated in patients with areflexic bladders (bladders with poor sensation and reflex activity; also bladders which cannot initiate urination normally). Some patients may require medication (such as Tolterodine) or surgery.

Additional steps for management of urinary incontinence include:

• Mobility - caregivers should help the patient walk if possible to a commode or toilet to void as movement helps bladder function. Being able to use proper toilet facilities also helps the morale and self image of the patient.
• Communication - if the patient has a communication deficit such as aphasia, the caregiver should create a method for the patient to signal that they need help getting to the bathroom.
• Maintaining adequate fluid intake - this is a challenge for some stroke patients who may either be physically unable to drink efficiently, to pour drinks for themselves, may not feel thirsty, or may lack motivation to drink. Fluid intake is very important for proper bladder function and also prevents urinary tract infections.
• Eating a proper diet - this is important in order to avoid fecal impaction or constipation which can cause or exacerbate urinary incontinence.
• Checking all medications prescribed to the patient to make sure they do not have side effects affecting the urinary system.

Bowel Dysfunction

Approximately 30% of stroke patients experience bowel dysfunction right after the stroke which typically resolves on its own within the first few weeks. Strokes may interfere with the reflex mechanisms for emptying the bowels, and reduced sensation or cognitive impairments may prevent control of defecation. Diet should include adequate fluids and fiber. Patients should be toileted after meals to take advantage of the gastrocolic reflex (an increase of peristaltic activity in the intestines and colon after food is introduced into an empty stomach). Stool softeners and bowel stimulants may be prescribed as necessary. Patients who remain incontinent may require suppositories every 1 to 2 days to prevent incontinence at socially inappropriate times. Persistent bowel incontinence greater than 4 weeks usually is a poor functional predictor.

Shoulder Pain

Estimates are that up to 84% of stroke survivors will experience at least one episode of shoulder pain during the first year of recovery. Common causes of painful hemiplegic shoulder include:

• Adhesive capsulitis
• Traction (compression) neuropathy
• Complex regional pain syndrome type I (CRPS-I, formerly known as reflex sympathetic dystrophy) which develops in up to 12% of patients with shoulder pain
• Shoulder trauma
• Bursitis
• Tendonitis
• Rotator-cuff tear
• Spastic muscles
• Peripheral nerve injury
• Infection

The most common cause of shoulder pain is spastic muscles which impair passive range of motion, especially external rotation. Diagnosis often may be determined from a physical examination alone, but radiographs, electromyography, bone scans, or magnetic resonance imaging may support clinical findings. Education in an effective self-range of motion exercise program is responsible for a decrease in the prevalence of significant shoulder pain and its complications. In addition, patients may be advised to take analgesic medication such as non-steroidal anti-inflammatory drugs (NSAIDs).