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Urinary Incontinence

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Is a problem across the lifespan, including persons above age 5 years. ... Kegel exercises-exercises to strengthen pelvic muscles and involve tightening ... – PowerPoint PPT presentation

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Title: Urinary Incontinence


1
Urinary Incontinence
  • By Karen Hanisch, Mary Ann Jakowicz, Stephanie
    Orth, and Heather Tietjen

2
Definition
  • Urinary incontinence is the unintentional leakage
    of urine at inappropriate times. What does a
    person with UI look like?

3
Vulnerable Populations
  • Is a problem across the lifespan, including
    persons above age 5 years.
  • Women have a higher incidence than men
  • 41 ratio ages below 60 years
  • 21 ratio ages above 60 years
  • Incidence increases with age

4
Vulnerable Population
  • Co-morbid diseases
  • Medications
  • Obesity
  • Status post hysterectomy
  • Pregnancy and Child birth
  • Physical disability two times more likely
  • Increases 50 with sleep disturbances
  • Men-Post-prostatectomy

5
Co-Morbidity
  • COPD-increased intra-abdominal pressure with
    coughing
  • Hip fracture-limited mobility
  • Parkinsons-limited mobility and neurological
    impairment
  • Fecal impaction-pressure/irritation to bladder

6
UI and Chronic Illness
  • CVA
  • Dementia
  • Multiple Sclerosis
  • Various Tumors
  • Spinal Cord injuries
  • Peripheral Vascular Insufficiency
  • Prostate Enlargement
  • Heart Failure
  • Diabetes

7
Medications
  • Anticholinergics
  • Antidepressants
  • Antipsychotics
  • Sedative/hypnotics
  • Antihistamines
  • Nervous system depressants
  • Narcotics
  • Alcohol
  • Ca channel blockers
  • a- and ß-adrenergics
  • Diuretics
  • Caffeine

8
Classifications of UI
  • Stress
  • Urge
  • Mixed
  • Overflow
  • Functional

9
Stress Incontinence
  • Failure to store urine due to urethral sphincter
    incompetence and hypermobility of bladder neck
  • Risk factors
  • Increased parity
  • Difficult vaginal birth/prolonged labor
  • Chronic cough
  • Chronic straining at stool
  • History of heavy lifting
  • Pelvic surgery
  • Obesity
  • Estrogen deficiency

10
Urge Incontinence (Overactive Bladder)
  • Associated with strong urge to void
    characterized by urgency, frequency, nocturia,
    urge/leakage with hearing running water/cold
    air/clothing removal at toilet/rushing to get to
    bathroom

11
Mixed Incontinence
  • Symptoms of two or more forms of UI, most
    commonly stress and urge.

12
Overflow Incontinence
  • Failure of bladder to empty completely R/T
    urethral obstruction or impaired bladder
    contractility
  • Bladder overdistention
  • Dribbling
  • Frequency
  • Diminished urinary stream
  • Sensation of incomplete voiding

13
Functional Incontinence
  • Loss associated with factors that interfere with
    access to a toilet such as physical, cognitive,
    or motivational impairment

14
Prevalence
  • Studies yield various results
  • used different populations
  • different criteria to define incontinence

15
Prevalence of Types of Incontinence
  • Stress incontinence proportionately more
    incontinence among younger women
  • Over active bladder (OAB) more common in women
    after age 60

16
Prevalence in Geriatrics
  • Overall about one half of the homebound and
    institutionalized elderly are incontinent
  • 25-30 of community-dwelling, ambulatory,
    non-homebound women over 60 years
  • 10-15 of community-dwelling, ambulatory,
    non-homebound men over 60 years.
  • Over 40 of postmenopausal women

17
Prevalence in Younger Women
  • 10-30 of women aged 15-64 years
  • One study reported 47 for women between 20-49
    years
  • Prevalence in pregnancy 23-67, postpartum
    prevalence ranges from 6-31

18
Prevalence in Younger Men
  • 1-5 of men aged 15-64 years
  • 10 of children (especially boys) over age 5
    years experience bedwetting
  • 1 of adolescents over age 16 years

19
Prevalence of Those Seeking Medical Care
  • Fewer than 50 percent seek medical care
  • Over 80 can be cured or improved with treatment
  • Myths
  • Incontinence is a normal result of aging or
    having children
  • Nothing can be done about it
  • I dont want surgery

20
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21
Implications of Urinary Incontinence
  • Medical, Psychosocial, and Economic implications
  • associated with decubitus ulcers, urinary tract
    infections, sepsis, renal failure, and increased
    mortality
  • loss of self-esteem, restricted social and sexual
    activities, depression, and dependence on
    caregivers
  • Often a key factor in Nursing Home placement
  • Associated with increased risk of falls

22
Cost of Urinary Incontinence
  • Overall economic burden of Urinary Incontinence
    is estimated at 17.5 billion annually
  • 2 of health care costs in the U.S.
  • Over 1,000 per person per year for pads

23
Costs of Urinary Incontinence
  • Treatments
  • medications
  • surgery
  • mechanical devices
  • Associated Morbidity hospitalizations and
    treatment
  • Supplies
  • absorbant pads
  • foley catheters
  • Supplementary costs
  • laundry costs
  • caregiver time
  • social isolation, dependency, institutionalization
  • social stigma
  • hygienic problems

24
Theoretical Model-Health Belief Model
  • Perceived Susceptiblity-opinion of getting
    condition
  • Perceived Severity-Opinion of seriousness of
    condition
  • Perceived Benefits-opinion of efficacy of action
    to reduce seriousness
  • Perceived Barriers-opinion of costs of action
  • Cues to Action-strategies to implement action
  • Self-Efficacy-confidence in ability to take action

25
Pathophysiology
  • Occurs when the urethra is not able to maintain
    closure against the force of pressure transmitted
    from the bladder
  • Causes not yet totally understood
  • ? Incompetent Detrusor Muscle or Urethral
    Sphincter Mechanism
  • Transient causes account for 1/3 of cases among
    community dwelling patients and 1/2 of
    hospitalized
  • Vaginal delivery R/T neuropathy, connective
    tissue damage, muscle injury

26
Pathophysiology
  • Detrusor Mechanism-detrusor muscle, pelvic
    nerves, spinal cord, cerebral centers
  • Subcortical centers-bladder relaxation to
    fill-Medications or disease may diminish ability
    to postpone urination
  • Neural impulses transmitted through the spinal
    cord and pelvic nerves to the detrusor muscle
    when urination desired-cholinergic activity
    causes detrusor contraction and bladder emptying
  • Prostaglandin receptors-prostaglandin inhibitors
    impair detrusor contractions

27
Pathophysiology of Detrusor Mechanism
  • Prostaglandin receptors-prostaglandin inhibitors
    impair detrusor contractions
  • Calcium channel dependent-calcium channel
    blockers impair contractions

28
Pathophysiology of the Sphincter Mechanism
  • Requires proper angulation and positioning
    between the urethra and the bladder
  • Alpha-adrenergic activity causes urethral
    sphincter contraction
  • alpha-adrenergic agonists can strengthen
    sphincter contractions
  • alpha-blocking agents impair sphincter closure
  • Beta-adrenergic agents cause sphincter relaxation
  • Beta-adrenergic blocking agents interphere with
    relaxation

29
Purpose of the Assessment
  • To determine the cause of the incontinence
  • To detect related urinary tract and nervous
    system pathology
  • To evaluate the patient comprehensively with
    regard to mental and physical status,
    comorbidity, medications, environment, quality of
    life, and availability of resources
  • Simple measures are often effective and some
    conditions may not be curable

30
Assessment Goals
  • Identify transient (easily reversible) causes of
    incontinence to implement effective treatment
  • Identify conditions that require special
    evaluation or referral
  • Classify UI based on symptoms to initiate proper
    treatment

31
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32
Holistic Evaluation
  • Cognitive/Functional
  • Psychological
  • Medical/Surgical history and ROS
  • Voiding History
  • Physical Examination
  • Evaluation of Bladder Function (testing)
  • Quick Assessment (DIAPPERS)

33
DIAPPERS Assessment in the Elderly
  • D-delirium
  • I-infection
  • A-atrophic urethritis/vaginitis
  • P-Psychiatric disorders
  • P-Pharmaceuticals
  • E-excess urine output
  • R-restricted mobility
  • S-Stool impaction

34
Interventions for UI
  • Medications (Ditropan, Detrol, collagen injection
    therapy)
  • Behavioral Therapy
  • Diet Modification
  • Pelvic Muscle Rehabilitation
  • Mechanical Devices
  • Hormone replacement therapy
  • Surgery
  • Supportive Interventions (Absorbent products)

35
Goals
  • Correcting faulty habits of frequent urination
  • Improving ability to control bladder urgency
  • Prolonging of voiding intervals
  • Increasing bladder capacity
  • Reducing episodes of incontinence
  • Building patient confidence

36
Medications
  • Ditropan-(oxybutynin)
  • FDA approved in 1972 for OBD
  • 2.5-5 mg TID-QID-49 for 60 tabs
  • Available in syrup-55 for 300 mL
  • High adverse event profile
  • Pregnancy Risk Category B
  • Transdermal patch
  • Ditropan XL
  • FDA approved 2002
  • 5-15 mg QD-74-88 for 30 tabs

37
Medications
  • Detrol (tolterodine tartrate)
  • FDA approved in 1998
  • 1-2 mg BID-84-89 for 60 tabs
  • Pregnancy risk category C
  • Lower adverse event profile than Ditropan
  • Detrol LA
  • FDA approved in 2001
  • 2-4 mg QD-75-78 for 30 caps

38
Behavioral Therapy
  • Bladder Diary
  • Bladder training-Requires cognitively intact and
    motivated patient capable of toileting and
    adhering to voiding regimen
  • Habit training and prompted voiding
  • Urinary schedules
  • Toileting programs
  • Smoking cessation
  • Maintain normal bowel movements

39
Diet Modification
  • Fluids and foods that function as bladder
    irritants and precipitate urgency and bladder
    contractions
  • Caffeine
  • Chocolate
  • Soft drinks
  • Alcohol
  • Artificial Sweetener
  • Hot Spicy foods
  • Orange Juice
  • Watermelon
  • Tomatoes
  • Restricted Fluid Intake in evenings
  • Maintain Normal BMI

40
Pelvic Muscle Rehabilitation
  • Kegel exercises-exercises to strengthen pelvic
    muscles and involve tightening and relaxing
    vaginal and rectal muscles
  • Expected short-term cure/improvement rate may
    reach 70

41
Mechanical Devices
  • Pessaries
  • Clean Intermittent Catheterization
  • Electrical Stimulation
  • Silicone Sheath Drainage System-Transfix
  • Artificial Urinary Sphincter-treatment of choice
    for post-prostatectomy
  • Male bulbourethral sling

42
Hormone Replacement
  • Reduces symptoms of urinary incontinence for
    post-menopausal women

43
Surgery
  • Consideration and trial of all non-surgical
    options first.
  • Pubovaginal slings
  • Endoscopic bladder neck suspensions
  • Bladder neck suspensions using bolsters
  • Periurethral injections
  • Artificial sphincter implants
  • Artificial bladder grafts
  • Studer Pouch-for bladder cancer
  • Clam ileocystoplasy-bladder augmentation for
    bladder instability

44
Application of Theory
  • Define and personalize risk
  • Specify personal consequences of risk and
    condition
  • Define action to take (how, where, when) and
    positive effects to be expected
  • Identify and reduce barriers through reassurance,
    incentives and assistance
  • Provide how-to information and reminders
  • Provide training and guidance for action

45
Outcome Measures
  • Complete absence of UI or decreased incidence
    (times or amount) of UI
  • Absence of nocturia
  • Improved social activity and self-esteem
  • Improved sexual relations
  • Increased productivity-work and home
  • Reassessment within 30 days with follow-up PRN
    and yearly

46
Further Research
  • Improved public awareness of treatment options
  • Incorporation of routine screening, assessment,
    and diagnosis of patients across the lifespan
  • Further studies in prevention, physiology, and
    treatments
  • ???

47
Resources and Services
  • Healthcare Providers
  • US Agency for Health Care Policy and Research
    (AHCPR)
  • International Continence Society
  • Association of Womens Health Obstetric and
    Neonatal Nurses (AWHONN)
  • www.overactivebladder.com (Detrol LA)
  • Local incontinence support groups (New
    Beginnings-Avera McKennan)
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