6 - Urinary Incontinence and Pressure Ulcers Flashcards
Describe the physiology of bladder function.
i.e. what are the main players?
- Detrusor Muscle (parasympathetic)
- Inhibition Detrusor Contraction (sympathetic)
- Internal Urethral Sphincter (sympathetic - alpha)
- External Urethral Sphincter (striated muscle)
- Micturition Center (pons)
What are some aging changes related to UI?
- Decreased bladder capacity
- Decreased ability to inhibit reflex bladder contractions
- Decreased urethral closing pressure
- Increased residual urine volume
What is normal urine residual volume?
50-100 mL
What are some readily treatable causes of UI? (short-term problems)
DIAPPERS: Delirium (confused state) Infection (UTI) Atrophic vaginitis/urethritis Pharmaceutical (diuretic, sedatives, Benadryl) Psychosocial Endocrine (Inc. glucose/Ca) Restricted mobility Stool impaction
What are the types of incontinence?
- Urge - Detrusor Instability
- Overflow
- Stress
- Functional
What is the most common cause of incontinence in elderly men and women > 70 yrs?
Urge incontinence!
Detrusor instability
What is the mechanism and cause of Urge Incontinence?
Mechanism: uninhibited detrusor contractions
Cause:
Defects in CNS regulation (neuron degeneration)
Hyperexcitability (local effect - like UTI)
Deconditioning ?
What makes urge incontinence unique?
The warning period: Urge!
What is the mechanism and cause of Overflow Incontinence?
Mechanism: intravesicular pressure cannot exceed intraurethral pressure –> basically bladder pressure is less than outlet pressure
Cause:
- Outlet obstruction
- Detrusor inadequacy (overactive bladder)
What is the mechanism and cause of Stress Incontinence?
Mechanism: sphincter insufficiency
Cause:
- Weakness of pelvic muscles
- Estrogen deficiency
- Urologic surgery (ex: prostate removal)
Are men or women more likely to experience stress incontinence?
Women!
–> especially those who had vaginal births (but can occur in women who never had children as well)
In a person with stress incontinence, what induces “accidents”?
Valsalva stress (from the abdomen)
- Sneeze
- Cough
- Laughter
True/False
There can be mixed abnormalities related to UI.
TRUE
“Cases of obstruction or stress UI often have associated detrusor instability”
What is the best way to find out if your patient has UI?
ASK!
Take a good history.
Many patients will not offer this info.
What are the components of a good history when assessing UI?
Pattern (stress? behavior? functional?)
Local factors (UTI, obstruction, surgical hx, neuro problems)
Systemic factors (diabetes, neoplasia, CNS dysfunction, meds)
What are some things to look for in the physical exam?
Estrogen deficiency Fecal impaction Prostatic hypertrophy Sacral neuro function Enlarged bladder after voiding - sometimes you can feel it "doming up" Incontinence with cough
What are some good labs?
- Serum glucose/Ca
- Urinalysis
- Post-void residual volume measurement (should be < 100 mL)
- Urodynamics
What are the components of urodynamic studies?
Post-void residual Urine Flow Cystometry Cystoscopy Electromyography
*Little is known about indication, specificity, sensitivity or predictive value in the elderly.
What is the criteria for referral for urodynamics
- Hx of pelvic surgery or irradiation
- Marked pelvic prolapse
- Evidence of prostatic obstruction
- Post-void residual > 100 mL
- Uncertain dx/unresponsive to tx
Medications that affect continence?
Effects?
- diuretics -> polyuria
- anticholinergics -> urinary retention
- alpha agonists -> urinary retention
- beta agonists -> urinary retention
- narcotics -> urinary retention
- hypnotics -> sedation
- alpha blockers -> sphincter relaxation
- caffeine -> detrusor irritation
How is cystometry performed?
Put in catheter and flow in some saline; in someone with an overactive bladder, they will start getting contractions at 1 or 2 mL
This is how you can prove that someone has detrusor instability/hyperreflexia.
What are the treatment goals for someone with:
- Detrusor Instability (Urge)
- Overflow Incontinence
- Stress Incontinence
- Functional
- ↓ Detrusor Contractions
- Remove obstructions
- ↑ Intraurethral Pressure
- Reestablish normal pattern, get a home health aid or care giver to assist a patient who can’t get to the bathroom
How can you treat urge incontinence/detrusor instability?
- Anti-cholinergic Agents/Bladder Relaxants
Examples: oxybutynin (Ditropan), tolterodine (Detrol), solifenacin (Vesicare) - Imipramine - for kids who wet the bed
- Bladder training/scheduled voiding
- Eliminate caffeine
- Formal training using biofeedback in pelvic floor (Kegel) contractions prn urge sensation
How can you treat overflow incontinence?
- Obstruction:
Surgery: may have detrusor instability for period post-op
Drug: alpha blockers, anti-androgens (e.g. finasteride) - Detrusor weakness:
Intermittent catheterization
Indwelling (Foley) catheter
How can you treat stress incontinence?
Estrogens Kegel exercises Bladder training Sympathomimetics Surgery - sling operations
How can you treat functional incontinence?
- Use an incontinence chart to find problems
- Use prompted voiding (by caregiver)
- Tx psych problems
- Assess any problems that make getting to the bathroom difficult
What is a pressure ulcer?
An area of soft tissue breakdown, usually occurring over a bony prominence
Describe Grade I ulcers.
Erythema present > 24 hrs
Indurated (abnormally hard)
Epidermis intact
Describe Grade II ulcers.
Break in epidermis or blistering
Surrounding erythema
Indurated
Describe Grade III ulcers.
Extends into dermis
Surrounding erythema
Indurated
Describe Grade IV ulcers.
Involvement of deep fascia and/or muscle
What should you keep in mind when assessing a pressure ulcer?
There is always a larger underlying defect.
What are some common locations of pressure ulcers?
Trochanter- lying on right or left side
Ischial tuberosity- wheechair
Heels- flat on back
(also any bony prominence can be effected)
WHat % of patients develop a pressure ulcer while in the hospital?
3-4.5%
What is the main reason patients get pressure ulcers?
They are in one position too long!
- > elevated interstitial pressure
- > filtration of capillary fluid
- > occlusion of lymphatics
- > accumulation of metabolic waste
What are contributing factors to the development of pressure ulcers?
Pressure Shearing force Friction Moisture Poor nutrition
What are the general measures of pressure ulcer management?
- Relieve pressure (turn q 2 hrs)
- Debride necrotic areas
- Wound dressing (keep wet)
- Improve general health (nutrition)
- Inspect skin (measure)
What are the specific measures of pressure ulcer management?
- Sheepskin pads
- Air or fluid support systems
- Special wheelchair cushions
- Occlusive biosynthetic dressings (clean wounds)
What are the objectives of surgery for pressure ulcers?
- Excision of ulcerated areas
- Resection of bony prominences
- Formation of large flaps
- Obtainment of additional padding (muscle)
What are some complications of pressure ulcers?
- Sepsis
- Osteomyelitis
- (infection and inflammation of the bone or bone marrow)
*Treat patient with fever and pressure ulcer with antibiotics!
