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Geriatrics Exam Prep > 6 - Urinary Incontinence and Pressure Ulcers > Flashcards

6 - Urinary Incontinence and Pressure Ulcers Flashcards

1
Q

Describe the physiology of bladder function.

i.e. what are the main players?

A
  1. Detrusor Muscle (parasympathetic)
  2. Inhibition Detrusor Contraction (sympathetic)
  3. Internal Urethral Sphincter (sympathetic - alpha)
  4. External Urethral Sphincter (striated muscle)
  5. Micturition Center (pons)
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2
Q

What are some aging changes related to UI?

A
  1. Decreased bladder capacity
  2. Decreased ability to inhibit reflex bladder contractions
  3. Decreased urethral closing pressure
  4. Increased residual urine volume
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3
Q

What is normal urine residual volume?

A

50-100 mL

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4
Q

What are some readily treatable causes of UI? (short-term problems)

A 
DIAPPERS:
Delirium (confused state)
Infection (UTI)
Atrophic vaginitis/urethritis
Pharmaceutical (diuretic, sedatives, Benadryl)
Psychosocial 
Endocrine (Inc. glucose/Ca)
Restricted mobility 
Stool impaction
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5
Q

What are the types of incontinence?

A
  1. Urge - Detrusor Instability
  2. Overflow
  3. Stress
  4. Functional
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6
Q

What is the most common cause of incontinence in elderly men and women > 70 yrs?

A

Urge incontinence!

Detrusor instability

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7
Q

What is the mechanism and cause of Urge Incontinence?

A

Mechanism: uninhibited detrusor contractions

Cause:
Defects in CNS regulation (neuron degeneration)
Hyperexcitability (local effect - like UTI)
Deconditioning ?

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8
Q

What makes urge incontinence unique?

A

The warning period: Urge!

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9
Q

What is the mechanism and cause of Overflow Incontinence?

A

Mechanism: intravesicular pressure cannot exceed intraurethral pressure –> basically bladder pressure is less than outlet pressure

Cause:

  1. Outlet obstruction
  2. Detrusor inadequacy (overactive bladder)
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10
Q

What is the mechanism and cause of Stress Incontinence?

A

Mechanism: sphincter insufficiency

Cause:

  1. Weakness of pelvic muscles
  2. Estrogen deficiency
  3. Urologic surgery (ex: prostate removal)
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11
Q

Are men or women more likely to experience stress incontinence?

A

Women!

–> especially those who had vaginal births (but can occur in women who never had children as well)

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12
Q

In a person with stress incontinence, what induces “accidents”?

A

Valsalva stress (from the abdomen)

  • Sneeze
  • Cough
  • Laughter
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13
Q

True/False

There can be mixed abnormalities related to UI.

A

TRUE

“Cases of obstruction or stress UI often have associated detrusor instability”

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14
Q

What is the best way to find out if your patient has UI?

A

ASK!
Take a good history.
Many patients will not offer this info.

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15
Q

What are the components of a good history when assessing UI?

A

Pattern (stress? behavior? functional?)

Local factors (UTI, obstruction, surgical hx, neuro problems)

Systemic factors (diabetes, neoplasia, CNS dysfunction, meds)

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16
Q

What are some things to look for in the physical exam?

A 
Estrogen deficiency 
Fecal impaction 
Prostatic hypertrophy 
Sacral neuro function 
Enlarged bladder after voiding - sometimes you can feel it "doming up"
Incontinence with cough
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17
Q

What are some good labs?

A
  1. Serum glucose/Ca
  2. Urinalysis
  3. Post-void residual volume measurement (should be < 100 mL)
  4. Urodynamics
18
Q

What are the components of urodynamic studies?

A 
Post-void residual
Urine Flow
Cystometry
Cystoscopy
Electromyography

*Little is known about indication, specificity, sensitivity or predictive value in the elderly.

19
Q

What is the criteria for referral for urodynamics

A
  1. Hx of pelvic surgery or irradiation
  2. Marked pelvic prolapse
  3. Evidence of prostatic obstruction
  4. Post-void residual > 100 mL
  5. Uncertain dx/unresponsive to tx
20
Q

Medications that affect continence?

Effects?

A
  1. diuretics -> polyuria
  2. anticholinergics -> urinary retention
  3. alpha agonists -> urinary retention
  4. beta agonists -> urinary retention
  5. narcotics -> urinary retention
  6. hypnotics -> sedation
  7. alpha blockers -> sphincter relaxation
  8. caffeine -> detrusor irritation
21
Q

How is cystometry performed?

A

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.

22
Q

What are the treatment goals for someone with:

  1. Detrusor Instability (Urge)
  2. Overflow Incontinence
  3. Stress Incontinence
  4. Functional
A
  1. ↓ Detrusor Contractions
  2. Remove obstructions
  3. ↑ Intraurethral Pressure
  4. Reestablish normal pattern, get a home health aid or care giver to assist a patient who can’t get to the bathroom
23
Q

How can you treat urge incontinence/detrusor instability?

A
  1. Anti-cholinergic Agents/Bladder Relaxants
    Examples: oxybutynin (Ditropan), tolterodine (Detrol), solifenacin (Vesicare)
  2. Imipramine - for kids who wet the bed
  3. Bladder training/scheduled voiding
  4. Eliminate caffeine
  5. Formal training using biofeedback in pelvic floor (Kegel) contractions prn urge sensation
24
Q

How can you treat overflow incontinence?

A
  1. Obstruction:
    Surgery: may have detrusor instability for period post-op
    Drug: alpha blockers, anti-androgens (e.g. finasteride)
  2. Detrusor weakness:
    Intermittent catheterization
    Indwelling (Foley) catheter
25
Q

How can you treat stress incontinence?

A 
Estrogens
Kegel exercises
Bladder training 
Sympathomimetics 
Surgery - sling operations
26
Q

How can you treat functional incontinence?

A
  1. Use an incontinence chart to find problems
  2. Use prompted voiding (by caregiver)
  3. Tx psych problems
  4. Assess any problems that make getting to the bathroom difficult
27
Q

What is a pressure ulcer?

A

An area of soft tissue breakdown, usually occurring over a bony prominence

28
Q

Describe Grade I ulcers.

A

Erythema present > 24 hrs
Indurated (abnormally hard)
Epidermis intact

29
Q

Describe Grade II ulcers.

A

Break in epidermis or blistering
Surrounding erythema
Indurated

30
Q

Describe Grade III ulcers.

A

Extends into dermis
Surrounding erythema
Indurated

31
Q

Describe Grade IV ulcers.

A

Involvement of deep fascia and/or muscle

32
Q

What should you keep in mind when assessing a pressure ulcer?

A

There is always a larger underlying defect.

33
Q

What are some common locations of pressure ulcers?

A

Trochanter- lying on right or left side
Ischial tuberosity- wheechair
Heels- flat on back

(also any bony prominence can be effected)

34
Q

WHat % of patients develop a pressure ulcer while in the hospital?

A

3-4.5%

35
Q

What is the main reason patients get pressure ulcers?

A

They are in one position too long!

  • > elevated interstitial pressure
    • > filtration of capillary fluid
    • > occlusion of lymphatics
    • > accumulation of metabolic waste
36
Q

What are contributing factors to the development of pressure ulcers?

A 
Pressure
Shearing force
Friction
Moisture
Poor nutrition
37
Q

What are the general measures of pressure ulcer management?

A
  1. Relieve pressure (turn q 2 hrs)
  2. Debride necrotic areas
  3. Wound dressing (keep wet)
  4. Improve general health (nutrition)
  5. Inspect skin (measure)
38
Q

What are the specific measures of pressure ulcer management?

A
  1. Sheepskin pads
  2. Air or fluid support systems
  3. Special wheelchair cushions
  4. Occlusive biosynthetic dressings (clean wounds)
39
Q

What are the objectives of surgery for pressure ulcers?

A
  1. Excision of ulcerated areas
  2. Resection of bony prominences
  3. Formation of large flaps
  4. Obtainment of additional padding (muscle)
40
Q

What are some complications of pressure ulcers?

A
  1. Sepsis
  2. Osteomyelitis
    - (infection and inflammation of the bone or bone marrow)

*Treat patient with fever and pressure ulcer with antibiotics!

Geriatrics Exam Prep (5 decks)

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