Continence Management

Question 1

why is bladder and bowel dysfunction important

Answer 1

Social stigmata - leads to restricted activities and depression
Medical complications - skin breakdown, increased urinary tract infections
Institutionalization - UI is the second leading cause of nursing home placement
Still seen as “dirty” subject
People do not know how to verbalize the problem especially about the bowel

Question 2

why is urinary incontinence often undiagnosed/untreated and why is this important

Answer 2

Only 32% of primary care physicians routinely ask about “incontinence”
50-75% of patients never describe symptoms to physicians
80% of urinary incontinence can be cured or greatly improved

Question 3

what is epidemiology re. urinary incontinence

Answer 3

10-25%ofwomenage15-64reporturinary incontinence
 15-40% of women over age 60 in the community report incontinence
 More than 50% of women in nursing homes are incontinent
 W.H.O. recognizes incontinence as an international health concern and a person centered initiative

Question 4

what are common misconceptions about urinary incontinence

Answer 4

76% women believe leakage is just a normal part of ageing
 2/5ths of women believe that leakage is caused by drinking too much water some attribute it to too much sex
 Majority of 66% of people have never discussed it with their doctor
 68% of all women have lived with UI over 3 years

Question 5

why do women not seek help for UI

Answer 5

Not a socially or hygienic problem to them
 Coping mechanisms, expected at a certain age
 We promote incontinence and not bladder health
 Studies demonstrate women wait 5 yrs before reporting to GP
 Lack of information, poor health care professional attitude and knowledge and little done when reported to doctor/nurse
 Pad expectation

Question 6

why is communicating about bowel difficult

Answer 6

Lack vocabulary
 Never before articulated
 Cannot describe easily
 Too embarrassed
 Too ashamed
 Too guilty
 Not legitimate to seek health care

Question 7

describe prevalence of constipation

Answer 7

Depends on definition (frequency, difficulty, consistency)
Rome ll criteria: frequency / hard stool /straining/ incomplete evacuation (2 or more, 25% of time)
Self-report: 26% women, 16% men over 65 years – increases with age
1-7% less than 3 stools per week
10% district nurses time
More take laxatives than say they are constipated
50-74% daily laxatives in Homes

Question 8

what are current five areas of need in people with bladder problems

Answer 8

Assessment
Treatment
Access to service provision 
Professional education 
Information

Question 9

30% of people in______ affected
40%-60% of people in __________ affected
Costly - UK cost ____ million
Treatable
Continence is associated within the domain of _____

Answer 9

30% of people in the community affected
40%-60% of in nursing homes affected
Costly - UK cost £400 million
Treatable
Continence is associated within the domain of nursing

Question 10

who should do continence assessments

Answer 10

Qualified nurses, pre registration student nurses and continence physiotherapists

Question 11

Studies show that people with UI who receive care in acute settings have been shown to lack appropriate care- why?

Answer 11

because of the deficit of knowledge about assessment and management

evidence suggests that nurses are more inclined to contain incontinence, Rather than actively
promote continence.

Largely around attitudes, beliefs and nursing practices (Visnes 2000,Henderson 2000, Mason 2002)
Effects of continence education on practices (Williams 1997, Rigby 2003 Saxer 2009)
Lack of theory taught at undergraduate level (Morishita 1994 ,Lomas 2010)
Staff over estimate their knowledge base (Irwin 2001, Wagg 2008)

Question 12

what is urge urinary incontinence

Answer 12

involuntary leakage accompanied by or immediately preceded by urgency

makes up 22% of UI (mixed w/ stress innocence = 29%)

Question 13

what is stress urinary incontinence

Answer 13

involuntary leakage on effort or exertion or on sneezing or coughing

makes up 49% (mixed w/ stress innocence = 29%)

Question 14

what is overactive bladder (OAB)

Answer 14

a syndrome of symptoms that suggest dysfunction of the lower urinary tract. Characterised by urgency with or without urge incontinence usually involving frequency and nocturia
Involuntary contractions of the detrusor muscle with sudden strong urge to void,often followed by involuntary loss of urine
• Contractions occur spontaneously or on provocation
• Time between desire to void and urine loss is very short
• Frequencyandnocturia
• Accentuated by caffeine, UTI, diuretics, constipation
• Othercauses–neurological increased sensory input to the bladder and idiopathic

Question 15

what is abnormal bladder function

Answer 15

Urgency - Patient opinion determines !
The sensation of urgency is difficult to objectively define hence the need to rely on patient perceptions i.e. Voiding more due to an uncomfortable sudden desire to pass urine so consider urgency
 But If voiding more because of stress incontinence and wants to keep her bladder empty has frequency without urgency

Question 16

what are the 2 classifications of urgency

Answer 16

Sensory - a strong uncomfortable need to void without the fear of impending leakage the bladder has become hypersensitive delaying voiding is painful but rarely leads to incontinence/ = OAB dry

Motor – urinates frequently because they are afraid of experiencing complete or partial involuntary void as a result of an involuntary bladder contraction = OAB wet

Question 17

describe bladder training

Answer 17

Neurotic Behavior is learned and is therefore open to unlearning (Clark 1997)
Problems must be current, repetitive and recordable
The principals of behavior management are clearly identified in bladder
training/drill
Treatment aimed at clearly defined goals
Bladder training
Prompted toileting
Progress is carefully monitored
Bladder training/drill can reduce frequency and voided volume nocturia
50-85% success rate
Also known as behavioural therapy
Based on the assumption that conscious efforts to suppress sensory stimuli re establishes cortical control over the bladder and thus a normal voiding pattern *
The aim is to reduce the frequency to 2-3 0r 3-4hrly

Question 18

describe the 12 weeks of bladder training

Answer 18

Takes 3 months to achieve - a few weeks to break cycle
 scheduled program either set and increased or self scheduling
 Must have a motivated patient and staff
 includes urge inhibition strategies such as mind games serial subtractions
 involve other tasks as distractions
 Positive affirmations using statements such as I can control my
bladder
 deep breathing exercises with imagery
 several rapid pelvic floor exercises to quiet bladder urgency fast twitch contractions
 if voiding occurs more than hourly initial voiding interval should be 1hr
 if voiding is less than hourly the initial voiding should be 30mins
 15 mins used for severe urgency and review
 Journaling adverse incidents is useful for the patient and nurse

Question 19

explain the fluid advice nurses should give

Answer 19

Literature suggests that incontinent people restrict their intake (Norton)
 This leads to urinary infection (Kennedy) urgency and frequency caused by irritation from concentrated urine (Norton ,Roe )
 Pearson stated that health professionals are giving detrimental advice about restricting fluid intake
See Abrams/Kevler weight fluid matrix
 Most fluid advice now comes with caffeine grams per cup
ecrease fluid intake by 25% more than 1L and less than 3L per day
 No real benefit now from reducing caffeine according to authors
 But risk factor to OAB is the relation to tea drinking
 Alcohol and caffeine can be diuretics
 Could be advised to stop drinking four hrs before bedtime if nocturia a problem
 Water content of fruit and veg could be as much as 500 mls and to avoid in the evening
 Intake of vit D protein and potassium seem to be protective of OAB and associated with decrease in onset
 Recent studies show that Diet Coke and caffeine free diet Coke produce similar increases in urgency and frequency compared to carbonated water or classic coke suggesting the problem is associated with artificial sweeteners (Cartwright 2007)

Question 20

what advice should nurses give about smoking and obesity

Answer 20

Obesity smoking carbonated drinks give a risk of OAB
 Higher consumption of veg,bread and chicken are
associated with a reduced risk
 5-10% weight loss seems to help SUI and urgency
 This results in decrease weight in pads and Kings health questionnaire scores with 10% weight loss
 In men obesity physical activity and smoking were not associated with OAB

Question 21

what are some adjuncts to care

Answer 21

 Lifestyle changes fluids/ weight loss/constipation
 Review medication fluid loading/diuretics
 Intermittent self catheterisation first line
 Inplants sacral stimulators
 intraurethral devices pessary
Products andcatheters last to attain socially dry

Question 22

what medications can be given to help

Answer 22

Oxybutinin 
Tolterodine 
Trospium
 Solifenacin

Question 23

describe pelvic floor exercises

Answer 23

PFES poorly taught. Digital palpation of the lavater ani is essential to ensure that patients are able to contract correct muscle before teaching and devising training schedule
 daily minmum of 30-45 pfes building to a duration of 10 secs
 PFE training is only effective if muscles are overloaded
 each client should have their own program Laycock 2000 need to be used for life if a cure is to be maintained(Stanton 1990) they are usually self purchased or given by the physiotherapist 70% cure rate
 Biofeedback computer monitored via rectal or vaginal probe older patients can be treated but may find it too intimate
 Electrostim aids pelvic floor to develop new fibres and increases the number of capillaries supplying blood to them usually 10-12 week treatments 38-49% cure rate over 8 wks
Pelvic Floor Exercises…. Never too early to start: Can stop a week before you die !!

Question 24

describe sacral neuromodulation

Answer 24

For women with refractory OAB
Exact mechanism of action remains unknown
Stimulation of S3 sacral nerve root shown to modulate detrusor activity through afferent, efferent & autonomic pathways
2 stages - Test phase
permanent for those with at least 50%
reduction of symptoms
Efficacy
For Test phase Trials show high success rates – range 52 – 80% but recent analysis of medicare / insurance show lower 35 – 50&%
For successful tests – permanent implant 56 – 90% Effective for at lease 5 years. Replace after 54 months.

Question 25

describe intraveseical botox

Answer 25

Injection of Botulinum Toxin Type A
Neurotoxic - Paralysis of detrusor muscle
More effective in pts who failed anti cholinergics due to S/E rather than in those it was ineffective
60% symptom improvement
Repeat injection 6 – 12 months
Rarely Ab’s form against BTX – confering resistence
ISC – 20%

Question 26

what are different treatment options

Answer 26

Behavioural therapy (60%-80%)
- Dietary modification
- Fluid management
- Bladder drill/bladder training –individual programmes- Pelvic floor exercises, biofeedback etc
Pharmacotherapy
- Anticholinergic therapy (60% “dry”)
- Surgical management  Intravesical botox  Cystodistension
- Bladder augmentation  Autoaugmentation
(>90% success)
- Clam cystoplasty
- TVT/TOT for SUI – mesh treatment now stopped in Scotland
- Urinary Diversion

Question 27

describe obstruction/voiding dysfunction

Answer 27

Outflow obstruction – Prostate
Frequent voids small amounts
Hesitancy (difficulty in initiating the flow)
Poor flow rate and post micturition dribble
• Frequency, urgency, nocturia, dribbling, can occur if residual large
• Detrusor sphincter dysinnergia- neurological impairment causing failure to coordinate bladder contraction with urethral relaxation

Question 28

what are symptoms of BOO

Answer 28

Irritative – frequency, urgency urge nocturia
Obstructive - hesitancy weak stream straining prolonged micturition post mictural dribble incomplete emptying
Other assoc.symptoms- dysuria haematuria and haemospermia

Question 29

what is a UTI inflammatory response

Answer 29

UTI inflammatory response to urothelium to bacterial invasion
 The inflammatory response causes a cluster of symptoms such as pain, bladder infection (cystitis) resulting in small frequent voids, urgency, suprapubic pain, urethral burning on voiding (dysuria)

Question 30

what does acute kidney infection pyelonephritis cause

Answer 30

fever chills malaise loin pain and associated with LUTS

Question 31

what is Bacteriuria

Answer 31

bacteria in urine can be asymptomatic or symptomatic if no pyuria indicates bacteriuria colonization of the urine rather than active infection

Question 32

what is pyuria

Answer 32

presence of white blood cells in the urine

Question 33

how do uncomplicated and complicated UTIs differ for patient

Answer 33

An uncomplicted UTI women respond quickly to a short course of antibiotics. E COLI GRAM NEG BACILLUS 85% OF COMMUNITY ACQUIRED AND 50 % HOSPITAL ACQUIRED INFECTION ALSO PROTEUS MIRABILIS, KLEBSIELLA

A complicated UTI results in the patient has DSD,or BOO or renal or bladder stones.E COLI, STREPTOCOCCUS FAECALIS OR STAP AUREUS

Question 34

what are the 3 classes of UTI

Answer 34

isolated, recurrent, unresolved

isolated = an interval of six mths of last infection
Recurrent >2 in the month or 3 in 12 mths
Recurrent maybe reinfection by different bacteria or bacterial resistance calculi ( infected prostate prostatitis)
Unresolved implies inadequate therapy

Question 35

what are risk factors for bacteriuria

Answer 35

Female sex
 Increasing age
 Menopause
 Diabetes
 Previous UTI
 Catheters
 And voiding dysfunction

Question 36

what are the host defences against a UTI

Answer 36

Commensal flora
Mechanical integrity of mucous membranes
Urinary immunoglobulin inhibits bacterial adherence
Mechanical flushing of urine through urinary tract
Mucopolysacharide coating on bladder Low PH high osmolarity

Question 37

how should recurrent UTIs be managed

Answer 37

Renal ultrasound
 Flexible cystoscopy
 If no functional abnormality found female patients need to be managed by -
 Avoid spermicides used with diaphragm or condom
 Oestrogen replacement for post menopausal loss of
vaginal lactobacilli increased colonisation of Ecoli
 Low dose antibiotics prophylaxis given at bedtime 6- 12mths
 Trimethroprim
 Nitrofurantoin
 Cefalexin 250mg nightly
 Ciprofloxacin
 Natural yogurt
 Post coital antibiotic
 Self start therapy

Question 38

describe a cystoscopy

Answer 38

To exclude lesions in the urethra and bladder.
The bladder neck is examined.
It should close in response to straining.
However, it opens in case of stress urinary incontinence.

Question 39

describe urodynamics

Answer 39

Medical science concerned with the study of urine transport from kidney to bladder as well as its storage and evacuation
 Classification:
1.Cystometrogram( most important test), Filling
Cystometry and Voiding Cystometry
2.Urethral pressure profile
3.Uroflow
4.Electromyography

Question 40

describe uroflowmetry

Answer 40

It records the rate of urine flow through the urethra when the patient is asked to void spontaneously while sitting on uroflow chair.
It is used to evaluate patients with stress incontinence before surgery to exclude difficulty in voiding which may be increased by bladder neck surgery.
Also for men with BOO

Question 41

what lab tests are helpful in evaluating incontinence

Answer 41

Postvoid residual is an easy initial test to obtain. After the patient voids, there should be less than
50 ml of urine in the bladder.
Postvoid residual is measured by ultrasound or in /out catheter
 A patient with an elevated Postvoid residual (repeat measurements greater than 150 ml) may have an underlying neurologic disorder suggesting voiding dysfunction

Question 42

what should you ask about when taking a history for UI

Answer 42

Duration, severity, symptoms, previous treatment, medications, GU surgery
3 P’s: Position of leakage (supine, sitting, standing), Protection (pads per day, wetness of pads), Problem (quality of life)
Bladder record or diary

Question 43

what are diagnostic tests for UI

Answer 43

Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr) Urine Culture
Simple Cystometrics

Question 44

what would the following values mean for interpretation if post void residue

1) <50ml
2? >150ml
3) >200ml
4) >400ml

Answer 44

1) adequate bladder emptying
2) avoid ladder relaxing drugs
3) refer to urology
4) overflow UI likely

Question 45

what is haematuria

Answer 45

Painless haematuria needs investigated urgently – suggests tumour OR TB
Dipstix confirm by microscopic MSU
PAIN SUGGESTS INFLAMMATION OR INFECTION
BLEEDING AT START OF STREAM URETHRA OR PROSTATE
TOTAL HAEMATURIA START TO END STREAM = UPPER URINARY TRACT BLADDER
AT END OF STREAM = PROSTATE /BLADDER CAN BE REFERRED TO UROLOGY HAEMATURIC CLINIC

Question 46

describe care panning/goal setting for UI

Answer 46

Eliminate the symptoms of frequency urgency and urge incontinence
Start with the least invasive treatment
Should there be a combination of behavioural and pharmalogical intervention at the outset?
Establish realistic treatment goals
Patients should be offered only evidence based treatments
Behavioural interventions form the key part of any nurse led clinic
The nurse makes the clinical decision when to use them
Programmes and structures need to be in place to support them
Nurses need to demonstrate competencies in each behavioural domain
Treatment that will focus on patient characteristics - beliefs about treatment
respond to patient goals and preferences
Targeted, tailored and individualised
move beyond the practitioner centered thinking - treatment is whatever it means to the patient
research has shown that there is special patient meaning and response to what a practitioner wears as well as manner, style and language the practitioner uses to interact
 Concordance/compliance
Do I assess their knowledge and attitudes?
Do I chose my other attitudes and words?
Do I deliver a programme using my skills to stay on their agenda ?
Do I deliberately reduce their anxiety? Do I summarise plans, next steps and
reassure the patient?
Do I reflect post clinic visit?

Question 47

what alternative therapies are there for UI

Answer 47

 Hypnotherapy reported to have had 86% subjective and 50% objective cure rate (Freeman and Baxby 1982) High relapse rate
 Acupuncture 76% Phillip et al 1988 lack of controlled trials due to difficulty in creating a placebo effect.
 Only one RCT published that stated women receiving 4 weekly bladder specific acupuncture treatments had significant improvement in bladder capacity, urgency, frequency and qol compared with placebo (2005)
 TENS sites include thigh and abdomen no RCT but subjective improvement (1998)
 Post tibial nerve stimulation near medial malleus 10-12 weeks duration 30 mins session reported 67-81%
 Recent study on refractory OAB treated for 10 weeks reported complete resolution of symptoms 54% with significant improvement in urgency and quality of life measures effect maintained up till 1yr in 23%
 But more studies required poor evidence for above