Continence (Part 2) Flashcards
What does assessment of continence include?
- Clinical history (nature of problem, duration/severity of symptoms)
- Medical and surgical history
- Exacerbating factors
- Functional and mental status
- Impact of symptoms on QOL
Which HPs are in the management team for incontinence?
- G.P.
- Geriatrician, Urologist, Urogynaecologist
- Continence nurse
- Physiotherapist
- Occupational therapist
- Social worker
- Dietician
What are the barriers to seeking help for incontinence?
- Embarrassment
- Social stigma
- Inevitable, untreatable, normal part of ageing
- Language, level of education and cultural factors
- Lack of bathroom privacy
- Inadequate identification & assessment by HPs
What are general management options for incontinence?
- Empathy (supportive role of staff)
- Improving environment (appropriate chair, rails in toilets, adequate lighting)
- Promotion of good bladder habits
What are the 4 steps of good bladder habits?
- Fluid intake
- Good bowel habits
- PF muscle exercises
- Good toilet habits
What are the guidelines for fluid intake?
- 1.5-2L per day
- Limit caffeine & alcohol
- Output 1-1.5L per day
What are good bowel habits?
- Avoid constipation
- Don’t ‘strain at stool’
- Positions for defecation
How can PF exercises be made functional?
- Ok to teach in lying but most don’t leak when in bed
- Task orientated & functional
- Specific to patient’s problem
- Involved in ADLs
- May need triggers as reminders
What are good toilet habits?
- No “just in case” toileting
- Taking time to completely empty bladder
Why should “just in case” toileting be avoided?
Increased frequency»_space; reduced stretching of bladder»_space; decreased capacity»_space; increased frequency
What are the aims of bladder training?
- Decrease frequency
- Increase urine quantity
- Defer urge
- Improve lifestyle
What does bladder training include?
- Practise PFM exercises
- Defer the urge
- Start at home
- Keep a bladder diary
- Seek help re medication
What should be avoided during bladder training?
- Decrease fluid intake
- Just in case toilet
- Wear pads
- Drink caffeine and alcohol
- Get stressed
What are the deferment strategies?
- Contract PF muscles
- Apply pressure to perineum (hold on, drop hip, corner of chair, roll towel, crossed thighs)
- Distract mind/relax
How should deferment strategies be implemented?
- Initially defer for 5 mins
- Gradually increase time
- Do not empty without urge
What are the physio interventions for incontinence?
- PF muscle exercises
- LL strength training
- Upper limb function (buttons, zips)
- Appropriate aids
What are the continence strategies for RAC?
- Mobility
- Prompted voiding
- Regular toileting
- Use of continence service
What is the aim of pharmacology in managing incontinence?
- Increase bladder emptying & storage
- Increase/decrease outlet resistance
What is anal incontinence?
Involuntary loss of flatus, (liquid or solid) stool that is a social or hygienic problem Can occur as a result of: - constipation - neurological damage - loss of sphincter control or - laxative abuse
What are the risk factors for constipation?
- Polypharmacy
- Anticholinergic drugs
- Opiates
- Iron supplements
- Calcium channel antagonists
- NSAIDs
- Immobility
- Institutionalisation
- PD
- Diabetes mellitus
- Low fluid intake
- Low dietary fibre
- Dementia
- Depression
What co-morbidities are related to faecal incontinence?
- Dementia
- CVA
- Diabetes mellitus with neuropathy
- Sacral cord dysfunction
What are the causes of FI?
- Functional FI
- Anorectal incontinence: IAS, EAS dysfunction, prolapse
- Loose stools / diarrhoea
- Excessive laxative use
- Rectal/colonic disease
What are the causes of diarrhoea?
- Stimulant laxatives
- Bowel/stomach infection
- Bowel disease
- Drug interactions
- Shortened bowel
- Food intolerance
- Radiotherapy
- Alcohol
What does diarrhoea management include?
- GP/specialist review may be necessary
- ?avoid insoluble fibres
- ?increase intake of soluble fibres
- ?increase fluid intake
- ?drug therapy
- Reduce alcohol, caffeine & smoking
What does management of constipation include?
- Firstly relieve the constipation, then revise the management
- Dietary: Fibre intake
- Fluids: 1.5-2 L non-irritative drinks
- Laxatives/Aperients
- Activity/Exercise
- Aids and appliances
- Environment (accessibility of toilet)
What are the signs & symptoms of urinary tract infections?
Signs:
- Increased body temperature
- +ve urine microbial culture with large number of pus cells
- Voiding dysfunction
Symptoms:
- Confusion, febrile, smelly urine
- Frequency/urgency
- Stinging
What is the treatment for UTI?
- Antibiotics
- Decrease pelvic floor & anterior urethral colonisation
- Personal hygiene (washing perineum, underwear etc)
What are the principles of catheter use?
- Relieve and manage urinary dysfunction
- Recognise & minimize risks of secondary complications
- Promote dignity and comfort
- Assist clients to reach self care & independence
What are the types of catheters?
- Suprapubic catheter (SPC)
- Indwelling catheter (IDC)
- Intermittent self catheterization (CISC or ISC)
What are the precautions for catheter use?
- Ensure urine is always allowed to flow freely
- No kinks in the tubing
- Urine bag must be kept below the level of the bladder
- Catheter secured with a leg strap to prevent being pulled out
What is the function of the PF?
- Pelvic organ support
- Additional occlusive force to external urethral sphincter
- Maintain anorectal angle
- Rectal support during defecation
- Bladder inhibition
- Sexual function
What factors contribute to PF dysfunction?
- Type of connective tissue
- Pregnancy, labour, delivery
- Menopause, ageing
- Medication
- Lifestyle
- Stretching of support structures
- Perineal trauma
- Urinary retention
- Postnatal care of perineum
What is pelvic organ prolapse (POP)?
Descent of pelvic organs towards the introitus
associated with vaginal wall & pelvic ligament weakness
What are the causes of POP?
- Stretched pelvic fascia & ligaments following very fast or very long 2nd stages
- Many large babies
- Patients with “cervix on view” at delivery are at higher risk of future prolapse
- Constipation and chronic cough
- Heavy lifting
- Chronic LBP with weak TA
What is the treatment for prolapse?
- Strengthen lower abs & PF
- Address constipation and respiratory disease
- Modify lifestyle
These measures will not cure vaginal wall
prolapse but may prevent further descent and will give surgery a better long-term outcome
What is chronic pelvic pain?
- Chronic or recurrent pelvic pain that apparently has a gynaecological origin but for which no definitive or cause is found
- Perceived in structures related to the pelvis
- Pain associated with symptoms of LUT, sexual, bowel or gynaecological dysfunction
What should the assessment of PFM include?
- Visual inspection
- Observation
- Sensation and neural
- Palpation external/internal
- PFM contractile activity
- Spasm
- Relaxation
What is the pain behaviour chronic pelvic pain?
- May have mechanical component
- Aggravated by stress
- Not necessarily associated with spinal dysfunction
- If spinal dysfunction present, may interact with myofascial dysfunction
- Visceral symptoms may be present (diarrhoea, constipation, period pain)
What are the treatments for chronic pelvic pain & PF dysfunction?
- Lifestyle interventions
- Exercises
- Down training
- Manual therapy (Myofacial and trigger points)
- Biofeedback and electrical stims
- Dilators
