Geri-Finals - Urinary Incontinence

Question 1

Aging changes in the bladder

Answer 1

– Increase the risk of incontinence—but do not cause it
– Review normal physiology of urinary excretion
– Changes that may increase risk
– Renal tubules less efficient in conserving water and sodium in response to hypo-osmolality and salt restriction
(so what is the effect on the urine of a healthy older person? – INFECTION !!

Question 2

Aging changes in the bladder

Causes:

• • Urinary Incontinence
• • Urinarystasis

Answer 2

• • Hypertrophy of bladder muscle (detrusor muscle) and thickening of bladder wall interfere with the bladder’s ability to expand, and the amount of urine that can be stored diminishes from 350-400 mL to 200-300 mL – REASON ELDERLY HAVE LOWER THRESHOLD
• • Connective tissue replaces some of the smooth MUSCLE in bladder and urethra (esp to elderly who had pregnant several times)—impacts ability to expand without increasing pressure
• • Loss of smooth muscle in urethra and relaxation of pelvic floor muscles reduce urethral resistance

Question 3

Pathologic risks

Answer 3

• • Weakening of pelvic floor muscles secondary to estrogen depletion or pregnancy—any increase in abdominal pressure may cause involuntary expulsion of urine; may also cause incomplete emptying of bladder with risk for bacteriuria
• • Cystocele, rectocele, or urethrocele may develop because of extreme pelvic muscle stretching or relaxation—often occur with uterovaginal prolapse (outpouching of the uterine)

Question 4

Pathologic risks

Benign prostatic hyperplasia (BPH)
– the most common cause of voiding problem in males

Answer 4

Benign prostatic hyperplasia (BPH)

• • a common cause of voiding problems; prostatic carcinoma a less common cause
• • Enlarged prostate obstructs vesical neck and compresses urethra
• • Eventually bladder wall thins and loses elasticity
• • Urinary retention occurs with risk for bacteriuria
• • Nocturia, decreased flow, incomplete emptying (can lead to renal failure), urgency and frequency

Question 5

Causes Incontinence

Answer 5

Dementia—complex relationship—functional declines
GI conditions—gastroenteritis, constipation, fecal impaction
Diabetes, alcoholism, multiple sclerosis, Parkinson’s disease, CVA, COPD
Delirium

Question 6

Medications for Urinary Incontinence

Urge incontinence: drugs with anticholinergic action;
– oxybutynin (Ditropan), tolterodine (Detrol), propantheline (Pro-banthine), others
Stress incontinence: Alpha-adrenergic agonists:
– phenylpropanolamine
Overflow: anti-adrenergic agonists:
– doxazosin (Cardura), terazosin (Hytrin), tamsulosin (Flomax), cholinergic bethanecol (Urecholine)

Answer 6

• Central or autonomic nervous system medications:
• Anticholinergics – used for urgency incontinence
• Alpha adrenergic blockers – increase urethral resistance
• Adrenergics –
• Ca channel blockers – ALSO relaxes the smooth muscle in the bladder

** Sedatives to give at night to induce sleep is not a good idea == it increases UI and Fall (going to the bathroom groggy)

Question 7

Environmental factors

Answer 7

FUNCTIONAL INCONTINENCE:

• • Obstacles to reaching and using toilet
• • Caregiver lazy attitude- “diapering”, delay in assistance

Question 8

Types of Incontinence

1) TRANSIENT Incontinence
→ Once issue is resolved, patient will be continent again

2) Chronic Incontinence

Answer 8

1) TRANSIENT Incontinence (Acute/Temporary):
- - Dehydration, delirium, diapers
- - Restricted mobility
- - Impaction, infection, inflammation (atrophic vaginitis)
- - Pharmaceutics, pyuria, psychological problem
* * Once issue is resolved, patient will be continent again

2) Chronic Incontinence:
- - Stress—leakage when intra-abdominal pressure increased
- - Urge—leakage when the urge to void is sensed but cannot be controlled in time
- - Overflow—decreased ability of detrusor muscle to contract
- - Functional—limitation of ability to reach toilet

Question 9

Urinary Incontinence

– Interventions

Answer 9

• Assessment
  —history, voiding diary, medications,
  – urinalysis (check colonies of bacteria),
  – POST-VOID RESIDUAL (PCP might say after the patient voided, check the residual from the bladder scan and then straight cath the patient)
• Positive attitude
• Toilet accessibility
• Protective undergarments

Question 10

Urinary Incontinence
– Interventions

• Behavioral Techniques

Answer 10

— Scheduled toileting—fixed schedule (caregiver directed)
Habit training—frequent checks and reminders (caregiver directed)
— Bladder retraining (patient directed)—lengthening of intervals between voidings: use distraction, pelvic floor exercises, breathing techniques, Crede’s maneuver
— Kegel exercises
— Biofeedback

Question 11

Urinary Incontinence
– Interventions

• Surgery

Answer 11

— Bladder suspension surgery or sling procedures for stress incontinence
— Implantation of an artificial urinary sphincter
— Minimally invasive procedures such as periurethral injections of collagen for stress incontinence
— Surgical insertion of a meshlike tape through vagina for support

Question 12

Methods that pose Problems

Answer 12

Fluid restriction

Indwelling catheter

Diaper