lecture 12: urinary incontenence

Question 1

define urinary incontinence (UI)

Answer 1

• urinary incontinence is not a normal change with aging

- it results from some age related changes, genitourinary pathology, comorbid conditions, and environmental obstacles

Question 2

DRIPP

Answer 2

• reversible causes
  D = delirium
  R = restricted mobility
  I = infection, inflammation, impaction of stool
  P = polyruia secondary to d.m., caffeien, volume overload
  P = pharmaceuticals (diuretics, atuonomic agents, psychiatric drugs)

Question 3

Urge incontinence

Answer 3

• patients experience sudden strong urge to urinate
• this happens at frequent intervals
• the DETRUSOR muscle responds to small urinary volumes with contraction
• URINE IS CLEAR
• Post void residual to usually less than 50ccs

Question 4

treatment of urge incontinence

Answer 4

• Tx = kiegel exercises and bladder relaxation
• common meds = ditropan and detrol (anticholinergics)
• -> meds can cause constipation, dry mouth, and can affect CNS

Question 5

Stress incontinence

Answer 5

• patients lose urine when intraabdominal pressure increases as with coughing, laughing, or lifting
• this represents failure of sphincter mechanisms to remain closed during bladder filling
• often due to insufficient pelvic support in women and secondary to trauma from prostate surgery in men

Question 6

tx for stress incontinence

Answer 6

• kiegel exercises and alpha blockage with agents like sudafed

Question 7

overflow incontinence

Answer 7

• caused by outflow obstruction or impaired detrusor contractility
  (volume builds up until gush of urine)
• causes of impaired contractility = B12 deficiency, diabetes, tabes dorsalis, alcoholism, spinal diseases
• outlet obstruction: prostatic hypertrophy, urethral stricture, neoplasia, constipation, large cystocele

Question 8

mixed UI

Answer 8

• combined urge and stress incontinence is very common in older women

Question 9

functional UI

Answer 9

• this is caused by an inability or unwillingness to toilet because of physical, cognitive, psychological, or environmental factors

Question 10

Other more unusual causes

Answer 10

• bladder-sphincter dyssynergia (neurological/spinal cord injury), fistulas, reduced detrusor compliance, and recurrent cystitis

Question 11

evaluation

Answer 11

• history and physical exam
• precipitant urgency suggest detrusor overactivity
• Loss of urine wiht cough or strain suggests stress ui
• continuous leakage suggests sphincter weakness or overflow
• On physical exam, note functional status, mental status, orthostatic bp and heart rate along with bladder distention and impaction
• neuro exam looking for signs of cord compression like muscle wasting, hoffman, babinksi signs
• Sacral root integrity is reflexed by RECTAL TONE and PERINEAL SENSATION

Question 12

voiding record

Answer 12

• it can be useful for the patient to keep track of episodes of incontinence, voiding patterns, and associated factors

Question 13

standing full bladder test

Answer 13

• relaxing followed by coughing with resultant loss of urine strongly suggests stress UI

Question 14

Post void residual

Answer 14

have patient empty bladder and then meausre urine volumen left in the bladder by cath or scan
- normal is less than 50 ccs

Question 15

management

Answer 15

• consider non-pharmacologic therapies
• decrease caffeine, etoh, and evening fluid
• for detrusor instability, instruct on relaxation techniques and kiegel exercises. also timed toileting with gradually increasing intervals can be helpful

Question 16

Management for stress incontinence

Answer 16

• kiegel exercises, biofeedback, PT therapy

Question 17

Pharmacologic management

Answer 17

• estrogen replacement may benefit womenw ith either stress UI or urge UI
• alpha stimulation with blockage with sudafed may help with stess ui by increasing the tone of the external urethral sphincter
• anticholinergice therapy may help with urge incontincene

Question 18

surgical therapy

Answer 18

• may benefit some women with stress incontinence who have failed the previous mentioned therapies

Question 19

Catheter care

Answer 19

• use ONLY for CHRONIC urinary retention, to allow skin healing, and when requested by patients and family for comfort
• used closed system only, aoid topical or systemic antibiotics or catheters treated with antibiotics
• SILVER alloy hydrogel catheters reduce UTI
• Consider catheter sling

Question 20

catheter care (bacteria)

Answer 20

• Bacteriuria is universal: terat only if symptoms are present: fever, dysuria, anorexia or delirium
• replace catheter to get culture
• nursing home patients with catheters should be in private rooms
• for acute retention, place catheter for seven to ten days, then remove
• change about each 6 to 8 weeks
• for recurrent blockage, increase fluids and consider dilute acetic acid irrigation