Lesson 4+5: Assessment + Management Of Urinary Incontinence Flashcards
Patient Interview - Chief Complaint
- Type of problem
— Difficulty emptying?
— Leakage? - Onset, duration, severity
- Past + present management
- Impact on lifestyle
- Goals for treatment
Patient Interview - Lower Urinary Tract Symptoms
Storage symptoms
- Frequency
- Urgency
- Nocturia
Incontinence
- Voiding symptoms
- Hesitancy
- Straining
- Weak stream
- Incomplete emptying
- Post-void dribbling
Post-void symptoms
- Post-void dribbling
Patient Interview - Key Questions
- Do you know when you need to urinate?
- Do you have any problems urinating/emptying your bladder?
- Do you ever leak urine?
— If yes, is there any associated strong urge to void? - What are your goals for treatment?
History - General
- height and weight
- recent weight changes
- alcohol + tobacco use
History - Urology
- recent, recurrent, or severe UTIs
- prostatic issues
- bladder or pelvic surgery
- recent onset sexual dysfunction
History - Gynaecology
- GTPAL
- Menopausal status
- Gynecological procedures
History - Neurology
CNS processes
- CVA
-MS
- TBI
- Parkinson’s
Spinal Cord Processes
- Spinal cord injury
- Spina bifida
- MS
- Lower back injury
History - Endocrine
Diabetic
- Type
- Duration
- Management
- Recent HbA1C
Hypercalcemia
Thyroid disorders
History - GI
- Stool frequency + consistency
- Problems with bowel control
- Any fecal incontinence
History - CVS
- Heart failure
- Use of diuretics
- Peripheral enema
History - Respiratory
Any conditions causing chronic cough
History - Pharmacologic
- all current meds (both Rx and OTC)
- any herbal supplements
History - Cognitive
- Mini-cog test
- MMSE
- Clock drawing test
History - Quality of Life
Use of quantified screening tool
History - Environmental/Functional
- Access to toilet facilities
- Time required to get to toilet
- Time required to prepare to void
- Dexterity + clothing
Focused Physical Exam - Abdominal Exam
- Identify bladder distension or colonic distension
- Inspect for obvious distension
— Localized vs general - Percuss from xiphoid to symphysis
— Evidence of bladder detention? - Percuss along length of colon
— Should be resonant/tympanic
— If dull - suggests full colon - Palpate abdomen
— Note masses, suprapubic tenderness, or palpable stool
Focused Physical Exam - Pelvic Exam
- Inspect perineal structures
— Urethra midline? - Inspect vaginal + urethral mucous
— Atrophic changes? - Inspect for obvious pelvic organ prolapse
— Both at rest and when bearing down - Leakage with cough
— Immediate = stress UI
— Delayed = urge UI - Pelvic muscle strength + function
— Assess muscle strength + function with correct contraction
Scale of Pelvic Muscle Strength
0: no discernible contraction
+1: very weak contraction held <1 second
+2: weak but clearly discernible contraction held for 1-3 seconds
+3: moderately strong contraction held for 4-6 seconds, repeated x3
+4: firm contraction held for 7-9 seconds, repeated 4-5 times
+5: strong contraction held for 10 seconds repeated 4-5 times
Focused Physical Exam - Anorectal Exam
- Routine for men, PRN for women
- Insert gloved finger and insert into anal canal
- Instruct patient to tighten and lift
— Male: assess sphincter muscle strength, duration of contraction, and scrotal lift
— Female: assess for circumferential contraction of sphincter - Assess for retained stool
- If neuro lesion suspected = assess for bulbocavernosus reflex/anal wink
Focused Physical Exam - Sensorimotor
When neurological lesion is a concern
Sensory
- Stroke perineum + inner thighs with cotton applicator and ask pt to identify structures
- Ask patient to identify site of greatest urge to void
— Male: glans or penile shaft
— Female: vaginal opening
Motor
- Gait, sphincter function, ability to fan toes laterally
- Ability to recognize bladder filling + voluntarily contract sphincter
Focused Physical Exam - Perineal Skin Status
- maceration
- dermatitis
- yeast rash
Focused Physical Exam - Urinary Stream
- Screening test for voiding dysfunction
- Have pt void on uroflow machine, listen to stream, or have pt select diagram
- Normal = no difficulty starting + continuous stream until empty
- Intermittent = difficulty starting + intermittent stream
- Poor = prolong + weak urinary stream
Diagnostics - Urinalysis
Rule out infection, hematuria, and glucosuria
- Best if clean catch
Diagnostics - PVR
If any suspected retention
- Feelings of incomplete emptying
- Poor or intermittent stream
Bedside ultrasound or straight catheter post-void
- No absolute cut-off for abnormal findings
- >250 mls = significant
- >350 mls = risk of damage to upper tract
Diagnostics - Bladder Diary
- Maintain for 2-3 days
- Time + volume of voided urine
- Time + estimated volumes of leakage episodes with associated factors
Insights
- Usual diurnal + nocturnal frequency
- Functional bladder capacity
- Frequency, severity, pattern of incontinence
- Type, volume, pattern of fluid instance
Bladder Diary - Stress UI
- Leakage with activity
- No leakage at HS
- No urgency
Bladder Diary - Urge UI
- Frequency
- Urgency
- Small voided volumes
- Nocturia
- Leakage
Bladder Diary - Voiding Dysfunction
- frequency
- urgency
- feelings of incomplete emptying
- urgency
Bladder Diary - Functional UI
- loss of continence
- pt unaware of need to void
Diagnostics - Cystoscopy
- Provides anatomic information
- Indicated for patients with hematuria or s/s of infection
Diagnostics - Urodynamics
Indications
- Neurogenic bladder
- Voiding dysfunction to determine cause
- High pressure chronic retention (HPCR) vs low pressure chronic retention (LPCR)
- Stress incontinence
- Severe pelvic organ prolapse
- To assess bladder compliance
Diagnostics - Uroflowmetry
Pt voids into special commode that graphs urinary system
- Provides peak and mean flow rates
4 patterns
- Normal
- Explosive
- Poor
- Intermittent
Diagnostics - Voiding Cystometrogram
Measures bladder’s ability to stretch/store and contract/empty
- Cystometrogram = storage study
- Pressure flow study = emptying study
Measured via catheter with pressure transducer inserted into bladder and rectum
- Measure bladder and abdo pressures
Insights
- Bladder capacity
- Bladder compliance
- Conscious sensation
- Involuntary bladder contractions
Diagnostics - Pressure Flow Study
- Emptying study
- Calculated bladder contractility and presence/absence of outlet obstruction
- Pt voids on uroflow device with pressure-sensitive catheter in place
Diagnostics - Sphincter Studies
- Measures function of voluntary sphincter
- Via patch or needle electrodes
- Can measure bulbocavernosus reflex
- Measure point at which sphincter function fails
- Determines severity of stress incontinence
Diagnostics - Urethral Pressure Profile
Measures urethral resistance
Hierarchy of Patient Management
1 - correct reversible factors
#2 - if chronic, determine type and develop management plan
#3 - consider need for absorptive products
Absorptive pads with adhesive strip
- For ambulatory patients with low volume leakage
- Varying lengths, designs, and absorbances
For men
- “Drip collectors” that fit over penis
Pant + pad absorptive systems
For ambulatory patients with light to moderate volumes of leakage
- Ie Urge UI
Do not interfere with toileting program
Varying absorbances with waterproof outer layer
Critical to change with wet to protect skin
Adult Brief
- High volume leakage or leakage of urine+stool
- Side tab openings for bedbound
- Pull-up for ambulatory
Petrolatum-Based
- Easy to apply + remove
- Less effective against liquid stool
- May transfer to pads/linens
Zinc-Based
- Good protection against liquid stool
- Difficult to remove
Dimethicone-based
- Easy to apply + remove
- Nonocclusive
- Non-greasy
- Does not protect against liquid stool
Hydrophilic Paste
- Hydrocolloid based
- Use on damaged skin
- Adheres to moist skin
Ostomy Powder
Crust on denuded areas with barrier spray
Cyanoacrylate liquid
Dressing for denuded areas
Avoid use of cleansers/ointments with emollients
