Urinary Incontinence Flashcards
1
Q
UI and OAB: Age
A
+ w/ age
Relaxation of pelvic floor = prolapse female pelvic organs
Stress incontinence age 45 - 54
UI age 35 - 64
2
Q
UI and OAB: Race
A
White = shorter urethra, weak pelvic floor muscle, lower bladder neck
3
Q
UI and OAB: Pregnancy/childbirth
A
Perineal trauma = partially reversible pudendal/pelvic nerve damage
Vag delivery = relaxation/lengthening of pelvic floor muscle
4
Q
UI and OAB: Menopause/estrogen depletion
A
- estrogen = - urethral mucosa vascularity/thickness
Estrogen receptors in urethra, bladder, pelvic floor muscle - ability to maintain seal
5
Q
UI and OAB: Pelvic/prostate surgery
A
40% UI increase w/ uterus removal
Loss of structural support, urethral scarring, pelvic nerve disruption
6
Q
UI and OAB: Smoking
A
Nicotine contracts bladder
Coughing = pressure + on bladder/urethra, damage to urethral/vag support, perineal nerve damage
7
Q
UI and OAB: Obesity
A
+ pressure on bladder
+ urethral mobility
Impairs blood flow and innervation to bladder
8
Q
UI and OAB: High-impact activities
A
Inadequate ABD pressure, pelvic floor muscle fatigue, connective tissue/collagen changes to pelvic floor muscles
Jumping, landings, dismounts
9
Q
UI and OAB: Medications
A
Diuretics impacts bladder filling/emptying
Anticholinergics: retention, impaction
Antidepressants: retention, impaction, sedation
CNS depressants: muscle relaxation, immobility, delerium
Narcotics: retention, fecal impaction, sedation, delerium
10
Q
Voiding diary
A
Keep for 3-day period # voids, time interval, fluid intake, urine volume, incontinence episodes, associated activities
11
Q
UI: Neurological exam
A
Lower extremities and perineum
Normal/equal strength
Deep tendon reflexes assess lumbosacral spinal cord
Sharp/dull sensation around thighs = lower micturition center intact
Anal wink
12
Q
UI: gynecologic exam
A
- estrogen = cherry red urethra/pale, smooth dry vag mucosa
Infection = afferent sensation of urethra = freq, urgency, dysuria
Cystocele, rectocele, enterocele, prolapse
Assess muscle for strength/endurance
Use of accessory muscles
Spasm
13
Q
Postvoid Residual (PVR)
A
-50mL = normal
+ due to infection, mechanical obstruction, neuro factors
14
Q
Pelvic floor muscle rehab
A
Kegel
Ideal for pt w/ stress incontinence
Weighted vag cones for proprioreceptive biofeedback
15
Q
Urge/Overactive Bladder
A
Involuntary bladder contractions = bladder pressure exceeds urethral pressure
Unstable bladder or detrusor instability 2nd to CNS disorder
16
Q
Overflow Incontinence
A
Hypotonic or acontractile detrusor, urethral obstruction
2nd to diabetic bladder, neuropathy, SCI
sx: palpable bladder, + PVR, interrupted urinary flow, continual leakage
17
Q
Dietary modifications for Urinary Continence
A
Alcohol Citrus Spices Carbonation Sugar Honey Milk Corn syrup Tea Coffee (even decaf) Artificial sweetener
18
Q
Goals for controlled voiding
A
- bladder spasm and exposure to irritants
- sphincter function and coaptation
- pelvic floor muscle support/function
- bladder outlet obstruction
- bladder tone/contractility
- Modify environment
- Facilitate complete voiding
19
Q
- bladder spasm and irritants: UTI
A
Dip-stick check of clean catch urine
Bacteria or WBC = double check for accuracy
Epithelial cells = specimen contamination
+ result = urine culture and antibiotics
Consult for bladder cancer rule out
20
Q
- bladder spasm and irritants: Fluid
A
Concentrated urine = urgency, freq, urge incontinence
- fluid = + UTI risk
Maintain bladder capacity to prevent deconditioning
21
Q
- bladder spasm and irritants: Urge
A
Urge Suppression
- Stop and stand
- Squeeze/relax pelvic muscles 5x
- Concentrate on urge suppression
- Distraction
- Allow urge to dissipate
- Urinate when bladder calm
22
Q
- bladder spasm and irritants: Bladder retraining
A
Treats urgency and frequency
Best for mild/moderate urge, stress/mixed incontinence
Strengthens brain’s control over urinary tract
Void on schedule
Clean/compliant rectum needed
Keep treatment log to record each void
23
Q
- sphincter function/coaptation: Bowel Management
A
Constipation = pressure on urethra = urine obstruction
24
Q
- bladder spasm and irritants: Meds
A
Not 1st line
Anticholinergics/Antimuscarinics/Beta-3 Adrenergic Agonits
I. Tolterodine (Detrol)
II. Oxybutynin (Ditropan)
III. (Sanctura, Vesicare, Enablex, Toviaz)
IV. Mirabegron (Myrbetriq)
25
2. + sphincter function/coaptation: Bulking Injections
Nonimmunogenic, hypoallergenic agent injected into periurethral space
+ urethral resistance by creating cushions to - lumen size
Product degrades w/i 2 yrs
26
2. + sphincter function/coaptation: Meds
- meds that relax bladder neck (alpha adrenergic antagonists)
+ meds that tighten bladder neck (alpha adrenergic agonists): estrogen, tricyclics, Duloxetine
27
2. + sphincter function/coaptation: Occlusion
Female: tampon-like w/ balloon, inserted in urethra
Male: Compress soft penile tissue (clamp/cuff), caution for ischemia, remove Q3hr
28
3. + pelvic floor muscle support/function: PME
Pelvic Muscle Exercise for stress, urge, mixed UI
Assess sensation (vag, perineal, rectal), anal wink
Assess vag mucosa
Assess resting tone of bag and rectum
Strength of contraction
Educate pt on IDing pelvic floor muscles
Goal: 10 second contract/relax phase (6-12 wks to accomplish)
29
3. + pelvic floor muscle support/function: Electrical Stimulation
Pts w/ stress/urge/mixed UI or freq, painful bladder
Electrodes stimulate afferent pudendal nerve fibers = reflex
Contraction of smooth and striated muscles in urethra and pelvic floor, reflex inhibition of detrusor
Must have intact sacral autonomic/somatic nerve pathways
High freq (50-100Hz) for stress incontinence, stimulate fast-twitch/slow-twitch fibers
Low freq (10-20Hz) for urge incontinence/OAB = reflex inhibition
30
3. + pelvic floor muscle support/function: PTNS
Posterior Tibial Nerve Stimulation
For urge incontinence or OAB if failed 2 trial meds
Stainless steel needle inserted 5cm above medial malleolus
Electrical impulse for 30 min/week to 12 weeks
Calms detrusor instability
May be done for 2 years
31
3. + pelvic floor muscle support/function: Vag cones
Assist to strengthen pelvic muscle
| Attempt to retain weight for 15 min while walking
32
3. + pelvic floor muscle support/function: KNACK
Purposeful voluntary contraction of pelvic muscles PRIOR to + abd presure (cough, sneeze, lifting)
Teach sustained contraction during routine activities
33
3. + pelvic floor muscle support/function: Magnetic
Extracorporeal Magnetic Innervation Therapy
Pelvic floor strengthening
Magnet activated = induces electrical depolarization of nerves/muscles in magnetic field
Strong contraction of pelvic muscles
Non-invasive
Pt sits on chair, fully clothed
2x/week for 6 weeks
34
3. + pelvic floor muscle support/function: Surgery
Repair of prolapse
Prerequisite: urodynamic testing to confirm urethral hypermobility present and UI not due to Type III SUI
Type II/III SUI: surgery only once less invasive interventions used
All procedures to - SUI must + urethral resistance
35
Surgery: Retropubic suspension
Marshall Marchetti Krantz
| Elevate lower urinary tract (especially urethrovesical junction)
36
Surgery: Needle Bladder Neck Suspension
Stamey or Raz procedure
| Tissue adjacent to urethral and bladder neck supported w/ sutures
37
Surgery: Anterior Vag Repair
Not used for SUI alone
Dissect anterior vag wall from bladder base and urethra , secure to pubocervical fascia
+ complication rate
Also used to repair cyctocele
38
Surgery: Sling Procedure
1st line w/ intrinsic sphincter deficiency AND hyper mobility
Strips of autologous fascia or synthetic material placed under urethra and anchored to retropubic or and structures to elevate urethra
Abdominal or bag approach or combination
TVT (tension-free vagina) preferred method 2nd - complications (transient retention, bladder perforation)
39
4. - bladder outlet obstruction: Pessaries
Non-surgical management of prolapse or SUI
| Self-clean or clinic removal monthly
40
4. - bladder outlet obstruction: Meds
- urethral resistance (alpha adrenergic antagonist) used for BPH, incomplete emptying, detrusor sphincter dyssynergia, or prevent autonomic dysreflexia
41
5. + bladder tone/contractility: Meds
Alpha adrenergic agonist (sudafed) + smooth muscle tone
Use in SUI
Side effects limit use
42
7. Facilitate complete voiding: Toileting Programs
Pts physically/cognitively impaired = dependent continence
| Voiding set at fixed times or voiding patterns and ability to participate
43
Habit Training/Individualized Scheduled Toileting (IST)
```
Pt w/ moderate cognitive impairment but cooperative
Modified voiding diary kept for 3 days
Pt checked Q1-2 hrs, record wet or dry
Track incontinent episodes
Fluid management
Maintain stable voiding pattern
```
44
Routine Scheduled Training (RST)
```
Timed/habit voiding
Toileting on fixed schedule
Pt cognitively impaired, unable to ID need to void, lacks motivation
Common at long-term care facilities
Useful when staffing limited
```
45
Prompted Voiding
Pt w/ mild/moderate cognitive impairment, able to follow directions, recognizes urge to void
Must be safe to transfer w/ 1 person
Goals: 1. + ability to respond to urge
2. + self-initiating toileting
Pt will relearn appropriate response to full bladder
ID pts normal voiding pattern and prompt voiding
Desired behavior praised
Undesired behavior not reinforced
46
Double Voiding
Mild cases of retention and overflow
Pt voids and rests while on toilet, 2nd void after 1-2 min
Pt has diabetes or MS w/ large post-void residual
47
Clean Intermittent Cath (CIC)
Maintain cath volumes at 400cc
If pt voids incompletely, cath at bedtime
If 0 voiding, cath 4-6x/day
Reuse cath for 7-10 days
Wash cath w/ soap while wash hands for 10 sec
Airdry cath on paper towel
Store in plastic bag
48
Indwelling Cath
Broad spectrum antibiotics given prior to insertion
Instill male w/ 10mL anesthetic 3-5 min prior
Large 18 Fr cath in males
Monitor for vasovagal response (sweat, pallor)
All indwelling caths 100% colonized by 30 days
49
Urinary Diversion or Bladder Augmentation
Pts w/ reflex incontinence and neurogenic bladder
Preserve upper tract (kidneys)
Neuro bladder = risk for upper urinary tract distress and kidney damage
50
Bladder Augmentation
Dome of bladder split and detubularized bowel segment anastomosed like patch over opening
Interrupts spastic detrusor contractions
- risk of reflux
51
Urinary Diversion
Continent or incontinent
Continent if bladder removed and new bladder created
Incontinent = ileal or sigmoid conduit
52
Artificial Urinary Sphincter
Small balloon reservoir for fluid, small pump, inflatable cuff
Cuff fits around bladder neck to act as sphincter
Pump used to deflate cuff to void
Pump placed in scrotum or labia
Postop problems: infection, erosion, mechanical malfunction
Common in males post prostatectomy
53
Attaining Bladder Continence
Infancy - 1y: 20 voids/day
| 2-3 yrs: aware on need to void and briefly delay
54
Bladder Control Development
Capacity (up to 12 yrs: capacity in ounces = age + 2)
Muscle control: By age 3
Micturition reflex control: initiate or inhibit bladder contraction
55
Posterior Urethral Valves
Abnormal membrane w/i male posterior urethra = obstruction
56
Main Causes of UI in children
Congenital abnormalities
Abnormal neurologic pathways
Developmental issues (functional incontinence)
57
Prune Belly System
0 abd musculature
Expanded bladder
Upper tract issues
Incomplete emptying = bladder, kidney, ureter impairment
58
Bladder Exstrophy
Failure of bladder wall to close
Bladder externalized
Seen w. pelvic diastasis (widening/separation)
Penis shortened w/ 0 urethral meatus
59
Non-neurogenic Functional Incontinence in Peds
```
Daytime incontinence, poor stream, encopresis, UTI
0 neurologic impairment
Urodynamics to determine pattern:
Small capacity hypertonic bladder
Detrusor hyperreflexia
Lazy Bladder Syndrome
Hinman Syndrome
```
60
Abnormal Neuro Pathways is Peds
Spinal cord trauma
| Neural tube defects (myelomeningocele, Sacral agenesis)
61
Nocturnal Enuresis
```
Primary - Nocturnal bedwetting in kid never dry at night
Secondary - Wet after dry for 6mo
More common in boys
Daytime more common in girls
More common if parents suffered
More common in poor, large families
2nd to maturational lag
```
62
Small Capacity Hypertonic Bladder
Bladder wall inflamed w/ sensory threshold altered = sense full bladder at - volume
Delay void 2nd to pain or inappropriate setting
Unstable contractions at low volume
Prolonged contraction of sphincter = outlet obstruction and incomplete emptying
63
Detrusor Hyperreflexia
Freq, urgency, sudden incontinence, nocturnal enuresis
Unstable detrusor contractions = pelvic floor/sphincter contractions
Leakage, incomplete emptying 2nd to bladder contracting against closed sphincter
Risk for dilation of ureters and recurrent UTIs
64
Lazy Bladder Syndrome
Infreq voiding (2x/day) 2nd to aversion to public WC or episode of dysuria
Incomplete voiding
Strain and + and pressure to void
Detrusor contractions min or 0
Large compliant bladder w/ large PVR and freq UTI
Chronic constipation or encopresis
65
Himan Syndrome
AKA non-neurogenic bladder
All features of neurogenic bladder but 0 lesion
Most severe of dysfunctional voiding disorders
Dyssynergic bladder-sphincter activity
Elevated PVRs, UTIs, vesicoureteral reflux and upper tract damage
66
Neurogenic Bladder
Lesion at any level of nervous system
Lack of coordination btwn detrusor contraction and sphincter relaxation (dyssynergia)
UTI (2nd bladder spasms)
Upper tract deterioration (2nd to reflux and functional outlet obstruction)
Preserve upper tract (Intermittent cath, oxybutin, bladder augmentation, artificial urinary sphincter)
67
Dysfunctional Voiding in Peds
Lacks awareness of bladder filling/need to void
Urgency, incontinence
- sensation of fullness
Dysfunctional voiding postures (squeeze penis, fingers against urethra w/ heel against perineum, kneeling)
Constipation
- or + voiding, UTIs
68
Dysfunctional Voiding Assessment in Peds
UA and urine culture
BUN and creatinine tests
0 urodynamic studies unless SCI, neural tube defects, congenital abnormalities, freq UTI
69
UTIs in Peds
Fever w/o cause or recurrent abd pain
+ treatment 2nd to risk for renal scarring/hydronephrosis
Urine specimen and culture w/ suspected UTI
Reculture 3 days post-antibiotic start, after antibiotics finished, 1 month after antibiotics finished
70
Red Flags in Peds History and Exam
Masses (retained stool/bladder distention)
+ daytime incontinence
Spinal anomalies
Abnormal neuro findings (- reflexes/sensation, altered gait)
- urinary stream
UTI
71
UTI Risk Factors in Peds
```
Vesicoureteral reflux (VUR)
Urinary tract obstruction (stones, strictures, PUV)
Renal malformation (polycystic kidney disease, dysplasia)
Non-circumcised
Defer urination/defecation
Poor hygiene
Catheterization
Pinworms
```
72
Voiding Cystourethrogram (VCUG)
```
Kids - 16 yrs w:
UTI
Male
Girls +5yrs w/ pyelonephritis
Recurrent UTI
Unresponsive to antibiotics
```
73
Management of Enuresis: Environ/Behavior Modifications
```
Self-awakening at night
Enuresis alarms (for 3-4 mo in kids 8+ yrs)
Counseling responsibility
Reward system
Urge inhibition and bladder retraining
```
74
Enuresis Meds: Imipramine
+ bladder capacity/control if behavioral interventions insufficient
Anticholinergic to relax bladder
Adrenergic to strengthen sphincters
Monitor serum levels - lethal at low doses
75
Enuresis Meds: Desmopressin accetate (DDAVP)
- nocturnal urine production by + H2O reabsorption and urine concentration in distal tubules
Nasal spray or PO
Rare adverse effects: epistaxis, nostril pain, nasal congestion, headache, water intoxication, seizures
Check electrolytes after 1st week of treatment
76
Stress, Urge, Mixed UI
80-90% all UI cases
Typically respond to 1st line treatment
0 threat to upper tract damage (hydronephrosis)
77
Q-Tip Test
ID urethral hypermobility (causative factor in SUI)
Sterile q-tip placed 2cm into urethra
Pt bears down/valsalva
Upward movement +30 = + test = bladder neck movement
78
Cough Test (Provocative Maneuvers)
Reproduce symptoms or leakage w/ exertion
Have pt cough and observe for leakage
If 0, repeat after pelvic exam
If loss delayed or large = overactive or urge UI
79
Pad Testing/Paper Towel Test
Pad: Weigh pt pad after exertion
Paper Towel: Hold towel against perineum while coughing, repeat test w/ contraction of pelvic muscles before coughing, compare wet spot size, smaller = need for pelvic muscle re-education
80
Phimosis
Difficulty retracting or restoring foreskin
81
Urine Analysis
```
Blood
Glucose
WBC
Protein
RBC
Nitrates for bacteria
Urine culture if WBCs or bacteria present
```
82
Post-Void Residual
Deliniate btwn overflow UI and OAB/urge UI
Pt w/ difficulty voiding, neuro problems
Obtain w/i 5 min of voiding
Normal = -50cc
Repeat = 100 - 200cc
Investigate = +250
PVRs +25% of total capacity = need for evaluation
83
Stress Urinary Incontinence (SUI)
Leakage w/ activity not associated w/ urgency
Immediate leakage w/ coughing
Positive pad test
Variable contractility and endurance of pelvic muscles
Vaginal deliveries
Hysterectomy
Pelvic surgery
84
OAB/Urge UI
Urgency, frequency, nocturia
Small void volumes
Urgency/leakage 2nd to stimuli (running H2O)
85
Blood Tests
BUN and Creatinine for renal function
Pt w/ +150cc PVR or w/ cystocele
Pt w/ upper urinary tract involvement
86
Ultrasonography
Evaluates hydronephrosis, renal masses, filling defects
| Displays image for eval of GU tract
87
Plain Film of Kidneys, Ureters, Bladder (KUB)
Evaluates soft tissue, skeletal structures, calculi, calcification
88
Intravenous Pyelography (IVP)
IV administration of contrast dye
Reveals kidneys, ureters, bladder abnormalities
Localizes renal masses, hydronephrosis
89
Cystoscopy
Evaluation of bladder via scope
Use for pain w/ filling, hypermobility w/ straining, urinary obstruction, total incontinence 2nd to open proximal urethra
Required for pt w/ hematuria or RBC on UA
Rule out bladder or urethral pathology
90
Radiography (VCUG) Voiding Cystourethrography
Info re anatomy of bladder, antegrade voiding, integrity of ureterovesical valve mechanism
Bladder filled w/ radiographic contrast while pt stands, strains, coughs, voids
Info re reflux into ureters, urethra diverticula
Will demonstrate PVR and anatomical changes
Bladder neck opens w/ contraction, may look like contraction = need cath placed during study
VCUG + measurement of bladder pressure = video urodynamic
91
Urodynamics
Tests evaluating bladder filling/storage and elimination
Must be done prior to surgery for SUI (IDs cause)
If conservative treatment fails
Voiding issues: blockage, +PVR
For pt w/ any neuro disease
92
Simple Urodynamics
Observation of voiding: hesitancy, straining, - stream
| Listen as pt voids
93
Bedside Cystometrogram (CMG)
Crude type of CMG
Detects bladder capacity/involuntary detrusor contractions
1. Indwelling cath placed
2. Toomey syringe placed on end of cath and held above symphysis pubis
3. Bladder slowly filled w/ sterile H2O
4. Monitor for fluid level - should remain consistent w/ filling
Rise in fluid level of syringe = low bladder wall compliance
Pt reports urge to void
Dramatic rise in syringe = bladder or detrusor contraction
94
Overflow Urodynamics
Invasive test
Measures flow rate while pt voids into uroflow device
Assess bladder capacity, quality of stream, intermittency
95
Cystogram (CMG)
Assess bladder/urethral anatomy
Localizes where leakage occurs
Records pressure w/i bladder while filling at set rate (40-60mL/min)
Document volumes triggering detrusor contractions/urge to void
96
Sympathetic NS and Urination
```
T10-L2 via hypogastric nerve plexus
Bladder relaxation/proximal sphincter contraction
Beta: bladder relaxation
Alpha: Sphincter contraction
Neurotransmitter: Norepinephrine
```
97
Parasympathetic NS and Urination
S2-S4 via pelvic nerve plexus
Bladder contraction/sphincter relaxation
Cholinergic receptor sites: muscarinic receptors
Neurotransmitter: Acetylcholine
98
Pudendal Nerve
Voluntary contraction of distal 2/3 urethral sphincter and pelvic floor nerves S2-S4
Sends/receives messages to diaphragm
99
Somatic Nerve System Neurotransmitters
Glutamine
Activates "on/off" switch promoting sphincter closure or inhibiting (ON) contraction to produce opening of urethra (OFF)
Activates 2 additional neurotransmitters at Onuf's nucleus to promote contraction of pelvic muscle and rhabdosphincter (norepinephrine, serotonin)
100
Good Urinary Control
Coordinated bladder contraction/sphincter relaxation
Bladder able to hold 10-12 oz urine
Sphincter able to close tightly even if + abd pressure
101
Genuine Stress Incontinence
Type 1 or Type 2 SUI (determined by pelvic support)
Weak pelvic floor muscles (levator ani)
Lack of support for bladder/urethra = Urethral Hypermobility (bladder neck displaced)
102
Intrinsic Sphincter Dysfunction (ISD)
Type 3 SUI
| Failure of sphincter to close to H2O tight seal (coaptation)
103
Risk Factors for SUI
```
Childbirth
Obesity
Pelvic relaxation/prolapse
Hysterectomy
- Estrogen (menopause)
Age
Chronic straining
Smoking
Sacral lesions (below S2)
Trauma
Radical prostatectomy
Autonomic neuropathy
Pelvic surgery
```
104
Genuine SUI (Type 3): Behavioral Treatment
PME/KNACK are 1st line
Biofeedback assisted PME (weighted cones)
Electrical Stimulation
Extracorporeal electromagnetic therapy
105
Genuine SUI (Type 3): Devices
Pessary
Urethral occlusion insert
Penile clamp
106
Genuine SUI (Type 3): Surgery
Tension-free Vaginal Taping (TVT)
Retropubic Suspension
Needle bladder neck suspension
Anterior vaginal repair (poor results)
107
Intrinsic Sphincter Dysfunction (type 3): Treatment
Periurethral bulking injection of collagen
Sling procedure
Artificial urinary sphincter
108
Stress Incontinence Medications
Alpha-adrenergic agonists (pseudofedrine, ephedrine)
Tricyclics (imipramine, useful for mixed UI)
Estrogen cream/ring (0 effectiveness in SUI alone)
Drug therapy - use 2nd to side effects/limited efficacy = adjunct to behavioral therapy
109
Urge Incontinence Causes: Sensory
Abnormal sensitivity to bladder filling
Freq/small amounts voided
Normal detrusor muscle function
Defective CNS
110
Urge Incontinence Causes: Motor
Overactivity of detrusor
Stimulated by cold, running H2O
Low/moderate volume of urine AKA detrusor instability
111
Detrusor Hyperactivity w/ Impaired Contractility (DHIC)
Elderly
| Overactive bladder w/ incomplete emptying
112
Urge Incontinence DHIC: Extrinsic Factors
```
Reversible
Dietary irritants
Infection
Stones
Constipation/Impaction
BPH
Meds (methotrexate, diuretics)
Atrophic vaginitis
Cystocele
Tumors
DM
CVA
MS
Parkinson's
```
113
Urge Incontinence DHIC: Intrinsic Factors
Idiopathic
Detrusor becomes less stable
Changes in normal cell junctions
114
Urge Incontinence: Treatment
```
1st correct reversible causes
DIAPPERS
Treat UTI
Eliminate dietary irritants/H2O +
Review contributing meds
Modify clothing/environment
```
115
Urge Incontinence: Behavioral Management
1st: urge suppression/bladder training w/ dietary changes
Biofeedback to + pelvic floor muscles
Electrical stimulation/PtnS for refractory OAB
Routine scheduled toileting
116
Urge Incontinence: Meds
Anticholinergic/antimuscarinic
Beta-3 adrenergic agonist
Estrogen cream or ring topically if atrophic/menopause
117
Mixed Incontinence (Urge/Stress): Meds
Imipramine (tofranil)
118
Overflow (Retention) Incontinence: Causes
1. Contractile dysfunction (underactive/hypotonic/atonic bladder)
r/t: neuro bladder: transient from anesthesia/narcotics; diabetic neuropathy; low SCI; MS
2. Obstructed urinary outflow (BPH)
r/t: obstruction 2nd to enlarged prostate, pelvic neoplasm/prolapse; impaction; urethral stricture; post surgery
119
Overflow (Retention) Incontinence: Treatment
1st clean intermittent cath to + drainage
Assistive voiding (abd straining)
Intermittent self-cath (14-6hrs) to keep residual -400mL
Surgical: TURP, pessary (prolapse), bowel program (impaction), indwelling cath or urostomy (last resort)
120
Overflow (Retention) Incontinence: Meds
Alpha-adrenergic antagonist to relax bladder neck (Tamulosin/Flomax, Doxazosin/Cardura)
Finasteride to - prostate size (if +40 g)
Cholinergic agonist if contractile dysfunction (- efficiency)
121
Reflex Incontinence
Subset of UI
Uncontrolled urine loss 2nd to neurogenic disorders/detrusor hyperreflexia (bladder spasm)
Leakage w/o desire to urinate
Unconscious UI: - or 0 sensory awareness
122
Reflex Incontinence: Complications
1. Detrusor sphincter dyssynergia (DSD): complication of detrusor hyperreflexia
Bladder/sphincter contract at same time = + bladder pressure/reflux = upper tract deterioration
- coordination btwn striated sphincter and detrusor
2. Autonomic Dysreflexia (AD): extreme stimulation of autonomic system (overextended bladder, kinked foley)
Dangerous +B/P, sweating, headache
SCI at T6 or higher
tx: stop stimuli, semi-fowler, meds
123
Reflex Incontinence: Causes
```
Spinal cord lesion C2-S1
r/t: invertebral disc disease
spinal stenosis
cervical spondylosis
MS
spina bifida
SCI
CP
Lupus
Guillain Barre
```
124
Reflex Incontinence: Treatment
External urine containment
For DSD: clean intermittent cath 1st + meds, sphincterectomy
Surgery for + pressure bladder to preserve upper tract (continent urinary diversion, ileal conduit, bladder augmentation)
Follow-up w/ urology annually
125
Reflex Incontinence: Meds
Alpha adrenergic antagonists
| Add anticholinergic to - bladder spasms when intermittent cath is the treatment
126
Urge Incontinence: Description
Strong urge to void
8+x/day
2+x/night
