Urinary Incontinence and Pressure Ulcers Flashcards
What is the physiology of bladder function?
detrusor muscle = paraympathetic
inhibition detrusor contraction = sympathetic
internal urethral sphincter= sympathetic (alpha)
external urethral sphincter = striated muscle
micturition center = in pons
What are changes with aging and urinary function?
decreased bladder capacity
ability to inhibit reflex bladder contractions
decrease urethral closing pressure
increase residual volume
What are readily treatable incontinence manifestations?
DIAPERS D- delirium I- infection A- atrophic vaginitis/urethritis P- pharmaceutical (diuretics, sedatives) E - endocrine (increase glucose/calcium) R- restricted mobility S- stool impaction
What are the types of incontinence?
Detrusor instability (urge)
overflow
stress incontinence
functional
Who most commonly gets urge incontinence?
elderly men
What is the mechanism of urge incontinence?
uninhibition of detrusor contractions
What is the cause of urge incontinence?
defects in CNS regulation
hyper-excitability (local effect)
De-conditioning
What is the mechanism of overflow incontinence?
intravesicular pressure cannot exceed intraurethral pressure
What is the cause of overflow incontinence?
outlet obstruction detrusor inadequacy (eg diabetic neuropathy)
What is the mechanism of stress incontinence?
sphincter insufficiency
What is the cause of stress incontinence?
weakness of pelvic muscles
estrogen deficiency
urological surgery
What are mixed abnormalities?
causes of obstruction or stress incontinence often have associated detrusor instability
detrusor hyperreflexia with impaired contractility: incomplete emptying combined with detrusor hyperreflexia in the absence of obstruction
When taking urinary incontinence history what do you need to ask about pattern?
incontinence chart: stress related, behavioral/functional problem
When taking urinary incontinence history what do you need to ask about local factors?
uti
outlet obstruction
hx pelvic surgery
local neurological symptoms
When taking urinary incontinence history what do you need to ask about systemic factors?
hx of neoplasia or diabetes
CNS dysfunction
medications
What do we look for in a physical exam for urinary incontinence?
estrogen deficiency fecal impaction prostatic hypertrophy sacral neurologic function enlarged bladder after voiding incontinence with coughing (supine vs upright)
What labs do we need to look at when assessing urinary incontinece?
serum glucose/calcium
UA
post-void residual volume measurement (normal <100ml)
urodynamics
T/F: little is known about indication, specificity, sensitivity or predictive value in the elderly
True
What are the aspects of urodynamics?
post-void residual urin flow cystometry cystoscopy electromyography
What are the criteria for referral for urodynamics?
Hx of pelvic surgery or irradiation marked pelvic prolapse evidence of prostatic obstruction post void residual > 100ml uncertain diagnosis, or when unresponsive to tx
T/F: Medications do not play a role on incontinence.
False
What is diuretics effect on continence?
polyuria
What are anticholinergics effects on continence?
urinary retention
What are the hypnotics effect on continence?
sedation
What are narcotics effect on continence?
urinary retention
What are alpha blockers effect on continence?
sphincter relaxation
What are the alpha agonists effect on continence?
urinary retention
What are the beta agonists effect on continence?
urinary retention
What is caffeine’s effect on continence?
detrusor irridation
What is the goal of detrusor instability?
decrease detrusor contractions
What is the goal of overflow incontinence?
remove obstructions
What is the goal of stress incontinence?
increase intraurethral pressure
What is the goal of functional problems?
reestablish normal pattern
When do you use an anti-cholinergic agent/bladder relaxant?
detrusor instability
What is the mechanism of anti-cholinergic agents?
block detrusor contractions
What are the side effects of anti-cholinergic agents?
dry mouth, constipation, CNS
What are examples of anti-cholinergic agents?
oxybutynin, tolterodine, solifenacin
When do you use impramine?
detrusor instability
What is the mechanism of imipramine?
anti-cholinergic and alpha-sympathetic agonist activity
What is a problem of imipramine?
side effects
What are the treatments for detrusor instability?
Bladder training/scheduled voiding
Eliminate caffeine
Formal training using biofeedback in pelvic floor (Kegel) contractions prn urge sensation
What are the treatment options for overflow incontinence caused by an obstruction?
surgery: may have detrusor instability for period post-op
drug: alpha blockers, anti-androgens (e.g. finasteride)
What are the treatment options for overflow incontinence caused by a detrusor weakness?
intermittent catheterization
indwelling (Foley) catheter
What are the treatments for stress incontinence?
estrogens kegel exercises bladder training sympathomimetics surgery
What is the treatment for functional incontinence?
re-establish normal pattern
What do you do to help re-establish normal pattern?
use an incontinence chart
tx psychologic problems
use prompted voiding
What are the types of pressure sores?
decubitis ulcers
bed sores
What is the definition of a pressure sore?
an area of soft tissue breakdown, usually occurring over a bony prominence
What is a grade one pressure sore?
erythema present >24 hours
indurated
epidermis intact
What is a grade two pressure ulcer?
break in the epidermis or blistering
surrounding erythema
indurated
What is a grade three pressure ulcer?
extends into dermis
surrounding erythema
indurated
What is a grade four pressure ulcer?
involvement of deep fascia and/or muscles
surrounding erythema
indurated
What is something to be aware of with pressure ulcers?
small openings at the surface may underlie a large undermining defect
What are the top two areas where pressure sores develop?
sacrum and ischium
What is the incidence of pressure sores?
3-4.5% of pts develop pressure sores during hospitalization
What is the effect of elevated interstitial pressure (>12mm) on pressure sores?
filtration of capillary fluid
occlusion of lymphatics
accumulation of metabolic wastes
What are contributing factors to pressure sores?
pressure shearing force friction moisture malnutrition
What are the general measures/management of pressure sores?
- relief of pressure (turn q 2 hours)
- debride necrotic areas
- wound dressing (keep wet)
- improve general health (nutrition)
- inspect skin (measure)
What is the difference in wound dressings for superficial and deep ulcers?
superficial: paraffin gauze
deep: wet-to-wet
What are the SPECIFIC measures for the management of pressure sores?
sheepskin pads
air-or fluid-support systems
special wheelchair cushions
occlusive biosynthetic dressings (clean wounds)
What are the objectives of surgery for pressure sores?
excision of ulcerated areas
resection of bony prominences
formation of large flaps
obtainment of additional padding (muscle)
What are complications of surgery with pressure sores?
sepsis (polymicrobial, anaerobes)
osteomyelitis
T/F: when there is no pressure there is no sore?
True
