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Medicine II: Geriatrics COPY > Urinary Incontinence and Pressure Ulcers > Flashcards

Urinary Incontinence and Pressure Ulcers Flashcards

1
Q

What is the physiology of bladder function?

A

detrusor muscle = paraympathetic
inhibition detrusor contraction = sympathetic
internal urethral sphincter= sympathetic (alpha)
external urethral sphincter = striated muscle
micturition center = in pons

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2
Q

What are changes with aging and urinary function?

A

decreased bladder capacity
ability to inhibit reflex bladder contractions
decrease urethral closing pressure
increase residual volume

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3
Q

What are readily treatable incontinence manifestations?

A 
DIAPERS
D- delirium
I- infection 
A- atrophic vaginitis/urethritis
P- pharmaceutical (diuretics, sedatives)
E - endocrine (increase glucose/calcium)
R- restricted mobility
S- stool impaction
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4
Q

What are the types of incontinence?

A

Detrusor instability (urge)
overflow
stress incontinence
functional

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5
Q

Who most commonly gets urge incontinence?

A

elderly men

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6
Q

What is the mechanism of urge incontinence?

A

uninhibition of detrusor contractions

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7
Q

What is the cause of urge incontinence?

A

defects in CNS regulation
hyper-excitability (local effect)
De-conditioning

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8
Q

What is the mechanism of overflow incontinence?

A

intravesicular pressure cannot exceed intraurethral pressure

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9
Q

What is the cause of overflow incontinence?

A 
outlet obstruction
detrusor inadequacy (eg diabetic neuropathy)
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10
Q

What is the mechanism of stress incontinence?

A

sphincter insufficiency

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11
Q

What is the cause of stress incontinence?

A

weakness of pelvic muscles
estrogen deficiency
urological surgery

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12
Q

What are mixed abnormalities?

A

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

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13
Q

When taking urinary incontinence history what do you need to ask about pattern?

A

incontinence chart: stress related, behavioral/functional problem

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14
Q

When taking urinary incontinence history what do you need to ask about local factors?

A

uti
outlet obstruction
hx pelvic surgery
local neurological symptoms

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15
Q

When taking urinary incontinence history what do you need to ask about systemic factors?

A

hx of neoplasia or diabetes
CNS dysfunction
medications

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16
Q

What do we look for in a physical exam for urinary incontinence?

A 
estrogen deficiency
fecal impaction
prostatic hypertrophy
sacral neurologic function
enlarged bladder after voiding
incontinence with coughing (supine vs upright)
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17
Q

What labs do we need to look at when assessing urinary incontinece?

A

serum glucose/calcium
UA
post-void residual volume measurement (normal <100ml)
urodynamics

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18
Q

T/F: little is known about indication, specificity, sensitivity or predictive value in the elderly

A

True

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19
Q

What are the aspects of urodynamics?

A 
post-void residual
urin flow
cystometry
cystoscopy
electromyography
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20
Q

What are the criteria for referral for urodynamics?

A 
Hx of pelvic surgery or irradiation
marked pelvic prolapse
evidence of prostatic obstruction
post void residual > 100ml
uncertain diagnosis, or when unresponsive to tx
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21
Q

T/F: Medications do not play a role on incontinence.

A

False

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22
Q

What is diuretics effect on continence?

A

polyuria

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23
Q

What are anticholinergics effects on continence?

A

urinary retention

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24
Q

What are the hypnotics effect on continence?

A

sedation

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25
Q

What are narcotics effect on continence?

A

urinary retention

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26
Q

What are alpha blockers effect on continence?

A

sphincter relaxation

27
Q

What are the alpha agonists effect on continence?

A

urinary retention

28
Q

What are the beta agonists effect on continence?

A

urinary retention

29
Q

What is caffeine’s effect on continence?

A

detrusor irridation

30
Q

What is the goal of detrusor instability?

A

decrease detrusor contractions

31
Q

What is the goal of overflow incontinence?

A

remove obstructions

32
Q

What is the goal of stress incontinence?

A

increase intraurethral pressure

33
Q

What is the goal of functional problems?

A

reestablish normal pattern

34
Q

When do you use an anti-cholinergic agent/bladder relaxant?

A

detrusor instability

35
Q

What is the mechanism of anti-cholinergic agents?

A

block detrusor contractions

36
Q

What are the side effects of anti-cholinergic agents?

A

dry mouth, constipation, CNS

37
Q

What are examples of anti-cholinergic agents?

A

oxybutynin, tolterodine, solifenacin

38
Q

When do you use impramine?

A

detrusor instability

39
Q

What is the mechanism of imipramine?

A

anti-cholinergic and alpha-sympathetic agonist activity

40
Q

What is a problem of imipramine?

A

side effects

41
Q

What are the treatments for detrusor instability?

A

Bladder training/scheduled voiding
Eliminate caffeine
Formal training using biofeedback in pelvic floor (Kegel) contractions prn urge sensation

42
Q

What are the treatment options for overflow incontinence caused by an obstruction?

A

surgery: may have detrusor instability for period post-op
drug: alpha blockers, anti-androgens (e.g. finasteride)

43
Q

What are the treatment options for overflow incontinence caused by a detrusor weakness?

A

intermittent catheterization

indwelling (Foley) catheter

44
Q

What are the treatments for stress incontinence?

A 
estrogens
kegel exercises
bladder training
sympathomimetics
surgery
45
Q

What is the treatment for functional incontinence?

A

re-establish normal pattern

46
Q

What do you do to help re-establish normal pattern?

A

use an incontinence chart
tx psychologic problems
use prompted voiding

47
Q

What are the types of pressure sores?

A

decubitis ulcers

bed sores

48
Q

What is the definition of a pressure sore?

A

an area of soft tissue breakdown, usually occurring over a bony prominence

49
Q

What is a grade one pressure sore?

A

erythema present >24 hours
indurated
epidermis intact

50
Q

What is a grade two pressure ulcer?

A

break in the epidermis or blistering
surrounding erythema
indurated

51
Q

What is a grade three pressure ulcer?

A

extends into dermis
surrounding erythema
indurated

52
Q

What is a grade four pressure ulcer?

A

involvement of deep fascia and/or muscles
surrounding erythema
indurated

53
Q

What is something to be aware of with pressure ulcers?

A

small openings at the surface may underlie a large undermining defect

54
Q

What are the top two areas where pressure sores develop?

A

sacrum and ischium

55
Q

What is the incidence of pressure sores?

A

3-4.5% of pts develop pressure sores during hospitalization

56
Q

What is the effect of elevated interstitial pressure (>12mm) on pressure sores?

A

filtration of capillary fluid
occlusion of lymphatics
accumulation of metabolic wastes

57
Q

What are contributing factors to pressure sores?

A 
pressure
shearing force
friction
moisture
malnutrition
58
Q

What are the general measures/management of pressure sores?

A
  1. relief of pressure (turn q 2 hours)
  2. debride necrotic areas
  3. wound dressing (keep wet)
  4. improve general health (nutrition)
  5. inspect skin (measure)
59
Q

What is the difference in wound dressings for superficial and deep ulcers?

A

superficial: paraffin gauze
deep: wet-to-wet

60
Q

What are the SPECIFIC measures for the management of pressure sores?

A

sheepskin pads
air-or fluid-support systems
special wheelchair cushions
occlusive biosynthetic dressings (clean wounds)

61
Q

What are the objectives of surgery for pressure sores?

A

excision of ulcerated areas
resection of bony prominences
formation of large flaps
obtainment of additional padding (muscle)

62
Q

What are complications of surgery with pressure sores?

A

sepsis (polymicrobial, anaerobes)

osteomyelitis

63
Q

T/F: when there is no pressure there is no sore?

A

True

Medicine II: Geriatrics COPY (10 decks)

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