Urinary Incontinence, UTI’s and Urosepsis in the Elderly

Question 1

Definition of Incontinence

Answer 1

Involuntary leakage of urine in sufficient volumes or frequency so as to cause hygienic or social problems

Question 2

UI can cause?

4

Answer 2

Common cause of

1. institutionalization,
2. social isolation, and
3. decline in function
4. Increased risk of fractures

Question 3

What factors do you want to look for in the history that may be causing this? 5

Answer 3

1. Fluid Intake
2. Medications
3. Gynecologic / Urologic Surgeries
4. Medical Conditions – DM, MS, UTIs
5. Radiation Treatment for Gynecologic / Urologic Cancer

Question 4

1. For women with UI: What are you looking for on the pelvic exam? 3
2. Rectal exam? 2
3. Other tests to perform? 2
4. Genitalia and Rectal exam for men? 3

Answer 4

1. • atrophy,
   • prolapse,
   • masses
2. • sphincter tone,
   • impaction
3. • Stress test
   • Q-tip Test
4. • prostate,
   • sphincter tone,
   • impaction

Question 5

Rule out Transient Causes

DIAPPERS?

Answer 5

D elirium
I nfection
A trophy
P harmeceuticals
P sychologic
E ndocrine or excess urine output
R estricted mobility
S tool impaction

Question 6

Common Drug Causes of Incontinence

7

Answer 6

1. Anticholinergics
2. Alpha agonists
3. Alpha antagonists
4. Diuretics (including caffeine)
5. Calcium channel blockers
6. Sedative hypnotics and any 7. CNS depressants, including ETOH

Question 7

1. Required Lab tests? 2

2. Useful? 4

Answer 7

1. REQUIRED:
   - U/A
   - Urine C&S
2. USEFUL:
   - BUN, Creatinine
   - Glucose
   - Calcium
   - Electrolytes

Question 8

Behavioral Approaches to UI?

4

Answer 8

1. Reduce caffeine, liquids
2. Timed voiding - go often enough to avoid accidents
3. Bladder training - lengthen time between voids gradually
4. Prompted voiding - caregiver positively reinforces dryness, neutral response to wetness

Question 9

Treatments options for UI? 3

Answer 9

1. Timed voiding, bladder training, prompted voiding
2. Biofeedback & electrical stimulation
3. Anticholinergics

Question 10

Anticholinergics options? 5

Answer 10

1. Oxybutinin XL (Ditropan XL) 5-30 mg QD
2. Oxybutinin 2.5mg QD - 5mg TID
3. Tolterodine 1-2mg PO BID
4. Imipramine 25-50mg QD or other TCAs
5. Dicyclomine, propantheline

Question 11

What will establish pattern in most chronic cases of UI? 3

Answer 11

1. Bladder diary,
2. simple H&P,
3. PVR

Question 12

UTI in the elderly: Risk factors?

9

Answer 12

1. Advanced age
2. Fecal incontinence/impaction
3. Neurogenic bladder
4. Vaginal atrophy/estrogen deficiency
5. Pelvic prolapse/cystocele
6. Insufficient fluid intake/dehydration
7. Indwelling foley catheter or instrument procedure
8. BPH
9. Diabetes

Question 13

UTI in elderly: Causitive aganets:

1. Top 2?
2. Other 4?

Answer 13

1. • E. coli ~30%
   • Proteus species (GI tract) ~30%
2. • Staph. Aureus,
   • Klebsiella,
   • psuedomonas (gram neg), &
   • Enterococcus (gram pos) ~40%

Question 14

UTI in women > 65YO be defined by at least 2 of the following? 4

Answer 14

1. Fever (>38 degrees C)
2. Frequency, urgency, dysuria, suprapubic tenderness or CVA tenderness
3. Positive urine culture of at least 10 to the 5th colony-forming units/mL with no more than 2 species of microorganisms
4. Pyuria (>/= 10 WBCs/mm3 of unspun urine)

Question 15

Urine cultures in infected elderly patients may have lower colony counts: Such as?

Answer 15

10 to 2nd or 10 to the 3rd**

Question 16

Therapeutic antibiotic “trials” are not recommended, to avoid drug toxicity and antimicrobial resistance

1. When the diagnosis of UTI is in doubt manage how?
2. _____% or older women with UTI sx will improve in this time frame without therapy

Answer 16

1. withold antibiotics for 1 week and follow-up (outpatients)
2. 25-50

Question 17

1. When a true UTI is documented in an older woman, therapy is based on: what?
2. UTI in older men is frequently caused by what?

Answer 17

1. • The location of the infection
   • Likely causative agent
2. by concomitant prostate disease or functional bladder impairment
   - UTIs in these populations are considered high risk

Question 18

What should be obtained when patients develop fever or otherwise unexplained systemic manifestations compatible with infection (eg, altered mental status, fall in blood pressure, metabolic acidosis, and respiratory alkalosis)?

Answer 18

Blood and urine cultures

Question 19

UTI in the elderly: Signs and Symptoms?

8

Answer 19

1. Nocturia, incontinence
2. Confusion
3. Lethargy
4. Anorexia
5. Fever or hypothermia
6. FTT [failure to thrive]
7. Pain/dysuria
8. Behavioral changes

Question 20

Dx of UTI in Elderly?

4

Answer 20

1. UA
2. Rapid tests for bacteria in urine
3. Gram stain of urine
4. Urine culture and sensitivity
5. CBC with diff

Question 21

What would the following show for UTI:

1. UA? 3
2. Rapid tests for bacteria in urine? 2
3. Gram stain of urine? 2
4. Urine culture and sensitivity: Culture requires how long for results?
5. CBC with diff? 2

Answer 21

1. Urinalysis:
   - assess pyuria,
   - bacteria (Bacterial count >100,000 /ml indicative of infection)
   - blood cells in urine;
2. Rapid tests for bacteria in urine***
   - Nitrite dipstick (turning pink = presence of bacteria)
   - Leukocyte esterase test (identifies WBC in urine)
3. Gram stain of urine: identify by
   -shape
   -characteristic (gram positive or negative);
   (obtain by clean catch urine or catheterization)
4. Urine culture and sensitivity: identify infecting organism and most effective antibiotic; culture requires 24 – 72 hours for results; obtain by clean catch urine or catheterization
5. WBC with differential:
   - leukocytosis and
   - increased number of neutrophils

Question 22

Definition of sepsis?

Answer 22

Septicemia refers to the active multiplication of bacteria in the bloodstream that results in an overwhelming infection

Question 23

1. Excess cytokines indicate? 3
2. Prognosis depends on what?
3. Death by?

Answer 23

1. Impaired
   - pulmonary,
   - hepatic, or
   - renal function
2. Prognosis depends on underlying health status and host defenses
3. Death by multi-system organ failure

Question 24

Urosepsis risk factors? 5

Answer 24

1. BPH
2. DM
3. SLE
4. Alcohol—excessive intake
5. Taking steroids

Question 25

Urosepsis: Pathogenesis? | 3

Answer 25

1. UTI 2. BPH 3. Pyelonephritis

Question 26

Urosepsis Signs and Symtpoms? 6

Answer 26

1. Hypotension 2. Tachycardia 3. Tachypnea 4. Rales 5. Respiratory distress 6. Anorexia, nausea, vomiting

Question 27

Urosepsis Workup 4

Answer 27

1. Blood tests 2. UA & Culture 3. CT/MRI/US 4. Catheterization

Question 28

What blood tests would you do for urosepsis? 3

Answer 28

1. Kidney functions 2. CBC 3. Chem 8

Question 29

Urosepsis Tx? 4

Answer 29

1. Immediate hospitalization 2. Treat for shock 3. Fluids 4. Broad-spectrum antibiotics IV

Question 30

Which Broad-spectrum antibiotics IV? 4

Answer 30

1. Imipenem 2. Meropenem 3. Piperacillin-tazobactam 4. Sulbactam-ampicillin