Urinary issues Flashcards
1
Q
What is incontinence?
A
- involuntary leakage of urine in sufficient volumes or frequency so as to cause hygienic or social problems
2
Q
Prevalence of incontinence?
A
- 5% (3%-34%) of community dwelling adults aged 65 or older
- 30% (15-50%) of acutely hosp. adults aged 65 or older
- 50% of homebound or nursing home adults aged 65 or older
- 3-25% of elderly w/ incontinence have severe incontinence
- costs over $16 billion/yr in US
- over $1 billion spent on adult absorbent products annually in US
3
Q
Clinical importance of incontinence?
A
- common, especially in women (ratio 4:1 in ages less than 60, 2:1 in ages greater than 60)
- women 60 and older:
30-50% have any UI
6-14% have daily UI - common causes of institutionalization, social isolation, and decline in fxn
- increased risk of fractures
- often not mentioned to providers
- providers often ill prepared to deal w/ it
4
Q
hx questions to ask your pt that has incontinence?
A
- do you ever lose your urine and get wet?
- how long have you had this problem?
- what caused it to begin?
- how often does it occur?
- how much urine leaks out?
- when does leakage occur?
- what precipitates the leakage?
- does it leak when you cough? Sneeze? strain? - stress
- do you feel the urge to urinate but the urine leaks out b/f you can get to the BR? - urge
- do you feel like your bladder doesn’t empty completely? incomplete bladder emptying
- Does it hurt to urinate?
- is there blood in urine?
- do you have trouble starting your urine stream?
- what have you done to tx the leakage?
- do you use pads to catch the leakage - if so, how many?
- fluids, meds, gyn/urologic surgeries, medical conditions: DM, MS, UTIs, radiation tx for gyn/urologic cancer
5
Q
Exam for incontinence?
A
- women:
pelvic - atrophy, prolapse, masses, stress test, q tip test, rectal - sphincter tone, impaction - men:
genitalia, rectal: prostate, sphincter tone, impaction
6
Q
What transient causes need to ruled out?
A
D: delirium I: infection A: atrophy P: pharm P: psych E: endocrine R: restricted mobility S: stool impaction
7
Q
Common drug causes of incontinence?
A
- anticholinergics
- alpha agonists
- alpha antagonists
- diuretics (including caffeine)
- CCBs
- sedative hypnotics and any CNS depressants, including ETOH
8
Q
Lab tests for incontinence?
A
reqd:
UA
urine C&S
useful: BUN, creatinine glucose Ca++ electrolytes
9
Q
How can incontinence affect the elderly?
A
- decrease self esteem: isolation, depression
- can lead to infections, falls
10
Q
Behavioral approaches to incontinence?
A
- reduce caffeine, liquids
- timed voiding: go often enough to avoid accidents
- bladder training: lengthen time b/t voids gradually
- prompted voiding: caregiver positively reinforces dryness, neutral response to wetness
11
Q
Tx for incontinence?
A
- timed voiding, bladder training, prompted voiding
- biofeedback and electrical stimulation
- anticholinergics -
oxybutinin, tolterodine, imipramine, dicyclomine - PCPs can manage many cases of low PVR incontinence
- many cases of high PVR incontinence will reqr referral or more involved eval
12
Q
Prevalence of UTIs in the elderly?
A
- community dwelling elders 25%
- long term care (LTCF) elders (chronically bacturemic) - male 25-50%, women 15-40%
- marked increase in men and women over the age of 65
13
Q
RFs for UTI in the elderly?
A
- advanced age
- fecal incontinence/impaction
- neurogenic bladder
- vaginal atrophy/estrogen deficiency
- pelvic prolapse/cystocele
- insufficient fluid intake/dehydration
- indwelling foley catheter or instrument procedure
- BPH
- diabetes
14
Q
Causative agents - UTIs in the LTCF elderly?
A
- E. coli around 30%
- proteus species (GI tract) - 30%
- staph, aureus, klebsiella, pseudomonas (gram negative), and enterococcus (gram positive) - 40%
15
Q
Asx bacteriuria prevalence?
A
- occurs in 6-16% of women in the community
- 25-54% in women in nursing homes
- frequency half that amt in men
- w/ chronic catheter rates are higher (nearly 100% for indwelling cath)
16
Q
UTI in women over 65 YO guidelines for dx and tx?
A
defined by at least 2 of the following:
- fever (over 38 degrees)
- frequency, urgency, dysuria, suprapubic tenderness or CVA tenderness
- positive urine culture of at least 10 to the 5th colony forming units/ml w/ no more than 2 species of microorganisms
- pyuria (10 or more WBCs/mm3 of unspun urine)
- urine cultures in infected elderly pts may have lower colony counts: 10 to 2nd or 10 to the 3rd
17
Q
When do you not use abx for UTIs in elderly?
A
- no abx trials are not recommend, to avoid drug toxicity and antimicrobial resistance
- when the dx of UTI is in doubt withhold abx for 1 wk and f/u (outpts)
- 25-50% of older women w/ UTI sx will improve in this time frame w/o therapy
18
Q
Therapy is based on what for UTIs? Both men and women?
A
-when a true UTI is documented in an older woman, therapy is based on:
location of infection
likely causative agent
- in older men - frequently caused by concomitant prostate disease or fxnl bladder impairment:
UTIs in these pops are considered high risk, short courses of therapy are not appropriate - need long term
19
Q
UTIs assoc w/ catheters?
A
- UTIs assoc w/ catheters are leading cause of secondary nosocomial bacteremia
- pts w/ indwelling catheters often don’t experience typically signs of UTI
- blood and urine cultures should be obtained when pts develop fevere or otherwise unexplained systemic manifestations compatible w/ infection (alt mental status, fall in BP, metabolic acidosis, respiratory alkalosis)
- most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated
20
Q
Signs and sxs of UTIs in elderly?
A
- nocturia, incontinence
- confusion
- lethargy
- anorexia
- fever or hypothermia
- FTT
- pain/dysuria
- behavioral changes
21
Q
Dx tests for UTIs?
A
- UA: pyuria, blood cells in urine, bacterial count over 100,000 ml indicative of infection
- rapid tests for bacteria in urine:
nitrite dipstick (turning pink - + for bacteria)
leukocyte esterase test: ID WBC in urine - gram stain of urine: ID by shape and characteristic (gram + or -), obtain clean catch urine or cath
- urine culture and sensitivity - ID infecting organism and most effective abx - culture reqrs 24-72 hrs for results - obtain by clean catch urine or catheterization
- WBC w/ diff: leukocytosis, and increased number of neutrophils
22
Q
What is sepsis? Prevalence in geri pop?
A
- septicemia: refers to the active multiplication of bacteria in the bloodstream that results in an overwhelming infection
- cytokines: impaired pulmonary, hepatic, or renal fxn
- prognosis depends on underlying health status and host defenses
- death by multi-system organ failure
- high incidence - over 65 = 12% of pop, 65% of sepsis cases
- cases expected to increase w/ 1.1 mill cases w/in the next 15 yrs
23
Q
RFs for urosepsis?
A
- BPH
- DM
- SLE
- ETOH: excessive intake
- taking steroids
24
Q
Pathogenesis of urosepsis?
A
- UTI
- BPH
- pyelonephritis
25
Signs and sxs of urosepsis?
- hypotension
- tachycardia
- tachypnea
- rales
- respiratory distress
- anorexia, N/V
26
W/U for urosepsis?
```
- blood:
kidney fxn
CBC
chem 8 (BMP)
- UA and culture
- CT/MRI/US
- catheterization
```
27
Tx of urosepsis?
- immediate hospitalization
- tx for shock: vasopressors,
- fluids: NS
- broad spectrum abx IV:
imipenem
meropenem
piperacillin-tazobactam
sulbactam-ampicillin
