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SPPICES: Urinary Incontinence

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1 SPPICES: Urinary Incontinence

2 Organizational Goal To organize continence services in an integrated fashion that focuses on the identification of patients, assessing their condition and implementing the most appropriate treatment plan. This model of good practice will allow staff to achieve more responsive and effective continence services and assist patients.

3 SPPICES Questions Do you have problem passing water/getting to the bathroom on time? Did you wear incontinence products at home? If there is a catheter, is it still needed? Was your last bowel movement 3 days ago?

4 Did you know that... 50% - 70% of persons with UI don’t seek help.
UI is a very common problem with treatments that work. Most cases of UI can be markedly improved. Reasons for not seeking help unclear but linked to: too embarrassed hope it will improve without intervention normal part of aging and / or nothing can be done afraid of needing an operation don’t perceive it as s serious problem compared to those who seek help

5 Prevalence 15% - 30% of seniors in the community
15.3% in acute care facilities 50% in nursing homes 15% = males; 30% = females rates vary between 8-51% because of: closet issue - too embarrassing to report unsure of true extent % of people don’t seek help problems with research (some use subjective report, white women, depends how question asked, varying levels of incontinence

6 Impact of UI Physical Psychosocial Financial Physical falls, fractures
urosepsis skin breakdown Psychosoocial social isolation embarrassment, feelings of shame loneliness stress on family/ caregiver Financial affects discharge from hospital or acceptance to RH, rehab one study found 44% of families who institutionalized their loved ones cited difficulty managing continence as reason for admission impact on family - children - sons increase time for care in hospital/NH cost of incontinent pads, briefs, laundering, catheters

7 Definition A common, disruptive, and potentially disabling condition in the aging population. An involuntary loss of urine in sufficient amounts or frequency to constitute a social and/or health problem. (Kane, Ouslander, & Abrass, 1994) Key is social/ health problem self described

8 Requirements for Continence
Effective lower urinary tract functioning  storage & emptying Adequate mobility and dexterity to use the toilet, toilet substitute, and to manage clothing Adequate cognitive function to recognize toileting needs and to find a toilet/substitute Motivation to be continent Absence of environmental and iatrogenic barriers such as inaccessible toilets/substitutes, unavailable family/caregivers and drug side effects

9 Established/Persistent UI: The Bladder
Normal Aging Changes Anatomy Physiology Aging itself does not cause UI!! Aging does contribute to: Decrease in bladder capacity Increase in residual urine Involuntary bladder contractions A 30%-40% loss of functional cells in the kidneys (nephrons) A decrease in the kidney’s ability to filter blood and concentrate urine Wearing out of the sensory nerve tract from brain to bladder and these can put people at greater risk of UI Decrease in bladder capacity – leading to the bladder not emptying fully leading to increase in frequency and residual urine leading to UTIs from the urine left in the bladder Bladder spasms create the “sensation to void” before the bladder is full leading to urge incontinence while patients are walking to the bathroom Men ~ prostatic enlargement causes a decrease in urine flow & detrusor motor instability Women ~ decline in bladder outlet and urethral resistance pressure

10 Types of UI Acute / Reversible
Established/Persistent Overflow Urge Functional Stress

11 Causes of Acute/Reversible UI
D Delirium I Infection A Atrophic Vaginitis/ Urethritis P Pharmaceuticals P Psychological causes E Excess fluid R Restricted mobility S Stool impaction (Resnick, 1992) List of causes: Delirium/confusional state Infection - 30% of hospitalized seniors have asymptomatic bacteruria. Ouslander (1992) recommended that incontinent elderly pts with significant bacteruria be considered symptomatic vs. asymptomatic Atrophic vaginitis - results from low estrogen levels in postmenopausal women pharmacueticals - caffeine, diuretics, sedatives/hypnotics, narcotics, anticholinergics, calcium channel blockers all can contribute psychological causes - depression, anger, hostility toward caregiver, regression in psych pts excess fluids - from high fluid intake (esp caffeine) or from volume overload with venous insufficiency or CHF endocrine problems like hyperglycemia and hypercalcemia both cause polyuria and can also trigger incontinence restricted mobility - surgery, fracture, restarints, arthritis, neuro stool impaction - causes outlet obstruction has been cited as a primary cause of incontinence occurring in 5-10% of frail NH pts

12 Established UI: Overflow
Urine loss (dribbling) associated with an overdistended bladder due to an obstruction in the urethra. Signs and Symptoms: Leakage of small amounts of urine Palpable or percussable bladder, suprapubic tenderness Hesitancy on voiding, interrupted urine flow or post void dribbling Urine loss without urge Sensation of incomplete voiding or bladder fullness Frequency This implies that the bladder cannot empty completely, retains urine, becomes overdistended, and then overflows. It is characterized by the constant leakage of small amounts of urine from a filled bladder. Causes: outlet obstruction: prostatic hypertrophy, fecal impaction, urethral stricture, pelvic organ prolapse (cystocele) chronic myogenic decompensation: peripheral neuropathy (DM, spinal cord injury, MS) acontractile, hypotonic, or underactive detrusor d/t anything that overdistends the bladder pt with 2000 cc emptied from bladder

13 Established UI: Urge Involuntary loss of urine (usually larger amounts) associated with a sudden, strong desire to void. Signs and Symptoms: Sudden “urgency” to void Nocturia and / or Enuresis Moderate to large amounts of urine loss Loss of urine at the sound of water running or when waiting to access a public toilet Nocturia = excessive urination at night; it may occur in older people who have excess fluids that are mobilized when theylie down at night Enuresis = incontinence of urine, especially in bed at night - unlike stress incontinence where small amount of urine lost, urge incontinence usually involves larger amounts Causes: lower urinary tract = UTI, cystitis, bladder tumour, bladder stones, urethritis, atrophic vaginitis central nervous system = CVA, dementia, Parkinsons, NPH, MS above result in uninhibited detrusor contractions these can also be caused by deconditioned voiding reflexes (ie frequent voiding to reduce risk of incontinence) - this reduces bladder capacity and with time the bladder wall thickens, aggravating the condition of decreased tone and increased instability incont d/t inhibited detrusor contractions in the absence of a neurological disorder is also called detrusor motor instability Usually caused by an “unstable bladder” or “detrusor instability” isolated or associated with CNS disorders.

14 Established UI: Functional
Urinary leakage associated with the inability to toilet because of impairments in cognition and/or physical functioning, psychological unwillingness or environmental barriers. Signs and Symptoms: Report of being unable to get to the bathroom on time Total emptying / large amounts of urine leakage No incontinence when access to a bathroom and assistance with toileting available Causes: Evidence of impaired mobility, manual dexterity, communication or cognitive skills Depression, anger, hostility Physical and/or chemical restraints

15 Established UI: Stress
An involuntary loss of urine (usually small amounts) with increases in intraabdominal pressure (ie. Cough, laugh, sneeze, exercise). Signs and Symptoms: Small amounts of urine leakage/loss associated with activity, lifting, coughing, sneezing, and/or laughing Urine leakage during the day while person is active Most common type of UI in women, less frequent in men Causes: incompetent urethra weak pelvic floor musculature Women – multiple childbirths, estrogen deficiency, trauma to external urinary sphincter Men – pelvic trauma or sphincter damage during prostatectomy Obesity Smoking with chronic coughing Pathophysiology losses of small amounts of urine in the absence of a detrusor contraction usually during sudden increases in intra-abdominal pressure (from coughing, sneezing, etc). The underlying cause is the inability of the urethra to sustain pressure that exceeds that of the bladder, particularly under exertional events

16 Interventions Environmental Alterations Lifestyle Management
Scheduling Regimes Pelvic Muscle Rehabilitation Continence Products Catheterization Occlusive & Pelvic Organ Support Devices Medication Surgery Intervention based on type of incontinence, severity and impact on life, pts cog and functional status, pt/caregivers preferences and expectations, cost-benefit factors assessment - voiding record, PVR Environmental Alterations - lighting, commode/urinal by bed, skirts vs pants for women; zippers vs. buttons; RTS; loose fitting clothes Lifestyle Management - reducing caffeine intake, weight reduction in obese people, reduce smoking to reduce chronic cough, prevent constipation through diet and exercise Scheduling Regimes- timed voiding, habit training, prompted voiding, bladder training Pelvic Muscle Rehabilitation - pelvic muscle exercises, vaginal weight training, biofeedback, electrical stimulation Continence Products Catheterization Occlusive & Pelvic Organ Support Devices - penile compression devices, pessaries (for pelvic organ prolapse) Medication - estrogen, oxybutinin Surgery PT proper skin care

New onset urinary incontinence Risk factors identified: Delirium/confusion Infection, urinary symptoms Atrophic vaginitis/urethritis Pharmaceuticals Psychologic disorders Endocrine disorders Restricted mobility Stool impaction Frequency Noctuira Enuresis Moderate to large amount of urine loss Frequent urination Post void dribbling Retention Hesitancy Sensation of fullness/pressure in abdomen Urine loss without urge Unable to get to toilet on time Small amount urine loss Associated with activity, Coughing Sneezing Bladder training Kegel exercises Liners/briefs if needed Environmental modifications Consider medical referral as indicated Provide urinal/commode Subjective/objective report of improvement Decreased use of liners/briefs Kegel exercise Bladder diary to establish routine Monitor weekly Subjective report of  in incontinent episodes Allow patient sufficient time to void Encourage double void PVR using bladder scanner Contact MD if appropriate for I/O or catheterization order Provide urinal or commode Medication review PVR Monitor daily then weekly Scheduled toileting Avoid restraints Ensure toilet accessible Provide commode etc at bedside Modify fluid intake pattern Modify environment eg remove obstacles Ensure adequate lighting OT/PT assessment Monitor weekly Subjective/objective report of  in incontinence episodes Clinical Assessment Symptoms Interventions Evaluation Type of Incontinence URGE STRESS OVERFLOW FUNCTIONAL

18 Case Study Mr. Yeung is a 90 year old man with a history of dementia, CHF, and osteoarthritis. He is on 40mg lasix BID, and Tylenol # 3 prn for his pain. During his hospitalization for exacerbation of his CHF, he has a new onset of urinary incontinence. What type of UI is Mr. Yeung experiencing? What would be your plan of action for him? What meds is he on? Is he constipated? Is his intake adequate? What’s his level of cog. Fx r/t dementia? Does he have a UTI? Does he have any mobility problems preventing him from getting to the toilet? Is he retaining urine? CLUES…Lasix, PVR = 30cc. Urine neg., bowel Normal, patient is not aware of when he needs to void or where the BR is, he is having difficulty getting to the BR MR. JONES HAS FUNCTIONAL INCONTINENCE!! Interventions OT to Ax cog. Fx; ability to find BR, remember where it is, ability to pull pants up/down and safety issues/barriers in environment PT to Ax mobility and ability to get on/off toilet safely Nursing to start voiding record to establish his normal voiding pattern Nursing to begin scheduled toileting routine Q2-4 H on days and Q4-6 on nights, or one that matches patient’s normal routine at home or as assessed from record OT/PT/Nursing attempt to get patient to use urinal if possible as assessed via cog.fx Ax by OT

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