1. dysfunctional voiding/nsu3062/rsetyowati
DYSFUNCTIONAL VOIDING PATTERNS URINARY INCONTINENCE URINARY RETENTION BPH
RAHAYU SETYOWATI
Degree of Nursing,
Padjadjaran University, INDONESIA

2. OBJECTIVE At the end of this session, student should be able to:
Understand and explain of the definition of urinary incontinence and
urinary retention
2. Understand and explain of the pathophisiology of urinary incontinence
and urinary retention
3. Understand and explain of the risk factor of urinary incontinence and
4. Understand and explain of the clinical manifestation of urinary retention
and urinary incontinence
5. Understand and explain of the complication of urinary incontinence and
6. Understand and explain of the diagnostic test of urinary incontinence
7. Understand and explain of the medical management of urinary reten
tion and urinary incontinence
8. Understand and explain of the nursing process of urinary retention

3. URINARY INCONTINENCE

4. DEFINITION PATHOPHYSIOLOGY
Urinary incontinence is the unplanned loss of urine that is suficient to be considered a problem.
Smeltzer,SC & Bare,B(2004)
PATHOPHYSIOLOGY
Continence is maintained via a complex communication system
of suprasacral, sacral and local nerve-mediated loops of infor-
mation. Any break in these loops of communication can cause
some degree of urinary dysfungtion.

5. Conditions causing adulth voiding dysfungtion
Neurologic Disorders
Cerebellar ataxia  incontinence
Cerebrovascular accident  retention or incontinence
Dementia  incontinence
Diabetes  incontinence and/or incomplete bledder empty
Multiple sclerosis  incontinence or incomplete bledder empty
Parkinson’s Disease  incontinence
Spinal cord dysfungtion
acut injury  urinary retention
degenerative disease  incontinence and/or incomplete bledder
empty
Nonneurologic disorders
bashful bladder  inability to initiate voiding in public bathroom
overactive bladder  urgency, urge and frequency incontinence
post-prostatectomy  incontinence
post general surgery  acut urine retention
stress incontinence  incontinence with cough, position change

6. TYPES OF URINARY INCONTINENCE
Stress
Urge
Overflow
Fungtional
Loss of urine associated with
increased intra-abdominal
pressure during sneezing,
coughing. Quantity of urine
lost is usually small.
Involuntari loss of urine
associated with a strong urge
to void
Inability to empty bladder,
resulting in overdistention
and frequent loss of small
amount of urine
Incontinence resulting from
phisical, environmental, or
psyco-social causes
Multiple pregnancies
Decreades estrogen level
Prostate surgery
Tumor,asites,obesity
Neurologic disorders
Detrusor muscle overactivity
(bladder obstruction, aging,
diabetes)
Spinal cord injury below S2
Diabetic neuropathy
Prostatic hypertropy
Fecal impaction
Confusion or dementia
Physical disability
Diuretic terapy or sedation
depression

8. Post voiding residual volume (PVR) Cystometrography Uroflowmetry
DIAGNOSTIC TESTS
Urinalysis and urine culture
Post voiding residual volume (PVR)
Cystometrography
Uroflowmetry
Intravenous Pyelography
Ultrasounography

9. Surgery Medications MEDICAL MANAGEMENT Surgery may be used to treat
Stress and urge incontinence
may improve with drug.
Postmenopausal incontinence,
estrogen therapy may effective.
Urge incontinence may be
treated with preparations that
increase bladder capacity.
Surgery
Surgery may be used to treat
stress incontinence associated
with cystocele or urethrocele
and oferflow incontinence
associated with an enlarged
prostate gland.
Other surgical procedures of
potential benefit in the treat-
ment of incontionence include
implanation of the artificial
sphincter, formation of the
uretral sling, augmentation of
the bladder with bowel.

10. NURSING PROCESS
Assessment
Health history :
- voiding diary
- frequency of incontinent episodes
- amount of urine loss
- activities associated with incontonence
- use of Kegel exercise or medication
- chronic disease releated surgeries
Physical examination :
- physical limitation or impaired cognition
- bladder distention (inspect, palpate, percuss)
- inspect perineal tisue for redness,irritation,
tissue breakdown

11. 1. Urinary Incontinence : Stress and/or Urge
Cont…nursing process
Nursing Diagnoses
1. Urinary Incontinence : Stress and/or Urge
2. Self-care deficit : toileting
3. Social Isolation

12. Urinary incontinence : stress and or urge
Intervention :
- instruct to keep voiding diary (voiding diaries provide
valuable information for identifying the type of incontinence)
- teach pelvic floor muscle exercise
- suggest dietary and fluid intake modifications to reduce
incontinence. Limiting caffeine, alcohol, citrus juice, limited
fluid intake to n less than 1,5 – 2,0 L per day, limited
evening fluid.

13. Pelvic Floor (Kegel) Exercise
Identify the pelvic muscles with these :
- stop the flow of urine during voiding and hold for a few second
- tighten the muscles at the vaginal entrance around a gloved
finger or tampon
- tighten the muscle around the anus as through resisting
defecation
Perform exercise by tightening pelvic muscles, holding for 10
second, and relaxing for 10 – 15 second. Continue the sequence
(tighten, hold, relax) for 10 repetitions
Keep abdominal muscles and brething relaxed while performing
exercises
Initially, exercise should be performing twice per day, working
up to four times per day

14. 2. Self care deficit : toileting
intervention :
- ass physical and mental abilities and limitations
- provide assistive devices as a needed
- plan to toileting schedule
- position for ease of voiding
- adjust fluid intake
- assist with clothing that is easily removed

15. URINARY RETENTION

16. Incomplete emptying of the bladder, can lead to overdistention
DEFINITION
Incomplete emptying of the bladder, can lead to overdistention
of the bladder, poor detrusor muscle contractility, and unability
to urinate.
Lemone,P & Burke,K(2004)
PHYSIOLOGY REVIEW
Bladder emptying is controlled by the interaction of muscle tone
and the autonomic nervous system. The sympatetic nervous
syetem relaxes the detrusor musle(closed the internal sphincter)
 the bladder fill with urine.
Pressure in the bladder ( ml)  spinal cord & cerebral
cortex  parasympathetic stimulation  the destrusor musce to
contract (opening the internal sphincter)  micturition

18. PATHOPHYSIOLOGY
Either mechanical obstruction of the bladder outlet or
Fungtional problem can cause urinary retention.
Benign Prostatic Hypertropy (BPH) is a common cause.
Urethral pathology (infection, tumor, calculus)
Bladder calculi
trauma (pelvic injuries)
pregnancy
neurology disorder (CVA, spinal cord injury, parkinson’s
disease, multiple sclerosis)

19. COMPLICATION
Chronic infection
hyhroureter
hydronephrosis
DIAGNOSTIC TEST
Urinalysis (hematuria)
Ultrasound

20. - Physical Examination
NURSING PROCESS
Assessment
- Health history
- Physical Examination
Nursing diagnoses
 Impaired Urinary Elimination
Intervention : - catheterization
Implementation
Evaluation

21. BENIGN PROSTATIC HYPERPLASIA
(BPH)

22. DEFINITION
BPH : nonmalignant enlargement of the prostate gland, is a
common disorder of the aging male.
The prostate, very small at birth, grows at puberty. Benign
hyperplasia (increased number of cells) begins at 40 to 45
years of age.

23. Review anatomi

25. Understanding the prostate
dysfunctional voiding/nsu3062/rsetyowati
Understanding the prostate
Walnut-shaped gland that forms part of the male reproductive system
Surrounds the urethra - the tube that carries urine from the bladder out of the body n n

26. dysfunctional voiding/nsu3062/rsetyowati
Understanding the prostate
Secretes semen which carries sperm
During orgasm, prostate muscles contract and propel ejaculate out of the penis n n

27. dysfunctional voiding/nsu3062/rsetyowati
BPH n
The size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostate
By the time men reach their 70’s and 80’s, 80% will experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment n

28. dysfunctional voiding/nsu3062/rsetyowati
What is Benign Prostatic Hyperplasia?
Peripheral zone
Transition zone
Urethra

29. dysfunctional voiding/nsu3062/rsetyowati
Peripheral zone
Transition zone
Urethra

30. ETIOLOGI
The cause of BPH is unknown.
Risk fact include :
age (increases with age)
famili history (higher rates)
race (highest in African American)
ethnicity (lowest in japanese)
hormonal factors

31. dysfunctional voiding/nsu3062/rsetyowati
What’s LUTS?
Voiding (obstructive)
symptoms
Hesitancy
Weak stream
Straining to pass urine
Prolonged micturition
Feeling of incomplete bladder emptying
Urinary retention
Storage (irritative or
filling) symptoms
Urgency
Frequency
Nocturia
Urge incontinence
LUTS can arise from a variety of causes, for example as a consequence of prolonged urinary obstruction due to BPH.
LUTS are categorised as being obstructive (voiding) or irritative (storage) symptoms.
Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention.
Irritative symptoms include urgency, frequency, nocturia, and urge incontinence. LUTS may also be due to inflammatory or infectious processes.
LUTS is not specific to BPH – not everyone with LUTS has BPH and not everyone with BPH has LUTS
Blaivas JG. Urol Clin North Am 1985;12:215–24

32. Serum creatinine levels
DIAGNOSTIC TESTS
Urinalysis : detects bacteria, WBC, or microscopic RBC
Serum creatinine levels
PSA ( Prostate Specific Antigen) levels. PSA is a glico-
protein produced only in the cytoplasm of benign prostate
cell.
DRE examines : external surface of the prostate gland.
Residual urine : amount of urine remaining in the bladder
after voiding.

34. When should BPH be treated?
dysfunctional voiding/nsu3062/rsetyowati
When should BPH be treated?
BPH needs to be treated ONLY IF:
Symptoms are severe enough to bother the patient and affect his quality of life
Complications related to BPH n n

35. Choosing the right treatment
dysfunctional voiding/nsu3062/rsetyowati
Choosing the right treatment
Consider risks, benefits and effectiveness of each treatment
Consider the outcome and lifestyle needs n n

36. dysfunctional voiding/nsu3062/rsetyowati
Treatment options
“Watchful waiting”
Medication
Surgical approaches
Minimal invasive
TURP
Invasive “open” procedures n n n

37. dysfunctional voiding/nsu3062/rsetyowati
“watchful waiting”
For mild symptoms. follow up1 to 2 times yearly n
Offer suggestions that help reduce symptoms
Avoid caffeine and alcohol
Avoid decongestants and antihistamines n n n

38. dysfunctional voiding/nsu3062/rsetyowati
Medication
First line of defense against bothersome urinary symptoms
Two major types:
α blockers - relax the smooth muscle of prostate and provide a larger urethral opening (Hytrin,Doxaben, Harnalidge) n n n
Relaxation of these muscle bundles lessens the resistance to outflow during urination.α
5 α reductase inhibitor - Shrink the prostate gland (Proscar, Avodart) n

39. Possible side effects of
dysfunctional voiding/nsu3062/rsetyowati
Possible side effects of
medication
Impotence
Dizziness
Headaches
Fatigue
Loss of sexual drive n n n
Relaxation of these muscle bundles lessens the resistance to outflow during urination. n n

40. dysfunctional voiding/nsu3062/rsetyowati
Surgical treatment
Until recently, the only option we could offer patients for treatment of their symptoms was either an open abdominal surgical procedure, or a trans-urethral resection of the prostate.

41. Indication of surgical intervention
Acute urinary retention
Gross hematuria
Frequent UTI
Vesical stone
BPH related hydronephrosis or renal function deterioration
Obstruction
IPSS≧8, prostate size, image study, UFR
cystoscopic findings, residual urine

42. Conventional Surgical Therapy
Transurethral resection of the prostate (TURP)
Open simple prostatectomy

43. dysfunctional voiding/nsu3062/rsetyowati
TURP
(transurethral resection of the prostate)
“Gold Standard” of care for BPH
Uses an electrical “knife” to surgically cut and remove excess prostate tissue
Effective in relieving symptoms and restoring urine flow n n n

44. TURP “Gold standard” of surgical treatment for BPH
80~90% obstructive symptom improved
30% irritative symptom improved
Low mortality rate 0.2%

45. The “gold standard”- TURP
dysfunctional voiding/nsu3062/rsetyowati
The “gold standard”- TURP
Benefits
Widely available
Effective
Long lasting
Disadvantages
Greater risk of side effects and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery n n n n n n n

46. Complication of TURP Immediate complication bleeding Late complication
capsular perforation with fluid extravasation
TUR syndrome
Late complication
urethral stricture
bladder neck contracture (BNC)
retrograde ejaculation
impotence (5-10%)
incontinence (0.1%)

47. Open Simple Prostatectomy
dysfunctional voiding/nsu3062/rsetyowati
Open Simple Prostatectomy
“too large prostate” -- >100 gm
Combined with bladder diverticulum or vesical stone surgery
Suprapubic or retropubic method

48. NURSING CARE
NURSING PROBLEM
Urinary Retention
Risk for infection
Deficit knowledge