urinary incontinence - aliza ben-zacharia

8/6/2019 Urinary Incontinence - Aliza Ben-Zacharia

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Urinary IncontinenceUrinary Incontinence

Aliza BenAliza Ben--Zacharia, ANP, MSNZacharia, ANP, MSN

The Corinne Goldsmith DickinsonThe Corinne Goldsmith DickinsonCenter for Multiple SclerosisCenter for Multiple Sclerosis

The Mount Sinai Medical CenterThe Mount Sinai Medical [email protected]@mssm.edu


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Anatomy of MicturitionAnatomy of Micturition

Detrusor muscleDetrusor muscle

External and InternalExternal and Internalsphinctersphincter

Normal capacity 300Normal capacity 300--

600cc600cc First urge to void 150First urge to void 150--

300cc300cc

CNS controlCNS control PonsPons -- facilitatesfacilitates

Cerebral cortexCerebral cortex -- inhibitsinhibits

ParasympatheticParasympathetic --Bladder contractionBladder contraction

SympatheticSympathetic -- BladderBladderRelaxationRelaxation

SympatheticSympathetic -- BladderBladderneck and urethralneck and urethralcontractioncontraction

Somatic (PudendalSomatic (Pudendalnerve)nerve) -- contractioncontractionpelvic floor musculaturepelvic floor musculature


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Prevalence of Urinary IncontinencePrevalence of Urinary Incontinence

Urinary incontinenceUrinary incontinenceinvoluntary loss of urineinvoluntary loss of urine

sufficient to be a problemsufficient to be a problem

Affects 13 million AmericansAffects 13 million Americans 33% of women >65 have some degree of UI33% of women >65 have some degree of UI

26% of women>18 experience various degree of SI26% of women>18 experience various degree of SI 15% to 30% of noninstitutionalized older adults15% to 30% of noninstitutionalized older adults

(19% men; 39% women)(19% men; 39% women)

Prevalence increases with age (not normal aging)Prevalence increases with age (not normal aging)

50% of those in nursing facilities50% of those in nursing facilities Nygaard et al., Obstet Gyneco 2003; 101: 149Nygaard et al., Obstet Gyneco 2003; 101: 149--56.56.

Thom D. J Am Geriat Society 1998; 46:473Thom D. J Am Geriat Society 1998; 46:473--80.80.


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Urinary Incontinence is CommonUrinary Incontinence is Common

Among Older AdultsAmong Older Adults

Men

Women

18

16

14

1210

8

64

2

0

Percenta

ge

ofresp

ondents

in

each

age

gr

oup

5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85Age (years)


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This is an example of one woman's idea ofThis is an example of one woman's idea ofanother great use for duct tape.another great use for duct tape.

(She lives in a household with five guys!)(She lives in a household with five guys!)


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Economic CostsEconomic Costs

10 Billion Dollars10 Billion Dollars19871987

30 Billion Dollars30 Billion Dollars19951995 Cost of UI in 1995 : $24.3 billion or $3,565 perCost of UI in 1995 : $24.3 billion or $3,565 per

incontinent personincontinent person

Cost of UI > Coronary artery bypass surgery + renalCost of UI > Coronary artery bypass surgery + renaldialysisdialysis

Cost : Physical, Psychosocial & economicCost : Physical, Psychosocial & economic Wagner, Urology 1998; 51:355Wagner, Urology 1998; 51:355--61.61.

Resnick, JAMA 1998; 280:2034Resnick, JAMA 1998; 280:2034--5.5.

Hendrix, DiseaseHendrix, Disease--AA--Month, 2002; 48:622Month, 2002; 48:622--636.636.


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Direct Cost of UrinaryDirect Cost of Urinary Incontinence in the USAIncontinence in the USA

US

$

billi

on

20

16

12

8

4

0

1984 1987 1993


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Factors Associated withFactors Associated with

Bladder Control ProblemsBladder Control ProblemsAge

Childbirth Gender

Menopausal Status Surgery

Prostate enlargement Lifestyle

Medications Concomitant illnesses


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Urinary IncontinenceUrinary Incontinence UI is not a normal partUI is not a normal part

of agingof aging

Loss of urine due to aLoss of urine due to acombination ofcombination of

Genitourinary pathologyGenitourinary pathology AgeAge--related changesrelated changes

Comorbid conditionsComorbid conditions

Environmental obstaclesEnvironmental obstacles

Age related changes (BPH,Age related changes (BPH,atrophic vaginitis)atrophic vaginitis)

Dementia, depression, stroke,Dementia, depression, stroke,PD, MSPD, MS

Constipation/FecalConstipation/Fecal

incontinenceincontinence COPD, or chronic coughCOPD, or chronic cough

Detrusor overactivity &Detrusor overactivity &uninhibited contractionsuninhibited contractions

Increased PVR or decreasedIncreased PVR or decreasedcapacitycapacity

Impaired ADLsImpaired ADLs

ObesityObesity


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Types of IncontinenceTypes of Incontinence

Urge incontinenceUrge incontinencestrong urge to voidstrong urge to void ImmediatelyImmediately preceded by a sensation of urgent need to urinate, with or withopreceded by a sensation of urgent need to urinate, with or withoutut

increased frequencyincreased frequency

Stress incontinenceStress incontinenceincreased intraincreased intra--abdominalabdominalpressure that lead to incontinencepressure that lead to incontinence

On exertion, or sneezing or coughingOn exertion, or sneezing or coughing Overflow incontinenceOverflow incontinenceoverover--distended bladderdistended bladder

leading to UI / dribblingleading to UI / dribbling

Functional incontinenceFunctional incontinencephysical / psychologicalphysical / psychologicalimpairmentimpairment UI due to inability getting to BRUI due to inability getting to BR

Mixed incontinenceMixed incontinencecombination of 2 or morecombination of 2 or more

typestypes


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Urge IncontinenceUrge Incontinence

Most common cause of UI >75 years of ageMost common cause of UI >75 years of age

Abrupt desire to void cannot be suppressedAbrupt desire to void cannot be suppressed Usually idiopathicUsually idiopathic

Causes: infection, tumor, stones, atrophicCauses: infection, tumor, stones, atrophicvaginitis or urethritis, stroke, Multiplevaginitis or urethritis, stroke, Multiple

sclerosis, Parkinsonsclerosis, Parkinsons Disease, dementias Disease, dementia

Other Names: OAB, detrusor hyperactivity, detrusor

instability, irritable bladder, spastic bladder


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Overactive BladderOveractive Bladder

Frequency

OVERACTIVE BLADDER

Urgency

Urge

incontinence


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When you got to go, you got to go!When you got to go, you got to go!


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Stress IncontinenceStress Incontinence Most common type in women < 75 years oldMost common type in women < 75 years old

Occurs with increase in abdominal pressure;Occurs with increase in abdominal pressure;cough, sneeze, etc.cough, sneeze, etc.

HypermotilityHypermotility of bladder neck and urethraof bladder neck and urethra;;associated with aging, hormonal changes, trauma of childbirthassociated with aging, hormonal changes, trauma of childbirthor pelvic surgery (85% of cases)or pelvic surgery (85% of cases)

Intrinsic sphincterIntrinsic sphincter problems;problems; due todue topelvic/incontinence surgery, pelvic radiation, trauma,pelvic/incontinence surgery, pelvic radiation, trauma,

neurogenic causes (15% of cases)neurogenic causes (15% of cases)


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Stress IncontinenceStress Incontinence(a) Continent woman (b) Woman with stress

incontinence

Externalurethral

sphincter

Sudden increase in intra-abdominal pressure


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Overflow IncontinenceOverflow Incontinence Over distention ofOver distention of

bladderbladder

Bladder outletBladder outletobstruction;obstruction; stricture,stricture,BPH, cystocele, fecalBPH, cystocele, fecalimpactionimpaction

NonNon--contractile bladdercontractile bladder(hypoactive detrusor or(hypoactive detrusor oratonic bladder);atonic bladder); Diabetes,Diabetes,MS, Spinal Injury,MS, Spinal Injury,MedicationsMedications


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Functional IncontinenceFunctional Incontinence Does not involve lower urinary tractDoes not involve lower urinary tract

Result of psychological, cognitive or physicalResult of psychological, cognitive or physicalimpairmentimpairment

i d I i ( ld )Mi d I i ( ld )


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Mixed Incontinence (older women)Mixed Incontinence (older women) Stress & Urge IncontinenceStress & Urge Incontinence

Sudden increasein intra-abdominalpressure

Uninhibited detrusorcontractions


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Potentially Reversible CausesPotentially Reversible Causes

DD -- DeliriumDeliriumII -- InfectionInfectionAA -- Atrophic vaginitis or urethritisAtrophic vaginitis or urethritisPP -- PharmaceuticalsPharmaceuticalsPP -- Psychological disordersPsychological disordersEE -- Endocrine disordersEndocrine disordersRR -- Restricted mobilityRestricted mobilitySS -- Stool impactionStool impaction

R ibl f i iR ibl f i i


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Reversible causes of incontinenceReversible causes of incontinence

(DRIP Mnemonic)(DRIP Mnemonic) DeliriumDelirium Restricted mobilityRestricted mobility

(illness, injury, gait(illness, injury, gaitdisorder, restraint)disorder, restraint)

Infection;Infection;

InflammationInflammation (atrophic(atrophicvaginitis);vaginitis); ImpactionImpaction ofofstoolstool

PolyuriaPolyuria (diabetes(diabetesmellitus, caffeine intake,mellitus, caffeine intake,volume overload);volume overload);

PharmaceuticalsPharmaceuticals


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Other factors causing IncontinenceOther factors causing Incontinence

Antidepressants, sedatives,Antidepressants, sedatives,antipsychoticantipsychotic

Sedation, retention (overflow)Sedation, retention (overflow)

DiureticsDiuretics Frequency, urgencyFrequency, urgency--OABOAB

CaffeineCaffeine Frequency, urgencyFrequency, urgency--OABOAB

AnticholinergicsAnticholinergics Retention (overflow)Retention (overflow)

AlcoholAlcohol

Sedation,frequencySedation,frequency

--OABOAB

NarcoticsNarcotics Retention, constipation, sedationRetention, constipation, sedation

(overflow/OAB)(overflow/OAB)

Adrenergic blockersAdrenergic blockers Decreased urethral toneDecreased urethral toneAdrenergic agonistsAdrenergic agonists--ClonidineClonidine Increased urethral toneIncreased urethral tone

Calcium Channel BlockersCalcium Channel Blockers Retention (overflow)Retention (overflow)

ACE inhibitorsACE inhibitors Cough (Stress Incontinence)Cough (Stress Incontinence)


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Why is Treatment of Incontinence Important?Why is Treatment of Incontinence Important?

Medical complicationsMedical complications -- skin breakdown,skin breakdown,

increased risk of fractures, increased urinaryincreased risk of fractures, increased urinary

tract infectionstract infections

Social stigmaSocial stigma -- leads to social isolation, declineleads to social isolation, declinein function, restricted activities and depressionin function, restricted activities and depression

InstitutionalizationInstitutionalization -- UI is the second leadingUI is the second leadingcause of nursing home placementcause of nursing home placement


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Urinary Incontinence is OftenUrinary Incontinence is Often

UnderUnder--Diagnosed and UnderDiagnosed and Under--TreatedTreated Only 32% of primary care physicians routinelyOnly 32% of primary care physicians routinely

ask about incontinenceask about incontinence

Often not mentioned to physiciansOften not mentioned to physicians

5050--75% of patients never describe symptoms75% of patients never describe symptoms

to physiciansto physicians

80% of urinary incontinence can be cured80% of urinary incontinence can be curedor improvedor improved


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Taking the HistoryTaking the History

Duration, severity,Duration, severity,

symptoms, previoussymptoms, previous

treatment, medications,treatment, medications,

GU surgeryGU surgery

3 P3 Pss Position of leakagePosition of leakage

(supine, sitting, standing)(supine, sitting, standing)

Protection (pads per day,Protection (pads per day,wetness of pads)wetness of pads)

Problem (quality of life)Problem (quality of life)

Voiding DiaryVoiding Diary

Document number ofDocument number ofvoids per dayvoids per day

VolumesVolumes

Number of incontinentNumber of incontinent

episodesepisodes Severity of the problemSeverity of the problem

Time of day withTime of day with

increased incontinenceincreased incontinence Morning incontinence mayMorning incontinence may

be associated with diureticbe associated with diureticuseuse


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Bladder DiaryBladder Diary

Date: Monday 19 MarchTime Drinks

(types and

amount)

Amountof urine

passed(ml)

Did you feel astrong and

sudden desire tourinate ( if yes)

If leakage occurs,amount of urine

leaked

SSmmaallll MMeeddiiuumm LLaarrggee8:00 am Tea, 2 cups

8:30 am 150 ml 10:00 am Coffee, 1 mug 11:15 am 200 ml

12:00 pm 100 ml

1:00 pm 100 ml

2:00 pm Cola, 1 can

2:30 pm


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Urinary AssessmentUrinary Assessment Four questions (Caroline Sampselle, PhD)Four questions (Caroline Sampselle, PhD)

Are you leaking urine?Are you leaking urine?

Do you have trouble making it to the BR orDo you have trouble making it to the BR or

Do you urinate very frequently?Do you urinate very frequently? Do you leak urine when you cough, stand,Do you leak urine when you cough, stand,

sneeze?sneeze? Do you wear a pad for urine leakage?Do you wear a pad for urine leakage?


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Evaluation of IncontinenceEvaluation of Incontinence

Medical historyMedical history::

SymptomsSymptomsassociated withassociated with

incontinenceincontinence

Surgical historySurgical history

Social historySocial history

Obstetric &Obstetric &

MedicationsMedications

PhysicalPhysical

examinationexamination: Neuro,: Neuro,abdominal & pelvic &abdominal & pelvic &

rectal examinationrectal examination

ExaminationExaminationproceduresprocedures: PVR,: PVR,

UrodynamicsUrodynamics LaboratoriesLaboratories: UA,: UA,

urine culture, blood testurine culture, blood test


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Interpretation of PostInterpretation of Post--Void ResidualVoid ResidualPVR < 50ccPVR < 50cc --

Adequate bladder emptyingAdequate bladder emptying

PVR > 100ccPVR > 100cc -- Detrusor weakness,Detrusor weakness,neuropathy or outlet obstructionneuropathy or outlet obstructionPVR > 150ccPVR > 150cc -- Avoid bladder relaxingAvoid bladder relaxingdrugsdrugsPVR > 200ccPVR > 200cc -- Refer to UrologyRefer to UrologyPVR > 400ccPVR > 400cc -- Overflow UrinaryOverflow UrinaryIncontinence likelyIncontinence likely


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Bladder PressureBladder Pressure--VolumeVolume

RelationshipRelationship


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Urinary IncontinenceUrinary Incontinence When to referWhen to refer Failure of initial conservative methodsFailure of initial conservative methods Significant stress urinary incontinenceSignificant stress urinary incontinence

Recurrent urinary tract infections; HematuriaRecurrent urinary tract infections; Hematuria

Recent onset of overactive bladderRecent onset of overactive bladder

Significant pelvic prolapseSignificant pelvic prolapse

Prior incontinence surgeryPrior incontinence surgery

Prior radical pelvic surgery or radiationPrior radical pelvic surgery or radiation


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Bladder IrritantsBladder Irritants Alcoholic beveragesAlcoholic beverages

CarbonatedCarbonatedbeveragesbeverages

Medications withMedications with

caffeinecaffeine

Highly spicy foodHighly spicy food

HoneyHoney Tomatoes andTomatoes and

tomato pastetomato paste

productsproducts

Milk or milkMilk or milk

productsproducts

Coffee or teaCoffee or tea

(including decaf)(including decaf)

Citrus juice and fruitsCitrus juice and fruits

SugarSugar

ChocolateChocolate Corn syrupCorn syrup

Artificial sweetenersArtificial sweeteners


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Treatment pathwayTreatment pathwayLifestyle

interventions Refer

Mixed UIOAB with or

without urge UI

Stress UI

OAB with orwithout urge UI

Stress UI

Urodynamics if appropriate, not routinely for pure stress UI

Assess and

categorise

Behavioral management, Medical approaches,Behavioral management, Medical approaches,

Medications, Surgical proceduresMedications, Surgical procedures


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Behavioral Therapy TechniquesBehavioral Therapy Techniques LifestyleLifestyle

InterventionsInterventions Fluid & DietaryFluid & Dietary

modificationsmodifications

Eliminating bladderEliminating bladderirritantsirritants

ConstipationConstipation

preventionprevention Weight reductionWeight reduction

Smoking cessationSmoking cessation

Bladder TrainingBladder Training

Patient educationPatient education

Scheduled voidingScheduled voiding

regimenregimen

Urge controlUrge controlstrategiesstrategies

Self monitoringSelf monitoring

Pelvic Floor MusclePelvic Floor Muscle

ContractionsContractions


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Good Bladder HabitsGood Bladder Habits

Step 1Step 1: Maintain appropriatefluid intake

Step 2Step 2: Practice good toilet habits

Step 3Step 3: Maintain good bowel habits

Step 4Step 4: Exercise of pelvic floor

muscles


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Pelvic Floor Muscle ExercisesPelvic Floor Muscle Exercises

Contracting the musclesContracting the muscles

for at least 10 secondsfor at least 10 seconds

3030--40 contractions/day40 contractions/day

can prevent & treat UIcan prevent & treat UI

Using vaginal cones orUsing vaginal cones orballs to do pelvic muscleballs to do pelvic muscle

contractionscontractions

Women using devices areWomen using devices areless likely to continueless likely to continue

PFMTPFMT

Women will see resultsWomen will see results

from PFMT after 12from PFMT after 12--1616

weeksweeks

May increase sexualMay increase sexual

pleasure while doingpleasure while doingthem during intercoursethem during intercourse

Do them prior to coughDo them prior to cough

or sneeze if has stressor sneeze if has stressincontinenceincontinence


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Pelvic Floor ExercisesPelvic Floor Exercises

Locate pelvic floor muscles

Squeeze pelvic

floor musclesas tightly aspossible for afew seconds(maximum of10 seconds)

Relax completely for atleast 10 seconds

Repeat, asrecommendedby physician/

continenceadvisor

Ph i l h B d


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Physical therapy & BodyPhysical therapy & Body

MechanicsMechanics Physical therapyPhysical therapy

programprogram

Strengthening pelvicStrengthening pelvic

floor musclesfloor muscles Controlling spasticityControlling spasticity

Maintaining postureMaintaining posture& body mechanics& body mechanics

while doing ADLswhile doing ADLs

Other interventions

Pessaries


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Pessaries

Incontinence Pads andIncontinence Pads and


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Incontinence Pads and

Protective EquipmentProtective Equipment

Absorbent pads

Dribble pouch

Reusable underpantsdesigned to carrydisposable absorbent pads

All-in-one briefs

Chair and bed pads

Bladder Catheterization VSBladder Catheterization VS


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Bladder Catheterization VSBladder Catheterization VS

Indwelling CatheterIndwelling Catheter

Stress IncontinenceStress Incontinence


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St ess Incontinence

ManagementManagement Behavioral therapyBehavioral therapy

Pelvic floor muscle exercisesPelvic floor muscle exercises (Kegel)(Kegel)

Exercises with biofeedbackExercises with biofeedback

MedicationsMedications

AlphaAlpha--adrenergic stimulantsadrenergic stimulants (urethral closure;(urethral closure;pseudoephedrine)pseudoephedrine)

Oral EstrogenOral Estrogen -- sensitize adrenergic receptors in thesensitize adrenergic receptors in thebladder neckbladder neck

Transvaginal EstrogenTransvaginal Estrogen may be used for atrophic vaginitismay be used for atrophic vaginitis

DuloxetineDuloxetine (Cymbalta(Cymbalta--SSRI & Norepinephrine reuptakeSSRI & Norepinephrine reuptakeinhibitor) Increases urethral sphincter contractioninhibitor) Increases urethral sphincter contraction



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ManagementManagement DevicesDevices

Extracorporeal magnetic innervation (ExMI) chairExtracorporeal magnetic innervation (ExMI) chaira chair that stimulates pelvic muscles via a low intensitya chair that stimulates pelvic muscles via a low intensitymagnetic field (twice weekly in 20 minutes sessions for 8magnetic field (twice weekly in 20 minutes sessions for 8weeks)weeks)

Intravaginal support devicesIntravaginal support devicesused in patients withused in patients withexercise induced incontinenceexercise induced incontinence

PessariesPessariesUsed to treat prolapseUsed to treat prolapsesupport to bladdersupport to bladder

neck (long term use requires monitoring for vaginalneck (long term use requires monitoring for vaginalinfection and ulceration)infection and ulceration)

Pessaries may worsen urge incontinencePessaries may worsen urge incontinence by reducingby reducing

obstruction as a result of the prolapseobstruction as a result of the prolapse



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ManagementManagement Behavioral therapyBehavioral therapy

Bladder trainingBladder trainingmore effective than oxybutinin &more effective than oxybutinin &improves incontinence in more than 50% of patientsimproves incontinence in more than 50% of patients

Dietary manipulationsDietary manipulations (Fluid intake: 30mL/kg of body(Fluid intake: 30mL/kg of bodyweight, 0.5oz/lb)weight, 0.5oz/lb)

Kegel exercisesKegel exercisesRCT: Patients doing Kegel exercisesRCT: Patients doing Kegel exerciseshad an 81% reduction in incontinence episodes comparedhad an 81% reduction in incontinence episodes comparedwith 69% decrease in oxybutinin patients (statisticalwith 69% decrease in oxybutinin patients (statistical

significant)significant) Biofeedback trainingBiofeedback training for learning effective Kegelfor learning effective Kegel

technique (does not show increase efficacy)technique (does not show increase efficacy)

d


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Medications for treatment of UrgeMedications for treatment of Urge

IncontinenceIncontinence AnticholinergicsAnticholinergics

Inhibit involuntaryInhibit involuntarybladder contractionsbladder contractions

Increase in bladderIncrease in bladder

capacitycapacity

Oral agentsOral agents

Oxybutinin (DitropanOxybutinin (Ditropan)) Tolterodine (DetrolTolterodine (Detrol))

Short & Long actingShort & Long acting

Side effectsSide effects:: Dry mouth,Dry mouth,

Constipation, Blurred vision,Constipation, Blurred vision,Nausea, Dizziness,Nausea, Dizziness,Headache, Altered cognitiveHeadache, Altered cognitivefunctionfunction

Transdermal agentTransdermal agent Oxybutinin (OxytrolOxybutinin (Oxytrol))

One patch twice weeklyOne patch twice weekly

BotoxBotox off labeloff label

Refractory to oral medsRefractory to oral meds& neurogenic bladder& neurogenic bladder



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ManagementManagement Electrical TherapyElectrical Therapy

Indicated in patients with severeIndicated in patients with severerefractory urge incontinencerefractory urge incontinence

A generator device that isA generator device that isinserted into the sq tissue of theinserted into the sq tissue of the

lower back or buttockslower back or buttocks The generator powers a lead thatThe generator powers a lead that

is placed through the sacralis placed through the sacralforamen to stimulate theforamen to stimulate the S3S3sacral nerve to decreasesacral nerve to decreasedetrusor muscle contractionsdetrusor muscle contractions

Effective treatmentEffective treatment

Cost of deviceCost of device--$10,000$10,000

(covered by Medicare)(covered by Medicare)

Overflow IncontinenceOverflow Incontinence


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Overflow IncontinenceOverflow Incontinence

ManagementManagement Urinary retentionUrinary retention? Bladder emptying? Bladder emptying

Identify the etiology of retentionIdentify the etiology of retention Poor detrusor contractionPoor detrusor contraction

A trial of betanechol (cholinergic agent)A trial of betanechol (cholinergic agent)

Multiple side effects: flushing, N/V/D, bronchospasm, H/A,Multiple side effects: flushing, N/V/D, bronchospasm, H/A,salivation, sweating, & visual changessalivation, sweating, & visual changes

Intermittent catheterization or a chronic indwelling catheter inIntermittent catheterization or a chronic indwelling catheter insevere detrusor hyposevere detrusor hypo--contractilitycontractility

Bladder outflow obstructionBladder outflow obstruction Usually associated with pelvic organ prolapseUsually associated with pelvic organ prolapse

Referral to a urologistReferral to a urologist

Mixed IncontinenceMixed Incontinence


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ManagementManagement Initial treatment ofInitial treatment of

symptomssymptoms

NonNon--invasive behavioral &invasive behavioral &rehabilitative therapyrehabilitative therapy

Bladder trainingBladder training

Eliminating irritantsEliminating irritants Pelvic muscle exercisesPelvic muscle exercises

Medical treatment optionsMedical treatment options

No drugs for SINo drugs for SI Surgical therapy for SUISurgical therapy for SUI

Referral to a urologistReferral to a urologist

Functional IncontinenceFunctional Incontinence


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Functional IncontinenceFunctional Incontinence

ManagementManagement

Physical or cognitivePhysical or cognitiveimpairmentsimpairments

Timed voidingTimed voiding Mobility assist devicesMobility assist devices

Bedside commodesBedside commodes Routine nursing careRoutine nursing care


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Transient & ContinuousTransient & Continuous


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Incontinence ManagementIncontinence Management Transient IncontinenceTransient Incontinence

Identification of theIdentification of theinciting factors forinciting factors for

transient incontinencetransient incontinence

Treat the reversible causesTreat the reversible causesas outlined by theas outlined by the

mnemonicmnemonic

DIAPPERS/DRIPDIAPPERS/DRIP

Transient incontinence canTransient incontinence can

persist if left untreatedpersist if left untreated

Continuous IncontinenceContinuous Incontinence --

urinary leakage or dribblingurinary leakage or dribbling

Unrelated to stress orUnrelated to stress orurgencyurgency

Related to an anatomicRelated to an anatomic

abnormalityabnormality Urethral diverticulumUrethral diverticulum

Urinary fistulaUrinary fistula

Referral to a specialistReferral to a specialist Further diagnostic evaluationFurther diagnostic evaluation

Surgical correctionSurgical correction

K Clini l r mm nd ti nKey Clinical recommendations


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Key Clinical recommendationsKey Clinical recommendations

Patients with urge incontinence should bePatients with urge incontinence should betaught Kegel exercises. Biofeedback does nottaught Kegel exercises. Biofeedback does not

improve the efficacy of the exercisesimprove the efficacy of the exercises Selection of an anticholinergic agent forSelection of an anticholinergic agent for

treatment of urge incontinence should betreatment of urge incontinence should bebased on a discussion with the patient aboutbased on a discussion with the patient aboutefficacy & side effectsefficacy & side effects

Electrical therapy can be considered inElectrical therapy can be considered inpatients with severe refractory urgepatients with severe refractory urgeincontinence who do not respond toincontinence who do not respond tobehavior therapy & medicationsbehavior therapy & medications


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Case StudyCase Study


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Case StudyCase Study

CC:CC: I have been having problems overI have been having problems over

the past 3 months with losing my urine. Ithe past 3 months with losing my urine. I

have leaked a small amount of urine whenhave leaked a small amount of urine when

I laugh or sneeze. But it is getting worse.I laugh or sneeze. But it is getting worse.

Sometimes when I sit I feel the urge toSometimes when I sit I feel the urge tourinate. When I urinate at that time I haveurinate. When I urinate at that time I have

large amounts of urine. I have been usinglarge amounts of urine. I have been usingpads to keep myself dry.pads to keep myself dry.

Case studyCase study


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Case studyCase study History (medical, family,History (medical, family,

social, meds, ROS)social, meds, ROS)

Physical examPhysical exam

Diagnostic testsDiagnostic tests UA, C&SUA, C&S

PVRPVR

Urinary diaryUrinary diary Labs;chemistryLabs;chemistry

PE; stress testPE; stress test

Stress incontinenceStress incontinence Urge incontinenceUrge incontinence

Mixed; stress+urgeMixed; stress+urge

Overflow incontinenceOverflow incontinence

Case StudyCase Study --TreatmentTreatment


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If UTIIf UTIA course ofA course of

antibioticsantibiotics

Education & NonEducation & Non--

pharmacological Txpharmacological Tx Fluid intake issuesFluid intake issues

Hygiene and sexualHygiene and sexual

Avoiding bladderAvoiding bladderirritantsirritants

Urge control by usingUrge control by using

breathing exercisesbreathing exercises KegelKegels/PFME cans/PFME can

be effectivebe effective

Stress IStress Ia sympathetica sympatheticagonist acts by increasingagonist acts by increasing

sphincter tonesphincter tone

(pseudoephedrine)(pseudoephedrine) Overflow IOverflow Iwith obstructionwith obstruction

a med to increase bladdera med to increase bladder

tonetonebethanecholbethanechol Overactive detrusorOveractive detrusoraa

med to decrease bladder tonemed to decrease bladder tone

anticholinergicanticholinergic

**AnticholinergicAnticholinergic

medications may causemedications may cause

urinary retentionurinary retention

To All Employees: To maximize productivity and make us more


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efficient, we are going to modify all work areas: It is expected that this change will increaseproductivity by approximately 4.58%
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urinary incontinence - aliza ben-zacharia

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