Transcript Urinary Incontinence - Wound/Ostomy Related Documents

Urinary
Incontinence
Barbara Dale RN CWON CHHN
Quality Home Health
September 25, 2006
Urinary Incontinence
• Urinary incontinence is defined as the
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involuntary leakage of urine from the bladder
Urinary Incontinence affects 17 million people in
the United States every year with 85% of them
women
One in three persons over age 60 are affected
by urinary incontinence
38% of women over 60 are affected
87% of all forms of incontinence can be
effectively managed
http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.htm
Causes
• Hormonal changes
• Weakened pelvic muscles r/t childbirth
• Prostate disorders/surgery
• Pelvic trauma
• Spinal cord damage
• Caffeine
• Medications
• Neurological/Cognitive disorders such as
MS & Alzeimer’s
Urinary incontinence is not a natural
part of aging.
It can happen at any age, and can be caused by
many physical conditions. Many causes of
incontinence are temporary and can be
managed with simple treatment. Some causes of
temporary incontinence are:
– Urinary tract infection
– Vaginal infection or irritation
– Constipation
– Effects of medicine
Voiding Physiology
• Normal voiding requires coordination
between multiple structures and nerve
pathways.
• Key structures include the brain,
brainstem, spinal cord, bladder, and
urethral sphincter mechanism.
The Brain and Social Continence
• The brain(cerebral cortex) provides overall
control and direction of bladder function.
– The Detrusor area in the cerebral cortex controls
bladder function by directing the micturition centers
to initiate or delay voiding depending on the social
situation. This is called social continence
– Any disruption in the cerebrocortical function can
cause or contribute to incontinence.
– CVA is a common cause of incontinence because the
two most common arteries involved in CVA are the
same two that supply the detrusor area of the brain.
Brainstem
• The pontine micturition center in the brainstem
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provides for automatic coordinated voiding.
Meaning the urethra opens before the bladder
contracts.
The pons also holds the micturition ‘reflex’
center which allows the bladder to empty when
reaching a certain fullness irregardless of social
situation. Especially important for spinal cord
patients.
Spinal Cord Pathways
• Parasympathetic-comes off at S2-S4 and
cause the bladder to contract and the
urethra to relax. Parasympathetic
stimulation initiates voiding.
• Sympathetic pathways come off at T-10
L2 that cause bladder neck to tighten and
also contribute to bladder relaxation.
Sympathetic stimulation contributes to
urine storage and promotes continence.
Bladder, Urethra, and Sphincters
Types of Incontinence
• Stress
• Urge
• Mixed stress/urge
• Overflow (retention)
People with urge incontinence lose urine as soon
as they feel a strong need to go to the
bathroom.
(AKA Overactive bladder)
If you have urge incontinence you may
leak urine:
• When you can't get to the bathroom quickly
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enough
When you drink even a small amount of liquid,
or when you hear or touch running water
You may go to the bathroom very often; for
example, every two hours during the day and
night
You may even wet the bed
Urge Incontinence Causes/Risk Factors
• Aging is a risk factor simply due to
reduced bladder capacity, delayed
recognition of bladder filling resulting in
reduced “response” time.
• Bladder irritants, neurological lesions,
stones, cancer, obstructed flow.
• Idiopathic
People with stress incontinence lose urine when
they exercise or move in a certain way. If you
have stress incontinence, you may leak urine:
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When you sneeze, cough, or laugh
When you get up from a chair or out of bed
When you walk or do other exercise
You may also go to the bathroom often during
the day to avoid accidents.
People with overflow incontinence may feel that
they never completely empty their bladder. If
you have overflow incontinence, you may:
• Often lose small amounts of urine during the
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day and night
Get up often during the night to go to the
bathroom
Often feel as if you have to empty your bladder
but can't
Pass only a small amount of urine but feel as if
your bladder is still partly full
Spend a long time at the toilet, but produce only
a weak, dribbling stream of urine
Overflow Incontinence Causes
• People with overflow incontinence do not feel the urge to urinate. The
bladder never empties normally and remains at least partially full; small
amounts of urine are leaked on a nearly continuous basis. Weak bladder
muscles -- caused by nerve damage from diabetes or other diseases -- or
a blocked urethra can be responsible for overflow incontinence.
• Overflow incontinence most frequently appears in older men in whom an
enlarged prostate hinders the flow of urine; urinary stones or tumors
also may block the urethra. Overflow incontinence is rare in women,
although sometimes it is caused by fibroid or ovarian tumors. Spinal cord
injuries or nervous system disorders are additional causes of overflow
incontinence.
Some of the symptoms of overflow incontinence are:
Feeling as though the bladder is never completely empty.
Feeling the urge to urinate, but not being able to.
Passing a dribbling stream of urine, even after spending a long time at
the toilet.
Frequently getting up at night to urinate.
Although some people with overflow incontinence never have the feeling
of a full bladder, they may leak urine day and night.
Functional Incontinence
• Diagnosis: Usually one of elimination. Patient
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voids large amounts at regular intervals.
Incontinence in patient with normal voiding
patterns and normal bladder function, usually
related to cognitive status, motivation, and/or
mobility issues.
Cortex doesn’t process the signals from the
bladder. An automatic voiding when bladder is
full. No social continence.
Tx: prompted or timed voiding. Containment
products and skin care.
Treatments
• Pelvic Muscle Rehabilitation
• Behavioral therapy
• Pharmacological Therapies
• Pessary
• Surgical Therapies
Assessment and Evaluation
• MD/UNP/WOCN
• DIAPPERS
• Bladder Diary
DIAPPERS
D-Delirium
I- Infection
A-Atrophic urethritis/vaginitis
P-Pharmaceuticals
P-Psychological Status
E-Endocrine changes
R-Restricted mobility
S-Stool Impaction
Pelvic Muscle Rehabilitation
• Kegels
• Vaginal weights
• Biofeedback
Kegel Exercises
• The first step is to find the right muscles. Imagine
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that you are sitting on a marble and want to pick up
the marble with your vagina. Imagine “pulling" the
marble up into your vagina.
Try not to squeeze other muscles at the same time.
Be careful not to tighten your stomach, legs, or
buttocks. Squeezing the wrong muscles can put more
pressure on your bladder control muscles. Just
squeeze the pelvic muscles. Don't hold your breath.
Do not practice while urinating.
• Repeat, but don't overdo it. At first, find a quiet spot to
practice—your bathroom or bedroom—so you can
concentrate. Pull in the pelvic muscles and hold for a
count of 3. Then relax for a count of 3. Work up to 3
sets of 10 repeats. Start doing your pelvic muscle
exercises lying down. This is the easiest position to do
them because the muscles do not need to work against
gravity. When your muscles get stronger, do your
exercises sitting or standing. Working against gravity is
like adding more weight.
• Be patient. Don't give up. It takes just 2-5 minutes a
day. You may not feel your bladder control improve for 3
to 6 weeks. Still, most people do notice an improvement
after a few weeks.
Behavioral Therapies
• Scheduled toileting
• Prompted voiding
• Improved access to toilets
• Managing fluids and diet
• Disposable absorbent undergarments
Bladder Training
• Bladder training has many variations but
generally consists of three primary
components:
– Education
– Scheduled voiding
– Positive reinforcement
• The education program usually combines a written,
visual, and verbal instruction package that
addresses the physiology and pathophysiology of
the lower urinary tract. The voiding schedule
incorporates a progressively increased interval
between mandatory voidings with concomitant
distraction or relaxation techniques. The person is
taught to delay voiding consciously. If the patient is
unable to delay voiding between schedules, one
approach is to adjust this schedule and start the
timing from the last void. Another option is to keep
the prearranged schedule and disregard the
unscheduled void between schedules. Positive
reinforcement is provided. A bladder retraining
program requires the participant to resist or inhibit
the sensation of urgency, to postpone voiding, and
to urinate according to a timetable rather than
according to the urge to void. This form of training
has been used to manage UI due to bladder
instability.
Habit Training
• Habit training or timed voiding is scheduled
toileting on a planned basis. The goal is to keep
the person dry by telling them/assisting them to
void at regular intervals. Attempts are made to
match the voiding intervals to the person's
natural voiding schedule. Unlike bladder
retraining, there is no systematic effort to
motivate the patient to delay voiding and resist
urge.
Timed Voiding Management
• Goal: To keep patient dry(at least during waking
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hours) by toileting him/her often enough to
prevent incontinence.
Guidelines: Determine patients usual voiding
frequency by having caregiver complete bladder
chart/diary. Instruct caregiver to take patient to
bathroom according to schedule and “cue” to
void. Alternative in LTC environment that may
be more effective is ADL based schedule: upon
arising, after lunch, before supper, and at
bedtime.
Trouble shooting Timed voiding
• Pt who is voiding small amounts needs to
be evaluated for additional factors
contributing to bladder dysfunction and
incontinence such as infection, impaction,
retention, bladder irritants. If reversible
factors and retention have been ruled out,
consult MD for possible trial of
anticholinergics.
Prompted Voiding
Prompted voiding has been shown to be effective
in dependent or cognitively impaired nursing
home incontinent patients. As a supplement to
habit training, prompted voiding attempts to
teach the incontinent person to discriminate
their incontinence status and to request
toileting assistance from caregivers. There are
three major elements to prompted voiding:
Monitoring. The person is checked by caregivers
on a regular basis and asked to report verbally
if wet or dry. Prompting. The person is asked
(prompted) to try to use the toilet. Praising.
The person is praised for maintaining
continence and for attempting to toilet.
Pharmacological
Work on parasympathetic nervous system
• Cholinergics
– Urecholine promotes bladder
contractility/reduce retention
• Anticholinergics
– Ditropan reduces sensory urgency and
bladder contractility
Medications that affect Continence
• Sedatives (hypnotics, alcohol)
• Diuretics
• Anticholinergic drugs (antipsychotics,
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antidepressants, antihistamines, antiParkinson’s, antiarrhythmics, antispasmodics,
antidiarrheals)
Antihypertensive drugs that relax smooth muscle
including the bladder neck (catapres, aldomet,
minipress)
Adrenergics-decongestants that tighten the
bladder neck (Afrin, Sudafed, Dexedrine,
Phenylephrine)
Pessaries
• A pessary is a rubber device that is inserted into
the vagina until it touches the cervix. The
pessary presses through the vaginal wall and
supports the urethra. It also pinches the urethra
closed to help retain urine in the bladder and
decrease stress incontinence. Some women
with stress incontinence use a pessary just
during activities that are likely to cause urine
leakage, such as jogging. However, many
pessaries can be worn all the time. If you use a
pessary, you should watch for possible vaginal
and urinary tract infections and see your health
professional regularly.
Surgery
• Typically utilized to correct urethral
hypermobility
• Sling procedures
• Collagen injections
• Bladder “tack’
Diagnostic Evaluations
• Urodynamics-to determine voiding dysfunction
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etiology and bladder/urethra function
Focused Physical examination and history
Dexterity testing
Pelvic muscle strength testing
Prostate exam
Cystoscopy to visualize bladder wall and identify
lesions.
Remember, incontinence is
sometimes curable, often
treatable, but Always
manageable.