Transcript فایل۲
اپیدمیولوژی و عوامل خطر اختالالت اورولوژی در سالمندان ارزیابی و تشخیص اختالالت اورولوژی در سالمندان Urinary incontinence is a major problem for the elderly: It afflicts 15% to 30% of older people living at home, one third of those in acutecare settings, and half of those in nursing homes UI is twice as common in women as in men Risk factors in women Pregnancy and vaginal delivery are significant risk factors, but become less important with age. Diabetes mellitus is a risk factor in most studies pelvic organ prolapse (POP) Risk factors in men increasing age, lower urinary tract symptoms (LUTS), infections, functional and cognitive impairment, neurological disorders and prostatectomy. perineal rashes, pressure ulcers, UTI, urosepsis, falls, and fractures embarrassment, stigmatization, isolation, depression, anxiety, sexual dysfunction, cost more than $26 billion to manage incontinence in America’s elderly in 1995 THE IMPACT OF AGE ON INCONTINENCE However, it appears that although bladder capacity does not change with age, bladder sensation, contractility, and the ability to postpone voiding decline in both sexes, while urethral length and maximum closure pressure, as well as striated muscle cells in the rhabdosphincter and urogenital diaphragm, probably decline withage in women Venous insufficiency, renal disease, heart failure, or BPH طبقه بندی بی اختیاری ادرار بر اساس زمان استمرار مشکل: الف -بی اختیاری ادرار گذرا :چنانچه سالمند داراي حداقل يك نشانه به صورت غير دايمي و گاهي اوقات از روز است در طبقه « در معرض مشکل» بي اختیاري ادرار گذرا قرار مي گيرد. ب -بی اختیاری ادراری دایمی :چنانچه سالمند داراي حداقل يك نشانه به صورت هميشگي يا اكثر اوقات در روز است ،در طبقه «مشكل» بي اختیاري ادراري دایمي قرار مي گيرد. CAUSES OF TRANSIENT INCONTINENCE: “DIAPERS” Delirium/ confusional state Infection—Urinary Atrophic urethritis/ vaginitis Pharmaceuticals Excess urine output Restricted mobility Stool impaction Commonly Used Medications That May Affect Continence Sedatives/hypnotics Alcohol Anticholinergics Narcotic analgesics(opiates) retention, fecal impaction α-Adrenergic antagonists & agonists: SUI in women Calcium channel blockers: fluid retention Potent diuretics NSAIDs: Nocturnal diuresis due to fluid retention Parkinson agents (some) ACE inhibitors: cough can precipitate SUI in women and in some men with prior prostatectomy جدول داروهاي به وجود آورنده اي تشديد كننده يب اختیاري ادراري Excess urine output excessive fluid intake; Diuretics metabolic abnormalities (e.g., hyperglycemia and hypercalcemia); fluid overload: CHF, peripheral venous insufficiency, hypoALB drug-induced peripheral edema: NSAIDs, Ca channel blockers amantadine (for Parkinson disease and influenza), and β blockers. Restricted mobility arthritis, hip deformity, postural or postprandial hypotension, claudication, spinal stenosis, heart failure, poor eyesight, fear of falling, stroke, foot problems, drug induced disequilibrium or confusion, or being restrained in a bed or chair stool impaction urge or overflow incontinence and typically have associated fecal incontinence as well. History “urge” Urinary frequency (greater than seven diurnal voids) Nocturia: 3 general reasons: excessive urine output, sleep-related difficulties, and urinary tract dysfunction تکرر ادرار (حداقل سه بار از صبح تا ظهر ) بیدار شدن مکرر از خواب براي ادرار كردن (حداقل دو بار در کمتر از 10ساعت ) باریك شدن یا قطع شدن و دوباره جریان یافتن ادرار (معموالً در مردان) احساس ناگهاني و شدید براي ادرار كردن و ریزش ادرار قبل از رسیدن به دستشویي خروج بي اختیار ادرار هنگام عطسه ،سرفه ،خنده و یا برخاستن ( معموالً در زنان) طول مدت بی اختیاری ادرار ( اکثر اوقات در روز یا همیشگی ،گاهی اوقات در روز یا گذرا ) *عالیممم عنونممت ادرار :تكممرر ادرار ،سمموزش ادرار ،ادرار تیممره (هممماروری) واحسمماس بمماقی ماندن ادرار Stress Urinary Incontinence Urge Urinary Incontinence / OAB Overflow Urinary Incontinence True Urinary Incontinence توصیه هايي براي Stress Incontinence هر دو ساعت براي ادرار كردن به توالت برود. در طول روز 6تا 8ليوان مايعات بنوشد. بعد از ساعت 8شب از نوشيدن مايعات خودداري كند. لباس هاي آزاد و راحت بپوشد. عضالت كف لگن را تقويت كند. مثانه را تقويت كند. اگر فرد چاق است ،وزن خود را کاهش دهد. در حين سرفه و يا عطسه عضالت کف لگن را منقبض کند. توصیه هايي براي Urge Incontinence براي داشتن آرامش تمرين كند( .تمرينات آرام سازي بخش بيماري هاي قلبي و عروقي) از ورزش هاي سخت اجتناب كند. قهوه ،نوشابه هاي گازدار ،غذاهاي پرادويه ميل نكند. از بروز يبوست پيشگيری کند. توصیه هايي براي Overflow Incontinence در اين حالت سالمند ،عالئم انسدادی و احساس باقی ماندن ادرار دارد .شب ها معموالً براي ادرار كردن از خواب بيدار مي شود ،جريان ادرار ضعيف است يا حين ادرار كردن قطع و دوباره وصل مي شود و سالمند نياز به زور زدن برای ادرار کردن دارد ،اين حالت بيشتر در مردها ديده مي شود. در طول روز 6تا 8ليوان مايعات بنوشد. بعد از ساعت 8شب از نوشيدن مايعات خودداري كند (تقريبا سه ساعت قبل از خواب) . در زمان ادرار كردن عضالت شكم را سفت كند .سپس به آرامي با دست زير شكم را به سمت پايين فشار دهد .اين فشار به مثانه منتقل شده و به تخليه ادرار كمك مي كند. ESTABLISHED INCONTINENCE Lower Urinary Tract Causes Detrusor overactivity (DO) is the most common type of lower urinary tract dysfunction in incontinent elderly of either sex one in which contractile function is preserved and one in which it is impaired: The latter condition is termed detrusor hyperactivity with impaired contractility (DHIC) and is likely the most common form of DO in the elderly SUI is the second most common cause of incontinence in older women. In men, SUI is usually due to sphincter damage following radical prostatectomy Incontinence in the setting of outlet obstruction is the second most common cause of incontinence it generally presents as urge incontinence owing to the associated DO; Detrusor underactivity is usually idiopathic When it causes incontinence, detrusor underactivity is associated with overflow incontinence Causes Unrelated to the Lower Urinary Tract (“Functional” Incontinence) attributed to deficits of cognition and mobility. may still have obstruction or stress incontinence and benefit from targeted therapy DIAGNOSTIC APPROACH Evaluation The evaluation should identify transient and established causes of incontinence, assess the patient’s environment and available support, and detect uncommon but serious conditions that may underlie incontinence Voiding Diary 48 to 72 hours the diary records the time of each void and incontinent episode functional bladder capacity Targeted Physical Examination neurologic diseases atrophic vaginitis general medical illnesses Stress Testing and PVR Measurement The cough or strain PVR Laboratory Investigation BUN, creatinine, U/A, U/C and PVR should be checked in all older patients. Serum sodium, calcium, and glucose should be measured in patients with confusion The first step is to identify individuals with overflow inc (e.g., PVR > 450 mL) Because obstruction and underactive detrusor cannot be differentiated clinically The next step is to search for hydronephrosis in men whose PVR exceeds 200 mL and to decompress those in whom it is found Urodynamic Testing When diagnostic uncertainty may affect therapy and when empiric therapy has failed and other approaches would be tried. راه هاي تقويت عضالت كف لگن تمرین اول :هر بار كه براي ادرار كردن به توالت مي رود ،رندین بار به طور ارادي ،دفع ادرار را شروع و قطع كند. تمرین دوم :ناحیة مقعد را سنت كند ،مانند حالتي كه مي خواهد مانع دفع مدفوع شود و این حالت را براي مدت 5ثانیه حنظ نموده و بعد رها كند. در طول انقباض ،ننس خود را حبس نكند .این كار را رندین بار در طول روز انجام دهد .تكرار تمرین باید در حدي باشد كه خسته نشود .این تمرین را می تواند در حالت ایستاده ،نشسته و یا خوابیده انجام دهد. - در همه انواع بي اختیاري ادرار ،از ورزش هاي سخت اجتناب نموده و غذاهاي پر ادویه مصرف نکند. - بهتر است به جای مصرف مقدار زیاد مایع در یک نوبت ،مقادیر کم مایعات ،در نوبت های بیشتر و به فواصل کوتاه در طول روز مصرف شود. - در افرادی که ادم اندام تحتانی دارند ،باال نگه داشتن پاها در غروب باعث کاهش شب ادراری می شود. - اگر فرد درار آلزایمر است ،باید هر سه ساعت به او یادآوری کرد که به دستشویی برود. Thank you Dr. Peyman Salehi Stepwise Approach to Treatment of Urinary Incontinence Detrusor overactivity with normal contractility (DO): Urge Bladder retraining or prompted voiding regimens pharmacologically and add intermittent or indwelling catheterization Drugs used in the treatment of OAB/detrusor overactivity (DO) Antimuscarinic drugs: Tolterodine Drugs acting on membrane channels: Calcium antagonists Drugs with mixed actions: Oxybutynin, Dicyclomine, Flavoxate Antidepressants: Imipramin, Duloxetine Toxins: Botulinum toxin (neurogenic), injected into bladder wall Detrusor hyperactivity with impaired contractility (DHIC): Urge If bladder empties adequately, behavioral methods If residual urine ≥150 mL, augmented voiding techniques or intermittent catheterization Stress incontinence: Stress 1. Conservative methods (weight loss if obese; treatment of cough or atrophic vaginitis; physical maneuvers to prevent leakage [e.g., tighten pelvic muscles before cough, cross legs]; occasionally, use of tampon or pessary is useful) 2. If leakage threshold ≥150 mL identified, adjust fluid excretion and voiding intervals appropriately 3. Pelvic muscle exercises 4. Surgery (sling, artificial sphincter, periurethral bulking injections) Urethral obstruction Urge/overflow 1. Conservative methods (including adjustment of fluid excretion, bladder retraining/ prompted voiding) if hydronephrosis, recurrent symptomatic UTI, and gross hematuria have been excluded 2. α-Adrenergic antagonist 3. Also consider adding a bladder relaxant if DO coexists, PVR is small, and surgery not desired/feasible; monitor PVR! 4. Finasteride, if the patient either prefers it or is not a surgical candidate 5. Surgery (incision, prostatectomy) is an effective alternative before or after these steps Underactive detrusor Overflow 1. Decompress for at least several days (the larger the PVR, the longer should be the decompression [up to a month]) and then perform a voiding trial 2. Exclude urethral obstruction if this has not already been done 3. If cannot void or PVR remains large, try augmented voiding techniques 4. α-Adrenergic antagonist For cognitively impaired patients, “prompted voiding” is used Asked every 2 hours whether they need to void, patients are escorted to the toilet if the response is affirmative Thus oxybutynin and tolterodine should be considered first-line pharmacotherapy in this population Regardless of which antimuscarinic is used, urinary retention may develop. The PVR and urine output should be monitored, especially with DHIC, in which the detrusor is already weak. Other remedies for urge incontinence, including electrical stimulation and selective nerve blocks, are successful in selected situations there is little evidence that vasopressin is effective for geriatric incontinence the high prevalence of contraindications to its use (e.g., hyponatremia, renal insufficiency, heart failure), the risk of inducing serious hyponatremia with fluid retention, the potentially adverse impact on calcium and potassium excretion Hormonal treatment of UI Oestrogen local administration may be the most beneficial route Condom catheters helpful for men, but they are associated with skin breakdown, bacteriuria, and decreased motivation to become dry Indwelling urethral catheters are not recommended for detrusor overactivity because they usually exacerbate it Stress Incontinence weight loss Caffeine intake reduction, by postural maneuvers : Crossing the legs and bending forward during coughing By therapy of precipitating conditions such as atrophic vaginitis or cough (e.g., due to an ACE inhibitor), and by insertion of a pessary Pelvic muscle exercises can decrease incontinence substantially in older women who are motivated Older women generally can tolerate a suburethral sling but the ability to perform the midurethral procedures under regional, or even local, anesthesia on an outpatient basis makes them more feasible Other treatments for sphincter incompetence include: periurethral bulking injections and insertion of an artificialsphincter Periurethral collagen injection Outlet Obstruction α-adrenergic antagonists: tamsulosin and alfuzosin, are more selective The 5α-reductase inhibitors (finasteride or dutasteride) have also proved effective as monotherapy Underactive Detrusor The first step is to use indwelling or intermittent catheterization: (at least 7 to 14 days) For patients presenting with acute retention, an α blocker should be used as well. Bethanechol (40 to 200 mg/day in divided doses) is occasionally useful in a patient whose bladder contracts poorly because of treatment with anticholinergic agents that cannot be discontinued (e.g., tricyclic antidepressant). Principles of Indwelling Catheter Care upper thigh or abdomen Empty the bag every 8 hours. Do not routinely irrigate the catheter Surveillance cultures are unnecessary to change it every 1 to 2 months