Transcript Working with Urinary and Fecal Incontinence and Pelvic Organ

Presented by:
Barbara Wiggin, PhD, ANP-BC
CCA, specializing in UI, FI, FSH, UDS, POP
www.cca-center.com
Fall 2015
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The bladder is composed of bands of interlaced smooth muscle
(detrusor). The innervation of the body of the bladder is different
from that of the bladder neck. The body is rich in beta adrenergic
receptors. These receptors are stimulated by
the sympathetic component of the autonomic nervous system
(ANS). Beta stimulation, via fibers of the hypogastric nerve,
suppress contraction of the detrusor.
Conversely, parasympathetic stimulation, by fibers in the pelvic
nerve, cause the detrusor to contract. Sympathetic stimulation is
predominant during bladder filling, and
theparasympathetic causes emptying.
Two sphincters control the bladder outlet. The internal sphincter
is composed of smooth muscle like the detrusor and extends into
the bladder neck. Like the detrusor, the internal sphincter is
controlled by the ANS and is normally closed. The primary
receptors in the bladder neck are alphaadrenergic. Sympathetic stimulation of these alpha receptors, via
fibers in the hypogastric nerve, contributes to urinary continence.
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The external sphincter is histologically different from the detrusor and internal
sphincter. It is striated muscle. Like skeletal muscle, it's under voluntary control. It
receives its innervation from the pudendal nerve, arising from the ventral horns of
the sacral cord. During micturition, supraspinal centers block stimulation by the
hypogastric and pudendal nerves. This relaxes the internal and external sphincters
and removes the sympathetic inhibition of theparasympathetic receptors. The
result is unobstructed passage of urine when the detrusor contracts.
The ureters pass between the layers of the detrusor and enter the bladder through
the trigone. The ureters propel urine into the bladder. The bladder passively
expands to accept urine. As the bladder expands and intravesicular pressure
increases, the ureters are compressed between the layers of muscle, creating a
valve mechanism. This valve mechanism limits the backflow of urine.
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The normal adult bladder can hold about 500 cc of urine. After
emptying, the bladder may still retain about 50 cc residual
volume. At about 150 cc of volume, stretch receptors in the
detrusor begin signaling the CNS via afferent nerves; at 400 cc we
are "seeking" an appropriate toilet
Summary: Normally, we are able to control where and when we
void. This is largely because the cerebrum is able to suppress the
sacral micturition reflex. If the sacral reflex is unrestrained,
parasympathetic stimulation via the pelvic nerve causes detrusor
contraction. Detrusor contraction is suppressed
by alpha and beta sympathetic stimulation via the hypogastric
nerve. In response to afferent stimulation, the cerebrum becomes
aware of the need to void. If it is appropriate, the cerebrum relaxes
the external sphincter, blocks sympathetic inhibition, the bladder
contracts and urine is expelled
Urinary System: Normal Anatomy & Physiology. http://www.rnceus.com/uro/norm2.htm
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Health history
Continence history
Uroflow
Bladder Diary
Medication evaluation
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Bowel status
Urine Analysis
Environmental &
mobility assessment
Urodynamic study
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Neurological disease
Back Problems
Obstetrical
Gynecological
Diabetes
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Acute
Chronic
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D delirium
I infection (UTI)
A atrophic urethritis,
vag.
P pharmaceuticals
P psychological
(depression)
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E excess output: CHF,
hyperglycemia
R restricted mobility
S stool impaction
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SUI & ISD
Overactive bladder: with and without
incontinence, IC
Mixed
Overflow & Retention
Functional
Reflex
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Oxybutynin: IR, ER, patch
Tolterodine: IR, ER: less constipation than
oxybutynin, dry mouth
Trospium: lower constipation
Solifenacin: lowest constipation (more selective
for M3 receptors)
Darifenacin: less mental confusion, fewer
cardiac side effects (more selective for M3
receptors)
Mirabegron(b3 adrenergic agonist)
SE:palpitation, urinary retention, dry mouth,
HTN, cold symptoms
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Glaucoma (usually just narrow angle)
Hx of Constipation
GI hypo motility
Hx of Urinary retention
Diminished mentation
Hx of tachycardia
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onabotulinum toxinA : blocks action of
acetylcholine and paralyses bladder muscle,
lasts for several months
Urgent PC: percutaneous tibial nerve
stimulation (PTNS), mild impulses from the
stimulator travel through the needle electrode,
along your leg and to the nerves in your pelvis
that control bladder function
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Electrical Stimulation
Extracorporeal Magnetic Innervation (Neotonus
Chair)
InterStimMedtronic Bladder Control Therapy
(Sacral Neuromodulation, delivered by the
InterStim® System) has been FDA-approved since
1997 for urge incontinence and since 1999
for urinary retention and significant symptoms of
urgency-frequency. Medtronic Bladder
Control Therapy is not intended for patients with a
urinary blockage.
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Behavioral
Pelvic Muscle Rehab
(written, verbal,
biofeedback)
Supportive
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pessaries
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Intraurethral Device
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FemSoft
Electrical Stimulation
Neotonus Chair
Surgery
Estrogen
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Fluid Management
Prevention of
Constipation
Elevation of LE
DC fluids 2-3 hours
before HS
Take a deep breath
and lean forward
when voiding
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Timed toileting
Suppression
techniques: “Quick
Flicks”
Monitor bladder
irritants
Use of Absorbent
pads for Urinary
Incontinence
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10 second sustained contraction of pelvic floor
muscle followed by 10 second relaxation of the
pfm done 10 times twice a day.
Use of biofeedback effective if unable to do
pfme
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PFMT with Biofeedback is most effective non surgical modality for
treatment of SUI
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Sling (use of cadaveric tissues, synthetic mesh,
animal or donor tissue)
Colpopexy mesh
Urethral Bulking (Collagen)
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Injection of bulking materials around the urethra to
increase outlet resistance
InterStim Therapy
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Stimulation of sacral nerve for treatment of overactive
bladder or retention.
 Neurostimulator supplying constant mild electrical pulses
 Electrode system placed at L/R 3rd sacral foramen
 Sacral nerves most common distal autonomic and somatic nerve
supply to the pelvic floor and lower urinary and gastrointestinal tract
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Evaluate Bowel Status
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Formed or not
Timing
Physical exam of
rectum
Current problem
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Treatment
Biofeedback
 Fiber
 Scheduled evacuation
 Fluid
 Exercise
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Indications: prolapse, desire not to have
surgery, diagnostic tool for surgical relief,
prediction of surgical outcome, Correcting
stress incontinence, uterine retrodisplacement,
preterm cervical dilation
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Pessary Wear and
Care
Intercourse
 Removal/Cleaning
 When to get a new
one
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Refitting
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Tips
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Menses
Gelhorn: Use a short
stem if long stem
bothers the patient
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New Visit
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Health history/sexual
activity
Focused physical
Pessary fitting
Teach patient how to care
for pessary
Follow up in 2 weeks and
then in 1-2 months
If patient managing care
of pessary q 6 months
If patient not managing
pessary
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F/U
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Check U/A, uroflow, PVR
Go over patient is
managing pessary
Evaluate if pessary is
supporting prolapse
 Stand to evaluate
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Evaluate skin integrity
Manage problems
Schedule at appropriate
interval
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Contraindication
Pelvic infections
 Lacerations or ulcers
 Non-compliance
 Wide introitus, short
vaginal vault
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Properly Fitted
Pessary
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Patient is unaware of
the pessary
No pain or
discomfort
Symptoms are
relieved
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Move and toilet pt at
least every 2-3 hours
Clean soiled area with
water and/or cleanser
Use a skin barrier
(A&D ointment)
Notify appropriate
staff if skin is
breaking down
Change pads when
soiled
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Good hydration
Good nutrition
Adequate fluid intake
(6-8 8 oz glasses of
non-caffeinated
fluids)
Monitor urine color
and odor
Monitor pt for
confusion, elevated
temp, not feeling well
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Adequate hydration
Dabbing when wiping
Pt. checked to ensure
he/she is emptying
completely
Void q 2-3 hours
Take a deep
breath/lean forward
to empty
Taking enough time
to void
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Using water to cleanse
vulva
Unavoidable if has
indwelling catheter,
CIC decreases UTIs
Consider UTI if pt has
increased confusion,
odorous urine,
changed bladder
pattern
Sex: F
Age: 92
c/o: frequency, nocturia, ui
Health Hx: arthritis, glaucoma, hypertension (not
a problem now), osteoporosis
Current medications: None
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Previous treatment: anticholinergics
Focused physical exam: pale vag. tissue, little
recruitment of pfm, U/A neg
UDS: normal capacity, poor compliance, SUI at
low pressure (56 cm H20), empties well,
increased pfm tone with voiding
Plan of Care: fluid management, elevation of
legs, stress technique, biofeedback assisted
pfme
Results of Treatment: often does not wear pads,
continues to do pfme, discussed collagen
implants.
Sex: F
Age: 77
c/o: overactive bladder
Health Hx: depression/anxiety, arthritis,
hysterectomy, HTN
Current medications: lansoprazole, estrogen,
valsartan, nabumetone, escitalopram,
tolterodine
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Previous treatment: tolterodine
Focused physical exam: pale vag. tissue, reddened
vulva, sl recruitment of pfm, atrophic introitus, U/A
neg
UDS: delayed 1st sensation, normal capacity, SUI at
low pressure (75 cm H20), empties well, emg activity
during void, after contraction
Plan of Care: Dc’d tolterodine, discussed collagen
implant, or sling, stress technique, urge technique,
biofeedback assisted pfme
Results of Treatment: pt. feel she is much improved,
continues to do pfme, does not want referral to
urologist.
Doughty, D. B. Urinary and fecal incontinence (3rd ed.) (pp. 21-54). St. Louis, MO:
Mosby/Elsevier.
Dr. Rose’s peripheral brain. (2012, October24). Neurogenic bladder:Bladder dysfunction
and urinary incontinence.
http://faculty.washington.edu/momus/PB/tableofc.htm
Effective Health Care Program (2012,April) Non-surgical treatments for urinary
incontinence, A review of the research for women. Agency for Healthcare,
Research and Quality. Pub No. 11(12)EHCO74-A
Gray, M.L. (2006). rdPhysiology of voiding. In Doughty, D. B. Urinary and fecal
incontinence (3 ed.) (pp. 21-54). St. Louis, MO: Mosby/Elsevier.
Kershen, R.T., Appell, R.A. (2003). Voiding dysfunction after anti-incontinence surgery
in women. Issues in Incontinence, Spring/Summer, 1,9-11.
Krissovich, M. (2006). Pathology and management rd
of the overactive bladder. In
Doughty, D. B. Urinary and fecal incontinence (3 ed.) (pp. 109-165). St. Louis, MO:
Mosby/Elsevier.
Mayo Clinic. (1998-2007). Overactive bladder.
http://www.mayoclinic.com/print/overactivebladder/DS00827/DSECTION=all&METHO...
Medtronic. What Is Medtronic Bladder Control Therapy?
http://www.medtronic.com/patients/overactive-bladder/about-therapy/what-isit/index.htm
National guidelines and clinical evidence only modestly influence prescribing of
antihypertensive agents. (2007, January). Research Activities, 317, 15.
Newman, D.K. (2007, March). Dawning of a dry day: Fresh perspectives in managing
overactive bladder. Paper presented at the Annual Symposium of the Society of
Urologic Nurses and Associates, Colorado Springs, CO.
Newman, D.K. (2006, October). Pharmacologic Management of OAB-You
make the call. Paper presented the Annual Meeting of the Society of
Urologic Nurses and Associates, Kansas City, MO.
Sand, P.K., Dmochowski, R. (2002). Analysis of the standards of
terminology of lower urinary tract dysfunction: Report from the
standardisation sub-committee of the International Continence
Society. Neurology and Urodynamics, 21, 167-78.
NIH. (2007). Urologic disease cost Americans $11 billion a year.
http://www.nih.gov/news/pr/may2007/niddk-01.htm.
Serels, S.R., Appell, R.A. (2002, 2001). Bladder control problems. Newton,
PA: Handbooks in Health Care Co.
Staskin, D. (2004). Lower urinary tract dysfunction in the female. In A.P.
Bourcier, E.J. McGuire, & P. Abrams (Eds.), Pelvic floor disorders (pp.
43-56). Philadelphia, PA: Elsevier Saunders.
Urinary Incontinence in Adults Guideline Update Panel. (1996). Urinary
incontinence in adults: Acute and chronic management. Clinical Practice
Guideline, No. 2, 1996 Update. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service, Agency for
Health Care Policy and Research (AHCPR Publication No.96-0682).
Urinary System: Normal Anatomy & Physiology.
http://www.rnceus.com/uro/norm2.htm
Uroplasty. Urgent ® PC Neuromodulation System.
https://www.uroplasty.com/healthcare