Bladder and Bowel Assessment Ann Yates Director of Continence Services. 18/07/2008 Cardiff and Vale NHS Trust

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1 Bladder and Bowel Assessment Ann Yates Director of Continence Services

2 Types of continence problems Bladder Stress incontinence Urgency and urge Incontinence Mixed incontinence Obstructive incontinence Functional incontinence Bowel Faecal incontinence Faecal leakage Constipation

3 Causes of incontinence In healthy older people little different to younger age groups However due to ageing process more susceptible to : Physiological Pharmacological And psychological risk factors

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5 PHYSIOLOGICAL CHANGES Renal function Bladder function Urethral changes Lower gastrointestinal tract Neurological control Cardiac function Endocrine factors Impaired functional ability Drug clearance, toxicity and polypharmacy

6 Drug clearance, toxicity and polypharmacy Ageing process affects absorption, distribution, metabolism and elimination of drugs Decrease in GFR decreases excretion of renally excreted drugs i.e. Digoxin, cephalosporins, oral hypoglycaemics etc Polypharmacy increases greater risk of drug interaction/ toxicity

7 Physical Changes Physical health Relationships and sexuality Skin problems Risk of falling Urinary tract infection

8 People with incontinence have: Significantly lower health status Disturbed sleep (nocturia) Need more personal care More likely to be depressed Emotionally distressed Loss of control Negative effects on relationships Vaginal dryness/ reduction in contractions Reduced sensitivity of penis Erectile dysfunction, premature ejacultion

9 cont Epidermis reduces by 50% by age of 80 Collagen stiffens and elastic fibres thicken Loss of fluid increases dryness, fragile, puckered skin Risk of incontinence dermatitis Falls common in older people increases with urge incontinence UTI s increase in older men due to prostate Decrease in immune competence and symptomatic bacteruria

10 Percentage of adults with UI by age group Age (years) Men (%) Women (%) > All Milsom I, et al. BJU International 2001; 87:

11 Urinary incontinence: Impact on quality of life Threat to self esteem Embarrassment Loss of personal control Anxiety Impact of urinary incontinence on quality of life Distress Depression Isolation Inconvenience 1. Jackson S. Urology 1997; 50 (suppl 6A): Abrams et al. Am J Manage Care 2000; 6 (suppl 11): S The Continence Foundation Broome BA. Health & Quality of Life Outcomes 2003; 1:35-38

12 Prevalence of Faecal Incontinence Associated with Age Adults over 65 at home 3.7% at least weekly 6.1% wear a pad just in case of leakage (Talley et al, 1992) Older Women years: 4.2% some loss of faeces Over 85: 16.9% faecally incontinent (Kok et al 1992)

13 Assessment key points History medical, surgical, obstetric history Symptoms and onset Current medication Bowel habit Attitude to problem QOL Environmental conditions Aids / appliances etc used

14 Drugs that affect urinary incontinence Diuretics Anticholinergics, antimuscarinics, antidepressants & anti parkinsonian Sedatives & hypnotics Beta blockers & antihistmines Muscle relaxants Alpha adrenergic Alpha agonists Alcohol, caffeine Drugs constipation analgesics,iron,diurectics antimuscarinics Diarrheoa antacids, antibiotics

15 Physical examination and tests Mobility Dexterity Hearing and eyesight Mental alertness Abdominal, vaginal, rectal examinations Residual urine urinalysis

16 Urine testing Rule out UTI s / diabetes If client becomes confused Sticks should show leucocytes/nitrates Check if blood in urine Is urine cloudy or smelly Does urine appear concentrated If recurrent infections?scan/ intermittent catheter

17 Aims of assessment Identify reversible factors that may be contributing to incontinence Identify those individuals who may need more specialist diagnostic evaluations Develop the most appropriate individual treatment or management plan

18 Transient incontinence D - Delirium or confusion I - Infection A - Atrophic urethritis / vaginitis P - Psychological disorders (severe depression, neurosis) P - Pharmacological factors (sedatives, hypnotics etc E - Endocrine disorders (hypercalcaemia, hperglycaemia) R - Reduced / restricted mobility S - Stool impaction

19 Stool impaction

20 PVRV >100mls and/or Reduced flow Pvrv > 100 mls And/or reduced flow Presence of voiding dysfunction prolapse, Presence of voiding Pain/mass noted dysfunction,prolapse, pain/mass noted

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22 Frequency / volume charts Diurnal frequency Nocturnal frequency Maximum bladder capacity Minimum bladder capacity Frequency of leakage Associated with any trigger factors Amount of leakage

23 All Wales Bladder/Bowel Care Pathway Doc 6 BOWEL SYMPTOM ALGORITHM Complaint of bowel symptoms (Presents to health care professional, e.g. G.P. D/N Initial Assessment (Clinical history, physical examination, bowel diary, +/- Digital rectal examination) Refer to medic if symptoms of 1.blood/mucus in stool 2. rectal bleeding 3. rectal pain 4. change in bowel habit. 5. concerns regarding general health e.g. unintentional weight loss / anaemia Faecal leakage loose stools (yellow) Inspect stool (send specimen) YES Refer to medic Infected? YES Follow, constipation care pathway NO Constipation with overflow? NO General advice Bulking agents/loperamide Sphincter/pelvic Muscle exercises No improvement after 12 weeks refer to continence service/medical opinion Faecal urgency inability to hold on (pink) General advice Sphincter/pelvic muscle exercises No improvement after 12 weeks refer to continence service/medical opinion YES Abdo X-ray Treat medication? 2 nd Care Impaction Constipation (blue) NO General advice Medication NO Refer to continence services/medical Improvement YES Discharge with advice to prevent recurrence.

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