Urinary Incontinence 9/17/2015. Conflict of Interest. Objectives. None
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1 Urinary Incontinence Karla Reinhart DNP, FNP-C, ARNP October, 2015 Conflict of Interest None Objectives Acquire knowledge of A & P of micturition, as well as pertinent pathologies for male and female incontinence Identify urinary incontinence risk factors including irritants Discuss types and causes of urinary incontinence Identify components of an incontinence assessment Identify interventions to treat urinary incontinence 1
2 Statistics More than 13 million people in the United States- male and female, young and old- experience incontinence Women experience incontinence twice as often as men, pregnancy and childbirth, menopause, and the structure of the female urinary tract account for the difference Underdiagnosed and underreported problem that increases with age with 50-84% of elderly affected Anatomy Relevant lower urinary tract Urethra Bladder Pathophysiology Micturition requires coordination of several physiological processes Somatic and autonomic nerves carry bladder volume input to the spinal cord Motor output innervating the detrusor, sphincter, and bladder musculature is adjusted accordingly Cerebral cortex exerts a inhibitory influence Brainstem facilitates urination by coordinating urethral sphincter relaxation and detrusor muscle contraction As bladder fills, sympathetic tone contributes to closure of the bladder neck and relaxation of the dome of the bladder, inhibiting parasympathetic tone. 2
3 Pathophysiology Continued With urination sympathetic and somatic tones in the bladder and periurethral muscles diminish resulting in decreased urethral resistance. Cholinergic parasympathetic tone increases, resulting in bladder contraction. Urine flow results when bladder pressure exceeds urethral resistance. Bladder capacity is ml, and the first urge to urinate generally occurs between bladder volumes of ml. Incontinence occurs when micturition physiology, functional toileting ability, or both have been disrupted. Pathologies Urinary incontinence (UI) is a multifactorial syndrome produced by a combination of genitourinary pathology, age-related changes, and comorbid conditions that impair normal micturition or the functional ability to toilet oneself, or both. Risk Factors Age Gender Race Obesity Surgery Diet 3
4 Bladder Irritants Too much or too little water intake Alcoholic beverages Caffeine containing drinks and foods Acidic foods and drinks Carbonated drinks Spicy foods Sugar, honey and artificial sweeteners Types and Causes Stress Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Functional Incontinence Urinary Incontinence: the accidental leakage of urine Stress Incontinence Can happen when there is an increase in abdominal pressure, urine leaks due to weakened pelvic floor muscles and tissue. Increased intra-abdominal pressure raises pressure within the bladder to the point it exceeds the urethra s resistance to urinary flow. Exercise Laugh Sneeze Cough 4
5 Causes Major cause is urethral hypermobility due to impaired support from pelvic floor. Less common cause is an intrinsic sphincter deficiency, usually secondary to pelvic surgeries. Pregnancy & Childbirth Overweight or obese Prostate surgery Certain medications: anti-hypertensive, anti-depressant, diuretics, sleeping pills, muscle relaxants Urge Incontinence Often referred to as overactive bladder. Urgent need to urinate but may leak if unable to get to bathroom in time. Gotta go Gotta go Involuntary urine loss associated with the feeling of urgency (detrusor over activity) Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of UTI or other obvious pathology. Unclear etiology and incompletely understood pathophysiology. Causes Damage to bladder nerves Damage to nervous system Damage to muscles Interstitial cystitis MS, Parkinson s, DM, stroke Bladder infection Bladder stones Medications: decongestants, estrogen, NSAIDs plus previous discussed 5
6 Mixed Incontinence A combination of stress incontinence and urge incontinence Approximately 40-60% of females with incontinence have this condition Generally defined as detrusor over activity and impaired urethral function, the actual pathophysiology of mixed urinary incontinence is still unknown. Bladder outlet is weak and the detrusor is overactive Overflow Incontinence Insufficient emptying of bladder causing leakage when bladder is full More common in men causing symptoms of dribbling of urine Causes Weak bladder muscles Blockage of urethra by prostate enlargement Tumors that cause obstruction of urine flow Constipation 6
7 Functional Incontinence Physical problems or cognitive problems prevent successful access to bathroom in time. DIAPPERS- delirium, infection, atrophic urethritis or vaginitis, pharmacologic agents, psychiatric illness, endocrine disorders, reduced mobility or dexterity, stool impaction Arthritis Dementia Incontinence Assessment Basic evaluation including history, physical exam, and urinalysis Voiding diary Cotton swab test Cough stress test Post void residual measurement Cystoscopy Urodynamic studies History Severity and quantity of urine lost and frequency of incontinence episodes Duration of complaint and if worsening Triggering factors or events Constant versus intermittent urine loss Associated frequency, urgency, dysuria, pain with full bladder History of UTIs Concomitant fecal incontinence or pelvic organ prolapse Coexistent complicating or exacerbating medical problems OB history History of pelvic surgery Other urological conditions Spinal and CNS surgery Lifestyle Issues BPH 7
8 Additional Diagnosis Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, and urinalysis. In selected patients, the following may also be needed: Voiding diary Cotton swab test Cough stress test Measurement of postvoid residual (PVR) urine volume Cystoscopy Urodynamic studies Treatment Interventions Estrogen- transvaginal Antimuscarinics B2 Adrenoceptor Agonist Anticholinergic agents Antispasmodic drugs Tricyclic antidepressants Botulinum toxin ACP Guideline 8
9 Non-Pharmaceutical Interventions Removal bladder irritants Bladder retraining Pelvic floor exercises- Kegel Biofeedback Devices- pessary, electrical stimulation Injections & Surgery Herbs/supplements Herbs/Supplements Most of the herbal preparations contain several herbs combined rather than a single herb. This allows a synergistic effect, addressing the urinary problem from several different angles at once. * Gosha-jinki-gan: improves urinary urgency, frequency, and nocturnal enuresis ( increases bladder capacity and reduces bladder contractions via effects on the nervous system). Bucha: used for bladder and kidney infections. Has anti-inflammatory, antibacterial, and diuretic properties (nourishes the bladder tissue). Cleavers: diuretic effects, coats along bladder wall that protects against irritation (irritation is a cause of overactive bladder). Horsetail: acts as a diuretic, anti-inflammatory, and antioxidant. (used to treat kidney and bladder stones, UTIs, and incontinence) Saw palmetto: may have anti-inflammatory properties, and testosterone effects (enlarged prostate) (caution with herbal usage is recommended- drug interactions, ingredient list not always accurate) References Luber, K. (2004). The definition, prevalence, and risk factors for stress urinary incontinence. Reviews in Urology, 6(3), Merkelj, I. (2002). Basic assessment of urinary incontinence. South Med J, 95(2), 1-6. Minassian, V., Stewart, W., & Wood, G. (2008). Urinary incontinence in women. Obstetrics & Gynecology, 111(2), Qaseem, A., Dallas, P., Forclea, M., Starkey, M., Denberg, T., & Shekelle, P. (2014). Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American college of physicians. American College of Physicians, 161(6),
10 References Peyrat, L., Haillot, O., Bruyere, F., Boutin, J.M., Bertrand, P., & Lanson, Y. (2002). Prevalence and risk factors of urinary incontinence in young and middle-aged women. BJU International, 89, Sacco, E., Prayer-Galetti, T., Pinto, F., Fracalanza, S., Betto, G., Pagano, F., & Artibani, W. (2006). Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU International, 97, Vasavada, S. & Kim, E. (2014). Urinary Incontinence retrieved from Watson, S. (2011). Herbal Remedies for Overactive Bladder retrieved from 10
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