Bladder Problems. Andrea Green. Clinical Nurse Consultant

Transcription

1 Bladder Problems Andrea Green Clinical Nurse Consultant

2 Incontinence is Loss of control of the bladder or bowel that is involuntary and socially unacceptable A symptom.. not a disease.

3 The extent of the problem Common 1:4 general population 1:3 women 1:10 men %% of hospitalised patients > 70% of the elderly in residential care.

4 Who is prone to incontinence: Something that affects all ages But those at particular risk include: Children pregnant women women at menopause the elderly those in hospital or other institutions those with disabilities sufferers of particular medical conditions people who strain at stool

5 The myths about incontinence A normal part of ageing Expected with childbearing There is nothing that can be done I am the only one Children will grow out of wetting It is not a serious problem.

6 Attitudes and incontinence Present a major problem in tackling this condition Attitudes of sufferers and their families Health professionals and carers The general public and the media

7 Continence is complex To be continent you need to be able to: Be aware of an urge to void/defecate Know what to do and where to go Be able to get there & manage clothing Store urine/bowel motion till right time Empty bladder/bowel on cue Manage wiping/drying/clothing

8 Not just about the bladder/bowel We need Intact central nervous system intact peripheral nervous system adequate mobility & dexterity adequate cognition bladder and bowel that is able to store and empty intact & functioning sphincters an environment that supports continence.

9 There are different types of urinary incontinence therefore: Need to identify the cause of the symptoms The different types of incontinence require different treatments Need to collect information so the correct type of management can be put into place.

10 For a complete assessment we need to collect Social history Medical & surgical history Obstetric/gynae Urological including previous investigations Medications Functional status Cognitive, mobility, dexterity, ADL s Environmental factors.

11 Objective data may include Urinalysis/MSU Bladder charts Intake and output volumes Incontinent episodes Uroflowometry Post void residual volume Formal ultrasound Medical examination

12 Stress Incontinence Involuntary loss of a small amount of urine, when coughing, sneezing or on sudden movements Not enough pressure in urethra to stop leak Weakened sphincters & pelvic floor muscles Excessive intra-abdominal pressure No detrusor contraction.

13 Stress Incontinence Weakened pelvic floor muscles Childbirth Persistent heavy lifting Obesity Straining at stool Chronic cough Fall in oestrogen levels Sphincter damage post surgery

14 Management SUI Pelvic floor exercises Identify muscles to be exercised appropriate position do not over tire muscle brochure Oestrogen cream/pessary? Alter type of anti-hypertensive.

15 Urge Incontinence Involuntary loss of urine, associated with a strong desire to void Complete bladder emptying-large volume Usually as the result of an involuntary contraction of the detrusor muscle Over active bladder (OAB).

16 Urge Incontinence Urinary Tract Infection Cystitis/calculi/tumours Constipation Caffeine/food additives Medications (anti-cholinergics) Anxiety Neurological causes CVA MS Parkinson s Disease

17 Urge Incontinence Inability to defer Urgency Frequency Decreased bladder capacity Nocturia 2 or more Nocturnal enuresis.

18 Management of UUI Treat UTI Alleviate constipation Review type and amount of fluid intake Bladder retraining -deferment Toileting times Oestrogen replacement Medications

19 Overflow Incontinence Inability to pass urine so builds up and overflows Blockage of bladder outlet/ obstrction Enlarged prostate, strictures, sphincters not relaxing on cue Faecal impaction Bladder muscle not contracting sufficiently Eg.Diabetes, some spinal injuries, MS Epidural anaesthetics

20 Overflow Incontinence Constant leakage or dribbling Post micturition dribble Difficulty starting flow/hesitancy Poor stream/interrupted Feeling of incomplete bladder emptying Frequency- small urinary volumes Nocturia >2 UTI Distended abdomen: pain/painless Confirmed with a portable bladder scan/residual

21 Management of Overflow Incontinence Alleviate constipation Treat UTI Retention of urine - treat Double void Toileting position Catheterize (long term/short term) types of catheters/flip-flow valve /suprapubic cleaning and care instructions

22 Management of Overflow Incontinence ISC - Intermittent Self Catheterization dexterity, eye sight, sensation, mobility education of ISC/teaching techniques Minipress Surgery

23 Functional Incontinence Sensation to void is present but unable to reach the toilet in time There is complete bladder emptying Causes: Cognitive impairment Impaired mobility Impaired dexterity Environmental reasons Location or toilets Chair height Availability of toilets

24 Management of Functional Incontinence Physio/OT assessment if required to improve mobility Alter chair height Different types of clothing Use close toilet/commode chair Use foot stool Well lit and private toilet Toileting times/prompted toileting

25 Urinary tract infections. To treat or not to treat?

26 Asymptomatic bacteriuria Presence of bacteria in the urine with the absence of clinical features 25-50% of Women in residential aged care 14-30% of Men at some time asymptomatic bacteriuria Urine odour alone Cloudy urine

27 Why asymptomatic bacteriuria should not be treated with antibiotics? Affected residents suffer no increased mortality Following course of antibiotics there is a rapid re-establishment of bacteria Increasing incidence of resistant bacteria with unnecessary antibiotic use

28 Clinical Features of asymptomatic bacteriuria Smelly and/or turbid urine No fever No genitourinary signs or some stable genitourinary signs eg: incontinence

29 Treatment of asymptomatic Increase fluid intake bacteriuria Report to GP If diagnosed with asymptomatic bacteriuria record as asymptomatic Follow medical plan which may include cranberry No further dipsticks required if the turbid urine state becomes chronic

30 Symptomatic UTI s in a catheterised resident Require 2 of the following features before treatment: Fever New loin pain Suprapubic pain Worsening mental/ functional status Change in urine eg: gross haematuria Onset of delerium/hypotension/shock

31 Treatment of symptomatic bacteriuria Increase fluid intake Report to GP MSU/CSU? Antibiotics while waiting for culture results Follow medical management plan

32 Dipstick urine tests Routine dipstick urine tests are not necessary Residents have a high background rate of asymptomatic bacteriuria Positive nitrites and leukocytes will be present in that percentage of residents who have asymptomatic bacteriuria. A negative dipstick makes UTI unlikely (but does not definitely exclude it). A positive dipstick test does not indicate a symptomatic UTI nor the need for antibiotic therapy in the absence of localising features.

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