Working with Urinary - PowerPoint Presentation

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Working with Urinary and Fecal Incontinence and Pelvic Organ Prolapse

Presented by: Barbara Wiggin, PhD, ANP-BCCCA, specializing in UI, FI, FSH, UDS, POPwww.cca-center.comFall 2015

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How the Bladder WorksThe 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 

alpha

-adrenergic. 

Sympathetic

 stimulation of these 

alpha

 receptors, via fibers in the

hypogastric

nerve, contributes to urinary continence

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How the Bladder WorksThe 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.Slide4

How the Bladder Works

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 toiletSummary: 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.htmSlide5

What is EvaluatedHealth history

Continence historyUroflowBladder DiaryMedication evaluationBowel statusUrine AnalysisEnvironmental & mobility assessmentUrodynamic studySlide6

Health HXNeurological disease

Back ProblemsObstetricalGynecologicalDiabetesSlide7

Types of UIAcuteChronicSlide8

Acute IncontinenceD delirium

I infection (UTI)A atrophic urethritis, vag.P pharmaceuticalsP psychological (depression)E excess output: CHF, hyperglycemiaR restricted mobilityS stool impactionSlide9

Chronic Incontinence & DysfunctionSUI & ISD

Overactive bladder: with and without incontinence, ICMixed Overflow & Retention Functional ReflexSlide10

Urodynamic StudiesSlide11

Male straining with mixed incSlide12

UUI with no OutflowSlide13

Non Compliance with ^EMGSlide14

SUISlide15

Medication to Treat OABAnticholinergics

Oxybutynin: IR, ER, patchTolterodine: IR, ER: less constipation than oxybutynin, dry mouthTrospium: lower constipationSolifenacin: 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 symptomsSlide16

Contraindications for AnticholinergicsGlaucoma (usually just narrow angle)

Hx of ConstipationGI hypo motilityHx of Urinary retentionDiminished mentationHx of tachycardiaSlide17

Treatment for UUIonabotulinum

toxinA : blocks action of acetylcholine and paralyses bladder muscle, lasts for several monthsUrgent 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 functionSlide18

Treatment for UUIElectrical StimulationExtracorporeal 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.Slide19

Treatment for SUIBehavioralPelvic Muscle Rehab (written, verbal, biofeedback)

SupportivepessariesIntraurethral DeviceFemSoftElectrical StimulationNeotonus ChairSurgeryEstrogenSlide20

Behavioral Management for UIFluid Management

Prevention of ConstipationElevation of LEDC fluids 2-3 hours before HSTake a deep breath and lean forward when voidingTimed toiletingSuppression techniques: “Quick Flicks”Monitor bladder irritants Use of Absorbent pads for Urinary IncontinenceSlide21

PFME10 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 pfmeSlide22

Biofeedback Assisted Pelvic Floor Muscle ExerciseSlide23

Effective Management of UI

PFMT with Biofeedback is most effective non surgical modality for treatment of SUISlide24

Surgical Treatment

Sling (use of cadaveric tissues, synthetic mesh, animal or donor tissue)Colpopexy meshUrethral Bulking (Collagen)Injection of bulking materials around the urethra to increase outlet resistanceInterStim TherapyStimulation of sacral nerve for treatment of overactive bladder or retention. Neurostimulator supplying constant mild electrical pulsesElectrode system placed at L/R 3rd sacral foramenSacral nerves most common distal autonomic and somatic nerve supply to the pelvic floor and lower urinary and gastrointestinal tractSlide25

Fecal IncontinenceEvaluate Bowel StatusFormed or not

TimingPhysical exam of rectumCurrent problemTreatmentBiofeedbackFiberScheduled evacuationFluidExerciseSlide26

Pessary Use and ManagementIndications: prolapse, desire not to have surgery, diagnostic tool for surgical relief, prediction of surgical outcome, Correcting stress incontinence, uterine retrodisplacement, preterm cervical dilationSlide27

Pessary Use and ManagementPessary Wear and Care

IntercourseRemoval/CleaningWhen to get a new oneRefittingTipsMensesGelhorn: Use a short stem if long stem bothers the patientSlide28

Pessary Use and ManagementNew Visit

Health history/sexual activityFocused physicalPessary fittingTeach patient how to care for pessary Follow up in 2 weeks and then in 1-2 monthsIf patient managing care of pessary q 6 monthsIf patient not managing pessary

F/U

Check U/A, uroflow, PVR

Go over patient is managing pessary

Evaluate if pessary is supporting prolapse

Stand to evaluate

Evaluate skin integrity

Manage problems

Schedule at appropriate intervalSlide29

Pessary Use and ManagementContraindication

Pelvic infectionsLacerations or ulcersNon-complianceWide introitus, short vaginal vaultProperly Fitted PessaryPatient is unaware of the pessaryNo pain or discomfortSymptoms are relievedSlide30

Skin CareMove and toilet pt at least every 2-3 hours

Clean soiled area with water and/or cleanserUse a skin barrier (A&D ointment)Notify appropriate staff if skin is breaking downChange pads when soiledGood hydrationGood nutritionAdequate fluid intake (6-8 8 oz glasses of non-caffeinated fluids)Monitor urine color and odorMonitor pt for confusion, elevated temp, not feeling well Slide31

Prevention of UTIsAdequate hydration

Dabbing when wipingPt. checked to ensure he/she is emptying completelyVoid q 2-3 hoursTake a deep breath/lean forward to emptyTaking enough time to voidUsing water to cleanse vulvaUnavoidable if has indwelling catheter, CIC decreases UTIsConsider UTI if pt has increased confusion, odorous urine, changed bladder patternSlide32

Case Study LLSex: F Age: 92

c/o: frequency, nocturia, uiHealth Hx: arthritis, glaucoma, hypertension (not a problem now), osteoporosisCurrent medications: NoneSlide33
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Case Study LLPrevious treatment: anticholinergics

Focused physical exam: pale vag. tissue, little recruitment of pfm, U/A negUDS: normal capacity, poor compliance, SUI at low pressure (56 cm H20), empties well, increased pfm tone with voidingPlan of Care: fluid management, elevation of legs, stress technique, biofeedback assisted pfmeResults of Treatment: often does not wear pads, continues to do pfme, discussed collagen implants.Slide35

Case Study DSSex: F Age: 77

c/o: overactive bladderHealth Hx: depression/anxiety, arthritis, hysterectomy, HTNCurrent medications: lansoprazole, estrogen, valsartan, nabumetone, escitalopram, tolterodineSlide36
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Case Study DSPrevious treatment: tolterodine

Focused physical exam: pale vag. tissue, reddened vulva, sl recruitment of pfm, atrophic introitus, U/A negUDS: 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 pfmeResults of Treatment: pt. feel she is much improved, continues to do pfme, does not want referral to urologist.Slide38

Bibliography

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

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Paper presented at the Annual Symposium of the Society of Urologic Nurses and Associates, Colorado Springs, CO.Slide39

Bibliography

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

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Urinary System: Normal Anatomy & Physiology. http://www.rnceus.com/uro/norm2.htm

Uroplasty

.

Urgent 

®

 PC

Neuromodulation

System. https://www.uroplasty.com/healthcareSlide40

The End