Urinary Incontinence Karla Reinhart DNP, FNP-C, ARNP October, 2015 - PDF document

9/17/2015 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

9/17/2015 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

9/17/2015 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 300-500 ml, and the first urge to urinate generally occurs between bladder volumes of 150-300 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

9/17/2015 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

9/17/2015 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

9/17/2015 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

9/17/2015 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

9/17/2015 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

9/17/2015 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), 53-59. 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), 324-331. 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), 429-446. 9

9/17/2015 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, 61-66. 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, 1234- 1241. Vasavada, S. & Kim, E. (2014). Urinary Incontinence retrieved from http://emedicine.medscape.com/article/452289-overview Watson, S. (2011). Herbal Remedies for Overactive Bladder retrieved from http://www.webmd.com/urinary-incontinence-oab-13/herbal-remedies 10