URINARY INCONTINENCE AND RETENTION P 1146 1152 URINARY INCONTINENCE UI Uncontrolled leakage of urine More common in women and older adults but NOT a normal part of aging o Effects quality of life and contributes to serious health problems Anything that effects bladder or urethral sphincter control o Confusion depression infection atrophic vaginitis urinary retention restricted mobility fecal impaction or drugs o Drugs alcohol a adrenergic receptors agonists and antagonist ACE inhibitors anticholinergic tricyclic antidepressants b adrenergic receptor antagonist CCB opioids sedative hypnotics diuretics methylxanthines antisiezure agents URINARY RETENION Inability to empty the bladder despite micturition accumulation of urine in the bladder Can be associated with urinary leakage or postvoid dribbling overflow UI Acute urinary retention medical emergency complete inability to pass urine Chronic urinary retention incomplete bladder emptying despite urination o Postvoid residual PVR volumes vary greatly Normal between 50 75 ml 100 ml indicate repeat test 200 twice further medical evaluation Small volume may indicate further evaluation if with reoccurring UTIs Caused by two different dysfunction o Bladder outlet obstruction Urine can no longer pass despite bladder contraction Common cause enlarged prostate o Deficient detrusor bladder muscle contraction strength Muscle no longer has enough force for a long enough period to empty bladder Common causes neurologic disease affecting sacral segments 2 4 long standing DM over distention chronic alcoholism and drugs mainly anticholingergics TYPES OF URINARY INCONTINENCE Stress incontinence o Occurs with coughing laughing sneezing heavy lifting exercising o Usually small amounts and may not occur daily o Caused by pelvic floor relaxation or weakness often women after delivery or men after BPH surgery o Kegel exercises weight loss smoking cessation Urge incontinence o Random involuntary urination due proceeded by urgency seen with overactive bladders o Leakage is periodic frequent and in large volumes o CNS disorders uncontrolled contraction overactive detrusor muscle o Treat underlying cause behavior interventions anticholinergic drugs Overflow incontinence o Pressure of an overfull bladder overcomes sphincter control o Leakage is frequent in small amounts o Caused by bladder or urethral obstruction after anesthesia neurogenic bladder o Urinary catheterization a adrenergic blocker 5a reductase surgery to correct underlying problem Reflux incontinence o Condition occurs with no warning or stress o Leakage is frequent moderate volume and at day and night o Spinal cord lesion above S2 detrusor hyperreflexia o Treat underlying cause bladder decompression intermittent self cath Valium to relax sphincter antibiotics and surgical spincterotomy Incontinence after trauma or surgery o Fistula in women and alteration in sphincter control in men o Surgery to correct fistula urinary diversion artificial sphincter condom cath penile clamp Functional incontinence o Loss of urine due to cognitive functional or environmental factors o Elderly who have balance and mobility issues o Environment modification easier and safer access to the toilet DIAGNOSTIC STUDIES Focused history physical assessment and bladder log void dairy include nocturia and leakage o General health mobility issues functional issues dexterity and cognitive function o Assess for signs of erosion or rashes on perineal area and pelvic organ prolapse Determine onset factors that promote leakage and associated conditions Urinalysis to identify factors such as UTI or DM PVR within 10 20 minutes of voiding ultrasound can be used for estimation COLLABORATIVE CARE AND NURSING INTERVETIONS URINARY INCONTINENCE Usually able to be cured or significantly improved Address dignity privacy and feelings of self worth Ensure in inpatient and long term care facilities to maximize toileting access o Scheduled voiding 2 3 hours Lifestyle modification o Self management strategies to reduce risk factors Smoking cessation weight reduction good bowel regimen reduce bladder irritants caffeine and alcohol and fluid modification Scheduling voiding regimens o Timed voiding o Habit retraining o Prompted voiding Fixed schedule every 2 3 hours while awake Scheduled toileting with adjustments of voiding intervals based on pattern Scheduled toileting that requires prompts to void from a caregiver o Bladder retraining and urge suppression strategies Scheduled toileting with progressive intervals Pelvic floor muscle rehabilitation o Kegel exercises Pelvic floor exercises o Vaginal weight training Active retention of increasing vaginal weights at least 2 times a day o Biofeedback alternative therapy rarely used o Electrical stimulation Application of low voltage electrical current to sacral and pudendal afferent fibers through vaginal anal or surface electrodes Anti incontinence devices o Intravaginal support device pessaries and bladder neck support prostheses Device to support bladder neck relieve minor prolapse and change pressure transmission to the urethra o Intraurethral occlusive device urethral plug Single use device that is worn in the urethra to provide mechanical leakage obstruction remove for voiding o Penile compression device Fixed compression applied to the penis to prevent any flow or leakage must be released hourly to void Containment devices o External collection devices Condom catheters o Absorbent products Disposable and reusable pads a adrenergic agonists increase bladder sphincter tone and urethral resistance o can cause HTN and tachycardia anticholinergic drugs relax bladder muscle and inhibit overactivity o side effects dry mouth dry eyes constipation blurred vision somnolence DRUG THERAPY SURGICAL THERAPY Stress UI o Reposition the urethra or create a backboard of support or otherwise stabilize the o Augment the urethral resistance of the intrinsic sphincter unit with a sling or urethra and bladder neck periurethral injectables o Suburethral sling women Autologous fascia cadeaveruc fascua ir synthetic material Complications vascular and bowel injury urinary retention mesh sling erosion infection urgency and bladder perforation o Bulking agents injected into the under the urethra mucosa Glutaraldehyde cross linked bovine collagen GAX collagen Reinjection required after several years COLLABORATIVE CARE URINARY RETENTION Scheduled voiding 2 3 hours Double voiding void sit on toilet for 3 4 minutes void