Transcript Grand Round : Continence

Continence What are we aiming for?!!
Dr Tammy Angel
Why is it important?
Curable!
QOL
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Occupational
Physical
Social
Psychological
Sexual
Domestic
Topics for today..
What’s normal?
What are the NICE guidelines for each
types of incontinence?
Local services and National initiatives
Working example..
Normal?
Bladder stores and voids
Usually sense ‘urge’ to
PU at 2-300mls
At socially convenient
time and place
Reflex relaxation of
external sphincter
Bladder muscle contracts
Types of incontinence
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Stress
Urge
Overflow
Functional
Cognitive/neurological/psychiatric
Mixed
NICE Rx UI
• At initial ax-SUI/UUI/
Mixed
• Hx is suffficient to inform
non invasive 1st line Rx
options
• (3 day) bladder diaries
• Invasive Ix NOT
recommended before
conservative Rx
Stress incontinence..
• Pelvic floor exercises .. ‘of at least 3 months duration’
– Digital ax PFM contraction- at least 8 contractions tds - consider electrical
stimulation/ biofeedback for pts unable to actively contract PF
• Duloxetine : ‘Not be routinely used 2nd line, may be offered as
alternative to surgical Rx’
• Urodynamics +/- surgical intervention (TVT TOT; injectables
colposuspension)
Stres s Urinary Incontinence care Plan
Additional instruction/information
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Stress urinary incontinence occurs w hen
the (pelvic floor) mu scles which usually
support the bladder have become
weakened, such that urine leaks when a
patient coughs sneezes picks up heavy
objects, runs jumps or laughs
The most common cause of weak pelvic
floor mu scles is pregnancy and childbirth,
being overweight, suf fering from
constipation or a prolonged cough
Pe lvic floor exercises are the best w ay to
improve stress incontinence (see separate
leaflert), there are drug and surgical
options
Comments section to be used to record
nursing actions on care plan
Patient label / details
Name:
_____________________________
D.O.B:
_____________________________
Hosp No:
___________________________
Consultant:
__________________________
Aims of Care / Goal:
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To reduce / cure symptoms of stress incontinence by providing appropriate
advice and specialist attention whenever necessary
Nursing Actions
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Condition has been explained to the patient
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Pa tients with chronic cough and or severe constipation should be
referred to junior doctor
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Pa tient given pelvic floor exercise leaflet and instructions explained
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Daily reinforceme nt of pelvic floor exercises
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Patient should be offered continence assessment/ further investigation
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Before discharge ask patient Ô
bothersome ratingÕ o
f symptoms of
stress incontinence
1 = no t bothersome 10 = very troublesome and af fecting quality of life
Follow up to be arranged with continence team on ext 2396
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Urge incontinence
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Rx UTI’s and stop unnecessary diuretics
OAB : Caffeine reduction and Bladder retraining .. ‘at least 6 weeks’
Anticholinergics ‘ non-proprietary oxybutynin due to cost effectiveness rather
efficacy - if not tolerated tolterodine; solifenacin, trospium
Intravaginal oestrogens for atrophy
Botulinium toxin A (willing to self catheterise); sacral nerve stimulation;
augmentation cystoplasty; urinary diversion
intravesical oxybutynin,
Overflow incontinence
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Clear bowels
Alphablockers eg tamsulosin
Stop anticholinergics
Intermittent self catheterisation
?prostatic surgery
Functional incontinence
• Physiotherapy
• Move closer to toilet
Neuropsych REGULAR TOILETTING
How should we assess pts history?
MEDICAL
COMORBITIES
MOBILITY
DRUGS
PSxH
BOWELS
INFECTION
COGNITION
Continence Assessment
Examination:
Abdomen/ Pelvis
Perineal/ cough
Rectal
Post micturition bladder
scan
+/- Neuro/ Gait
• Investigation
• Fluid volume charts
• Urinalysis/ MSU
• Creatinine
• PSA
• AXR
+/- USS Renal tracts
Hemel initiatives..
Weekly ward round : “the dry, the wet and the catheterised”!
Rolling Educational Programme for All
Assessment of patients in Day Hospital and RAU
Management Algorithims and care plan
Participation in National Continence Audit
Local Catheter Audit
+ Identify HCA + Trained on each ward
+ Weekly screening--> see referrals
+ rationalise pad usage
Bleep 1725
Shape of new service
Monday Tuesday
Wednesday Thursday
Hemel
F/U
Watford SACH
Watford
Wards
RAU/OPD F/U
Wards
TA/ AC
WR
Friday
Hemel
Clinic/
WR
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Admin/
Community Audit
Service Objectives..
Patients identified, comprehensively assessed, and
appropriately managed
Patients receive written information about their
condition
Better follow up for patients
Improve transfer of information into community
Promote education
My interpretation..
GP Assessment
TRIAGE
Gynaecologist
eg post partum SUI
Urologist
eg enlarged prostate +LUTS
Community
Continence
Advisors
Geriatrics
Comorbidities + UI
Working example
• 70 yr old woman;
• C/O: severe urgency, UI, nocturnal
frequency..needs radioactive iodine!
• PMH : ‘CCF’, HT, OA awaiting THR
• DH: BFZ, Frusemide, Diltiazem, doxazosin
tramadol
• PSH: N and no previous ix
Further hx and ix
• O/E: well in self , mild SOA,
abdo NAD, PV N, PR loaded
• Urinalysis = clear
• Bladder scan when ‘desperate’ = 60 mls and
PMRV = 0 mls
• WHAT NEXT?…
Assessment..
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Overactive bladder with small capacity
Exacerbated by diuretics,
Reduced mobility due to OA,
SOA ? Diltiazem/Gravity/RVF
Constipation
Plan and outcome
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Stopped BFZ, doxazosin
Frusemide at 5pm then fluid restrict
Detrusitol XL 4 mg od
Bladder retraining exercises – holding on
Senna and docusate
Leg elevation during the day
DRY!!.. Rx radioiodine
Conclusions
Dispel 2 urban myths:
1. Incontinence is not normal for age
2. It is curable…
A continence nurse specialist will
dramatically improve quality of service
and community integration!
Any questions ?