Transcript National Continence Month – An Interactive Discussion on

National Continence
Month – An
Interactive Discussion
on Adult and Older
Adult Bladder and
Bowel Continence
Marcia Carr – CNS and NCA
Fraser Health – Burnaby Hospital
GNABC – Education Coorinator
November 2008.
It is all about dignity and
respect!
Objectives
Upon completion of this Telehealth education
session, the learner will be able to:
1. identify common contributing factors affecting
transient and persistent urinary incontinence
2. discuss strategies and interventions to better
manage urinary incontinence in their clientele
3. identify common contributing factors affecting
bowel incontinence
4. discuss strategies and interventions to better
manage bowel incontinence in their clientele
Acknowledgements
 Jennifer Skelly RN, PhD, NCA
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Director, Continence Program
St. Joseph’s Health Care
Associate Professor, SON
McMaster University
 Sandra Whytock RN, MSN, NCA
Prevalence of the three most common
types of UI by age
Factors Across the Life
Cycle
 Pregnancy
 Childbirth
 Weight
 Muscle strength (pelvic floor, abdominal)
 Mobility and functional status
 Hormones or lack of…
 Integrity of CNS
 Reproductive organs (uterus, ovaries,prostate)
 Chronic disease (e.g. diabetes, thyroid)
Prevention!!!
 Teach early about bladder and bowel
health and hygiene
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How to cleanse
Intercourse
UTI
Constipatrion
 EXERCISE – pelvic and abdominal
Aging
Is incontinence to be expected?
Age Related Changes
That can Impact on
Continence
The Bladder
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Smaller voided volumes
Increased residual volume
Debate: Smaller capacity or detrusor instability?
Increase in involuntary detrusor contractions
Decreased contractility of the bladder during
voiding
Combination of detrusor overactivity on filling and
poor contractility during voiding ( detrusor
hyperactivity)
Atrophic Changes of the Urethra and
Vagina
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mucosal thinning and
proteoglycans reduce
urethral wall apposition
which may contribute to
retrograde movement of
perineal bacteria into the
bladder causing UTI’s.
these mucosal changes
can extend up to the
bladder trigone, casing
irritation of sensory
afferent nerves, and
possibly triggering
involuntary detrusor
contractions
The Bowels
 Slower transit time
 Decreased peristalsis
 Decreased thirst drive so not drinking
adequate fluids to hydrate stool
The etiology of urinary incontinence in the
elderly is always multifactorial.
Functional
Ability
Medical Issues
Bladder Capacity
Atrophic Changes
Fluid Intake
Pelvic Muscle
Support
In order to maintain continence
in the elderly we need to:
 Know if it is a problem – So ASK routinely
 Identify the contributing factors
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Transient = DISAPPEAR
Persistent
 Develop treatment goals that the patient is
willing to work on.
 Refer to correct health care provider
Transient Causes of Urinary
Incontinence
 D – Delirium (Drugs and/or Bugs)
 I – Infection & Intake
 S – Stool impaction/constipation
 A – Atrophic vaginitis or urethritis
 P – Pharmaceuticals
 P – Psychological ( depression, psychosis)
 E – Excess urine (endocrine)
 A – Abnormal lab values
 R – Restricted mobility
Persistent Urinary
Incontinence
 Failure to Store: hyperactive or poorly
compliant bladder (urge UI); poor pelvic
floor or sphincter weakness (stress UI)
 Failure to Empty: OVERFLOW UI poor
bladder contraction; obstruction
(prostate)
 Mixed: combined etiologies
 Functional: unable to get to the toilet to
void (stroke, dementia etc.)
Contributing Factors
and Conservative
Interventions
Persistent Urinary or Fecal
Incontinence
Persistent UI
 Neuro: cerebral cortex, brainstem,
sacral spinal cord, neuropathy
 Hormonal: de-estrogenated; thyroid
dysfunction; PSA; anti-diuretic hormone
 Pelvic Floor Muscle: childbirth, surgery,
constipation, obesity
 Functional: immobility, dementia,
arthritis
Contributing Factors
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Urinary Tract Infections
Caffeine Intake
Alcohol Intake
Medications (e.g.
diuretics,
anticholinergics
Atrophic changes
Pelvic muscle tone
7/17/2015
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Mobility
Function
Weight
 Constipation
 Diarrhea
Comorbid medical illnesses
 Stroke
 Diabetes or other endocrine diseases
 Dementia, depression, delirium
 Cardiovascular disease
 COPD
 Cancers
 Pelvic organ prolapse or obstruction
 Irritable bowel or Inflammatory bowel
Cranberry and UTI
Dr Lynn Stothers
• Two tabs per day with water
• Be alert to anti-coagulants as potentiates
them
• Pure Cranberry juice – 250-500 ml/day
• Exact dose is being researched
Hormones
 A little dab will do you – estrogen and/or
progesterone
 Hypothyroidism and constipation
Medications
Is this the magic bullet that people
want?
Targeting symptoms with meds
 Decrease the urgency felt with urge
 Increase the flow
 Main issues
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Side effects
Adherence to achieve efficacy
Cost
Combining Behavior Treatment and Medication
Percent reductions in UI episodes after 8 weeks
Behavioral
therapy alone
(N = 8)
57.5%
When drug
therapy added
(N = 8)
88.5%
Drug therapy
alone
(N = 21)
72.7%
When behavioral
therapy added
(N = 27)
84.3%
P-value
0.034
0.001
Burgio et al, JAGS. 2000
Loss of Pelvic Muscle Support
Improving Pelvic Muscle Strength
 The role of Kegel exercises
 Do they really work?
 Used with both women and men
7/17/2015
KEGEL EXERCISES
Long ‘Ems
And
Short ‘Ems
The Pelvic Floor Muscles:
Structure & Function
Uterus
Rectum
Bladder
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The Pelvic Floor Muscles:
Kegels – Long ‘Ems
HOW ?
WHERE ?
WHEN ?
WHY ?
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Tips to find the muscle
 No squeezing face “cheeks” or buttock “cheeks”
 Breathe! And do not push down; only pull or draw
up on the muscle
 Female:
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Roll a towel and straddle it
 Male:
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Use a mirror under scrotum
Keys to success
 Locating the correct muscle
 Rhythm – equal relaxation and contraction
of the muscle
 Hold the contraction for a count of 3 or 5
 How long it takes to see results – minimum
of 8 weeks
Helpful Tip
 To remember to do
your Kegel’s or pelvic
muscle exercises
each day do them
during the
commercial's of your
favourite 30 minute
program.
Short ‘Em and Urge
Suppression
 100/day for short fibres
 Urge suppression
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5-10 quick Kegel exercises
Distraction
Perineal pressure
Sit down and cross legs
Stand on “tippy” toes
Cystocele
Managing Prolapse
 The role of the
pessary
Ring Pessary with support
Pessary care
 Regular changes every 3 – 4 months
 Use of a vaginal lubricant or premarin
cream once or twice a week will
reduce the problem with discharge,
odor and erosions
Fluids!!!
 Caffeine free
 Hydration
 Irritants
 Timing
Urinary Incontinence: Pharmacologic and Surgical Interventions
Alpha agonist
Intraurethral
bulking agents
Vaginal sling
Fecal Incontinence
Find the underlying cause and
contributing factors
Constipation
 Pushing, ”bearing down” – pelvic floor strain
leading to poor pelvic floor strength
 Impaction – bypassing (urine and stool)
 Smearing/staining - ? Rectocele
 Poor fibre and fluid intake
 Immobility
Action
Bowel Program – Be consistent!
Get it formed, get it down, get it out.
Fluid, Fibre and Mobilize
Positioning on toilet
Laxatives??? Lazy Bowel???
Get Up and Go Cookies
Irritable Bowel, Colitis, Crohn’s…
 Require gastroenterologist work-up for
Dx.
 When diarrhea present need to try to
bulk up stool and assure pelvic floor and
sphincter integrity = fine balance
 Suggest:
 Canadian Society of Intestinal Research
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604-875-4875
[email protected]
Maintaining Dignity!
Products can be positive or
negative. Beware!!!
Incontinence Products
 Containment
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pads, combo, pull-up pants
external “plugs/clamps” (NOT recommended)
 Adaptive Devices
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commode, urinals (male and female), The Whiz
 Catheters
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indwelling (urethral, suprapubic)
condom
intermittent – retention
Zassi, flexi-seal for diarrhea
Everyone’s concern
Chronic Disease Management
Approach
Chronic Disease Management
A systematic approach to health care
that emphasizes helping individuals
maintain independence and keep as
healthy as possible through prevention,
early detection, and management of
chronic conditions such as CHF,
asthma, diabetes, and other debilitating
illnesses or conditions.
Does this apply to Incontinence?
 Persistent incontinence can be a chronic
condition
 Affects individuals’ independence and overall
health status
 Prevention, early detection and certainly
evidence-based management applies to urinary
incontinence.
Self-management
The use of skills to (1) manage the work of dealing
with your chronic illness/condition, (2) manage the
work of continuing your daily activities, and (3)
manage the changing emotions brought about by
chronic illness/condition.
Self
Caregiver
Client Requirements: 5 Basic Skills of SM
 Problem-solving
 Decision-making
 Resources: Client knows
who & where to call
 Forming partnership with
HC providers
 Taking action
Goal Attainment Scale
 Defines a unique set of goals set by and
for each client or program
 The criteria of the programs success
becomes the extent to which individual
goals are achieved
 This is about the patient!
Self management of incontinence
requires
 Problem
solving - recognize changes in
continence and how to adjust own action plan
 Locating
and using resources - health care
(clinics) and community based (CCF)
 Interaction
and communication with health
care providers
 Maintaining
and Managing their continence
on day-to-day basis
Clinical Case
History
 68 year old woman, diabetic, over weight with
severe arthritis
 Loss of urine with physical activity as well as
urgency, frequency and nocturia x 5.
 Five year history of recurrent UTI’s symptoms
are pressure and discomfort in her pelvic region
 Difficulty starting to void, does not feel that she
empties
 Low fluid intake ( 1000 mls per day)
 Assessment? Diagnosis?
Clinical Case
Assessment
 Voided 50 mls– post void ultrasound 350 mls
 Atrophic changes noted – grade 2 bladder prolapse
 Hard, impacted rectum with small rectocele
Recommendations
 Vaginal pessary? Surgical referral?
 Premarin Cream
 Increase fluids – cranberry capsules
 Kegel’s
 Bowel regime
Clinical Case
Follow up at 4 weeks
 Pessary fitting comfortably
 Residual urine now 100 mls
 Nocturia reduced to twice at night
 No urine loss
 Client rated her improvement as
significant
Take Home Message
 Regaining and maintaining continence is
possible if addressed early and the patient
is able to lean how to manage.
 You need to ask if it is a problem
 Combinations of treatment may be needed
to successfully treat or manage UI and FI
Your Cases
Discussion
Not everyone is
ready or able to
make changes in their
behavior but many can
surprise us and
themselves with their
abilities.