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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 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 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 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 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 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 Urinary Tract Infections Caffeine Intake Alcohol Intake Medications (e.g. diuretics, anticholinergics Atrophic changes Pelvic muscle tone 5/25/2017 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 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 5/25/2017 KEGEL EXERCISES Long ‘Ems And Short ‘Ems The Pelvic Floor Muscles: Structure & Function Uterus Rectum Bladder 28 The Pelvic Floor Muscles: Kegels – Long ‘Ems HOW ? WHERE ? WHEN ? WHY ? 29 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: Roll a towel and straddle it Male: 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 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 604-875-4875 [email protected] Maintaining Dignity! Products can be positive or negative. Beware!!! Incontinence Products Containment pads, combo, pull-up pants external “plugs/clamps” (NOT recommended) Adaptive Devices commode, urinals (male and female), The Whiz Catheters 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.