Urinary Incontinence- Involuntary loss of urine



Urinary Tract Infection

• Second most common infection in the US

• Not much morbidity

• Divide into upper and lower UTI

• Lower is much more common

• Upper includes kidney

• Lower is bladder

• Most commonly an older person problem

• Over the age of 65 4-10%

• Below this age is 1-4%

• Mainly an adult problem

• Young group is pediatric females—diapers to toilet training

• This is a hygiene problem

o Wearing diapers too long

o Wiping front to back or back to front

o Bubble baths—urethra has bacterostatic chemicals

• 80-90% have E. coli at the base of the problem

• UTI's are ascending infections

• Ratio of men to women is 1:10

• Subcategories

o Blockage of one ureter

o Catheter

• 5%/day risk of getting a UTI of a hospital stay

o Now at 1%

o Coated w/tephalon

o Less frequent changing of catheter

• 18-27 y/o women—sexually active

o Honeymoon cystitis

o Peri-urethral swelling

o Increase urethral outlet pressure

o Harder to urinate

o Urinary stasis

o Good medium for bacterial growth

• Pregnant women

• Diabetes Mellitus

o Reduced immune status

o Enhanced environment for bacteria—glucose in urine

• Obstruction of any type

o Hypertrophy of prostate

o Floor of pelvis tightened—women

o Surgery

o Stenosis of urethra

• Obstruction leads to stasis

• Hypertension

o Upper urinary tract—kidneys

o Form of renal failure

• Neurogenic bladder

o Lost ability to contract bladder

How to decide if Lower or Upper

• If common UTI, can be treated conservatively

• Have to be more cautious w/upper

• Upper UTI is sicker

o 102 to 104

o Shaking chills

o Unilateral flank pain (can be B/L)

o Casts

▪ Historical—what happened wks ago

▪ Bloody casts

o Epithelial cells (renal)

o Pt looks ill

o Urine labs are abnormal

o Very unusual for Dysuria

• Lower

o Change in urinary output

o Burning pain w/urethritis

o Females do not have strong urethritis (pain is not prominent)

o Males are more likely to have pain and copious discharge

o Fever is present is low grade

o Cystitis—low grade

o ESR slightly elevated if bladder, none w/urethritis

o Urine labs abnormal

▪ Combination of bacterial and WBC

▪ Bacterial or WBC alone consider contamination

o Double catch for women

o Triple catch for men

o Blood may be in urine

Kidney and upper UTI

• Medullary portion affected first

• Can occur from ascension

• Build up of urine from stenosis of ureter

• Cortex affect primarily or only—can't talk about ascension

o Look at vascular tree

o Patchy infiltrate of infection

o Septicemia—look at both kidneys

o This is worse than medullary—environment is hostile due to osmolarity

Investigate Pt.

• IVP and retro exam

• Include abdominal US

Tx

• Only one's that look for spinal cause and susceptibility to infection

• Don't know why have UTI but do

• Hydrating the pt will help the pt—flush out the organisms

• Cranberry juice

o Not b/c acidifier

o A component that makes it difficult for the bacteria to grab onto the wall

o Reduced bacterial adhesions

• We do not know for sure how much to drink

• Recommend 4-8oz glasses per day—Dr. Kuhn got results w/this

• If this is going to work, it will tend to work quickly

• If this does not work, look at the water that they are drinking

• Recommend steamed, distilled water

Prostatitis

• Bacterial acute

o Young men significantly

o Instrumentation—catheter

o Has more Sx that are more recognizable

o May be the first time that they have difficulty urination

o May see discharge which is reliable

o Burning sensation

o Rectal/digital exam—enlargement of gland

o Typical that it hurts during the exam and noticeably enlarged

o Positive cup 3 test (more so than chronic)

o Fever, blood, ( WBC

o Ascending UTI

• Bacterial chronic

o Older men

o Idiopathic

o Recurrent UTI

• Misc.—non-bacterial

o Viral

o Meds that irritate gland

o Less discharge

o Less burning

o Long standing Sx

o More workup is required

• Rectal/digital exam

o Size

o Texture

o Shape

o DO NOT MASSAGE THE GLAND

▪ This introduces the bacteria deeper into the gland where the body can not deal w/it as well

Urethritis

• E. coli origin

• Ascending route

• Anytime aggravate urethra

• 2 categories

o Gonococcal

▪ Epidemic

▪ Sx for men are worse

← Burning urination

← Copious discharge

← Have urgency and frequency

▪ Women

← Some discharge

← Not a lot of burning

▪ Complications

← Endocarditis

← Meningitis

← Synovial inflammation—synovitis—arthralgia as complication

← Severity of the infection does not correlate to the complications

▪ Dx

▪ Tx

← Penicillin

←

o Non-gonococcal

▪ Chlamydia

▪ Less discharge

▪ Same differences of Sx of men and women

▪ Penicillin does work

▪ Sulfa drugs

• E. coli

o Sx

▪ Burning on urination

▪ Men have more prominent complaints

← More tissue to have aggravated

▪ Bacteria and WBC

▪ Urgency due to bladder outlet

Urinary Incontinence- Involuntary loss of urine

Incidence:

• More than 12 million Americans

• In women (approx. 38%)

• 40% of hospitalized elderly persons

• 50% of nursing home residents

• a leading cause of nursing home admissions

Cost $$:

• Over $1 billion in sales/year

• Psychological costs

o Embarrassment and social inhibition

o Depression, impaired nutrition in elderly

Causes:

• Myth: normal and expected age-related change

• Age-related physiological changes in the lower urinary tract or chronic illness may predispose to urinary incontinence

o Changes consist of: decrease bladder capacity, flow rate, ability to postpone voiding, nocturnal fluid excretion, and prostate size.

Anatomy

• Detrusor muscle and two sphincters

• Detrusor muscle innervations

o Pelvic nerve via PSNS (cholinergic receptor- Ach neurotransmitter)

• Bladder neck and proximal urethra

o SNS (alpha-adrenergic receptor- nor-epinephrine neurotransmitter)

• Base of the urethra (skeletal muscle- voluntary)

o Pudendal nerve (Ach neurotransmitter)

Function

• Storing urine

o Relaxation of detrusor muscle

o Contraction of sphincters

o Intravesicular pressure is less than urethral pressure

• Voiding urine:

o Detrusor muscle contracts and sphincter relax

o Intravesicular pressure is greater that urethral pressure

Causes of Reversible Incontinence

• Acute illness with:

o Confusion or disorientation

o Immobility

o Lethargy

• Urinary tract infection

• Fecal impaction

• Use of certain drugs

Classification of Persistent Incontinence

• Persistent incontinence may result from untreated illness or arise insidiously

• 5 basic classifications

o stress

o urge

o overflow

o functional

o mixed

Stress Incontinence- loss of small amounts of urine during coughing, laughing, or other activities which increase intra-abdominal pressure

• Due to weak pelvic floor and urethral muscles

• Predominantly found in women

Urge Incontinence- leakage of large amounts of urine precipitate by involuntary bladder contractions. Inability to delay voiding once a sensations of bladder fullness is perceived.

• Due to various GU and CNS conditions that cause hyper-reflexia of bladder contractions

o Urethritis, cystitis, stones, stroke, spinal cord injury, MS, Parkinson’s Alzheimer’s, tumors

*low volume voider, a patient that empties the bladder frequently, she decreases the amount being able to be held.

Overflow Incontinence- constant dribbling of small amounts of urine also known as: paradoxical incontinence, Neurogenic incontinence.

• Due to over-distention of the bladder

• Causes include:

o Anatomic obstruction

o Hypocontractile bladder

o Use of certain medications

Functional Incontinence- involuntary loss of urine resulting from the inability to use a toilet

• Due to physical, psychological, or environmental factors

• Occurs despite normal urinary tract infection.

Mixed Incontinence- combinations of the four previous categories

• Most common combination- stress and urge incontinence

• Identifying presence of greater than 1 type important for treatment options.

Patient Evaluation

• Primary goal: identify reversible factors contributing to incontinence

• History:

o Symptoms (frequency, volume, Dysuria, urgency)

o Active and past medical conditions

o Environmental factors and medications

• Urobehavioral diary

o Self-monitoring and feedback

• Physical exam

o Neurologic, abdominal, pelvic, rectal

• Lab

o Serum electrolyte, BUN, glucose

o Urinalysis (hematuria, Pyuria, bacteriuria, glycosuria) and culture

• Spinal exam

• Urodynamic evaluation (co-management)

o Sonography, catheterization, cystography

Treatment Goals in Elderly

• Maintain existing continence

• Improve socialization

• Decrease embarrassment

• Preserve renal function

• Avoid catheterization and the need for absorbent undergarments

Conservative Treatment Options

• Biofeedback Methods

o Monitoring pelvic floor muscle. And contraction of external urethral sphincter through reinforcement with visual and auditory signals

o 25% success rate

o requires expensive equipment

Aggressive Treatment

• Collagen injections

• Nip and Tuck

10/17/05

Nocturnal Enuresis- wetting the bed at night

• Common problem in children

• 4% of people have incontinence up until age 60

Causes:

• Psychosocial- divorce, terminal illness,

• Regression- regress into a younger mental state due to stress

• UTI- #1 on differential

Breneman- study that followed children growing up with NE, they found that 66% of cases could be eliminated from food allergies

• Most common allergen is cow’s milk

Esperanea & Gerard

• Dairy products are allergens that trigger enuresis, some citrus products and decrease threshold in sphincter muscles.

Etiologies for Enuresis

• Children seem to be late walkers (possibly from skeletal muscle immaturity)

• Seem to be on the smaller side of the height and weight charts

• Are not good at school

• Are very deep sleepers, so if they don’t wake up, they just pee

• Most destructive aspect is punishment/reward from parents

Carcinoma to GU System

#1 primary is prostate

• 70, 000/year and climbing

• 32,000 deaths/yr

• Lab studies—PSA

• Change in urinary habits

• can be prevented by surgical removal, and early detection (the more invasive, more expensive surgeries ten to have a better outcome)

Patient History

•

#2 Bladder is next 37,000/yr

• 3:2 males: females (females are increasing)

• Women are working in places that they did not use to

• Women are smoking more

• In males a triple catch urine specimen would be abnormal

• Tx. Options:

Mets to bladder

• Melanoma—GIGU

• An increase in acidphosphatase is an indicator that the mets has left the prostate and moved elsewhere

#3 Testicular Carcinoma (rare)

• earliest sign is a mass (part of male physical examination)

• pain, which is from the mass blocking the secretory duct

•

Kidneys

• ¾ w/calcifications on lumbar films are malignant processes

o This includes diabetes mellitus

o Hematuria is the most consistent sign, and it is only present 50-60% of the time

o Flank pain, but by the time the flank pain shows up it is a considerably large lesion.

o ¼ of all patients with renal cell carcinoma have evidence of metastasis at the time of diagnosis. Typically it moves to the lungs- repeat episodes of pneumonia.

Urinary Tract Infection

• Second most common infection in the US

• Not much morbidity

• Divide into upper and lower UTI

• Lower is much more common

• Upper includes kidney

• Lower is bladder

• Most commonly an older person problem

• Over the age of 65 4-10%

• Below this age is 1-4%

• Mainly an adult problem

• Young group is pediatric females—diapers to toilet training

• This is a hygiene problem

o Wearing diapers too long

o Wiping front to back or back to front

o Bubble baths—urethra has bacterostatic chemicals

• 80-90% have E. coli at the base of the problem

• UTI's are ascending infections

• Ration of men to women is 1:10

• Subcategories

o Blockage of one ureter

o Catheter

• 5%/day risk of getting a UTI of a hospital stay

o Now at 1%

o Coated w/tephalon

o Less frequent changing of catheter

• 18-27 y/o women—sexually active

o Honeymoon cystitis

o Peri-urethral swelling

o Increase urethral outlet pressure

o Harder to urinate

o Urinary stasis

o Good medium for bacterial growth

• Pregnant women

• Diabetes Mellitus

o Reduced immune status

o Enhanced environment for bacteria—glucose in urine

• Obstruction of any type

o Hypertrophy of prostate

o Floor of pelvis tightened—women

o Surgery

o Stenosis of urethra

• Obstruction leads to stasis

• Hypertension

o Upper urinary tract—kidneys

o Form of renal failure

• Neurogenic bladder

o Lost ability to contract bladder

How to decide if Lower or Upper

• If common UTI, can be treated conservatively

• Have to be more cautious w/upper

• Upper UTI is sicker

o 102 to 104

o Shaking chills

o Unilateral flank pain (can be B/L)

o Casts

▪ Historical—what happened wks ago

▪ Bloody casts

o Epithelial cells (renal)

o Pt looks ill

o Urine labs are abnormal

o Very unusual for Dysuria

• Lower

o Change in urinary output

o Burning pain w/urethritis

o Females do not have strong urethritis (pain is not prominent)

o Males are more likely to have pain and copious discharge

o Fever is present is low grade

o Cystitis—low grade

o ESR slightly elevated if bladder, none w/urethritis

o Urine labs abnormal

▪ Combination of bacterial and WBC

▪ Bacterial or WBC alone consider contamination

o Double catch for women

o Triple catch for men

o Blood may be in urine

Kidney and upper UTI

• Medullary portion affected first

• Can occur from ascension

• Build up of urine from stenosis of ureter

• Cortex affect primarily or only—can't talk about ascension

o Look at vascular tree

o Patchy infiltrate of infection

o Septicemia—look at both kidneys

o This is worse than medullary—environment is hostile due to osmolality

Investigate Pt

• IVP and retro exam

• Include abdominal US

Tx

• Only one's that look for spinal cause and susceptibility to infection

• Don't know why have UTI but do

• Hydrating the pt will help the pt—flush out the organisms

• Cranberry juice

o Not b/c acidifier

o A component that makes it difficult for the bacteria to grab onto the wall

o Reduced bacterial adhesions

• We do not know for sure how much to drink

• Recommend 4-8oz glasses per day—Dr. Kuhn got results w/this

• If this is going to work, it will tend to work quickly

• If this does not work, look at the water that they are drinking

• Recommend steamed, distilled water

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