presented by: barbara wiggin, phd, anp-bc cca, specializing in ui, fi, fsh, uds, pop fall 2015
TRANSCRIPT
WORKING WITH URINARY AND FECAL INCONTINENCE AND PELVIC
ORGAN PROLAPSE
Presented by: Barbara Wiggin, PhD, ANP-BC
CCA, specializing in UI, FI, FSH, UDS, POPwww.cca-center.com
Fall 2015
How the Bladder Works The bladder is composed of bands of interlaced smooth muscle
(detrusor). The innervation of the body of the bladder is different from that of the bladder neck. The body is rich in beta adrenergic receptors. These receptors are stimulated by the sympathetic component of the autonomic nervous system (ANS). Beta stimulation, via fibers of the hypogastric nerve, suppress contraction of the detrusor. Conversely, parasympathetic stimulation, by fibers in the pelvic nerve, cause the detrusor to contract. Sympathetic stimulation is predominant during bladder filling, and theparasympathetic causes emptying.
Two sphincters control the bladder outlet. The internal sphincter is composed of smooth muscle like the detrusor and extends into the bladder neck. Like the detrusor, the internal sphincter is controlled by the ANS and is normally closed. The primary receptors in the bladder neck are alpha-adrenergic. Sympathetic stimulation of these alpha receptors, via fibers in the hypogastric nerve, contributes to urinary continence.
How the Bladder Works The external sphincter is histologically different from the detrusor and
internal sphincter. It is striated muscle. Like skeletal muscle, it's under voluntary control. It receives its innervation from the pudendal nerve, arising from the ventral horns of the sacral cord. During micturition, supraspinal centers block stimulation by the hypogastric and pudendal nerves. This relaxes the internal and external sphincters and removes the sympathetic inhibition of theparasympathetic receptors. The result is unobstructed passage of urine when the detrusor contracts.
The ureters pass between the layers of the detrusor and enter the bladder through the trigone. The ureters propel urine into the bladder. The bladder passively expands to accept urine. As the bladder expands and intravesicular pressure increases, the ureters are compressed between the layers of muscle, creating a valve mechanism. This valve mechanism limits the backflow of urine.
How the Bladder Works
The normal adult bladder can hold about 500 cc of urine. After emptying, the bladder may still retain about 50 cc residual volume. At about 150 cc of volume, stretch receptors in the detrusor begin signaling the CNS via afferent nerves; at 400 cc we are "seeking" an appropriate toilet
Summary: Normally, we are able to control where and when we void. This is largely because the cerebrum is able to suppress the sacral micturition reflex. If the sacral reflex is unrestrained, parasympathetic stimulation via the pelvic nerve causes detrusor contraction. Detrusor contraction is suppressed by alpha and beta sympathetic stimulation via the hypogastric nerve. In response to afferent stimulation, the cerebrum becomes aware of the need to void. If it is appropriate, the cerebrum relaxes the external sphincter, blocks sympathetic inhibition, the bladder contracts and urine is expelled
Urinary System: Normal Anatomy & Physiology. http://www.rnceus.com/uro/norm2.htm
What is Evaluated
Health history Continence history Uroflow Bladder Diary Medication
evaluation
Bowel status Urine Analysis Environmental &
mobility assessment
Urodynamic study
Health HX
Neurological disease Back Problems Obstetrical Gynecological Diabetes
Types of UI
Acute Chronic
Acute Incontinence
D delirium I infection (UTI) A atrophic
urethritis, vag. P pharmaceuticals P psychological
(depression)
E excess output: CHF, hyperglycemia
R restricted mobility
S stool impaction
Chronic Incontinence & Dysfunction
SUI & ISD Overactive bladder: with and without
incontinence, IC Mixed Overflow & Retention Functional Reflex
Urodynamic Studies
Male straining with mixed inc
UUI with no Outflow
Non Compliance with ^EMG
SUI
Medication to Treat OABAnticholinergics
Oxybutynin: IR, ER, patch Tolterodine: IR, ER: less constipation than
oxybutynin, dry mouth Trospium: lower constipation Solifenacin: lowest constipation (more
selective for M3 receptors) Darifenacin: less mental confusion, fewer
cardiac side effects (more selective for M3 receptors)
Mirabegron(b3 adrenergic agonist) SE:palpitation, urinary retention, dry mouth, HTN, cold symptoms
Contraindications for Anticholinergics
Glaucoma (usually just narrow angle) Hx of Constipation GI hypo motility Hx of Urinary retention Diminished mentation Hx of tachycardia
Treatment for UUI
onabotulinum toxinA : blocks action of acetylcholine and paralyses bladder muscle, lasts for several months
Urgent PC: percutaneous tibial nerve stimulation (PTNS), mild impulses from the stimulator travel through the needle electrode, along your leg and to the nerves in your pelvis that control bladder function
Treatment for UUI
Electrical Stimulation Extracorporeal Magnetic Innervation
(Neotonus Chair) InterStimMedtronic Bladder Control Therapy
(Sacral Neuromodulation, delivered by the InterStim® System) has been FDA-approved since 1997 for urge incontinence and since 1999 for urinary retention and significant symptoms of urgency-frequency. Medtronic Bladder Control Therapy is not intended for patients with a urinary blockage.
Treatment for SUI
Behavioral Pelvic Muscle
Rehab (written, verbal, biofeedback)
Supportive pessaries
Intraurethral Device FemSoft
Electrical Stimulation
Neotonus Chair Surgery Estrogen
Behavioral Management for UI
Fluid Management Prevention of
Constipation Elevation of LE DC fluids 2-3 hours
before HS Take a deep breath
and lean forward when voiding
Timed toileting Suppression
techniques: “Quick Flicks”
Monitor bladder irritants
Use of Absorbent pads for Urinary Incontinence
PFME
10 second sustained contraction of pelvic floor muscle followed by 10 second relaxation of the pfm done 10 times twice a day.
Use of biofeedback effective if unable to do pfme
Biofeedback Assisted Pelvic Floor Muscle Exercise
Effective Management of UI
PFMT with Biofeedback is most effective non surgical modality for treatment of SUI
Surgical Treatment
Sling (use of cadaveric tissues, synthetic mesh, animal or donor tissue)
Colpopexy mesh Urethral Bulking (Collagen)
Injection of bulking materials around the urethra to increase outlet resistance
InterStim Therapy Stimulation of sacral nerve for treatment of overactive
bladder or retention. Neurostimulator supplying constant mild electrical pulses Electrode system placed at L/R 3rd sacral foramen
Sacral nerves most common distal autonomic and somatic nerve supply to the pelvic floor and lower urinary and gastrointestinal tract
Fecal Incontinence
Evaluate Bowel Status Formed or not Timing Physical exam of
rectum Current problem
Treatment Biofeedback Fiber Scheduled
evacuation Fluid Exercise
Pessary Use and Management
Indications: prolapse, desire not to have surgery, diagnostic tool for surgical relief, prediction of surgical outcome, Correcting stress incontinence, uterine retrodisplacement, preterm cervical dilation
Pessary Use and Management
Pessary Wear and Care Intercourse Removal/Cleaning When to get a new
one Refitting
Tips Menses Gelhorn: Use a
short stem if long stem bothers the patient
Pessary Use and Management
New Visit Health history/sexual
activity Focused physical Pessary fitting Teach patient how to
care for pessary Follow up in 2 weeks
and then in 1-2 months If patient managing
care of pessary q 6 months
If patient not managing pessary
F/U Check U/A, uroflow,
PVR Go over patient is
managing pessary Evaluate if pessary is
supporting prolapse Stand to evaluate
Evaluate skin integrity Manage problems Schedule at
appropriate interval
Pessary Use and Management
Contraindication Pelvic infections Lacerations or
ulcers Non-compliance Wide introitus,
short vaginal vault
Properly Fitted Pessary Patient is unaware
of the pessary No pain or
discomfort Symptoms are
relieved
Skin Care
Move and toilet pt at least every 2-3 hours
Clean soiled area with water and/or cleanser
Use a skin barrier (A&D ointment)
Notify appropriate staff if skin is breaking down
Change pads when soiled
Good hydration Good nutrition Adequate fluid intake
(6-8 8 oz glasses of non-caffeinated fluids)
Monitor urine color and odor
Monitor pt for confusion, elevated temp, not feeling well
Prevention of UTIs
Adequate hydration Dabbing when wiping Pt. checked to ensure
he/she is emptying completely
Void q 2-3 hours Take a deep
breath/lean forward to empty
Taking enough time to void
Using water to cleanse vulva
Unavoidable if has indwelling catheter, CIC decreases UTIs
Consider UTI if pt has increased confusion, odorous urine, changed bladder pattern
Case Study LL
Sex: F Age: 92c/o: frequency, nocturia, uiHealth Hx: arthritis, glaucoma,
hypertension (not a problem now), osteoporosis
Current medications: None
Case Study LL
Previous treatment: anticholinergics Focused physical exam: pale vag. tissue,
little recruitment of pfm, U/A neg UDS: normal capacity, poor compliance,
SUI at low pressure (56 cm H20), empties well, increased pfm tone with voiding
Plan of Care: fluid management, elevation of legs, stress technique, biofeedback assisted pfme
Results of Treatment: often does not wear pads, continues to do pfme, discussed collagen implants.
Case Study DS
Sex: F Age: 77c/o: overactive bladderHealth Hx: depression/anxiety, arthritis,
hysterectomy, HTNCurrent medications: lansoprazole,
estrogen, valsartan, nabumetone, escitalopram, tolterodine
Case Study DS
Previous treatment: tolterodine Focused physical exam: pale vag. tissue,
reddened vulva, sl recruitment of pfm, atrophic introitus, U/A neg
UDS: delayed 1st sensation, normal capacity, SUI at low pressure (75 cm H20), empties well, emg activity during void, after contraction
Plan of Care: Dc’d tolterodine, discussed collagen implant, or sling, stress technique, urge technique, biofeedback assisted pfme
Results of Treatment: pt. feel she is much improved, continues to do pfme, does not want referral to urologist.
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