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.
Objectives Upon completion of this Telehealth education session, the learner will be able to: • 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
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 Atrophic Changes Bladder Capacity Pelvic Muscle Support Fluid Intake
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
Urinary Tract Infections Caffeine Intake Alcohol Intake Medications (e.g. diuretics, anticholinergics Atrophic changes Pelvic muscle tone Mobility Function Weight Constipation Diarrhea Contributing Factors
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 When drug P-value therapy alone therapy added (N = 8) (N = 8) 57.5% 88.5% 0.034 Drug therapy When behavioral alone therapy added (N = 21) (N = 27) 72.7% 84.3% 0.001 Burgio et al, JAGS. 2000
Improving Pelvic Muscle Strength • The role of Kegel exercises • Do they really work? • Used with both women and men
KEGEL EXERCISES Long ‘Ems And Short ‘Ems
The Pelvic Floor Muscles:Structure & Function Rectum Uterus 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
Managing Prolapse • The role of the pessary
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@example.com
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.