7. Incontinencia: Epidemiología
1. Comunidad: 15-30%
Hospital de agudos: 30-40%
Instituciones: 50-80%
2. Estudio de Madrid: Varones 14,5 %
Mujeres 16%
Por grupos de edad: 65-74 13%
75-84 16%
>84 26%
8. Prevalence of Urinary Incontinence
Estimated 10% to 35% of adults
> 50% of 1.5 million nursing home residents
A conservative estimated cost of $5.2 billion
per year for urinary incontinence in nursing
homes
Fant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy and
Research. 1996. AHCPR Publication No. 90-06 National Center for Health Statistics. Vital Health Statistics Series.
13(No. 102). 1989e in
9. ¿Cuán Común es la Incontinencia?
Prevalencia se incrementa con la edad (pero no
es parte del envejecimiento normal)
25-30% de la comunidad de ancianas
10-15% de la comunidad de ancianos
50% residentes de hogares; frecuentemente
asociado con demencia, incontinencia fecal,
pérdida de la habilidad para caminar y
trasladarse independientemente
10. La Incontinencia Urinaria es Frecuentemente
Sub-diagnósticada y Sub-tratada
Sólo el 32% de los médicos generales
preguntan rutinariamente acerca de la
incontinencia
50-75% de los pacientes nunca describen
síntomas a los médicos
80% de las incontinencias urinarias
pueden ser curadas o mejoradas
11. Incontinencia urinaria: repercusiones
Físicas:
Infecciones, sepsis, úlceras, caídas
Psíquicas:
Ansiedad, depresión, pérdida autoestima,
Interferencias sexuales
Sociales:
Aislamiento, mayor necesidad de recursos,
institucionalización
Económicas:
Costes de complicaciones y de medidas paliativas
12. Impact on Quality of Life
Loss of self-esteem
Decreased ability to maintain independent
lifestyle
Increased dependence on caregivers for
activities of daily life
Avoidance of social activity and interaction
Restricted sexual activity
Grimby et al. Age Aging. 1993; 22:82-89.
Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. Washington
DC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988.
Noelker L. Gerontologist. 1987; 27:194-200.
13. Consequences of UI
An increased propensity for falls
Most hip fractures in elders can be traced to
nocturia especially if combined with urgency
Risk of hip fracture increases with
physical decline from reduced activity
cognitive impairments that may accompany a UTI
medications often used to treat incontinence
loss of sleep related to nocturia
14. Risk Factors
Aging
Medication side effects
High impact exercise
Menopause
Childbirth
16. Age Related Changes in the
Genitourinary Tract
Majority of urine production occurs at rest
Bladder capacity is diminished
Quantity of residual urine is increased
Bladder contractions become uninhibited
(detrusor instability)
Desire to void is delayed
17. Cambios del tracto urinario inferior con
el envejecimiento
Disminución de:
Capacidad vesical
Longitud de la uretra funcional
Contractilidad vesical
Presión de cierre uretral
Habilidad para posponer la micción
Aumento de:
Residuo vesical postmiccional
Contracciones no inhibidas del detrusor
19. Causas Potencialmente Reversibles
D - Delirio
I - Infección
A - Atrofia vaginal o uretritis
F - Fármacos
P - Psycológicos
E - Endocrinos
M - Mobilidad restringida
I - Impactación fecal
2
20. Cause of Stress Urinary
Incontinence
Failure to store secondary to urethral
sphincter incompetence
21. Causes of Urge Urinary
Incontinence
Failure to store, secondary to bladder
dysfunction
Involuntary bladder contractions
Decreased bladder compliance
Severe bladder hypersensitivity
22. Stress Incontinence vs. Urge
Incontinence: System Check List
Symptoms Stress
Incontinence
Urge
Incontinence
Urgency accompanies incontinence
(strong, sudden desire to void)
NO YES
Leaking during physical activity (e.g.
coughing, sneezing, lifting, etc.)
YES NO
Ability to reach the toilet in time,
following an urge to void
YES NO
Waking to pass urine at night SELDOM OFTEN
23. Causes of Mixed Urinary
Incontinence
Combination of bladder overactivity and stress
incontinence
One type of symptom (e.g., urge or stress
incontinence) often predominates
24. Symptoms of Overactive Bladder
Urgency
Frequency
Nocturia, and/or urge incontinence
ANY COMBINATION - in the absence of any
local pathological or metabolic disorder
25. Causes of Overflow Urinary
Incontinence
Loss of urine
associated with over
distention of the
bladder
Failure to empty
Underactive bladder
Vitamin B12
deficiency
Outlet obstruction
Enlarged Prostate
Urethral Stricture
Fecal Impaction
Neurological Conditions
Diabetic Neuropathy
Low Spinal Cord Injury
Radical Pelvic Surgery
26. Neurogenic Bladder
What is a neurogenic bladder?
A medical term for overflow incontinence,
secondary to a neurologic problem
However, this is NOT a type of urinary
incontinence
27. Basic Types and Underlying Causes of
Incontinence
Type Definition Causes
Stress Loss of urine with increase in intra-
abdominal pressure (coughing,
laughing, exercise, standing, etc.)
Weakness and laxity of
pelvic floor musculature,
bladder outlet or urethral
sphincter weakness
Urge Leakage of urine because of
inability to delay voiding after
sensation of bladder fullness is
perceived
Detrusor muscle instability,
hypersensivity associated
with local genitourinary
conditions or central
nervous system disorders
Overflow Leakage of urine resulting from
mechanical forces on an over
distended bladder, or from other
effects of urinary retention on
bladder and sphincter function
Anatomic obstruction by
prostate, stricture,
cystocele, acontractile
bladder, detrusor-sphincter
dyssynergy
Mixed Urinary leakage associated with
inability to toilet because of
impairment of cognitive and/or
physical functioning, unwillingness,
or environmental barriers
Severe dementia, other
conditions that cause
severe immobility, and
psychological factors
28. Reversible or Transient Conditions That
May Contribute to UI
“D” Delirium
Dehydration*
“R” Restricted mobility
Retention
“I” Infection
Inflammation
Impaction
“P” Polyuria
Pharmaceuticals
29. *Dehydration
Dehydration due to decreased fluid intake;
increased output from diuretics, diabetes, or
caffeinated beverages; or increased fluid
volume due to congestive heart failure can
concentrate the urine (increased specific
gravity) and also lead to fecal impaction
The specific gravity of the urine can be tested to
determine whether or not the resident is
dehydrated
30. Medications That May Cause Incontinence
Diuréticos
Anticolinérgicos - antihistaminas,
antipsicóticos, antidepresivos
Sedantes/hipnóticos
Alcohol
Narcoticos
Agonistas/antagonistas α-adrenérgicos
Bloqueadores de los canales de Calcio
31. Tipos clínicos de Incontinencia Urinaria
1. AGUDA
2. PERSISTENTE
a) de urgencia
b) de estrés
c) por rebosamiento
d) funcional
32. Types of Urinary Incontinence
Stress
Urge
Mixed
Overflow
Total
33. Types of Urinary Incontinence
Stress: Leakage of small amounts of urine as
a result of increased pressure on the
abdominal muscles (coughing, laughing,
sneezing, lifting)
Urge: Strong desire to void but the inability to
wait long enough to get to a bathroom
34. Types of Urinary Incontinence
(continued)
Mixed: A combination of two types, stress
and urge
Overflow: Occurs when the bladder overfills
and small amounts of urine spill out (bladder
never empties completely, so it is constantly
filling)
Total: Complete loss of bladder control
36. Taking the History
Duration, severity, symptoms, previous
treatment, medications, GU surgery
3 P’s
Position of leakage (supine, sitting, standing)
Protection (pads per day, wetness of pads)
Problem (quality of life)
Bladder record or diary
1
37. Evaluation is the Key!
Identification of the type of
urinary incontinence is the key
to effective treatment.
40. Basic Evaluation for Differential
Diagnosis
Patient History
Focus on medical, neurological, genitourinary
Review voiding patterns and medications
Voiding diary
Administer mental status exam, if appropriate
Physical Exam
General, abdominal and rectal exam
Pelvic exam in women, genital exam in men
Observe urine loss by having patient cough vigorously
41. Basic Evaluation for Differential
Diagnosis (continued)
Urinalysis
Detect hematuria, pyuria, bacterimia,
glucosuria, proteinuria
Post void residual volume measurement by
catheterization or pelvic ultrasound
42. Lab Results
Lab results from approximately the last 30
days:
Calcium level normal 8.6 - 10.4 mg/dl
Glucose level normal fasting 65 - 110 mg/dl
BUN normal 10 - 29 mg/100 ml (OR)
Creatinine normal 0.5 - 1.3 mg/dl
B12 level (within the last 3 years) normal 200 -
1100pg/ml
*Normal lab values may vary depending on laboratory used.
43. Three Day Voiding Diary
Three day voiding diary should be completed
on the resident
Assessment should be completed 24 hours a
day for 3 days
Make sure CNA’s are charting when the
resident is dry or not, the amount of
incontinence, if the voiding was requested or
prompted
44. Basic Continence Evaluation
Focused Physical Exam, including:
Pelvic exam to assess pelvic floor & vaginal wall
relaxation and anatomic abnormalities including digital
palpation of vaginal sphincter
Rectal exam to rule out fecal impaction & masses
including digital palpation of anal sphincter.
Neurological exam focusing on cognition & innervation
of sacral roots 2-4 (Perineal Sensation)
Post Void Residual to rule out urinary retention
Mental Status exam when indicated
45. Simple Urologic Tests
Provocative Stress Testing
Key components
Bladder must be full
Obtain in standing or lithotomy position
Sudden leakage at cough, laughing, sneezing,
lifting, or other maneuvers
46. The Bulbocavernous Reflex Test
When the nurse is inserting a finger into the
anus to check for fecal impaction, the anal
sphincter should contract
When the nurse is applying the litmus paper
to check the vaginal pH, the vaginal muscle
should contract
(When both these muscles contract this indicates
intact reflexes)
47. Post Void Residual
A post void residual should be obtained after
voiding via a straight catheterization or via the
the bladder scan
If the resident has > 200 cc residual the test is
positive
(Document the exact results on the assessment
form)
48. Mini Mental Exam (MMSE)
Complete a mini mental exam on the resident
Chart the score on the assessment form
Score the resident on the number of
questions they answered correctly to the total
number of questions reviewed
52. Incontinencia Urinaria Persistente-
tipos (I)
Tipo Concepto Causas
De urgencia
Pérdidas de gran
volumen
Incapacidad para
diferir la micción
Residuo postmiccional
pequeño
Inestabilidad del detrusor,
aislada o asociada a:
- alteraciones locales: cistitis,
cálculos, tumores,
divertículos, obstrucción.
- lesiones SNC: demencia,
ACV, Parkinson, lesiones
medulares.
53. Urge Incontinence
Most common cause of UI >75 years of age
Abrupt desire to void cannot be suppressed
Usually idiopathic
Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s
Disease, dementia
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder
54. Incontinencia Urinaria Persistente-
tipos (II)
Tipo Concepto Causas
De estrés
Pérdidas de pequeño
volumen
Al aumentar la presión
abdominal
Residuo postmiccional
pequeño
Debilidad y laxitud
muscular del suelo de la
pelvis
Incompetencia del esfínter
uretral
55. Stress Incontinence
Most common type in women < 75 years old
Occurs with increase in abdomenal pressure;
cough, sneeze, etc.
Hypermotility of bladder neck and urethra;
associated with aging, hormonal changes, trauma of childbirth or
pelvic surgery (85% of cases)
Intrinsic sphinctor problems; due to
pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic
causes (15% of cases)
56. Incontinencia Urinaria Persistente-
tipos (III)
Tipo Concepto Causas
Por
rebosamiento
Pérdidas
continuadas de
pequeño volumen
Residuo
postmiccional
> 100 cc
Obstrucción anatómica:
próstata, cistocele, uretra
Vejiga acontráctil: diabetes,
lesión medular,
anticolinérgicos
Disinergia vesico-
esfinteriana (lesiones
medulares suprasacras)
57. Overflow Incontinence
Over distention of bladder
Bladder outlet obstruction; stricture, BPH,
cystocele, fecal impaction
Non-contractile baldder (hypoactive
detrusor or atonic bladder); diabetes, MS, spinal
injury, medications
58. Incontinencia Urinaria Persistente-
tipos (IV)
Tipo Concepto Causas
Funcional
Pérdidas de orina
asociadas con
incapacidad para ir al
retrete o usar
sustitutivos, con falta
de motivación o
existencia de barreras
arquitectónicas
Demencia severa u otros
trastornos neurológicos
Factores psicológicos
(depresión, regresión,
hostilidad)
Falta o ineficacia de los
cuidadores
59. Functional Incontinence
Does not involve lower urinary tract
Result of psychological, cognitive or
physical impairment
60. Incontinencia urinaria: orientación diagnó
1. Historia clínica:
Comienzo, cantidad, desencadenante, ficha de
incontinencia
2. Historia farmacológica
3. Exploración física:
general, ginecológica, urológica, rectal
3. Pruebas complementarias:
Analítica de sangre y orina, urocultivo
4. Pruebas urodinámicas:
(Si dificultad diagnóstica ó falta de respuesta)
61. Tratamiento de la incontinencia urinaria
Medidas generales
1. Adaptación del entorno
2. Medidas higiénico-dietéticas
3. Modificación de fármacos
4. Modificación de conducta:
- dependiente del paciente: Reentrenamiento vesical
Ejercicios de Kegel
- dependiente del cuidador: Ficha de incontinencia
Micción programada
5. Medidas paliativas
62. Treatment Options
Reduce amount and timing of fluid intake
Avoid bladder stimulants (caffeine)
Use diuretics judiciously (not before bed)
Reduce physical barriers to toilet (use
bedside commode)
1
65. Surgical Interventions
Urethral Hypermotility
Marshall-Marchetti-Kantz
procedure
Needle neck suspension
Intrinsic sphincter
deficiency
Sling procedure
Surgery is reported to “cure” 4 out of 5 cases,
but success rate drops to 50% after 10 years.
66. Other Interventions
Pessaries
Periurethral bulking agents (periurethral
injection of collagen, fat or silicone)
Diapers or pads
Chronic catheterization
Periurethral or suprapubic
Indwelling or intermittant
70. Indwelling Catheters
Indwelling catheters (urethral or suprapubic)
may be necessary for certain residents with
incontinence:
Urinary retention that cannot be corrected medically or
surgically, cannot be managed by intermittent
catherization and is causing persistent overflow
incontinence, symptomatic UTIs
Pressure ulcers or skin lesions that are being
contaminated by incontinent urine
Terminally ill severely impaired residents
72. ratamiento de la incontinencia de urgencia
(inestabilidad del detrusor)
1. Medidas generales
2. Fármacos
Anticolinérgicos puros: cloruro de trospio
Anticolinérgicos mixtos: Oxibutinina
Tolterodina
Otros: Bloqueantes del calcio
Antidepresivos tricíclicos
3. Estimulación eléctrica
73. Tratamiento de la incontinencia de estrés
1. Medidas generales
2. Conos vaginales
3. Fármacos: estrógenos locales
4. Pesario
5. Cirugía: colporrafia, colposuspensión, etc.
6. Otros: Estimulación eléctrica
Inyección de expansores de volumen
Esfínter urinario artificial
74. amiento de la incontinencia por rebosamiento
1. Obstrucción: tratamiento de la obstrucción
2. Arreflexia vesical: - cateterismo intermitente
- agonistas colinérgicos (betanecol)
Tratamiento de la incontinencia funcional
1. Evaluación integral del paciente y de su entorno
2. Evaluación de la formación y capacidad de los
cuidadores
3. Aplicación de medidas generales
79. Urinary Tract Infections (UTI)
The vaginas of postmenopausal women
not being treated with estrogen have
been found to be predominately
colonized by E. coli
81. Positive Effects of Estrogen
Replacement
A decrease in vaginal pH
Reemergence of lactobacilli
Colonization of the vagina rarely occurs when
the pH is below 4.5
85. Bladder Training & Urgency
Inhibition Training
Bladder Training - techniques for postponing
voiding
Urge Inhibition Training - techniques for
resisting or inhibiting the sensation of
urgency
Bladder training & urge inhibition training is
strongly recommended for urge & mixed
incontinence & is recommended for
management of stress incontinence
86. Behavior Treatments
Pelvic muscle exercises
Effects of exercises
Support, lengthen and compress the Urethra
Elevate the urethrovesical junction
Increase pelvic/muscle tone
87. Behavior Treatments
Pelvic muscle (Kegel) exercises
Goal: to improve urethral resistance and
urinary control through the active exercise of
the pubococcygenus muscle
Components:
Proper identification of muscle (if able to stop urine
mid-stream)
Planned active exercise (hold for 10 seconds then
relax) 30-80 times per day for a minimum of 8
weeks
88. Biofeedback
Very helpful in assisting patients in identifying
and strengthening pelvic muscles
Give positive feedback for bladder training,
habit training and/or Kegels
90. Surgical Treatment
(Last Choice)
More than 100 techniques
Repair hypermobility
Repair urethral support
Contigen ™ implants (ISD)
91. When do you Refer to a Specialist?
Uncertain diagnosis/no clear treatment plan
Unsuccessful therapy/resident requests further
therapy
Surgical intervention considered/ previous
surgery failed
Hematuria without infection
92. Referral to Specialist (continued)
Existence of other comorbid conditions:
Recurrent symptomatic urinary tract infection
Persistent symptoms of difficulty with bladder emptying
Symptomatic pelvic prolapse
Prostate nodule enlargement, asymmetry, suspicion of
cancer
Abnormal post void residual urine
Neurological condition: multiple sclerosis, spinal cord
lesion/injury
History of previous radical pelvic or anti-incontinence
surgery
Notas del editor
Estimated that approximately 10% to 35% of all adults in the United States suffer from bladder control problems. The highest prevalence occurs in the elderly in both community and institutional settings. 50% of 1.5 million nursing home residents are urinary incontinent.
Although urinary incontinence is classified as a medical disease, it most importantly affects: quality of life self-esteem social activities alters daily functioning
Falls and hip fractures are very common in the elderly population and are often the reasons for prolonged hospitalization and admission to a long term care facility. Rushing to the bathroom is frequently the cause of a fall. Nocturia is defined as getting up to the bathroom more than twice during the night.
There are many different things that put a person at risk for incontinence. These are risks for incontinence, not causes .
Side effects of many medications can significantly contribute to bladder control problems, along with irritants such as caffeine. antihypertensives include medications such as calcium channel blockers, beta adrenergics, and diuretics. hypnotics include psycatropic and psychoactive, in addition to drugs with adrenergic side effects. Some foods that are thought to contribute to bladder leakage include: alcoholic beverages carbonated beverages (with or without caffeine) milk or milk products coffee or tea (even decaffeinated) citrus juices and fruits tomatoes highly spicy foods sugar and honey chocolate, corn syrup and artificial sweeteners
Normal changes that occur with the aging process can also put a person at risk for bladder control problems. Residual urine is the amount of urine left in the bladder after a void. normally less than 100cc. many elderly people have larger amounts left in the bladder after a void, even though they demonstrate no signs of this. That is, they do not feel full or uncomfortable, that have good urine output, and do not seem to have a large bladder by palpation or percussion.
Stress incontinence usually associated with weakening of the supporting tissue surrounding the bladder neck and urethra. this damage can be the result of pregnancy vaginal deliveries trauma during GYN or urologic surgery obesity chronic coughing while stress incontinence is uncommon in men, it can occur as a result of injury to the sphincter during prostate surgery or radiation therapy.
People with urge incontinence may experience inappropriate contractions of the detrusor muscle during the storage phase of the micturition cycle.
Mixed incontinence is very common in the geriatric population.
Local GU conditions include: cystitis urethritis tumors stones diverticuli outflow obstruction CNS disorders include: stroke dementia parkinsons suprasacral spinal cord injury or disease Vit B 12 deficiency: biggest reason for overflow incontinence. affects the maturation of the erythrocytes. diagnosis is confirmed by a reduced erythrocyte count and a peripheral blood smear that demonstrates megoblastic maturation. Confirmation of the megoblastic, macrocytic type of anemia is established by an increased MCV about 94 microns and increased MCH above 30ug and a normal MCHC on the CBC.
Normal specific gravity range is 1.003 to 1.030. It is increased in dehydration.
Stress incontinence can also occur when a resident is being moved, for example when transferring from chair to bed, or wheelchair to toilet. It is caused by weakness or damage to the pelvic floor or urethra. Urge incontinence caused by detrusor muscle weakness, damage, or hyperactivity.
Mixed incontinence most common in the elderly. Overflow incontinence caused by neurological factors or obstruction, such as benign prostatic hypertrophy (BPH). obstruction can also occur in females due to prolapse of the uterus.
When a foley is removed it takes three days to retrain the bladder. During this time, it will be necessary to use intermittent catheterizations.
Effects of local estrogen (short lived urinary symptoms related to atrophy) tend to reappear several weeks after treatment ends.
These are listed in descending order. Lease invasive to most invasive. Pads and absorbent products are used to manage urinary incontinence NOT to treat.
Other behavioral treatments include careful fluid management. Residents can become incontinent due to dehydration. Concentrated urine with a specific gravity >1.030 indicates that a resident is not drinking enough fluids.