Urinary Incontinence and Pressure Ulcers Flashcards Preview

Medicine II: Geriatrics > Urinary Incontinence and Pressure Ulcers > Flashcards

Flashcards in Urinary Incontinence and Pressure Ulcers Deck (63):
1

What is the physiology of bladder function?

detrusor muscle = paraympathetic
inhibition detrusor contraction = sympathetic
internal urethral sphincter= sympathetic (alpha)
external urethral sphincter = striated muscle
micturition center = in pons

2

What are changes with aging and urinary function?

decreased bladder capacity
ability to inhibit reflex bladder contractions
decrease urethral closing pressure
increase residual volume

3

What are readily treatable incontinence manifestations?

DIAPERS
D- delirium
I- infection
A- atrophic vaginitis/urethritis
P- pharmaceutical (diuretics, sedatives)
E - endocrine (increase glucose/calcium)
R- restricted mobility
S- stool impaction

4

What are the types of incontinence?

Detrusor instability (urge)
overflow
stress incontinence
functional

5

Who most commonly gets urge incontinence?

elderly men

6

What is the mechanism of urge incontinence?

uninhibition of detrusor contractions

7

What is the cause of urge incontinence?

defects in CNS regulation
hyper-excitability (local effect)
De-conditioning

8

What is the mechanism of overflow incontinence?

intravesicular pressure cannot exceed intraurethral pressure

9

What is the cause of overflow incontinence?

outlet obstruction
detrusor inadequacy (eg diabetic neuropathy)

10

What is the mechanism of stress incontinence?

sphincter insufficiency

11

What is the cause of stress incontinence?

weakness of pelvic muscles
estrogen deficiency
urological surgery

12

What are mixed abnormalities?

causes of obstruction or stress incontinence often have associated detrusor instability

detrusor hyperreflexia with impaired contractility: incomplete emptying combined with detrusor hyperreflexia in the absence of obstruction

13

When taking urinary incontinence history what do you need to ask about pattern?

incontinence chart: stress related, behavioral/functional problem

14

When taking urinary incontinence history what do you need to ask about local factors?

uti
outlet obstruction
hx pelvic surgery
local neurological symptoms

15

When taking urinary incontinence history what do you need to ask about systemic factors?

hx of neoplasia or diabetes
CNS dysfunction
medications

16

What do we look for in a physical exam for urinary incontinence?

estrogen deficiency
fecal impaction
prostatic hypertrophy
sacral neurologic function
enlarged bladder after voiding
incontinence with coughing (supine vs upright)

17

What labs do we need to look at when assessing urinary incontinece?

serum glucose/calcium
UA
post-void residual volume measurement (normal <100ml)
urodynamics

18

T/F: little is known about indication, specificity, sensitivity or predictive value in the elderly

True

19

What are the aspects of urodynamics?

post-void residual
urin flow
cystometry
cystoscopy
electromyography

20

What are the criteria for referral for urodynamics?

Hx of pelvic surgery or irradiation
marked pelvic prolapse
evidence of prostatic obstruction
post void residual > 100ml
uncertain diagnosis, or when unresponsive to tx

21

T/F: Medications do not play a role on incontinence.

False

22

What is diuretics effect on continence?

polyuria

23

What are anticholinergics effects on continence?

urinary retention

24

What are the hypnotics effect on continence?

sedation

25

What are narcotics effect on continence?

urinary retention

26

What are alpha blockers effect on continence?

sphincter relaxation

27

What are the alpha agonists effect on continence?

urinary retention

28

What are the beta agonists effect on continence?

urinary retention

29

What is caffeine's effect on continence?

detrusor irridation

30

What is the goal of detrusor instability?

decrease detrusor contractions

31

What is the goal of overflow incontinence?

remove obstructions

32

What is the goal of stress incontinence?

increase intraurethral pressure

33

What is the goal of functional problems?

reestablish normal pattern

34

When do you use an anti-cholinergic agent/bladder relaxant?

detrusor instability

35

What is the mechanism of anti-cholinergic agents?

block detrusor contractions

36

What are the side effects of anti-cholinergic agents?

dry mouth, constipation, CNS

37

What are examples of anti-cholinergic agents?

oxybutynin, tolterodine, solifenacin

38

When do you use impramine?

detrusor instability

39

What is the mechanism of imipramine?

anti-cholinergic and alpha-sympathetic agonist activity

40

What is a problem of imipramine?

side effects

41

What are the treatments for detrusor instability?

Bladder training/scheduled voiding
Eliminate caffeine
Formal training using biofeedback in pelvic floor (Kegel) contractions prn urge sensation

42

What are the treatment options for overflow incontinence caused by an obstruction?

surgery: may have detrusor instability for period post-op
drug: alpha blockers, anti-androgens (e.g. finasteride)

43

What are the treatment options for overflow incontinence caused by a detrusor weakness?

intermittent catheterization
indwelling (Foley) catheter

44

What are the treatments for stress incontinence?

estrogens
kegel exercises
bladder training
sympathomimetics
surgery

45

What is the treatment for functional incontinence?

re-establish normal pattern

46

What do you do to help re-establish normal pattern?

use an incontinence chart
tx psychologic problems
use prompted voiding

47

What are the types of pressure sores?

decubitis ulcers
bed sores

48

What is the definition of a pressure sore?

an area of soft tissue breakdown, usually occurring over a bony prominence

49

What is a grade one pressure sore?

erythema present >24 hours
indurated
epidermis intact

50

What is a grade two pressure ulcer?

break in the epidermis or blistering
surrounding erythema
indurated

51

What is a grade three pressure ulcer?

extends into dermis
surrounding erythema
indurated

52

What is a grade four pressure ulcer?

involvement of deep fascia and/or muscles
surrounding erythema
indurated

53

What is something to be aware of with pressure ulcers?

small openings at the surface may underlie a large undermining defect

54

What are the top two areas where pressure sores develop?

sacrum and ischium

55

What is the incidence of pressure sores?

3-4.5% of pts develop pressure sores during hospitalization

56

What is the effect of elevated interstitial pressure (>12mm) on pressure sores?

filtration of capillary fluid
occlusion of lymphatics
accumulation of metabolic wastes

57

What are contributing factors to pressure sores?

pressure
shearing force
friction
moisture
malnutrition

58

What are the general measures/management of pressure sores?

1. relief of pressure (turn q 2 hours)
2. debride necrotic areas
3. wound dressing (keep wet)
4. improve general health (nutrition)
5. inspect skin (measure)

59

What is the difference in wound dressings for superficial and deep ulcers?

superficial: paraffin gauze
deep: wet-to-wet

60

What are the SPECIFIC measures for the management of pressure sores?

sheepskin pads
air-or fluid-support systems
special wheelchair cushions
occlusive biosynthetic dressings (clean wounds)

61

What are the objectives of surgery for pressure sores?

excision of ulcerated areas
resection of bony prominences
formation of large flaps
obtainment of additional padding (muscle)

62

What are complications of surgery with pressure sores?

sepsis (polymicrobial, anaerobes)
osteomyelitis

63

T/F: when there is no pressure there is no sore?

True