Urinary Incontinence and Pressure Ulcers

Question 1

What is the physiology of bladder function?

Answer 1

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

Question 2

What are changes with aging and urinary function?

Answer 2

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

Question 3

What are readily treatable incontinence manifestations?

Answer 3

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

Question 4

What are the types of incontinence?

Answer 4

Detrusor instability (urge)
overflow
stress incontinence
functional

Question 5

Who most commonly gets urge incontinence?

Answer 5

elderly men

Question 6

What is the mechanism of urge incontinence?

Answer 6

uninhibition of detrusor contractions

Question 7

What is the cause of urge incontinence?

Answer 7

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

Question 8

What is the mechanism of overflow incontinence?

Answer 8

intravesicular pressure cannot exceed intraurethral pressure

Question 9

What is the cause of overflow incontinence?

Answer 9

outlet obstruction
detrusor inadequacy (eg diabetic neuropathy)

Question 10

What is the mechanism of stress incontinence?

Answer 10

sphincter insufficiency

Question 11

What is the cause of stress incontinence?

Answer 11

weakness of pelvic muscles
estrogen deficiency
urological surgery

Question 12

What are mixed abnormalities?

Answer 12

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

Question 13

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

Answer 13

incontinence chart: stress related, behavioral/functional problem

Question 14

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

Answer 14

uti
outlet obstruction
hx pelvic surgery
local neurological symptoms

Question 15

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

Answer 15

hx of neoplasia or diabetes
CNS dysfunction
medications

Question 16

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

Answer 16

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

Question 17

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

Answer 17

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

Question 18

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

Answer 18

True

Question 19

What are the aspects of urodynamics?

Answer 19

post-void residual
urin flow
cystometry
cystoscopy
electromyography

Question 20

What are the criteria for referral for urodynamics?

Answer 20

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

Question 21

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

Answer 21

False

Question 22

What is diuretics effect on continence?

Answer 22

polyuria

Question 23

What are anticholinergics effects on continence?

Answer 23

urinary retention

Question 24

What are the hypnotics effect on continence?

Answer 24

sedation

Question 25

What are narcotics effect on continence?

Answer 25

urinary retention

Question 26

What are alpha blockers effect on continence?

Answer 26

sphincter relaxation

Question 27

What are the alpha agonists effect on continence?

Answer 27

urinary retention

Question 28

What are the beta agonists effect on continence?

Answer 28

urinary retention

Question 29

What is caffeine's effect on continence?

Answer 29

detrusor irridation

Question 30

What is the goal of detrusor instability?

Answer 30

decrease detrusor contractions

Question 31

What is the goal of overflow incontinence?

Answer 31

remove obstructions

Question 32

What is the goal of stress incontinence?

Answer 32

increase intraurethral pressure

Question 33

What is the goal of functional problems?

Answer 33

reestablish normal pattern

Question 34

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

Answer 34

detrusor instability

Question 35

What is the mechanism of anti-cholinergic agents?

Answer 35

block detrusor contractions

Question 36

What are the side effects of anti-cholinergic agents?

Answer 36

dry mouth, constipation, CNS

Question 37

What are examples of anti-cholinergic agents?

Answer 37

oxybutynin, tolterodine, solifenacin

Question 38

When do you use impramine?

Answer 38

detrusor instability

Question 39

What is the mechanism of imipramine?

Answer 39

anti-cholinergic and alpha-sympathetic agonist activity

Question 40

What is a problem of imipramine?

Answer 40

side effects

Question 41

What are the treatments for detrusor instability?

Answer 41

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

Question 42

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

Answer 42

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

Question 43

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

Answer 43

intermittent catheterization | indwelling (Foley) catheter

Question 44

What are the treatments for stress incontinence?

Answer 44

``` estrogens kegel exercises bladder training sympathomimetics surgery ```

Question 45

What is the treatment for functional incontinence?

Answer 45

re-establish normal pattern

Question 46

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

Answer 46

use an incontinence chart tx psychologic problems use prompted voiding

Question 47

What are the types of pressure sores?

Answer 47

decubitis ulcers | bed sores

Question 48

What is the definition of a pressure sore?

Answer 48

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

Question 49

What is a grade one pressure sore?

Answer 49

erythema present >24 hours indurated epidermis intact

Question 50

What is a grade two pressure ulcer?

Answer 50

break in the epidermis or blistering surrounding erythema indurated

Question 51

What is a grade three pressure ulcer?

Answer 51

extends into dermis surrounding erythema indurated

Question 52

What is a grade four pressure ulcer?

Answer 52

involvement of deep fascia and/or muscles surrounding erythema indurated

Question 53

What is something to be aware of with pressure ulcers?

Answer 53

small openings at the surface may underlie a large undermining defect

Question 54

What are the top two areas where pressure sores develop?

Answer 54

sacrum and ischium

Question 55

What is the incidence of pressure sores?

Answer 55

3-4.5% of pts develop pressure sores during hospitalization

Question 56

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

Answer 56

filtration of capillary fluid occlusion of lymphatics accumulation of metabolic wastes

Question 57

What are contributing factors to pressure sores?

Answer 57

``` pressure shearing force friction moisture malnutrition ```

Question 58

What are the general measures/management of pressure sores?

Answer 58

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)

Question 59

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

Answer 59

superficial: paraffin gauze deep: wet-to-wet

Question 60

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

Answer 60

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

Question 61

What are the objectives of surgery for pressure sores?

Answer 61

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

Question 62

What are complications of surgery with pressure sores?

Answer 62

sepsis (polymicrobial, anaerobes) | osteomyelitis

Question 63

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

Answer 63

True