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.

BibliographyDoughty, D. B. Urinary and fecal incontinence (3rd ed.) (pp. 21-54). St. Louis, MO:

Mosby/Elsevier.Dr. Rose’s peripheral brain. (2012, October24). Neurogenic bladder:Bladder dysfunction

and urinary incontinence. http://faculty.washington.edu/momus/PB/tableofc.htmEffective Health Care Program (2012,April) Non-surgical treatments for urinary

incontinence, A review of the research for women. Agency for Healthcare, Research and Quality. Pub No. 11(12)EHCO74-A

Gray, M.L. (2006). Physiology of voiding. In Doughty, D. B. Urinary and fecal incontinence (3rd ed.) (pp. 21-54). St. Louis, MO: Mosby/Elsevier.

Kershen, R.T., Appell, R.A. (2003). Voiding dysfunction after anti-incontinence surgery in women. Issues in Incontinence, Spring/Summer, 1,9-11.

Krissovich, M. (2006). Pathology and management of the overactive bladder. In Doughty, D. B. Urinary and fecal incontinence (3rd ed.) (pp. 109-165). St. Louis, MO: Mosby/Elsevier.

Mayo Clinic. (1998-2007). Overactive bladder. http://www.mayoclinic.com/print/overactive-bladder/DS00827/DSECTION=all&METHO...

Medtronic. What Is Medtronic Bladder Control Therapy? http://www.medtronic.com/patients/overactive-bladder/about-therapy/what-is-it/index.htm

National guidelines and clinical evidence only modestly influence prescribing of antihypertensive agents. (2007, January). Research Activities, 317, 15.

Newman, D.K. (2007, March). Dawning of a dry day: Fresh perspectives in managing overactive bladder. Paper presented at the Annual Symposium of the Society of Urologic Nurses and Associates, Colorado Springs, CO.

BibliographyNewman, D.K. (2006, October). Pharmacologic Management of OAB-You

make the call. Paper presented the Annual Meeting of the Society of Urologic Nurses and Associates, Kansas City, MO.

Sand, P.K., Dmochowski, R. (2002). Analysis of the standards of terminology of lower urinary tract dysfunction: Report from the standardisation sub-committee of the International Continence Society. Neurology and Urodynamics, 21, 167-78.

NIH. (2007). Urologic disease cost Americans $11 billion a year. http://www.nih.gov/news/pr/may2007/niddk-01.htm.

Serels, S.R., Appell, R.A. (2002, 2001). Bladder control problems. Newton, PA: Handbooks in Health Care Co.

Staskin, D. (2004). Lower urinary tract dysfunction in the female. In A.P. Bourcier, E.J. McGuire, & P. Abrams (Eds.), Pelvic floor disorders (pp. 43-56). Philadelphia, PA: Elsevier Saunders.

Urinary Incontinence in Adults Guideline Update Panel. (1996). Urinary incontinence in adults: Acute and chronic management. Clinical Practice Guideline, No. 2, 1996 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research (AHCPR Publication No.96-0682).

Urinary System: Normal Anatomy & Physiology. http://www.rnceus.com/uro/norm2.htm

Uroplasty. Urgent ® PC Neuromodulation System. https://www.uroplasty.com/healthcare