Urinary incontinence in the elderly
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Topic: Urinary incontinence in the elderly
Posted By: random1982
Subject: Urinary incontinence in the elderly
Date Posted: Apr 05 2010 at 6:10am
http://physiophysio.blogspot.com/2009/09/urinary-incontinence-in-elderly.html - Urinary
incontinence in the elderly http://physiophysio.blogspot.com/2009/09/urinary-incontinence-in-elderly.html - - Urinary incontinence in the
elderly
UI
is undertreated:
-stigma of UI
-Professional lack of
awareness regarding options of interventionl.
• Symptoms tend to
become progressively worse wit age, especially in women reaching the
postmenopausal years.
• Only 1 in 10 women
will seek professional services
for incontinence
• several
forms of treatment are effective in improving or curing UI.
What is UI?
Incontinence is
the passing of urine in an undesirable place.
A normal urination
patter?? in adults includes:
1.Maintenance of dry
underclothes at all times.
2. Urination volume of approximately 300
to 400 ml at each void
3. Urination frequency of approximately 4 to 6
times during the day and no more than once at night.
3. Urination
without any discomfort, excessive effort, or false starts and stops.
Several components are
needed to maintain continence:
-Recognize the need to
urinate.
-Locate the proper place to urinate;
-Reach that place to
urinate in an efficient time period.
-Retain the urine until the
place is securely reached
- Able to urinate once arriving at the
proper place.
Prevalence:
• Women experience incontinence twice as
often as men.
• 15% to 30% of women in all age groups affected
•
Among middle-aged women, research indicates that 58% reported some urine
loss, but only 25% sought treatment.
• Among non-institutionalized
women older than 60, it was found that 37.7% suffered from incontinence.
•
Low-end estimates of the prevalence of incontinence among nursing home
residents start at 50%.
Physiology of Micturition:
• Micturition is controlled by phases of
storage and emptying.
• During the storage phase the bladder slowly
fills with fluid from the kidney via the ureters.
• Promotion of
storage is assisted by sympathetic relaxation of the bladder muscle (the
detrusor) and by contraction or closure of both the pelvic muscles and
the urethral sphincter.
• The urethral sphincter surrounds the
urethral outlet and must exert enough pressure to withstand the effects
of the bladder filling with urine.
• The urethral sphincter has a
reciprocal relationship with the bladder; it is contracting while the
detrusor muscle of the bladder is relaxing.
• This mechanism
maintains continence until the bladder is full, approximately 375 ml,
and/or until ready for the emptying stage.
• During the emptying
phase the bladder detrusor pushing the urine out while the urethral
sphincter and pelvic floor muscles relax to allow passage.
• After
the bladder is empty, the pelvic floor returns to a contracted state and
the urethral outlet is closed shut.
As long as this outlet pressure
is stronger (using the support of the pelvic muscles) than the pressure
from the bladder, there is no unwanted urine leakage.
Causes of UI:
subtypes
•
There are six subtypes of UI: urge, stress, mid, overflow, function and
reflex.
• The pathophysiology of each subtype varies along with
particular signs and symptoms.
• Transient, or reversible
incontinence may be triggered by infection, such as a urinary tract infection, delirium,
medications or stool impaction.
. serious conditions that may present
as incontinence include brain and spinal cord lesions, carcinoma of the
bladder or prostate and bladder stones.
Incontinence and Aging:
•
The older old (> 75 years) are more likely to suffer from
incontinence, but this condition is not automatically in ed with aging
and has nothing to do with dementia
Physiological changes in the urinary system:
•
Kidneys have diminished urine concentration —, increased volume of
urine passing through the bladder.
• Hypotrophic changes in collagen,
elastic tissue, and smooth muscle of the bladder.
• Reduced urethral
closure pressure (? due to lower estrogen levels — which leads to
decreased submucosal blood supply and decreased muscle thickness around
the urethra)
• Bladder capacity remains the same over lifetime
unless affected by illness.
•neurological disorders can trigger
bladder instability primarily because-they interfere with normal
parasympathetic control of urination.
• The inability to completely
empty the bladder leads to increase in residual urine volume that may
promote urinary tract infections, which themselves can stimulate
incontinence
Additional
factors:
Side effects of pharmaceuticals.
• Lack of
necessary social and or medical support.
interaction
of various pathologies that can lead to functional disability.
Gender-specific causes
of urinary incontinence in women:
• childbirth, gynecological
surgeries (e.g., hysterectomy), menopause, and weakened pelvic support.
Examination
1. History:
A.
Incontinence profile
The following questions are useful in the
initial identification and examination of urinary incontinence:
• Can
you tell me about the problems you are having with your bladder?
•
Can you tell me about the trouble you are having holding your urine
(water)?
• How often do you lose urine when you don’t want to? -.
•
When do you lose urine when you don’t want to? What activities or
situations are linked with leakage? Is it associated with laughing,
coughing, or getting to the bathroom?
• How often do you wear a pad
for protection?
• Do you use other protective devices to collect your
urine?
• How long have you been having a problem with urine
leakage?
B. Self-identify the pattern of urinary symptoms in a
log/diary form.
C. Bowel patterns.
2. Self-assessment (stop test): the ability
to stop the flow of urine.
Recommended as an occasional-use test
only
3. Pad
test:
• The subject is asked to wear a pre-weighed pad and to
drink 500 ml of fluid in a set period of time.
• The subject
performs a variety of set functions for 30 minutes(e.g., sit to stand,
walking, jumping, reaching for an object on the floor, and running water
over the hands).
• The pad is then re-weighed to collect data on
urine loss during activity.
Intervention:
Therapeutic Exercise
for Pelvic Muscle http://physiophysio.blogspot.com/ - Rehabilitation
•
The effectiveness of pelvic muscle exercise (PME) in incontinence
improvement is established
• Have the patient assume a comfortable
supine position with the legs well-supported and apart.
• The patient
should be instructed to tighten or draw up the muscles around the
openings of the vagina, urethra, and rectum as if he/she were trying to
prevent the flow of urine.
• The therapist then encourages the
patient to hold the contraction as long as possible (striving for a goal
of a10 seconds contraction).
• The patient should then allow the
muscle to relax or rest for twice as long as it contracted.
• The
therapist should then have the patient repeat the Cycle of contraction
and_relaxation and increase the muscle action.
• The baseline muscle
performance should be measured by recording how long a contraction can
be held and how many times it is repeated.
• After noting this
baseline assessment of performance, the patient should be encouraged to
increase the repetitions, duration, and frequency of the exercise.
•
Do the exercise in different positions
• How many times ?
•
Various recommendations range from a high of 300 to 400 repetitions per
day to as few as three to four maximal contractions performed three
times a week
• Three to four sets of 8 to 12 repetitions be performed
3 times a week.
• 10-second contractions of the pelvic muscles
followed by 10 seconds of relaxation 2 to 3 times a day for 20 minutes at each bout of
exercise.
• Performing the exercise improperly can have an undesired
effect by increasing intra-abdominal pressure.
• Many women actually
bear down by holding their breath and performing a Valsalva’s maneuver
or substitute for the appropriate muscle contractions by contracting
muscles in the thighs or buttocks.
• Consequently, mere verbal or
written instruction may be inadequate preparation to undertake a home
program .
Biofeedback
•
Visual and auditory feedback can be provided using a perineometer.
• The perineometer
transmits pressure changes relating to pelvic muscle contractile forces.
Electrical Stimulation
• Electrical stimulation uses faradic or
interferential current delivered via internal and/or external electrodes
to recruit muscles fibers, beginning with large-diameter fibers and
eventually the small-diameter fibers.
• Treatment protocols vary,
and intensity is determined according to patient tolerance.
• A
stimulation frequency of 35 Hz provides muscle feedback can elicit a
cortical response.
• A frequency that is too high may unduly fatigue a
muscle.
• Pulse width is generally set at 200 to 400 microseconds.
•
An adequate rest period, usual at least equal to or longer than the
stimulation phase, is mandatory.
• Electrical stimulation is
contraindicated during menstruation or pregnancy and in patients with
malignancy, metal implants, or a pacemaker.
Subtypes of UI
Urge: Involuntary loss of urine
associated with a strong sensation of urinary urgency.
Causes:
Involuntary detrusor
(bladder) contraction or detrusor instability
Stress: Urethral sphincter failure
usually associated with increased intra-abdominal pressure
Causes:
Urethral hypermobility due
to anatomical changes or defects.
Intrinsic urethral sphincter
deficiency, or failure of the sphincter at rest
Mixed:
Combination of urge and
stress UI
Causes:
Same as
for urge and stress UI.
Overflow
Bladder
overdistention
Causes:
Acontractile
detrusor, hypotonic or underactive detrusor secondary to drugs, fecal
impaction, diabetes, lower spinal cord injury, or disruption of the
motor innervation of the detrusor muscle. Secondary obstruction due to
prostatic hyperplasia.
Functional
Consequence
of chronic impairments of physical or cognitive function
Causes:
Not pathophysiological in
origin; secondary to functional limitations or impairments
Unconscious or reflex
Neurological
dysfunction .
Source: http://physiophysio.blogspot.com/2009/09/urinary-incontinence-in-elderly.html - http://physiophysio.blogspot.com/2009/09/urinary-incontinence-in-elderly.html
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