Online Video Library Bladder Health: Dysfunctional Voiding Tools for Families

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Alison Martin
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Outreach Education Online Video Library 2009-2010... Bladder Health: Dysfunctional Voiding Tools for Families.

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1 Outreach Education Online Video Library Bladder Health: Dysfunctional Voiding Tools for Families.... Program Handouts This information is provided as a courtesy by Children's Health Care System and its related organizations (CHCS). Persons accessing this information assume full responsibility for the use of the information and understand and agree that CHCS is not responsible or liable for any claim, loss or damage arising from the use of the information. The views and opinions of the document authors do not necessarily state or reflect those of CHCS. Neither the authors nor CHCS nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Marianne Gonterman - Outreach Education (206) or (800) ext. 2 marianne.gonterman@ seattlechildrens.org

This class has no commercial support or sponsorship, nor is it co-sponsored.

2 Slide 1 Nursing Grand Rounds Bladder Health: Dysfunctional Voiding Tools for Families Slide 2 Disclosure We do not have any conflict of interest or will be discussing any off-label product use. This class has no commercial support or sponsorship, nor is it co-sponsored. Slide 3 Objectives Describe the anatomy and physiology of the voiding cycle Explain elements of dysfunctional voiding Discuss 3 tools parents can use to treat dysfunctional voiding

3 Slide 4 Scope of Presentation Disorder where voiding patterns are abnormal for the patient s age No obvious or identifiable neurologic lesion No obvious or identifiable anatomic abnormalities Lower urinary tract Provide knowledge so that nurses can educate and empower parents and caregivers to manage dysfunctional voiding Slide 5 Anatomical Overview Anatomy of the urinary tract Anatomic diagrams of urinary tract: girls, boys idneys-and- Bladder.aspx?articleID=10239&categoryID=XK Slide 6 Anatomical Overview Pertinent physiology of the bladder Layered wall Transitional epithelium, elastic protective barrier Lamina propria, connective tissue allowing distention Detrusor muscle, smooth muscle fibers arranged in longitudinal and circular layers

4 Slide 7 Slide 8 Anatomical Overview Pertinent physiology of the bladder outlet The bladder base or neck, arranged layers of smooth muscle fibers, longitudinal and circular, often described as containing the internal sphincter The urethra, contains a mix of smooth and striated muscles in it s wall. Thin smooth muscle layers and an area of striated muscle fibers which makes up the external sphincter Slide 9 Overview: A&P of the Pelvic Floor 2 major muscular supporting structures Upper, pelvic diaphragm Formed by the levator ani and coccygeaus muscles Lower supporting structure perineal membrane and associated muscles

Slide 10 Overview: A&P of the Pelvic Floor Diagram, pelvic floor muscles Slide 11 Physiology and development of bladder function The voiding cycle http://www.aboutkidshealth.

5 Slide 10 Overview: A&P of the Pelvic Floor Diagram, pelvic floor muscles Slide 11 Physiology and development of bladder function The voiding cycle Bladder-Filling-and- Emptying.aspx?articleID=10256&categoryID=XKnh4 Slide 12 Physiology and development of bladder function Bladder function in infants Works/Bladder-Control-in- Babies.aspx?articleID=10257&categoryID=X K-nh4-01

Slide 13 Physiology and development of bladder function Bladder function in children http://www.aboutkidshealth.ca/howthebody Works/Bladder-Control-in-Older- Children.aspx?

6 Slide 13 Physiology and development of bladder function Bladder function in children Works/Bladder-Control-in-Older- Children.aspx?articleID=10258&categoryID= XK-nh4-02 Slide 14 Development of Mature Bladder Control Voiding Patterns Change During Development coordination Slide 15 Dysfunctional Voiding Disorder where voiding patterns are abnormal for the patient s age From the patient s perspective From the parent s perspective From the clinician s perspective

7 Slide 16 Patient s Perspective I don t have to go! I didn t feel it Don t notice it as a problem An outcome of establishing control Complaints of abdominal pain Sense of resignation Shame or embarrassment Slide 17 Parent s Perspective I just want this to be fixed, now! I think my child needs a surgery My other child doesn t have this problem There is not a problem with constipation Feelings of helplessness We ve been hoping she will grow out of it I m really concerned about all the antibiotics she has had She will be starting school this fall and I don t want her to experience embarrassment for how others might treat her Slide 18 Clinician s Perspective Collecting an elimination history is the key to plan of care Filling phase dysfunction Emptying phase dysfunction Pt/family education is the key to successful management Psychosocial issues are influential

Urge incontinence The above problems are often transient, but may lead to: holding behaviors

8 Slide 19 Clinician s Perspective Elimination history Voiding log Questionnaire and/or interview Slide 20 Slide 21 Dysfunctional Voiding During bladder filling Urgency/frequency Urge incontinence The above problems are often transient, but may lead to: holding behaviors Decreased fluid intake Urinary tract infections Stress incontinence (uncommon) Giggle incontinence (uncommon)

9 Slide 22 Dysfunctional Voiding During bladder emptying Staccato voiding (delayed, interrupted stream) Fractionated voiding (incomplete, small volumes, straining to void) Infrequent voids Chronic problems may lead to Decreasing urge sensation Urinary tract infections Incontinence, with or without urgency gradual deterioration in detrusor contractility decreased emptying efficiency with gradually increasing post void residual Hematuria larger than normal bladder capacity Non-neurogenic neurogenic bladder Vesicovaginal entrapment Slide 23 Dysfunctional Voiding Factors in UTI Obstruction 5-10% Vesico-Ureteral Reflux 30-40% Voiding Dysfunction 70-80% Constipation 30-50% KEY: ID and Treat to Prevent Future UTI Slide 24 Voiding Dysfunction and Reflux The most common lower urinary tract abnormality to co-exist with reflux is voiding dysfunction Early detection and proper management of dysfunctional voiding results in increase of spontaneous resolution of reflux

10 Slide 25 Constipation and Urinary Symptoms 234 children ~ chronic constipation Daytime incontinence 29% Nighttime incontinence 34% UTI s 11% / VUR 16% Bowel treatment program Disimpaction / maintenance Results: Constipation relieved 52% Daytime dry 89% Nighttime dry 63% No UTI s Warne, Godley, & Wilcox, 2004 Slide 26 Dysfunctional Elimination Syndrome Describes coexistence of significant constipation/encopresis and dysfunctional voiding. Slide 27 Psychosocial Factors Secondary effect Voiding postponement Family dysfunction Abuse

11 Slide 28 Summarize Underlying abnormality may vary, but leads to same group of symptoms No matter what the symptom/s, the treatment is the same Slide 29 Glossary of Terms Vesicoureteral reflux: the condition in which urine travels backward from the bladder toward the kidney and may effect one or both ureters. In most children, reflux is a birth defect and is caused by an abnormal attachment between the ureter and the bladder. Encopresis: accidents with stool, involuntary fecal soiling. Uroflow: measures flow and force of urine stream Urodynamics: a group of diagnostic procedures providing measurements of bladder function (requires catheterization) Slide 30 Glossary of Terms, page 2 Urge incontinence - having strong, sudden urge to void, which results in a wetting accident Voiding postponement - urination may be delayed in 3-5 year olds, due to intense concentration during play Non-Neurogenic Neurogenic Bladder - condition has clinical and urodynamic findings typical of neuropathic bladder dysfunction but no neurologic pathology can be demonstrated

Slide 31 Treatments for dysfunctional voiding Toilet position Relaxing while voiding Constipation management Timed voiding Hydration Dietary irritants Voiding dairy Biofeedback

and 2 o clock positions Hands relaxed on lap Torso neutral position BOYS: Encourage boys to sit while voiding, apply same positional strategies above If standing, knees slightly

12 Slide 31 Treatments for dysfunctional voiding Toilet position Relaxing while voiding Constipation management Timed voiding Hydration Dietary irritants Voiding dairy Biofeedback therapy Medication Slide 32 Toilet position GIRLS: Place a footstool beneath the feet to have feet flat on a stable surface- promotes balance and stability Knees apart-knees at 10 and 2 o clock positions Hands relaxed on lap Torso neutral position BOYS: Encourage boys to sit while voiding, apply same positional strategies above If standing, knees slightly bent, feet shoulder width apart. Slide 33 Relaxing while voiding Allow two to three minutes for each attempt. Please don t teach kids to push! Be aware of Detrusor Sphincter Dyssenergia

Slide 34 Dysfunctional voider caught on film!

elicit an accurate history Abdominal image KUB is most revealing Bladder Side view Bowel Nerves Spine Slide 36

Tract Infections Break through constipation- liquid stool passing around larger impacted stool burdens

13 Slide 34 Dysfunctional voider caught on film! Spin top urethra- voiding against a tightened external sphincter Slide 35 Constipation Management Important to elicit an accurate history Abdominal image KUB is most revealing Bladder Side view Bowel Nerves Spine Slide 36 Constipation Management Constipation can lead to: Bladder frequency Bladder contractions and urgency Urinary Tract Infections Break through constipation- liquid stool passing around larger impacted stool burdens Treatment has many facets: Bowel clean out Miralax, magnesium citrate. MOM mineral oil, lactulose Daily dosing of supplement- maybe Miralax, fiber, Senna tea- varies child to child Sit program

14 Slide 37 Timed voiding Timed voiding- voiding every two three hours while awake. Watches for timed voiding- promote child s independence and consistency, helpful in school setting We provide letters for school that encourage free access to restrooms with gentle prompting of child as available Slide 38 Hydration Increase water intake! People often ask How much water should my child drink? Teach the kids this: Side view Side view Slide 39 Dietary irritants

temperature, sweat gland activity, and muscle tension, conveying the information to the patient in real-time.

15 Slide 40 Voiding dairy A voiding bowel movement dairy 2 days of data intake/ output/ accidents Slide 41 Biofeedback Biofeedback is a non-medical process that involves measuring a subject's specific and quantifiable bodily functions such as blood pressure, heart rate, skin temperature, sweat gland activity, and muscle tension, conveying the information to the patient in real-time. This raises the patient's awareness and therefore the possibility of conscious control of those functions. Slide 42 Medications Ditropan- anticholinergic Detrol- anticholinergic

16 Slide 43 Teaching to Parents So much to tell families! How to reach them? Best use of clinic time for nurse and family? Kids or no kids? Slide 44 CUPS Attended Seminar at SCH / Came to clinic for follow up Dec % 2% Jan % 29% Feb % 35% VT Fed Way March % 33% VT Fed Way, Olympia, Bellevue April % 30% VT Fed Way, Olympia, Bellevue May % 20% VT Fed Way, Olympia, Bellevue June % 20% July % 2% VT Fed Way, Olympia, Bellevue Aug no class Sept 2 classes 81% 24% VT Fed Way, Olympia, Bellevue, Everett 70% 27% VT Fed Way, Olympia, Bellevue, Everett Slide 45 Thank you Questions?

Physiology & Neurophysiology of lower U.T.

Physiology & Neurophysiology of lower U.T. Classification of voiding dysfunction Evaluation of a child with voiding dysfunction Management Storage Ø Adequate volume of urine Ø At LOW pressure Ø With NO