Bladder Matters. Peggy P. Francis DNP, RN, MSN, CS, FNP-BC

Transcription

1 Bladder Matters Peggy P. Francis DNP, RN, MSN, CS, FNP-BC

2 Disclosures Please be advised that I am on the following speaker bureaus: Astellas/GlaxoSmithKline Ortho Women s Health/Bayer Healthcare Pfizer Watson Warner Chilcott Boehringer Ingelheim

3 Disclosures I am not being financially compensated by pharma to speak today. I am not endorsing any particular pharmaceutical agent.

4

5 What is Urinary Incontinence? Urinary incontinence (UI) is the unintentional loss of urine* Urge Urinary Incontinence (UUI) Stress Urinary Incontinence (SUI) Mixed Urinary Incontinence *Clinical Practice Guidelines on Urinary Incontinence in Adults, 1996

6 Stress, Urge, or Mixed Incontinence? Stress Incontinence If you leak urine during physical activity, such as coughing, sneezing, lifting, running Urgency Incontinence If you have strong, immediate urges to urinate and leak before getting to the bathroom Mixed Incontinence If you have strong, immediate urges to void in addition to leaking during a physical activity

7 Evaluation of Incontinence Medical History Voiding history Pelvic Exam Laboratory Test (Urinalysis)

8 Transient Causes of Urinary Incontinence A Atrophic Vaginitis D Delirium U Urgency L Lack of Control T Trigone is By-Gone B Birthing Babies R Restricted mobility I Infection E Excess urine output F Fistula S stool impaction

9 Prevalence of Incontinence 13 million Americans* 1 in 11 adults 85% of those affected are women* Clinical Practice Guidelines on Urinary Incontinence in Adults, 1996

10 Incontinence Myths Myth: Normal part of aging Fact: Many older adults never experience incontinence Fact: Most people with this condition are under age 65. Myth: Nothing can be done Fact: 50-75% of the time patients do not mention symptoms to their healthcare provider* Chutka, et al, Mayo Clin Proc 71,1996;

11 Urogenital Distress Inventory (UDI) Do you experience, and if so how much are you bothered by 1. Frequent urination? 2. Urine leakage related to the feeling of urgency? 3. Urine leakage related to physical activity, coughing, or sneezing? 4. Small amounts of urine leakage drops? 5. Difficulty emptying the bladder? 6. Pain or discomfort in the lower abdominal or genital area?

12 Incontinence Impact Questionnaire Has urine leakage affected your 1. Ability to do household chores 2. Physical recreation? 3. Entertainment activities? 4. Ability to travel more than 30 min from home? 5. Participation in social activities outside your home? 6. Emotional health? 7. Feeling frustrated?

13 Overactive Bladder (OAB) It is estimated that more than 33 million adults in the US suffer from urge or mixed urinary incontinence and OAB 33% report urge incontinence episodes Urge urinary incontinence occurs in 40% 70% of elderly patients who present with complaints Estimated that less than 40% seek treatment Wein AJ. Urology. 2002;60(Suppl 5A):7-12. Merkelj I. Southern Med J. 2001;94: Roberts RO. J Amer Geriatr Soc. 1998;46: Johnson TM. J Amer Geriatr Soc. 2000;48:

14 What Does OAB Feel Like? URGENCY: strong, sudden urges to urinate WORRY: not reaching the bathroom in time or not being able to hold it FREQUENCY: urinating 8 or more times per 24 hours which may include getting up at night to urinate FRUSTRATION: voiding only a little, despite strong urges INCONVENIENCE: needing to be aware of where a bathroom is at all times

15 Common Misconceptions About OAB Loss of bladder control is a normal part of aging There is no effective treatment for UI Moderate symptoms do not require treatment Nonpharmacologic/pharmacologic treatment is ineffective and surgery is required Adapted from Wyman JF, et al. J Am Geriatr Soc. 1990;38:

16 Social Consequences of OAB Fear of odor and embarrassment Disruption of domestic, social life Social isolation, low self-esteem, depression Limitation of daily activities Risk of job loss Risk of institutionalization Crespi-Lofton J. J Am Pharm Assoc. 2001;41(Suppl 2):S3-S17. Brown JS. J Womens Health. 1998;7:

17 Quality of Life Impact of OAB: With Disease Progression Medical Consequences Decreasing Patient QoL Social Consequences Inconvenience and Coping Mechanisms Depression Anxiety Job Loss Isolation Assisted Living and Long-Term Care Early-Stage Mid-Stage Late-Stage Wyman JF, et al. Obstet Gynecol. 1987;70: Crespi-Lofton J. J Am Pharm Assoc. 2001;41(Suppl 2):S3-S17. Brown JS. J Womens Health. 1998;7:

18 What is Urge Incontinence? The complaint of involuntary urine leakage accompanied by or immediately proceeded by urgency* *International Continence Society

19 Overactive Bladder (OAB) Defined by symptoms Urgency, with or without urge incontinence, usually with frequency and nocturia In the absence of infection or pathologic conditions that might explain these symptoms Abrams P, et al. Neurourol Urodyn. 2002;21:

20 Demographics of OAB OAB prevalence underestimated Variations due to census type Inadequate reporting of symptoms OAB more frequent with age OAB is associated with comorbidities: Increased risk of falls Urinary tract and skin infections Sleep disturbances and depression

21 Common Symptoms of OAB Urinary storage failure is secondary to bladder dysfunction Involuntary bladder contractions Decreased bladder responsiveness Overactive detrusor muscle Signs: Urine loss on way to toilet Urgency: strong urge to urinate Nocturia: awakening at night to void Urinating large amounts Miller, SW. J Am Soc Consult Pharm. 1999;14(Suppl 4):S1-S11. Diokno AC, Atassi O. Comprehen Ther. 1996;22: Payne CK. Urology. 1998;51(Suppl 2A):3-10.

22 Risk Factors for OAB Lifestyle Morbid obesity Stroke Disorders Childhood bedwetting Cognitive status Estrogen depletion Fecal impaction Activities High-impact physical activities Impaired mobility Environmental barriers Degenerative disease Diabetes: endocrine Dehydration Medications Pelvic muscle weakness Crespi-Lofton J. J Am Pharm Assoc. 2001;41(Suppl 2):S3-S17. Newman D.K. Managing and Treating Urinary Incontinence Health Professional Press.

23 Disease States That Present With Symptoms of OAB Multiple sclerosis Spinal cord injury Bladder cancer Prostate cancer Urinary retention Crespi-Lofton J. J Am Pharm Assoc. 2001;41(Suppl 2):S3-S17. Newman D.K. Managing and Treating Urinary Incontinence Health Professional Press.

24 Therapeutic Agents That Can Mimic the Symptoms of OAB Diuretics Anticholinergics Calcium channel blockers Anticonvulsants Rosiglitazone Narcotics Caffeine Antidepressants Antipsychotics Alpha-adrenergic agonists & antagonists Beta-adrenergic agonists Alcohol Crespi-Lofton J. J Am Pharm Assoc. 2001;41(Suppl 2):S3-S17. Newman D.K. Managing and Treating Urinary Incontinence Health Professional Press.

25

26 Medications Used for OAB Muscarinic Receptor Antagonists (anticholinergics) Etiology of the drug category for this indication Short acting vs Long Acting Dosage Forms Available- oral, sustained release system, patch, gels

27 Anticholinergic Side Effects Dry as a bone - Dry Mouth, skin, eyes Mad as a hatter - Delirum Blind as a bat - Mydriasis Red as a beet - Flushing Hot as a hare - Hyperthermia

28 CAUTION: Commonly Used Medications With Anticholinergic Effects Captopril Cimetidine Codeine Digoxin Furosemide Isosorbide Nifedipine Ranitidine Theophylline Triamterene and hydrochlorothiazide Warfarin Pollock BG. ElderCare. 2004;4(2):5-7. Lu C, Tune LE. Am J Geriatr Psychiatry. 2003;11:

29 Stress Incontinence The complaint of involuntary leakage with effort or exertion or on sneezing or coughing* *International Continence Society

30 What Causes Stress Occurs when pelvic muscles have been damaged Pregnancy/Childbirth Prior surgery (hysterectomy) Hormonal changes Radiation Incontinence?

31 Treatment of Stress Pelvic floor exercises Medications Surgical procedures (TOT or TVT) Incontinence Like a sling or hammock for the urethra

32 Prompted Voiding Regular monitoring with encouragement to report continence status Prompting to toilet on a scheduled basis Praise and positive feedback when the resident is continent For dependent or more cognitively impaired residents Guidance to Surveyors for Long Term Care Facilities. Accessed 2/8/ downloads/ som107ap_pp_guidelines_ltcf.p df

33 Pelvic Floor Muscle Rehabilitation Also called Kegel and pelvic floor muscle exercise Strengthen the muscular components of urethral supports and pelvic organs Requires residents to participate and follow careful instructions and monitoring Guidance to Surveyors for Long Term Care Facilities. Accessed 2/8/ downloads/ som107ap_pp_guidelines_ltcf.p df

34 Percutaneous Tibial Nerve Stimulation (PTNS)

35 Urinary frequency Urinary urgency Urge incontinence PTNS These symptoms may be present in patients with Overactive Bladder, Interstitial Cystitis or Post-Radical Prostatectomy

36 Painful Bladder Syndrome (Interstitial Cystitis) Symptoms: frequency of urination with a significant Pain component Prevalence: 0.5% to 13.0%; 90% are women Diagnosis: urine specimen; exam Treatment: healthy bladder behaviors; fluid and diet management; bladder retraining; medications

37 Enlarged Prostate Enlarged prostate aka--benign prostatic hyperplasia (BPH) BPH is a non-cancerous condition in which prostate cells increase in number Causes the gland to compress the urethra, making urination painful or difficult Affects more than half of all men between the ages of 40-60

38 Normal vs. Enlarged Prostate Bladder Bladder Urethra Normal Prostate Urethra Enlarged Prostate

39 Symptoms of Enlarged Prostate Frequent and urgent need to urinate Difficulty starting urination Weak urine flow Stopping and starting of urine flow Feeling the bladder does not empty completely Urinary incontinence Interference with sexual activity

40 Male Stress Incontinence-Treatments Pads, Catheters, Clamps Kegel Exercises Contraction/relaxation of perineal muscles Injectable Bulking Agents Collagen, Macroplastique Surgery Male Sling, Artificial Sphincter

41 Artificial Urinary Sphincter More than 65,000 procedures The Gold Standard for treatment of moderate to severe incontinence Minimally invasive Outpatient procedure 92% of patients would have the AMS 800 placed again* 96% of patients would recommend it to a friend* 33 years on the market *Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success. J of Urol 1996; 156:

42 Differential Diagnosis When to consider a referral to a Specialist Benign prostatic hyperplasia (BPH) Prolapse Atrophic vaginitis Pelvic Floor Dysfunction Interstitial Cystitis Diabetes Fluid Intake urinary output disorders Genitourinary (GU) malignancy Recurrent urinary tract infection (UTI) Stress urinary incontinence (SUI) Overactive Bladder (OAB) not responsive to treatment

43

44 Peggy P. Francis DNP, RN, MSN, CS, FNP-BC 7909 Fredericksburg, Suite 210 San Antonio, TX (210)