continence - what are we aiming for?!!

Continence - What are we aiming for?!!

Dr Tammy Angel

Why is it important?

Curable!Curable!

QOL

• Occupational• Physical• Social• Psychological• Sexual• Domestic

Topics for today..

What’s normal?What are the NICE guidelines for each

types of incontinence?Local services and National initiativesWorking example..

Normal?

Bladder stores and voids

Usually sense ‘urge’ to PU at 2-300mls

At socially convenient time and place

Reflex relaxation of external sphincter

Bladder muscle contracts

Types of incontinence

• Stress

• Urge

• Overflow

• Functional

• Cognitive/neurological/psychiatric

• Mixed

NICE Rx UI

• At initial ax-SUI/UUI/ Mixed

• Hx is suffficient to inform non invasive 1st line Rx options

• (3 day) bladder diaries

• Invasive Ix NOT recommended before conservative Rx

Stress incontinence..

• Pelvic floor exercises .. ‘of at least 3 months duration’– Digital ax PFM contraction- at least 8 contractions tds - consider electrical

stimulation/ biofeedback for pts unable to actively contract PF

• Duloxetine : ‘Not be routinely used 2nd line, may be offered as alternative to surgical Rx’

• Urodynamics +/- surgical intervention (TVT TOT; injectables colposuspension)

Stress Urinary Incontinence care Plan

Additional instruction/information Stress urinary incontinence occurs when

the (pelvic floor) muscles which usuallysupport the bladder have becomeweakened, such that urine leaks when apatient coughs sneezes picks up heavyobjects, runs jumps or laughs

The most common cause of weak pelvicfloor muscles is pregnancy and childbirth,being overweight, suffering fromconstipation or a prolonged cough

Pelvic floor exercises are the best way toimprove stress incontinence (see separateleaflert), there are drug and surgicaloptions

Comments section to be used to recordnursing actions on care plan

Patient label / details

Name:_____________________________

D.O.B:_____________________________

Hosp No:___________________________

Consultant:__________________________

Aims of Care / Goal: To reduce / cure symptoms of stress incontinence by providing appropriate

advice and specialist attention whenever necessary

Nursing Actions

1. Condition has been explained to the patient

2. Patients with chronic cough and or severe constipation should bereferred to junior doctor

3. Patient given pelvic floor exercise leaflet and instructions explained

4. Daily reinforcement of pelvic floor exercises

5 Patient should be offered continence assessment/ further investigation

6 Before discharge ask patient Ôbothersome ratingÕ of symptoms ofstress incontinence1 = not bothersome 10 = very troublesome and affecting quality of life

7 Follow up to be arranged with continence team on ext 2396

Urge incontinence

• Rx UTI’s and stop unnecessary diuretics• OAB : Caffeine reduction and Bladder retraining .. ‘at least 6 weeks’• Anticholinergics ‘ non-proprietary oxybutynin due to cost effectiveness rather

efficacy - if not tolerated tolterodine; solifenacin, trospium• Intravaginal oestrogens for atrophy• Botulinium toxin A (willing to self catheterise); sacral nerve stimulation;

augmentation cystoplasty; urinary diversion • intravesical oxybutynin,

Overflow incontinence

• Clear bowels• Alphablockers eg tamsulosin• Stop anticholinergics• Intermittent self catheterisation• ?prostatic surgery

Functional incontinence

• Physiotherapy• Move closer to toilet

Neuropsych REGULAR TOILETTINGREGULAR TOILETTING

How should we assess pts - history?

MOBILITY

DRUGS

BOWELS

COGNITION

INFECTION

MEDICALCOMORBITIES

PSxH

Continence Assessment

Examination:

Abdomen/ Pelvis

Perineal/ cough

Rectal

Post micturition bladder scan

+/- Neuro/ Gait

• Investigation• Fluid volume charts• Urinalysis/ MSU• Creatinine• PSA• AXR

+/- USS Renal tracts

Hemel initiatives..

Weekly ward round : “the dry, the wet and the catheterised”!Rolling Educational Programme for AllAssessment of patients in Day Hospital and RAUManagement Algorithims and care planParticipation in National Continence AuditLocal Catheter Audit

+ Identify HCA + Trained on each ward+ Weekly screening--> see referrals + rationalise pad usage

Bleep 17251725

Shape of new service

Monday Tuesday Wednesday Thursday Friday

Hemel

F/U

Watford

Wards

SACH

RAU/OPD

Watford

F/U

Hemel

Clinic/

WR

Wards TA/ AC

WR

? Community

Admin/

Audit

Service Objectives..

Patients identified, comprehensively assessed, and appropriately managed

Patients receive written information about their condition

Better follow up for patients

Improve transfer of information into community

Promote education

My interpretation..

Gynaecologisteg post partum SUI

Urologisteg enlarged prostate +LUTS

GeriatricsComorbidities + UI

GP AssessmentTRIAGE

CommunityContinenceAdvisors

Working example

• 70 yr old woman;

• C/O: severe urgency, UI, nocturnal frequency..needs radioactive iodine!

• PMH : ‘CCF’, HT, OA awaiting THR

• DH: BFZ, Frusemide, Diltiazem, doxazosin tramadol

• PSH: N and no previous ix

Further hx and ix

• O/E: well in self , mild SOA,

abdo NAD, PV N, PR loaded

• Urinalysis = clear

• Bladder scan when ‘desperate’ = 60 mls and PMRV = 0 mls

• WHAT NEXT?…

Assessment..

1. Overactive bladder with small capacity

2. Exacerbated by diuretics,

3. Reduced mobility due to OA,

4. SOA ? Diltiazem/Gravity/RVF

5. Constipation

Plan and outcome

• Stopped BFZ, doxazosin• Frusemide at 5pm then fluid restrict• Detrusitol XL 4 mg od• Bladder retraining exercises – holding on• Senna and docusate• Leg elevation during the day

DRY!!.. Rx radioiodine

Conclusions

Dispel 2 urban myths:

1. Incontinence is not normal for age

2. It is curable…

A continence nurse specialist will dramatically improve quality of service and community integration!

Any questions ?