Urinary issues Flashcards

1
Q

What is incontinence?

A
  • involuntary leakage of urine in sufficient volumes or frequency so as to cause hygienic or social problems
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2
Q

Prevalence of incontinence?

A
  • 5% (3%-34%) of community dwelling adults aged 65 or older
  • 30% (15-50%) of acutely hosp. adults aged 65 or older
  • 50% of homebound or nursing home adults aged 65 or older
  • 3-25% of elderly w/ incontinence have severe incontinence
  • costs over $16 billion/yr in US
  • over $1 billion spent on adult absorbent products annually in US
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3
Q

Clinical importance of incontinence?

A
  • common, especially in women (ratio 4:1 in ages less than 60, 2:1 in ages greater than 60)
  • women 60 and older:
    30-50% have any UI
    6-14% have daily UI
  • common causes of institutionalization, social isolation, and decline in fxn
  • increased risk of fractures
  • often not mentioned to providers
  • providers often ill prepared to deal w/ it
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4
Q

hx questions to ask your pt that has incontinence?

A
  • do you ever lose your urine and get wet?
  • how long have you had this problem?
  • what caused it to begin?
  • how often does it occur?
  • how much urine leaks out?
  • when does leakage occur?
  • what precipitates the leakage?
  • does it leak when you cough? Sneeze? strain? - stress
  • do you feel the urge to urinate but the urine leaks out b/f you can get to the BR? - urge
  • do you feel like your bladder doesn’t empty completely? incomplete bladder emptying
  • Does it hurt to urinate?
  • is there blood in urine?
  • do you have trouble starting your urine stream?
  • what have you done to tx the leakage?
  • do you use pads to catch the leakage - if so, how many?
  • fluids, meds, gyn/urologic surgeries, medical conditions: DM, MS, UTIs, radiation tx for gyn/urologic cancer
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5
Q

Exam for incontinence?

A
  • women:
    pelvic - atrophy, prolapse, masses, stress test, q tip test, rectal - sphincter tone, impaction
  • men:
    genitalia, rectal: prostate, sphincter tone, impaction
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6
Q

What transient causes need to ruled out?

A
D: delirium
I: infection
A: atrophy
P: pharm
P: psych
E: endocrine 
R: restricted mobility 
S: stool impaction
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7
Q

Common drug causes of incontinence?

A
  • anticholinergics
  • alpha agonists
  • alpha antagonists
  • diuretics (including caffeine)
  • CCBs
  • sedative hypnotics and any CNS depressants, including ETOH
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8
Q

Lab tests for incontinence?

A

reqd:
UA
urine C&S

useful:
BUN, creatinine
glucose
Ca++
electrolytes
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9
Q

How can incontinence affect the elderly?

A
  • decrease self esteem: isolation, depression

- can lead to infections, falls

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10
Q

Behavioral approaches to incontinence?

A
  • reduce caffeine, liquids
  • timed voiding: go often enough to avoid accidents
  • bladder training: lengthen time b/t voids gradually
  • prompted voiding: caregiver positively reinforces dryness, neutral response to wetness
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11
Q

Tx for incontinence?

A
  • timed voiding, bladder training, prompted voiding
  • biofeedback and electrical stimulation
  • anticholinergics -
    oxybutinin, tolterodine, imipramine, dicyclomine
  • PCPs can manage many cases of low PVR incontinence
  • many cases of high PVR incontinence will reqr referral or more involved eval
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12
Q

Prevalence of UTIs in the elderly?

A
  • community dwelling elders 25%
  • long term care (LTCF) elders (chronically bacturemic) - male 25-50%, women 15-40%
  • marked increase in men and women over the age of 65
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13
Q

RFs for UTI in the elderly?

A
  • advanced age
  • fecal incontinence/impaction
  • neurogenic bladder
  • vaginal atrophy/estrogen deficiency
  • pelvic prolapse/cystocele
  • insufficient fluid intake/dehydration
  • indwelling foley catheter or instrument procedure
  • BPH
  • diabetes
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14
Q

Causative agents - UTIs in the LTCF elderly?

A
  • E. coli around 30%
  • proteus species (GI tract) - 30%
  • staph, aureus, klebsiella, pseudomonas (gram negative), and enterococcus (gram positive) - 40%
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15
Q

Asx bacteriuria prevalence?

A
  • occurs in 6-16% of women in the community
  • 25-54% in women in nursing homes
  • frequency half that amt in men
  • w/ chronic catheter rates are higher (nearly 100% for indwelling cath)
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16
Q

UTI in women over 65 YO guidelines for dx and tx?

A

defined by at least 2 of the following:

  • fever (over 38 degrees)
  • frequency, urgency, dysuria, suprapubic tenderness or CVA tenderness
  • positive urine culture of at least 10 to the 5th colony forming units/ml w/ no more than 2 species of microorganisms
  • pyuria (10 or more WBCs/mm3 of unspun urine)
  • urine cultures in infected elderly pts may have lower colony counts: 10 to 2nd or 10 to the 3rd
17
Q

When do you not use abx for UTIs in elderly?

A
  • no abx trials are not recommend, to avoid drug toxicity and antimicrobial resistance
  • when the dx of UTI is in doubt withhold abx for 1 wk and f/u (outpts)
  • 25-50% of older women w/ UTI sx will improve in this time frame w/o therapy
18
Q

Therapy is based on what for UTIs? Both men and women?

A

-when a true UTI is documented in an older woman, therapy is based on:
location of infection
likely causative agent
- in older men - frequently caused by concomitant prostate disease or fxnl bladder impairment:
UTIs in these pops are considered high risk, short courses of therapy are not appropriate - need long term

19
Q

UTIs assoc w/ catheters?

A
  • UTIs assoc w/ catheters are leading cause of secondary nosocomial bacteremia
  • pts w/ indwelling catheters often don’t experience typically signs of UTI
  • blood and urine cultures should be obtained when pts develop fevere or otherwise unexplained systemic manifestations compatible w/ infection (alt mental status, fall in BP, metabolic acidosis, respiratory alkalosis)
  • most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated
20
Q

Signs and sxs of UTIs in elderly?

A
  • nocturia, incontinence
  • confusion
  • lethargy
  • anorexia
  • fever or hypothermia
  • FTT
  • pain/dysuria
  • behavioral changes
21
Q

Dx tests for UTIs?

A
  • UA: pyuria, blood cells in urine, bacterial count over 100,000 ml indicative of infection
  • rapid tests for bacteria in urine:
    nitrite dipstick (turning pink - + for bacteria)
    leukocyte esterase test: ID WBC in urine
  • gram stain of urine: ID by shape and characteristic (gram + or -), obtain clean catch urine or cath
  • urine culture and sensitivity - ID infecting organism and most effective abx - culture reqrs 24-72 hrs for results - obtain by clean catch urine or catheterization
  • WBC w/ diff: leukocytosis, and increased number of neutrophils
22
Q

What is sepsis? Prevalence in geri pop?

A
  • septicemia: refers to the active multiplication of bacteria in the bloodstream that results in an overwhelming infection
  • cytokines: impaired pulmonary, hepatic, or renal fxn
  • prognosis depends on underlying health status and host defenses
  • death by multi-system organ failure
  • high incidence - over 65 = 12% of pop, 65% of sepsis cases
  • cases expected to increase w/ 1.1 mill cases w/in the next 15 yrs
23
Q

RFs for urosepsis?

A
  • BPH
  • DM
  • SLE
  • ETOH: excessive intake
  • taking steroids
24
Q

Pathogenesis of urosepsis?

A
  • UTI
  • BPH
  • pyelonephritis
25
Q

Signs and sxs of urosepsis?

A
  • hypotension
  • tachycardia
  • tachypnea
  • rales
  • respiratory distress
  • anorexia, N/V
26
Q

W/U for urosepsis?

A
- blood: 
kidney fxn
CBC
chem 8 (BMP) 
- UA and culture
- CT/MRI/US
- catheterization
27
Q

Tx of urosepsis?

A
  • immediate hospitalization
  • tx for shock: vasopressors,
  • fluids: NS
  • broad spectrum abx IV:
    imipenem
    meropenem
    piperacillin-tazobactam
    sulbactam-ampicillin