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Urinary incontinence in the elderly

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    Posted: Apr 05 2010 at 6:10am

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 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

Physical therapy and rehabilitation protocols
http://physiophysio.blogspot.com/
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