National Continence Month – An Interactive Discussion on Adult and Older Adult Bladder and Bowel Continence

1. National Continence Month – An Interactive Discussion on Adult and Older Adult Bladder and Bowel Continence Marcia Carr – CNS and NCA Fraser Health – Burnaby Hospital GNABC – Education Coorinator November 2008.

2. It is all about dignity and respect!

3. Objectives Upon completion of this Telehealth education session, the learner will be able to: • identify common contributing factors affecting transient and persistent urinary incontinence 2. discuss strategies and interventions to better manage urinary incontinence in their clientele 3. identify common contributing factors affecting bowel incontinence 4. discuss strategies and interventions to better manage bowel incontinence in their clientele

4. Acknowledgements • Jennifer Skelly RN, PhD, NCA • Director, Continence Program • St. Joseph’s Health Care • Associate Professor, SON • McMaster University • Sandra Whytock RN, MSN, NCA

5. Prevalence of the three most common types of UI by age

6. Factors Across the Life Cycle • Pregnancy • Childbirth • Weight • Muscle strength (pelvic floor, abdominal) • Mobility and functional status • Hormones or lack of… • Integrity of CNS • Reproductive organs (uterus, ovaries,prostate) • Chronic disease (e.g. diabetes, thyroid)

7. Prevention!!! • Teach early about bladder and bowel health and hygiene • How to cleanse • Intercourse • UTI • Constipatrion • EXERCISE – pelvic and abdominal

8. Aging Is incontinence to be expected?

9. Age Related Changes That can Impact on Continence

10. The Bladder • Smaller voided volumes • Increased residual volume • Debate: Smaller capacity or detrusor instability? • Increase in involuntary detrusor contractions • Decreased contractility of the bladder during voiding • Combination of detrusor overactivity on filling and poor contractility during voiding ( detrusor hyperactivity)

11. Atrophic Changes of the Urethra and Vagina • mucosal thinning and proteoglycans reduce urethral wall apposition which may contribute to retrograde movement of perineal bacteria into the bladder causing UTI’s. • these mucosal changes can extend up to the bladder trigone, casing irritation of sensory afferent nerves, and possibly triggering involuntary detrusor contractions

12. The Bowels • Slower transit time • Decreased peristalsis • Decreased thirst drive so not drinking adequate fluids to hydrate stool

13. The etiology of urinary incontinence in the elderly is always multifactorial. Functional Ability Medical Issues Atrophic Changes Bladder Capacity Pelvic Muscle Support Fluid Intake

14. In order to maintain continence in the elderly we need to: • Know if it is a problem – So ASK routinely • Identify the contributing factors • Transient = DISAPPEAR • Persistent • Develop treatment goals that the patient is willing to work on. • Refer to correct health care provider

15. Transient Causes of Urinary Incontinence • D – Delirium (Drugs and/or Bugs) • I – Infection & Intake • S – Stool impaction/constipation • A – Atrophic vaginitis or urethritis • P – Pharmaceuticals • P – Psychological ( depression, psychosis) • E – Excess urine (endocrine) • A – Abnormal lab values • R – Restricted mobility

16. Persistent Urinary Incontinence • Failure to Store: hyperactive or poorly compliant bladder (urge UI); poor pelvic floor or sphincter weakness (stress UI) • Failure to Empty:OVERFLOW UI poor bladder contraction; obstruction (prostate) • Mixed: combined etiologies • Functional: unable to get to the toilet to void (stroke, dementia etc.)

17. Contributing Factors and Conservative Interventions Persistent Urinary or Fecal Incontinence

18. Persistent UI • Neuro: cerebral cortex, brainstem, sacral spinal cord, neuropathy • Hormonal: de-estrogenated; thyroid dysfunction; PSA; anti-diuretic hormone • Pelvic Floor Muscle: childbirth, surgery, constipation, obesity • Functional: immobility, dementia, arthritis

19. Urinary Tract Infections Caffeine Intake Alcohol Intake Medications (e.g. diuretics, anticholinergics Atrophic changes Pelvic muscle tone Mobility Function Weight Constipation Diarrhea Contributing Factors

20. Comorbid medical illnesses • Stroke • Diabetes or other endocrine diseases • Dementia, depression, delirium • Cardiovascular disease • COPD • Cancers • Pelvic organ prolapse or obstruction • Irritable bowel or Inflammatory bowel

21. Cranberry and UTI Dr Lynn Stothers • Two tabs per day with water • Be alert to anti-coagulants as potentiates them • Pure Cranberry juice – 250-500 ml/day • Exact dose is being researched

22. Hormones • A little dab will do you – estrogen and/or progesterone • Hypothyroidism and constipation

23. Medications Is this the magic bullet that people want?

24. Targeting symptoms with meds • Decrease the urgency felt with urge • Increase the flow • Main issues • Side effects • Adherence to achieve efficacy • Cost

25. Combining Behavior Treatment and Medication Percent reductions in UI episodes after 8 weeks Behavioral When drug P-value therapy alone therapy added (N = 8) (N = 8) 57.5% 88.5% 0.034 Drug therapy When behavioral alone therapy added (N = 21) (N = 27) 72.7% 84.3% 0.001 Burgio et al, JAGS. 2000

26. Loss of Pelvic Muscle Support

27. Improving Pelvic Muscle Strength • The role of Kegel exercises • Do they really work? • Used with both women and men

28. KEGEL EXERCISES Long ‘Ems And Short ‘Ems

29. The Pelvic Floor Muscles:Structure & Function Rectum Uterus Bladder 28

30. The Pelvic Floor Muscles:Kegels – Long ‘Ems HOW ? WHERE ? WHEN ? WHY ? 29

31. Tips to find the muscle • No squeezing face “cheeks” or buttock “cheeks” • Breathe! And do not push down; only pull or draw up on the muscle • Female: • Roll a towel and straddle it • Male: • Use a mirror under scrotum

32. Keys to success • Locating the correct muscle • Rhythm – equal relaxation and contraction of the muscle • Hold the contraction for a count of 3 or 5 • How long it takes to see results – minimum of 8 weeks

33. Helpful Tip • To remember to do your Kegel’s or pelvic muscle exercises each day do them during the commercial's of your favourite 30 minute program.

34. Short ‘Em and Urge Suppression • 100/day for short fibres • Urge suppression • 5-10 quick Kegel exercises • Distraction • Perineal pressure • Sit down and cross legs • Stand on “tippy” toes

35. Cystocele

36. Managing Prolapse • The role of the pessary

37. Ring Pessary with support

38. Pessary care • Regular changes every 3 – 4 months • Use of a vaginal lubricant or premarin cream once or twice a week will reduce the problem with discharge, odor and erosions

39. Fluids!!! • Caffeine free • Hydration • Irritants • Timing

40. Urinary Incontinence: Pharmacologic and Surgical Interventions Alpha agonist Intraurethral bulking agents Vaginal sling

41. Fecal Incontinence Find the underlying cause and contributing factors

43. Constipation • Pushing, ”bearing down” – pelvic floor strain leading to poor pelvic floor strength • Impaction – bypassing (urine and stool) • Smearing/staining - ? Rectocele • Poor fibre and fluid intake • Immobility

44. Action • Bowel Program – Be consistent! • Get it formed, get it down, get it out. • Fluid, Fibre and Mobilize • Positioning on toilet • Laxatives??? Lazy Bowel??? • Get Up and Go Cookies

45. Irritable Bowel, Colitis, Crohn’s… • Require gastroenterologist work-up for Dx. • When diarrhea present need to try to bulk up stool and assure pelvic floor and sphincter integrity = fine balance • Suggest: • Canadian Society of Intestinal Research • 604-875-4875 • info@badgut.com

46. Maintaining Dignity! Products can be positive or negative. Beware!!!

47. Incontinence Products • Containment • pads, combo, pull-up pants • external “plugs/clamps” (NOT recommended) • Adaptive Devices • commode, urinals (male and female), The Whiz • Catheters • indwelling (urethral, suprapubic) • condom • intermittent – retention • Zassi, flexi-seal for diarrhea

48. Everyone’s concern Chronic Disease Management Approach

49. Chronic Disease Management A systematic approach to health care that emphasizes helping individuals maintain independence and keep as healthy as possible through prevention, early detection, and management of chronic conditions such as CHF, asthma, diabetes, and other debilitating illnesses or conditions.

50. Does this apply to Incontinence? • Persistent incontinence can be a chronic condition • Affects individuals’ independence and overall health status • Prevention, early detection and certainly evidence-based management applies to urinary incontinence.