Urinary issues

Question 1

What is incontinence?

Answer 1

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

Question 2

Prevalence of incontinence?

Answer 2

• 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

Question 3

Clinical importance of incontinence?

Answer 3

• 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

Question 4

hx questions to ask your pt that has incontinence?

Answer 4

• 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

Question 5

Exam for incontinence?

Answer 5

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

Question 6

What transient causes need to ruled out?

Answer 6

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

Question 7

Common drug causes of incontinence?

Answer 7

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

Question 8

Lab tests for incontinence?

Answer 8

reqd:
UA
urine C&S

useful:
BUN, creatinine
glucose
Ca++
electrolytes

Question 9

How can incontinence affect the elderly?

Answer 9

• decrease self esteem: isolation, depression

- can lead to infections, falls

Question 10

Behavioral approaches to incontinence?

Answer 10

• 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

Question 11

Tx for incontinence?

Answer 11

• 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

Question 12

Prevalence of UTIs in the elderly?

Answer 12

• 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

Question 13

RFs for UTI in the elderly?

Answer 13

• 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

Question 14

Causative agents - UTIs in the LTCF elderly?

Answer 14

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

Question 15

Asx bacteriuria prevalence?

Answer 15

• 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)

Question 16

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

Answer 16

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

Question 17

When do you not use abx for UTIs in elderly?

Answer 17

• 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

Question 18

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

Answer 18

-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

Question 19

UTIs assoc w/ catheters?

Answer 19

• 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

Question 20

Signs and sxs of UTIs in elderly?

Answer 20

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

Question 21

Dx tests for UTIs?

Answer 21

• 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

Question 22

What is sepsis? Prevalence in geri pop?

Answer 22

• 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

Question 23

RFs for urosepsis?

Answer 23

• BPH
• DM
• SLE
• ETOH: excessive intake
• taking steroids

Question 24

Pathogenesis of urosepsis?

Answer 24

• UTI
• BPH
• pyelonephritis

Question 25

Signs and sxs of urosepsis?

Answer 25

- hypotension - tachycardia - tachypnea - rales - respiratory distress - anorexia, N/V

Question 26

W/U for urosepsis?

Answer 26

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

Question 27

Tx of urosepsis?

Answer 27

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