Incontinencia urinaria

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  • Estimated that approximately 10% to 35% of all adults in the United States suffer from bladder control problems. The highest prevalence occurs in the elderly in both community and institutional settings.  50% of 1.5 million nursing home residents are urinary incontinent.
  • Although urinary incontinence is classified as a medical disease, it most importantly affects: quality of life self-esteem social activities alters daily functioning
  • Falls and hip fractures are very common in the elderly population and are often the reasons for prolonged hospitalization and admission to a long term care facility. Rushing to the bathroom is frequently the cause of a fall. Nocturia is defined as getting up to the bathroom more than twice during the night.
  • There are many different things that put a person at risk for incontinence. These are risks for incontinence, not causes .
  • Side effects of many medications can significantly contribute to bladder control problems, along with irritants such as caffeine. antihypertensives include medications such as calcium channel blockers, beta adrenergics, and diuretics. hypnotics include psycatropic and psychoactive, in addition to drugs with adrenergic side effects. Some foods that are thought to contribute to bladder leakage include: alcoholic beverages carbonated beverages (with or without caffeine) milk or milk products coffee or tea (even decaffeinated) citrus juices and fruits tomatoes highly spicy foods sugar and honey chocolate, corn syrup and artificial sweeteners
  • Normal changes that occur with the aging process can also put a person at risk for bladder control problems. Residual urine is the amount of urine left in the bladder after a void. normally less than 100cc. many elderly people have larger amounts left in the bladder after a void, even though they demonstrate no signs of this. That is, they do not feel full or uncomfortable, that have good urine output, and do not seem to have a large bladder by palpation or percussion.
  • Stress incontinence usually associated with weakening of the supporting tissue surrounding the bladder neck and urethra. this damage can be the result of pregnancy vaginal deliveries trauma during GYN or urologic surgery obesity chronic coughing while stress incontinence is uncommon in men, it can occur as a result of injury to the sphincter during prostate surgery or radiation therapy.
  • People with urge incontinence may experience inappropriate contractions of the detrusor muscle during the storage phase of the micturition cycle.
  • Mixed incontinence is very common in the geriatric population.
  • Local GU conditions include: cystitis urethritis tumors stones diverticuli outflow obstruction CNS disorders include: stroke dementia parkinsons suprasacral spinal cord injury or disease Vit B 12 deficiency: biggest reason for overflow incontinence. affects the maturation of the erythrocytes. diagnosis is confirmed by a reduced erythrocyte count and a peripheral blood smear that demonstrates megoblastic maturation. Confirmation of the megoblastic, macrocytic type of anemia is established by an increased MCV about 94 microns and increased MCH above 30ug and a normal MCHC on the CBC.
  • Normal specific gravity range is 1.003 to 1.030. It is increased in dehydration.
  • Stress incontinence can also occur when a resident is being moved, for example when transferring from chair to bed, or wheelchair to toilet. It is caused by weakness or damage to the pelvic floor or urethra. Urge incontinence caused by detrusor muscle weakness, damage, or hyperactivity.
  • Mixed incontinence most common in the elderly. Overflow incontinence caused by neurological factors or obstruction, such as benign prostatic hypertrophy (BPH). obstruction can also occur in females due to prolapse of the uterus.
  • When a foley is removed it takes three days to retrain the bladder. During this time, it will be necessary to use intermittent catheterizations.
  • Effects of local estrogen (short lived urinary symptoms related to atrophy) tend to reappear several weeks after treatment ends.
  • These are listed in descending order. Lease invasive to most invasive. Pads and absorbent products are used to manage urinary incontinence NOT to treat.
  • Other behavioral treatments include careful fluid management. Residents can become incontinent due to dehydration. Concentrated urine with a specific gravity >1.030 indicates that a resident is not drinking enough fluids.
  • Incontinencia urinaria

    1. 1. Incontinencia UrinariaIncontinencia Urinaria
    2. 2. Anatomía de la Micción Músculo Detrusor Esfínter Externo e Interno Capacidad Normal 300-600cc Primera sensación 150-300cc Control SNC Puente - facilita Corteza Cerebral - inhibe Efectos Hormonales - estrógenos
    3. 3. Nervios Periféricos en la Micción Parasimpático (colinérgico) – contracción vesical Simpático - Relajación vesical Simpático - Relajación vesical (β adrenérgico) Simpático – Contracción del Cuello vesical yuretral (α adrenérgico) Somático (nervio pudendo) - contracción de lamusculatura del piso pélvico
    4. 4. Control de la micciónCuello vesicalUretra proximalMúsculo detrusorVejigaEsfínter uretral externoSuelo de la pelvisNervio pudendoS2 – S4SimpáticoD11 – L2ParasimpáticoS2 – S4CortexÀrea motora del detrusor(+)(+)(+)(-)(-)Núcleo pontino(+)(-)
    5. 5. Nervios Periféricos en la Micción
    6. 6. Incontinencia urinaria“Pérdida involuntaria de orina,demostrable objetivamente,que ocasiona un problema desalud o social”.(International Continence Society)
    7. 7. Incontinencia: Epidemiología1. Comunidad: 15-30%Hospital de agudos: 30-40%Instituciones: 50-80%2. Estudio de Madrid: Varones 14,5 %Mujeres 16%Por grupos de edad: 65-74 13%75-84 16%>84 26%
    8. 8. Prevalence of Urinary Incontinence Estimated 10% to 35% of adults > 50% of 1.5 million nursing home residents A conservative estimated cost of $5.2 billionper year for urinary incontinence in nursinghomesFant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy andResearch. 1996. AHCPR Publication No. 90-06 National Center for Health Statistics. Vital Health Statistics Series.13(No. 102). 1989e in
    9. 9. ¿Cuán Común es la Incontinencia? Prevalencia se incrementa con la edad (pero noes parte del envejecimiento normal) 25-30% de la comunidad de ancianas 10-15% de la comunidad de ancianos 50% residentes de hogares; frecuentementeasociado con demencia, incontinencia fecal,pérdida de la habilidad para caminar ytrasladarse independientemente
    10. 10. La Incontinencia Urinaria es FrecuentementeSub-diagnósticada y Sub-tratada Sólo el 32% de los médicos generalespreguntan rutinariamente acerca de laincontinencia 50-75% de los pacientes nunca describensíntomas a los médicos 80% de las incontinencias urinariaspueden ser curadas o mejoradas
    11. 11. Incontinencia urinaria: repercusionesFísicas:Infecciones, sepsis, úlceras, caídasPsíquicas:Ansiedad, depresión, pérdida autoestima,Interferencias sexualesSociales:Aislamiento, mayor necesidad de recursos,institucionalizaciónEconómicas:Costes de complicaciones y de medidas paliativas
    12. 12. Impact on Quality of Life Loss of self-esteem Decreased ability to maintain independentlifestyle Increased dependence on caregivers foractivities of daily life Avoidance of social activity and interaction Restricted sexual activityGrimby et al. Age Aging. 1993; 22:82-89.Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. WashingtonDC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988.Noelker L. Gerontologist. 1987; 27:194-200.
    13. 13. Consequences of UI An increased propensity for falls Most hip fractures in elders can be traced tonocturia especially if combined with urgency Risk of hip fracture increases with physical decline from reduced activity cognitive impairments that may accompany a UTI medications often used to treat incontinence loss of sleep related to nocturia
    14. 14. Risk Factors Aging Medication side effects High impact exercise Menopause Childbirth
    15. 15. Factors Contributing toUrinary Incontinence Medications Diuretics Antidepressants Antihypertensives Hypnotics Analgesics Narcotics Sedatives Diet Caffeine Alcohol Bowel Irregularities Constipation Fecal Impaction
    16. 16. Age Related Changes in theGenitourinary Tract Majority of urine production occurs at rest Bladder capacity is diminished Quantity of residual urine is increased Bladder contractions become uninhibited(detrusor instability) Desire to void is delayed
    17. 17. Cambios del tracto urinario inferior conel envejecimientoDisminución de:Capacidad vesicalLongitud de la uretra funcionalContractilidad vesicalPresión de cierre uretralHabilidad para posponer la micciónAumento de:Residuo vesical postmiccionalContracciones no inhibidas del detrusor
    18. 18. Causas de Incontinencia Urinaria aguda-Infecciones-Síndrome confusional agudo-Inmovilidad-Impactación fecal-Vaginitis atrófica-Medicamentos:Diuréticos, anticolinérgicos, antidepresivos,Neurolépticos, hipnóticos, sedantes,Mórficos, bloqueantes del calcio,Antiparkinsonianos, antihistamínicos,Antidiarreicos, agonistas alfa y beta adrenérgicos
    19. 19. Causas Potencialmente ReversiblesD - DelirioI - InfecciónA - Atrofia vaginal o uretritisF - FármacosP - PsycológicosE - EndocrinosM - Mobilidad restringidaI - Impactación fecal2
    20. 20. Cause of Stress UrinaryIncontinence Failure to store secondary to urethralsphincter incompetence
    21. 21. Causes of Urge UrinaryIncontinence Failure to store, secondary to bladderdysfunction Involuntary bladder contractions Decreased bladder compliance Severe bladder hypersensitivity
    22. 22. Stress Incontinence vs. UrgeIncontinence: System Check ListSymptoms StressIncontinenceUrgeIncontinenceUrgency accompanies incontinence(strong, sudden desire to void)NO YESLeaking during physical activity (e.g.coughing, sneezing, lifting, etc.)YES NOAbility to reach the toilet in time,following an urge to voidYES NOWaking to pass urine at night SELDOM OFTEN
    23. 23. Causes of Mixed UrinaryIncontinence Combination of bladder overactivity and stressincontinence One type of symptom (e.g., urge or stressincontinence) often predominates
    24. 24. Symptoms of Overactive Bladder Urgency Frequency Nocturia, and/or urge incontinence ANY COMBINATION - in the absence of anylocal pathological or metabolic disorder
    25. 25. Causes of Overflow UrinaryIncontinence Loss of urineassociated with overdistention of thebladder Failure to empty Underactive bladder Vitamin B12deficiency Outlet obstruction Enlarged Prostate Urethral Stricture Fecal Impaction Neurological Conditions Diabetic Neuropathy Low Spinal Cord Injury Radical Pelvic Surgery
    26. 26. Neurogenic BladderWhat is a neurogenic bladder? A medical term for overflow incontinence,secondary to a neurologic problem However, this is NOT a type of urinaryincontinence
    27. 27. Basic Types and Underlying Causes ofIncontinenceType Definition CausesStress Loss of urine with increase in intra-abdominal pressure (coughing,laughing, exercise, standing, etc.)Weakness and laxity ofpelvic floor musculature,bladder outlet or urethralsphincter weaknessUrge Leakage of urine because ofinability to delay voiding aftersensation of bladder fullness isperceivedDetrusor muscle instability,hypersensivity associatedwith local genitourinaryconditions or centralnervous system disordersOverflow Leakage of urine resulting frommechanical forces on an overdistended bladder, or from othereffects of urinary retention onbladder and sphincter functionAnatomic obstruction byprostate, stricture,cystocele, acontractilebladder, detrusor-sphincterdyssynergyMixed Urinary leakage associated withinability to toilet because ofimpairment of cognitive and/orphysical functioning, unwillingness,or environmental barriersSevere dementia, otherconditions that causesevere immobility, andpsychological factors
    28. 28. Reversible or Transient Conditions ThatMay Contribute to UI“D” DeliriumDehydration*“R” Restricted mobilityRetention“I” InfectionInflammationImpaction“P” PolyuriaPharmaceuticals
    29. 29. *Dehydration Dehydration due to decreased fluid intake;increased output from diuretics, diabetes, orcaffeinated beverages; or increased fluidvolume due to congestive heart failure canconcentrate the urine (increased specificgravity) and also lead to fecal impaction The specific gravity of the urine can be tested todetermine whether or not the resident isdehydrated
    30. 30. Medications That May Cause Incontinence Diuréticos Anticolinérgicos - antihistaminas,antipsicóticos, antidepresivos Sedantes/hipnóticos Alcohol Narcoticos Agonistas/antagonistas α-adrenérgicos Bloqueadores de los canales de Calcio
    31. 31. Tipos clínicos de Incontinencia Urinaria1. AGUDA2. PERSISTENTEa) de urgenciab) de estrésc) por rebosamientod) funcional
    32. 32. Types of Urinary Incontinence Stress Urge Mixed Overflow Total
    33. 33. Types of Urinary Incontinence Stress: Leakage of small amounts of urine asa result of increased pressure on theabdominal muscles (coughing, laughing,sneezing, lifting) Urge: Strong desire to void but the inability towait long enough to get to a bathroom
    34. 34. Types of Urinary Incontinence(continued) Mixed: A combination of two types, stressand urge Overflow: Occurs when the bladder overfillsand small amounts of urine spill out (bladdernever empties completely, so it is constantlyfilling) Total: Complete loss of bladder control
    35. 35. HistoryObtaining an accurate andcomprehensive UI History
    36. 36. Taking the History Duration, severity, symptoms, previoustreatment, medications, GU surgery 3 P’s Position of leakage (supine, sitting, standing) Protection (pads per day, wetness of pads) Problem (quality of life) Bladder record or diary1
    37. 37. Evaluation is the Key!Identification of the type ofurinary incontinence is the keyto effective treatment.
    38. 38. Basic Evaluation Physical Exam Female genitalia abnormalities Rectocele Urethral Prolapse Cystocele Atrophic Vaginitis
    39. 39. Physical Examination Mental status Mobility Fluid overload Abdominal exam Neurologic exam Pelvic Rectal
    40. 40. Basic Evaluation for DifferentialDiagnosis Patient History Focus on medical, neurological, genitourinary Review voiding patterns and medications Voiding diary Administer mental status exam, if appropriate Physical Exam General, abdominal and rectal exam Pelvic exam in women, genital exam in men Observe urine loss by having patient cough vigorously
    41. 41. Basic Evaluation for DifferentialDiagnosis (continued) Urinalysis Detect hematuria, pyuria, bacterimia,glucosuria, proteinuria Post void residual volume measurement bycatheterization or pelvic ultrasound
    42. 42. Lab Results Lab results from approximately the last 30days: Calcium level normal 8.6 - 10.4 mg/dl Glucose level normal fasting 65 - 110 mg/dl BUN normal 10 - 29 mg/100 ml (OR) Creatinine normal 0.5 - 1.3 mg/dl B12 level (within the last 3 years) normal 200 -1100pg/ml*Normal lab values may vary depending on laboratory used.
    43. 43. Three Day Voiding Diary Three day voiding diary should be completedon the resident Assessment should be completed 24 hours aday for 3 days Make sure CNA’s are charting when theresident is dry or not, the amount ofincontinence, if the voiding was requested orprompted
    44. 44. Basic Continence EvaluationFocused Physical Exam, including: Pelvic exam to assess pelvic floor & vaginal wallrelaxation and anatomic abnormalities including digitalpalpation of vaginal sphincter Rectal exam to rule out fecal impaction & massesincluding digital palpation of anal sphincter. Neurological exam focusing on cognition & innervationof sacral roots 2-4 (Perineal Sensation) Post Void Residual to rule out urinary retention Mental Status exam when indicated
    45. 45. Simple Urologic Tests Provocative Stress Testing Key components Bladder must be full Obtain in standing or lithotomy position Sudden leakage at cough, laughing, sneezing,lifting, or other maneuvers
    46. 46. The Bulbocavernous Reflex Test When the nurse is inserting a finger into theanus to check for fecal impaction, the analsphincter should contract When the nurse is applying the litmus paperto check the vaginal pH, the vaginal muscleshould contract(When both these muscles contract this indicatesintact reflexes)
    47. 47. Post Void Residual A post void residual should be obtained aftervoiding via a straight catheterization or via thethe bladder scan If the resident has > 200 cc residual the test ispositive(Document the exact results on the assessmentform)
    48. 48. Mini Mental Exam (MMSE) Complete a mini mental exam on the resident Chart the score on the assessment form Score the resident on the number ofquestions they answered correctly to the totalnumber of questions reviewed
    49. 49. Diagnostic Tests Stress test (diagnostic for stress incontinence; specificity >90%) Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture Simple (bedside) Cystometrics
    50. 50. Bladder Pressure-VolumeRelationship
    51. 51. Interpretation of Post-Void ResidualPVR < 50cc - Adequate bladderemptyingPVR > 150cc - Avoid bladder relaxingdrugsPVR > 200cc - Refer to UrologyPVR > 400cc - Overflow UI likely
    52. 52. Incontinencia Urinaria Persistente-tipos (I)Tipo Concepto CausasDe urgenciaPérdidas de granvolumenIncapacidad paradiferir la micciónResiduo postmiccionalpequeñoInestabilidad del detrusor,aislada o asociada a:- alteraciones locales: cistitis,cálculos, tumores,divertículos, obstrucción.- lesiones SNC: demencia,ACV, Parkinson, lesionesmedulares.
    53. 53. Urge Incontinence Most common cause of UI >75 years of age Abrupt desire to void cannot be suppressed Usually idiopathic Causes: infection, tumor, stones, atrophicvaginitis or urethritis, stroke, Parkinson’sDisease, dementiaOther Names: detrusor hyperactivity, detrusor instability,irritable bladder, spastic bladder
    54. 54. Incontinencia Urinaria Persistente-tipos (II)Tipo Concepto CausasDe estrésPérdidas de pequeñovolumenAl aumentar la presiónabdominalResiduo postmiccionalpequeñoDebilidad y laxitudmuscular del suelo de lapelvisIncompetencia del esfínteruretral
    55. 55. Stress Incontinence Most common type in women < 75 years old Occurs with increase in abdomenal pressure;cough, sneeze, etc. Hypermotility of bladder neck and urethra;associated with aging, hormonal changes, trauma of childbirth orpelvic surgery (85% of cases) Intrinsic sphinctor problems; due topelvic/incontinence surgery, pelvic radiation, trauma, neurogeniccauses (15% of cases)
    56. 56. Incontinencia Urinaria Persistente-tipos (III)Tipo Concepto CausasPorrebosamientoPérdidascontinuadas depequeño volumenResiduopostmiccional> 100 ccObstrucción anatómica:próstata, cistocele, uretraVejiga acontráctil: diabetes,lesión medular,anticolinérgicosDisinergia vesico-esfinteriana (lesionesmedulares suprasacras)
    57. 57. Overflow Incontinence Over distention of bladder Bladder outlet obstruction; stricture, BPH,cystocele, fecal impaction Non-contractile baldder (hypoactivedetrusor or atonic bladder); diabetes, MS, spinalinjury, medications
    58. 58. Incontinencia Urinaria Persistente-tipos (IV)Tipo Concepto CausasFuncionalPérdidas de orinaasociadas conincapacidad para ir alretrete o usarsustitutivos, con faltade motivación oexistencia de barrerasarquitectónicasDemencia severa u otrostrastornos neurológicosFactores psicológicos(depresión, regresión,hostilidad)Falta o ineficacia de loscuidadores
    59. 59. Functional Incontinence Does not involve lower urinary tract Result of psychological, cognitive orphysical impairment
    60. 60. Incontinencia urinaria: orientación diagnó1. Historia clínica:Comienzo, cantidad, desencadenante, ficha deincontinencia2. Historia farmacológica3. Exploración física:general, ginecológica, urológica, rectal3. Pruebas complementarias:Analítica de sangre y orina, urocultivo4. Pruebas urodinámicas:(Si dificultad diagnóstica ó falta de respuesta)
    61. 61. Tratamiento de la incontinencia urinariaMedidas generales1. Adaptación del entorno2. Medidas higiénico-dietéticas3. Modificación de fármacos4. Modificación de conducta:- dependiente del paciente: Reentrenamiento vesicalEjercicios de Kegel- dependiente del cuidador: Ficha de incontinenciaMicción programada5. Medidas paliativas
    62. 62. Treatment Options Reduce amount and timing of fluid intake Avoid bladder stimulants (caffeine) Use diuretics judiciously (not before bed) Reduce physical barriers to toilet (usebedside commode)1
    63. 63. Treatment Options Bladder training Patient education Scheduled voiding Positive reinforcement Pelvic floor exercises (Kegel Exercises) Biofeedback Caregiver interventions Scheduled toileting Habit training Prompted voiding2
    64. 64. Pharmacological Interventions Urge Incontinence Oxybutynin (Ditropan) Propantheline (Pro-Banthine) Imipramine (Tofranil) Stress Incontinence Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed) Estrogen (orally, transdermally or transvaginally)
    65. 65. Surgical Interventions Urethral Hypermotility Marshall-Marchetti-Kantzprocedure Needle neck suspension Intrinsic sphincterdeficiency Sling procedureSurgery is reported to “cure” 4 out of 5 cases,but success rate drops to 50% after 10 years.
    66. 66. Other Interventions Pessaries Periurethral bulking agents (periurethralinjection of collagen, fat or silicone) Diapers or pads Chronic catheterization Periurethral or suprapubic Indwelling or intermittant
    67. 67. Inserts Pessary Urethral inserts Vaginal weights
    68. 68. Pessaries
    69. 69. Pessary
    70. 70. Indwelling Catheters Indwelling catheters (urethral or suprapubic)may be necessary for certain residents withincontinence: Urinary retention that cannot be corrected medically orsurgically, cannot be managed by intermittentcatherization and is causing persistent overflowincontinence, symptomatic UTIs Pressure ulcers or skin lesions that are beingcontaminated by incontinent urine Terminally ill severely impaired residents
    71. 71. Indwelling Catheter
    72. 72. ratamiento de la incontinencia de urgencia(inestabilidad del detrusor)1. Medidas generales2. FármacosAnticolinérgicos puros: cloruro de trospioAnticolinérgicos mixtos: OxibutininaTolterodinaOtros: Bloqueantes del calcioAntidepresivos tricíclicos3. Estimulación eléctrica
    73. 73. Tratamiento de la incontinencia de estrés1. Medidas generales2. Conos vaginales3. Fármacos: estrógenos locales4. Pesario5. Cirugía: colporrafia, colposuspensión, etc.6. Otros: Estimulación eléctricaInyección de expansores de volumenEsfínter urinario artificial
    74. 74. amiento de la incontinencia por rebosamiento1. Obstrucción: tratamiento de la obstrucción2. Arreflexia vesical: - cateterismo intermitente- agonistas colinérgicos (betanecol)Tratamiento de la incontinencia funcional1. Evaluación integral del paciente y de su entorno2. Evaluación de la formación y capacidad de loscuidadores3. Aplicación de medidas generales
    75. 75. Remember...Urinary Incontinence canbe treated even if the residenthas dementia!!
    76. 76. TreatmentGuidelines recommend leastinvasive evaluation andtreatment as baseline!!
    77. 77. Treat Transient Causes FirstSuch as: Atrophic vaginitis Symptomatic urinary tract infections (UTI)
    78. 78. Hypoestrogenation Causes(Loss of Estrogen) Decreased glycogen Decreased lactic acid Increased vaginal pH Increased risk of UTI’s
    79. 79. Urinary Tract Infections (UTI)The vaginas of postmenopausal womennot being treated with estrogen havebeen found to be predominatelycolonized by E. coli
    80. 80. Circulating Estrogen InhibitsUropathogen Growth by: Colonization of the vagina with lactobacilli Maintenance of acidic pH (<5)
    81. 81. Positive Effects of EstrogenReplacement A decrease in vaginal pH Reemergence of lactobacilli Colonization of the vagina rarely occurs whenthe pH is below 4.5
    82. 82. Symptoms tend to re-appearwhen estrogen treatment ends!
    83. 83. Other Treatments of UrinaryIncontinence Behavioral therapy Pharmacotherapy Electrical Stimulation Denervation/decentralization Augmentation cystoplasty Catheterization Urinary diversion
    84. 84. Behavioral Treatments Fluid management Voiding frequency Toileting assistance Scheduled toileting Prompted voiding Bladder training Pelvic floor muscle exercise
    85. 85. Bladder Training & UrgencyInhibition Training Bladder Training - techniques for postponingvoiding Urge Inhibition Training - techniques forresisting or inhibiting the sensation ofurgency Bladder training & urge inhibition training isstrongly recommended for urge & mixedincontinence & is recommended formanagement of stress incontinence
    86. 86. Behavior Treatments Pelvic muscle exercises Effects of exercises Support, lengthen and compress the Urethra Elevate the urethrovesical junction Increase pelvic/muscle tone
    87. 87. Behavior Treatments Pelvic muscle (Kegel) exercises Goal: to improve urethral resistance andurinary control through the active exercise ofthe pubococcygenus muscle Components: Proper identification of muscle (if able to stop urinemid-stream) Planned active exercise (hold for 10 seconds thenrelax) 30-80 times per day for a minimum of 8weeks
    88. 88. Biofeedback Very helpful in assisting patients in identifyingand strengthening pelvic muscles Give positive feedback for bladder training,habit training and/or Kegels
    89. 89. Pharmacotherapy Medications To relax or augment bladder or urethral activity
    90. 90. Surgical Treatment(Last Choice) More than 100 techniques Repair hypermobility Repair urethral support Contigen ™ implants (ISD)
    91. 91. When do you Refer to a Specialist? Uncertain diagnosis/no clear treatment plan Unsuccessful therapy/resident requests furthertherapy Surgical intervention considered/ previoussurgery failed Hematuria without infection
    92. 92. Referral to Specialist (continued) Existence of other comorbid conditions: Recurrent symptomatic urinary tract infection Persistent symptoms of difficulty with bladder emptying Symptomatic pelvic prolapse Prostate nodule enlargement, asymmetry, suspicion ofcancer Abnormal post void residual urine Neurological condition: multiple sclerosis, spinal cordlesion/injury History of previous radical pelvic or anti-incontinencesurgery

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