Urinary Tract Infections and Urinary Incontinence By Ana Corona, FNP-Student University of Phoenix January 2003 More presentations at: www.nurseana.com

Prevalence of UTIs Urinary Tract Infection (UTI) is the most common bacterial infection affecting humans UTI is a serious health problem affecting millions of people each year Over 8 million Americans seek medical attention for urinary tract infections annually. Women are especially susceptible: one in five women will have at least one urinary tract infection during her life .

Urinary Tract Infection (UTI) is the most common bacterial infection affecting humans

UTI is a serious health problem affecting millions of people each year

Over 8 million Americans seek medical attention for urinary tract infections annually.

Women are especially susceptible: one in five women will have at least one urinary tract infection during her life .

Pathophysiology The urinary system consists of the kidneys, ureters, bladder, and urethra. The kidneys remove liquid waste from the blood in the form of urine Keep a stable balance of salts & substances in the blood, and produce a hormone that aids the formation of RBCs.

The urinary system consists of the kidneys, ureters, bladder, and urethra.

The kidneys remove liquid waste from the blood in the form of urine

Keep a stable balance of salts & substances in the blood, and produce a hormone that aids the formation of RBCs.

Pathophysiology: continued The ureters carry urine from the kidneys to the bladder located in the lower abdomen. Urine is stored in the bladder and emptied through the urethra. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body Normal urine is sterile. It contains fluids, salts, and waste products. It is free of bacteria, viruses, and fungi.

The ureters carry urine from the kidneys to the bladder located in the lower abdomen.

Urine is stored in the bladder and emptied through the urethra.

The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body

Normal urine is sterile.

It contains fluids, salts, and waste products.

It is free of bacteria, viruses, and fungi.

Pathophysiology: Routes of Infection Three well recognized routes of infection: Ascending Transurethral Infection : fecal microorganisms colonizing the periurethral area and enter the bladder via the urethra Hematogenous : spread as in staphylococcal bacteremia or renal cortex resulting in abscess formation Direct Extension : enterovesical fistula

Three well recognized routes of infection:

Ascending Transurethral Infection : fecal microorganisms colonizing the periurethral area and enter the bladder via the urethra

Hematogenous : spread as in staphylococcal bacteremia or renal cortex resulting in abscess formation

Direct Extension : enterovesical fistula

Pathophysiology: Ascending Transurethral Infection Is most common route Short female urethra allows bacteria quick access to the bladder. Sexual intercourse forces bacteria into bladder Presence of foreskin, fecal incontinence, and poor toilet habits promote colonization by the fecal bacteria and contribute to the higher prevalence of infection seen in uncircumcised infants, young sexually active men and elderly men with poor anal sphincter control

Is most common route

Short female urethra allows bacteria quick access to the bladder.

Sexual intercourse forces bacteria into bladder

Presence of foreskin, fecal incontinence, and poor toilet habits promote colonization by the fecal bacteria and contribute to the higher prevalence of infection seen in uncircumcised infants, young sexually active men and elderly men with poor anal sphincter control

Pathophysiology: Hematogenous Spread Hematogenous spread of bacteria, fungi, and mycobacteria from distant focus of infection may invade the kidney, bladder or prostate

Hematogenous spread of bacteria, fungi, and mycobacteria from distant focus of infection may invade the kidney, bladder or prostate

Pathophysiology: Direct Extension Direct extension of bacteria from the gut into the bladder may occur via a colovesical fistula secondary to diverticulitis or colon cancer, Crohn’s disease

Direct extension of bacteria from the gut into the bladder may occur via a colovesical fistula secondary to diverticulitis or colon cancer, Crohn’s disease

Classification of Urinary Tract Infections Lower UTI : cystitis, urethritis, prostatitis Upper UTI : acute or chronic pyelonephritis, renal or perirenal abscess Uncomplicated and Complicated lower or upper UTI

Lower UTI : cystitis, urethritis, prostatitis

Upper UTI : acute or chronic pyelonephritis, renal or perirenal abscess

Uncomplicated and Complicated lower or upper UTI

Classification of Urinary Tract Infections Complicated Lower or Upper UTI: Risk of renal damage, urosepsis, abscess formation Due to Presence of functional or anatomic abnormalities, obstruction, calculi/catheter/stent, pregnancy, hospitalization, immunosuppression, diabetes mellitus, sickle cell disease, analgesic/NSAID abuse

Complicated Lower or Upper UTI:

Risk of renal damage, urosepsis, abscess formation

Due to

Presence of functional or anatomic abnormalities, obstruction, calculi/catheter/stent, pregnancy, hospitalization, immunosuppression, diabetes mellitus, sickle cell disease, analgesic/NSAID abuse

Classification of Urinary Tract Infections Acute urethral syndrome : dysuria/frequency with less than 10/ 5 colonies/ml of urine Asymptomatic bacteriuria : asymptomatic with more than 10/ 5 colonies of the same bacteria per ml of clean-catch mid-stream urine

Acute urethral syndrome : dysuria/frequency with less than 10/ 5 colonies/ml of urine

Asymptomatic bacteriuria : asymptomatic with more than 10/ 5 colonies of the same bacteria per ml of clean-catch mid-stream urine

Presenting Signs & Symptoms Uncomplicated lower UTI Acute Bacterial Cystitis: Dysuria Frequency Urgency Nocturia Voiding of small urine volumes Incontinence Suprapubic or pelvic pain

Acute Bacterial Cystitis:

Dysuria

Frequency

Urgency

Nocturia

Voiding of small urine volumes

Incontinence

Suprapubic or pelvic pain

Associated Signs & Symptoms Hematuria Foul smelling cloudy urine Men experience a fullness in the rectum Fever Flank tenderness

Hematuria

Foul smelling cloudy urine

Men experience a fullness in the rectum

Fever

Flank tenderness

Acute pyelonephritis Signs & Symptoms : Flank or low back pain, chills, fever, sweats, nausea, vomiting, headache and malaise Associated Signs & Symptoms : May have symptoms of cystitis Hematuria, dysuria, polyuria

Signs & Symptoms :

Flank or low back pain, chills, fever, sweats, nausea, vomiting, headache and malaise

Associated Signs & Symptoms :

May have symptoms of cystitis

Hematuria, dysuria, polyuria

Signs & Symptoms in the Elderly Less obvious signs: Loss of appetite or a change in eating habits. The sudden onset of confusion Urinary incontinence

Less obvious signs:

Loss of appetite or a change in eating habits.

The sudden onset of confusion

Urinary incontinence

Complicated UTI: S/S Clinical manifestations can range from asymptomatic bacteriuria to a severe gram-negative sepsis with shock Can also present with signs and symptoms of acute cystitis or acute pyelonephritis Hospitalized patients who suddenly develop signs and symptoms of septic shock or urosepsis should be considered even in the absence of urinary symptoms, particularly after a recent instrumentation of catherization.

Clinical manifestations can range from asymptomatic bacteriuria to a severe gram-negative sepsis with shock

Can also present with signs and symptoms of acute cystitis or acute pyelonephritis

Hospitalized patients who suddenly develop signs and symptoms of septic shock or urosepsis should be considered even in the absence of urinary symptoms, particularly after a recent instrumentation of catherization.

Physical Findings Acute Cystitis: Suprapubic tenderness and distension Acute Pyelonephritis: Fever 104 F Abdominal distension, hypotonic bowel sounds, severe tenderness in lumbar region

Acute Cystitis:

Suprapubic tenderness and distension

Acute Pyelonephritis:

Fever 104 F

Abdominal distension, hypotonic bowel sounds, severe tenderness in lumbar region

Physical Examination PE in men should include: Inspection and palpation of the genitals for evidence of urethral discharge, meatal erythema, inflammation of the glans penis, penile lesions, enlarged or tender epididymis or testicle, and inguinal lymphadenopathy. A rectal examination with palpation of the prostate gland should be a standard part of the PE in all men with UTI symptoms

PE in men should include:

Inspection and palpation of the genitals for evidence of urethral discharge, meatal erythema, inflammation of the glans penis, penile lesions, enlarged or tender epididymis or testicle, and inguinal lymphadenopathy.

A rectal examination with palpation of the prostate gland should be a standard part of the PE in all men with UTI symptoms

Diagnostic studies: Urinalysis "clean catch“ (midstream) Urine Culture & Sensitivity When an infection does not clear up with treatment and is traced to the same strain of bacteria further tests may be ordered: Computed Tomography (CT) Ultrasound Intravenous Pyelogram (IVP) Cystoscope

Urinalysis "clean catch“ (midstream)

Urine Culture & Sensitivity

When an infection does not clear up with treatment and is traced to the same strain of bacteria further tests may be ordered:

Computed Tomography (CT)

Ultrasound

Intravenous Pyelogram (IVP)

Cystoscope

Diagnostics Urinalysis test: urine is examined for white and red blood cells and bacteria. Urine Culture & Sensitivity: bacteria are grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. One of these infections are suspected when there are symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria.

Urinalysis test: urine is examined for white and red blood cells and bacteria.

Urine Culture & Sensitivity: bacteria are grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria.

Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures.

One of these infections are suspected when there are symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria.

Differential Diagnosis Acute Bacterial Cystitis should be differentiated from vulvovaginitis caused by yeast, trichomoniasis species or bacterial infections STDs involving the urethra and cervix such as those caused by C. trachomatis, N. Gonorrhoeae and herpes simplex virus. Between 10% to 30% of women with STDs or other forms of vaginitis have frequency and dysuria

Acute Bacterial Cystitis should be differentiated from vulvovaginitis caused by yeast, trichomoniasis species or bacterial infections

STDs involving the urethra and cervix such as those caused by C. trachomatis, N. Gonorrhoeae and herpes simplex virus.

Between 10% to 30% of women with STDs or other forms of vaginitis have frequency and dysuria

Clinical Decision Making: Differential Diagnosis Vulvovaginitis : external dysuria, soreness of the vulva, malodorous vaginal discharge, pruritus and dyspareunia Pyuria and hematuria is rare Urine culture reveals less than 10/ 2 colonies/ml Urethritis: caused by sexually transmitted pathogens- gradual onset of dysuria without other urinary symptoms, vaginal discharge or bleeding or lower abdominal pain. Pyuria with urine culture showing less than 10/ 2 colonies/ml No hematuria

Vulvovaginitis : external dysuria, soreness of the vulva, malodorous vaginal discharge, pruritus and dyspareunia

Pyuria and hematuria is rare

Urine culture reveals less than 10/ 2 colonies/ml

Urethritis: caused by sexually transmitted pathogens- gradual onset of dysuria without other urinary symptoms, vaginal discharge or bleeding or lower abdominal pain.

Pyuria with urine culture showing less than 10/ 2 colonies/ml

No hematuria

Clinical Decision Making based on Laboratory Findings Urine Dip Stick: bacterial counts >10/ 5 Enterobacteriaceae/ml of urine with concomitant pyuria can be detected by this method Microscopic examination of centrifuged urine can detect the presence of significant pyuria (>4 WBCs per high power field), hematuria (>4 RBCs per high-power field) or both. This provides further support for the diagnosis of UTI

Urine Dip Stick:

bacterial counts >10/ 5 Enterobacteriaceae/ml of urine with concomitant pyuria can be detected by this method

Microscopic examination of centrifuged urine can detect the presence of significant pyuria (>4 WBCs per high power field), hematuria (>4 RBCs per high-power field) or both.

This provides further support for the diagnosis of UTI

Clinical Decision Making based on Laboratory Findings Leukocyte casts: strongly support the diagnosis of pyelonephritis Urine culture: identifies pathogenic microorganism 1 st a.m. Urine: presence of >1 bacterium per high-power field on a gram-stained film of uncentrifuged urine correlates with >10/ 5 bacterial colonies/ml in 90% of pts

Leukocyte casts: strongly support the diagnosis of pyelonephritis

Urine culture: identifies pathogenic microorganism

1 st a.m. Urine: presence of >1 bacterium per high-power field on a gram-stained film of uncentrifuged urine correlates with >10/ 5 bacterial colonies/ml in 90% of pts

Clinical Decision Making: Differential Diagnosis Presence of pyuria does not differentiate upper from lower UTIs Pyuria in the absence of bacteriuria should raise the possibility of renal tuberculosis or allergic interstitial nephritis Postmenopausal Women: atrophic changes in mucosa of the vulvovagina and urethra caused by hormone deficiency may result in persistent or recurrent frequency and dysuria Renal and genitourinary neoplasms need to be ruled out

Presence of pyuria does not differentiate upper from lower UTIs

Pyuria in the absence of bacteriuria should raise the possibility of renal tuberculosis or allergic interstitial nephritis

Postmenopausal Women: atrophic changes in mucosa of the vulvovagina and urethra caused by hormone deficiency may result in persistent or recurrent frequency and dysuria

Renal and genitourinary neoplasms need to be ruled out

Differential Diagnosis Acute Pyelonephritis Young female patient should be differentiated from: Pelvic inflammatory disease Appendicitis Atopic pregnancy Ruptured ovarian cyst

Acute Pyelonephritis

Young female patient should be differentiated from:

Pelvic inflammatory disease

Appendicitis

Atopic pregnancy

Ruptured ovarian cyst

Etiology: Risk Factors Any abnormality of the urinary tract that obstructs the flow of urine such as a kidney stone, sets the stage for an infection. An enlarged prostate gland can slow the flow of urine - raising the risk of infection A common source of infection is catheters, or tubes, placed in the bladder. The elderly or those with nervous system disorders who lose bladder control, may need a catheter for life

Any abnormality of the urinary tract that obstructs the flow of urine such as a kidney stone, sets the stage for an infection.

An enlarged prostate gland can slow the flow of urine - raising the risk of infection

A common source of infection is catheters, or tubes, placed in the bladder.

The elderly or those with nervous system disorders who lose bladder control, may need a catheter for life

Etiology: Risk Factors People with diabetes have a higher risk of a UTI because of changes in the immune system. Immunosuppressed patients are at risk of a urinary infection. For many women, sexual intercourse seems to trigger an infection Women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control. Women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina

People with diabetes have a higher risk of a UTI because of changes in the immune system.

Immunosuppressed patients are at risk of a urinary infection.

For many women, sexual intercourse seems to trigger an infection

Women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control.

Women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina

Recurrent UTI infections Nearly 20% of women who have a UTI will have another 30% of those will have yet another. Of the last group, 80 percent will have recurrences. Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection. Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.

Nearly 20% of women who have a UTI will have another

30% of those will have yet another.

Of the last group, 80 percent will have recurrences.

Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection.

Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.

Uncomplicated UTIs TMP-SMZ or 1 st generation cephalosporin Staphylococcus saprophyticus Amoxicillin Enterococcus faecalis TMP-SMZ or 1 st generation cephalosporin Klebsiella pneumoniae Amoxicillin or TMP-SMZ Proteus mirabilis TMP-SMZ or 1 st generation cephalosporin Escherichia coli Antibacterial of Choice: Organisms Commonly Found:

Complicated UTIs Antipseudomonal penicillin + aminoglycoside; ceftazidime; fluoroquinolone Pseudomonas Penicillinase-resistant penicillin or vancomycin Staphylococcus Imipenem; TMP-SMZ Acinetobacter 3 rd generation cephalosporin; TMP-SMZ Indole-+ Proteus & Serratia Fluoroquinolone; TMP-SMZ; Imipenem Enterobacter Ampicillin or vancomycin + aminoglycoside Enterococcus faecalis 1 st , 2 nd , or 3 rd generation cephalosporin E-coli, Proteus & Klebsiella

Clinical Decision Making: Upper vs. Lower UTI Clinical signs and symptoms may not always be accurate for distinguishing between Upper and Lower UTIs Distinction between them is best assessed by the response to treatment

Clinical signs and symptoms may not always be accurate for distinguishing between Upper and Lower UTIs

Distinction between them is best assessed by the response to treatment

Clinical Decision Making : UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping to select the most effective drug.

UTIs are treated with antibacterial drugs.

The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria.

The sensitivity test is especially useful in helping to select the most effective drug.

Acute Uncomplicated Cystitis: Single Dose Treatment Single Dose TMP-SMZ 320/1600 mg, 2 double strength tabs Amoxicillin 3gm Cephaloridine 2gm Gentamicin 5 mg/kg Doxycycline 300 mg Young woman, first episode

TMP-SMZ 320/1600 mg, 2 double strength tabs

Amoxicillin 3gm

Cephaloridine 2gm

Gentamicin 5 mg/kg

Doxycycline 300 mg

Acute Uncomplicated Cystitis: Short Course Treatment Short course 3 to 5 days Trimethoprim 100-200mg q 12 hrs TMP-SMZ 160/800 mg q 12 hrs Nitrofurantoin 100 mg q 8 or 6 hrs Amoxicillin 250 mg q 8 hrs Ciprofloxacin 250-500 mg q 12 hrs Norfloxacin 400 mg q 12 hrs Young woman, first episode

Trimethoprim 100-200mg q 12 hrs

TMP-SMZ 160/800 mg q 12 hrs

Nitrofurantoin 100 mg q 8 or 6 hrs

Amoxicillin 250 mg q 8 hrs

Ciprofloxacin 250-500 mg q 12 hrs

Norfloxacin 400 mg q 12 hrs

Acute Uncomplicated Cystitis: 7 to 10 days Trimethoprim 100-200mg q 12 hrs TMP-SMZ 160/800 mg q 12 hrs Nitrofurantoin 100 mg q 8 or 6 hrs Amoxicillin 250 mg q 8 hrs Ciprofloxacin 250-500 mg q 12 hrs Norfloxacin 400 mg q 12 hrs Diabetes Mellitus Symptoms >7 days Age >65 yrs Diaphragm

Trimethoprim 100-200mg q 12 hrs

TMP-SMZ 160/800 mg q 12 hrs

Nitrofurantoin 100 mg q 8 or 6 hrs

Amoxicillin 250 mg q 8 hrs

Ciprofloxacin 250-500 mg q 12 hrs

Norfloxacin 400 mg q 12 hrs

Diabetes

Mellitus

Symptoms

>7 days

Age >65 yrs

Diaphragm

Acute Uncomplicated Cystitis 7 to 10 days Trimethoprim 100-200mg q 12 hrs TMP-SMZ 160/800 mg q 12 hrs Ciprofloxacin 250-500 mg q 12 hrs Norfloxacin 400 mg q 12 hrs Young healthy man

Trimethoprim 100-200mg q 12 hrs

TMP-SMZ 160/800 mg q 12 hrs

Ciprofloxacin 250-500 mg q 12 hrs

Norfloxacin 400 mg q 12 hrs

Recurrent Cystitis Single dose or 3-5 days 3-5 days, then 1 yr of prophylaxis TX as 1 st episode in young woman TMP+SMZ, amoxicillin, Nitrofurantoin, ciprofloxacin or Norfloxacin, followed by low-dose antibiotic prophylaxis Reinfection: < 2 episodes/yr > 3 episodes/yr 14 days TX based on sensitivity results R/O renal stones, Scars, cysts, Chronic Bacterial Prostatitis Relapses

TX based on sensitivity results

R/O renal stones,

Scars, cysts,

Chronic Bacterial

Prostatitis

Recurrent Cystitis Topical estradiol cream+low-dose antibiotic prophylaxis Postmenopause Postcoital prophylaxis TMP+SMZ, Nitrofurantoin cephalexin; voiding after intercourse Temporally related to coitus

Asymptomatic Bacteriuria 3 – 5 days Amoxicillin/Ampicillin, Nitrofurantoin oral cephalosporin Pregnancy 10 – 14 days No TX unless symptomatic, neutropenic, renal transplant, urea splitting bacteria, obstruction, diabetes mellitus, sickle cell disease/trait, NSAID/analgesic abuse With/without catheter

Acute Uncomplicated Pyelonephritis 14 days Parenteral: ceftriaxone, gentamicin+ampicillin, aztreonam, or TMP-SMZ until afebrile, then oral regimen Pregnancy 14 days; if relapse, 6 weeks Oral: TMP+SMZ, amoxicillin, ciprofloxacin, Norfloxacin Not very sick Very sick or septic 14 days; if relapse, 6 weeks Parenteral: TMP-SMZ, ciprofloxacin, ceftriaxone, or gentamicin+ampicillin until afebrile, then oral regimen

Symptomatic Complicated Upper UTI 2 – 3 week; if relapse, 6 weeks Oral: ciprofloxacin, Norfloxacin, or TMP-SMZ (if sensitive) Not very sick 2 – 3 week; if relapse, 6 weeks Parenteral: gentamicin+ampicillin, ceftriaxone, aztreonam, imipenem-cilastatin, ciprofloxacin, ticarcillin-clavulanate Very sick or septic

Patient Education Teach proper hygiene: Women wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra. Take showers instead of tub baths Encourage patient to increase fluid intake and avoid of bladder irritants such as caffeine, smoking and alcohol. Recommend cranberry juice that may decrease bladder colonization Encourage patient to urinate when he/she feels the need

Teach proper hygiene: Women wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra.

Take showers instead of tub baths

Encourage patient to increase fluid intake and avoid of bladder irritants such as caffeine, smoking and alcohol.

Recommend cranberry juice that may decrease bladder colonization

Encourage patient to urinate when he/she feels the need

Patient Education: Continue Advise voiding before and after sex Cleanse the genital area before and after sexual intercourse. Recommend alternative methods of contraception for women using diaphragms if recurrent infections exist Avoid using feminine hygiene sprays and scented douches, which may irritate the urethra. Discuss the need to complete entire course of medication

Advise voiding before and after sex

Cleanse the genital area before and after sexual intercourse.

Recommend alternative methods of contraception for women using diaphragms if recurrent infections exist

Avoid using feminine hygiene sprays and scented douches, which may irritate the urethra.

Discuss the need to complete entire course of medication

Follow-up & Referrals Follow-up: Repeat U/C after completion of medication Advise pt to return if s/s increase in severity or fail to improve after 3 days of therapy. Consultation/Referral if: Renal Calculi are suspected Infection persists after two courses of appropriate treatment If pyelonephritis is suspected If patient has insulin dependent diabetes When patient has existing renal disease History of 3 UTIs in one year

Follow-up:

Repeat U/C after completion of medication

Advise pt to return if s/s increase in severity or fail to improve after 3 days of therapy.

Consultation/Referral if:

Renal Calculi are suspected

Infection persists after two courses of appropriate treatment

If pyelonephritis is suspected

If patient has insulin dependent diabetes

When patient has existing renal disease

History of 3 UTIs in one year

Research Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract. A recent NIH-funded study has also shown that women with recurrent UTIs tend to have certain blood types. Some researchers speculate that women with these blood types are more prone to UTIs because the cells lining the vagina and urethra may allow bacteria to attach more easily. Further research will show whether this association is sound and proves useful in identifying women at high risk for UTIs.

Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract.

A recent NIH-funded study has also shown that women with recurrent UTIs tend to have certain blood types.

Some researchers speculate that women with these blood types are more prone to UTIs because the cells lining the vagina and urethra may allow bacteria to attach more easily.

Further research will show whether this association is sound and proves useful in identifying women at high risk for UTIs.

Research Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder. In such cases, kidney infections rarely lead to kidney damage or kidney failure unless they go untreated

Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder.

In such cases, kidney infections rarely lead to kidney damage or kidney failure unless they go untreated

Research: Vaccine Development In the future, scientists may develop a vaccine that can prevent UTIs from coming back. Researchers in different studies have found that children and women who tend to get UTIs repeatedly are likely to lack proteins called immunoglobulins, which fight infection. Children and women who do not get UTIs are more likely to have normal levels of immunoglobulins in their genital and urinary tracts

In the future, scientists may develop a vaccine that can prevent UTIs from coming back.

Researchers in different studies have found that children and women who tend to get UTIs repeatedly are likely to lack proteins called immunoglobulins, which fight infection.

Children and women who do not get UTIs are more likely to have normal levels of immunoglobulins in their genital and urinary tracts

Research: Vaccine Development Continued Early tests indicate that a vaccine helps patients build up their own natural infection-fighting powers. The dead bacteria in the vaccine do not spread like an infection; instead, they prompt the body to produce antibodies that can later fight against live organisms. Researchers are testing injection and oral vaccines to see which works best. Another method being considered for women is to apply the vaccine directly as a suppository in the vagina

Early tests indicate that a vaccine helps patients build up their own natural infection-fighting powers.

The dead bacteria in the vaccine do not spread like an infection; instead, they prompt the body to produce antibodies that can later fight against live organisms.

Researchers are testing injection and oral vaccines to see which works best.

Another method being considered for women is to apply the vaccine directly as a suppository in the vagina

Urinary Incontinence (UI) UI is the involuntary loss of urine severe enough to result in social or hygienic consequences It is a major clinical problem and a significant cause of disability and dependence Affects an estimate of 13 million adults in the United States 10% to 20% women age 15 to 64 years 40% women >60 years

UI is the involuntary loss of urine severe enough to result in social or hygienic consequences

It is a major clinical problem and a significant cause of disability and dependence

Affects an estimate of 13 million adults in the United States

10% to 20% women age 15 to 64 years

40% women >60 years

Urinary Incontinence: It results in a loss of self-esteem and a decrease in ability to maintain an independent lifestyle UI is one of the major causes of institutionalization of the elderly 1995 – cost of treatment $26 billion for patients over age 65 years

It results in a loss of self-esteem and a decrease in ability to maintain an independent lifestyle

UI is one of the major causes of institutionalization of the elderly

1995 – cost of treatment $26 billion for patients over age 65 years

Relevant Pathophysiology: Process of Urination In adults the process of urination involves voluntary and reflexive control of the bladder, urethra, detrusor muscle and urethral sphincter. When bladder volume reaches approx 400-500cc, stretch receptors send nerve impulses to the spinal cord. Nerve impulses leaving the cord then cause the bladder to contract and the sphincters to relax so that urination may take place Urinary Incontinence occurs as a result of a disruption at any point in the process

In adults the process of urination involves voluntary and reflexive control of the bladder, urethra, detrusor muscle and urethral sphincter.

When bladder volume reaches approx 400-500cc, stretch receptors send nerve impulses to the spinal cord.

Nerve impulses leaving the cord then cause the bladder to contract and the sphincters to relax so that urination may take place

Urinary Incontinence occurs as a result of a disruption at any point in the process

Risk Factors for Urinary Incontinence include any of the following: Birth defects Childbirth CHF Constipation - Impaction Decreased mobility Diabetes Mellitus Diuretic medication Hormone imbalances in women Infection/inflammation of the urinary tract, vagina, or prostate Injury or trauma Medication Effects Menopause Nerve disorders or injuries Overactive bladder muscles Pelvic radiation Thx Pelvic surgery Polyuria Prostate enlargement Psychological factors Weakness of the bladder, muscles that support the bladder or Sphincter muscles that surround the urethra

Birth defects

Childbirth

CHF

Constipation - Impaction

Decreased mobility

Diabetes Mellitus

Diuretic medication

Hormone imbalances in women

Infection/inflammation of the urinary tract, vagina, or prostate

Injury or trauma

Medication Effects

Menopause

Nerve disorders or injuries

Overactive bladder muscles

Pelvic radiation Thx

Pelvic surgery

Polyuria

Prostate enlargement

Psychological factors

Weakness of the bladder, muscles that support the bladder or

Sphincter muscles that surround the urethra

S/S: UI is a Symptom UI is a symptom rather than a disease It can be caused by Anatomical Physiological pathological (genitourinary) factors That may Affect the urinary tract as well as external (nongenitourinary) factors Multiple and interacting factors often contribute to UI development especially in frail older patients

UI is a symptom rather than a disease

It can be caused by

Anatomical

Physiological

pathological (genitourinary) factors

That may Affect the urinary tract as well as external (nongenitourinary) factors

Multiple and interacting factors often contribute to UI development especially in frail older patients

S/S of UI including all of the following : Events precipitating incontinence: cough, exercise, straining Dribbling, bladder pain with filling Lower urinary tract infection symptoms: Dysuria, hematuria, hesitancy, nocturia, frequency, poor or interrupted stream, straining, suprapubic or perineal pain

Events precipitating incontinence: cough, exercise, straining

Dribbling, bladder pain with filling

Lower urinary tract infection symptoms:

Dysuria, hematuria, hesitancy, nocturia, frequency, poor or interrupted stream, straining, suprapubic or perineal pain

Physical Examination Abdominal examination to assess for: Diastasis recti Fluid collections Masses Organomegaly Peritonitis Genital examination in men for: Skin conditions Abnormalities of: Foreskin Glans penis Perineal skin

Abdominal examination to assess for:

Diastasis recti

Fluid collections

Masses

Organomegaly

Peritonitis

Genital examination in men for:

Skin conditions

Abnormalities of:

Foreskin

Glans penis

Perineal skin

Physical Examination: continued Neurologic Examination for: Abnormalities that may suggest: Multiple sclerosis Stroke Spinal cord compression Other neurologic conditions Elderly or frail patients to assess: Cognition Manual dexterity rule out toileting skills mobility

Neurologic Examination for:

Abnormalities that may suggest:

Multiple sclerosis

Stroke

Spinal cord compression

Other neurologic conditions

Elderly or frail patients to assess:

Cognition

Manual dexterity rule out toileting skills

mobility

Pelvic examination in women to assess: Carcinoma Genital atrophy Paravaginal muscle tone Pelvic mass Perineal skin condition Pelvic organ prolapse Cystocele Rectocele Uterine prolapse Urethral diverticulum Urethral inflammation

Carcinoma

Genital atrophy

Paravaginal muscle tone

Pelvic mass

Perineal skin condition

Pelvic organ prolapse

Cystocele

Rectocele

Uterine prolapse

Urethral diverticulum

Urethral inflammation

Rectal Examination to assess: Consistency and contour of prostate Fecal incontinence Fecal impaction Perineal sensation Rectal mass Sphincter tone (resting and active) Laboratory Testing : Complete blood count (CBC) Chemistry panel Renal function (BUN, Creatinine) Urinalysis Urine culture

Rectal Examination to assess:

Consistency and contour of prostate

Fecal incontinence

Fecal impaction

Perineal sensation

Rectal mass

Sphincter tone (resting and active)

Laboratory Testing :

Complete blood count (CBC)

Chemistry panel

Renal function (BUN, Creatinine)

Urinalysis

Urine culture

Diagnostic Studies Catherization for postvoid residual (PVR) Cough stress test Pelvic ultrasound Urodynamic tests: Cystometry to document: Abnormalities of bladder compliance, Bladder capacity, Detrusor, contractions or PVR Cystometrogram (CMG) to document: Diversed bladder compliance Increase in intraabdominal pressure Involuntary detrusor contraction

Catherization for postvoid residual (PVR)

Cough stress test

Pelvic ultrasound

Urodynamic tests:

Cystometry to document:

Abnormalities of bladder compliance, Bladder capacity, Detrusor, contractions or PVR

Cystometrogram (CMG) to document:

Diversed bladder compliance

Increase in intraabdominal pressure

Involuntary detrusor contraction

Diagnostic Studies: continued Cystoscopy to document: Sterile hematuria or pyuria Cause of any of the following: Bladder pain, Irritative voiding symptoms, Recurrent cystitis, Suspected foreign body Electromyography (EMG) to document detrusor sphincter dyssynergia (DSD) Urethral pressure profilometry (UPP) to document: Intrinsic sphincter deficiency (ISD), Resting and dynamic pressures in the urethra and Sphincter function

Cystoscopy to document:

Sterile hematuria or pyuria

Cause of any of the following:

Bladder pain, Irritative voiding symptoms, Recurrent cystitis, Suspected foreign body

Electromyography (EMG) to document detrusor sphincter dyssynergia (DSD)

Urethral pressure profilometry (UPP) to document:

Intrinsic sphincter deficiency (ISD), Resting and dynamic pressures in the urethra and Sphincter function

Diagnostic Studies: continued Uroflometry to document urine flow rate Voiding CMG to document: Detrusor contractility, Outlet obstruction, Urodynamic obstruction Endoscopic tests including cystourethroscopy to document: Bladder lesions, Fistulas, Foreign bodies, ISD, Strictures, Urethral diverticula Imaging Tests: Nonvoiding lateral Cystourethrography, to document: Degree of cystocele, Funneling of bladder neck and proximal urethra, Mobility or fixation of bladder neck

Uroflometry to document urine flow rate

Voiding CMG to document:

Detrusor contractility, Outlet obstruction, Urodynamic obstruction

Endoscopic tests including cystourethroscopy to document:

Bladder lesions, Fistulas, Foreign bodies, ISD, Strictures, Urethral diverticula

Imaging Tests:

Nonvoiding lateral Cystourethrography, to document:

Degree of cystocele, Funneling of bladder neck and proximal urethra, Mobility or fixation of bladder neck

Diagnostic Studies: continued Imaging Tests: Nonvoiding lateral Cystourethrography, to document: Degree of cystocele, Funneling of bladder neck and proximal urethra, Mobility or fixation of bladder neck Voiding Cystourethrography to document: Obstruction, Urethral diverticulum, Vesicoureteral reflux Upper tract imaging - excretory urography (IVP) for: Incontinent patients with hematuria Further evaluation of upper tract obstruction or other pathology identified by ultrasound

Imaging Tests:

Nonvoiding lateral Cystourethrography, to document:

Degree of cystocele, Funneling of bladder neck and proximal urethra, Mobility or fixation of bladder neck

Voiding Cystourethrography to document:

Obstruction, Urethral diverticulum, Vesicoureteral reflux

Upper tract imaging - excretory urography (IVP) for:

Incontinent patients with hematuria

Further evaluation of upper tract obstruction or other pathology identified by ultrasound

Differential Diagnosis Incontinence may be considered as fixed or transient Transient incontinence usually has definable, sudden onset and often has a discrete cause A simple Mneumonic summarizes the differential diagnosis of transient incontinence

Incontinence may be considered as fixed or transient

Transient incontinence usually has definable, sudden onset and often has a discrete cause

A simple Mneumonic summarizes the differential diagnosis of transient incontinence

Etiologies for Transient Urinary Incontinence: DIAPERS Mneumonic D rugs : hypnotics, sedatives, anticholinergic agents, diuretics, adrenergic agents D elirium : or altered mental status I nfection A trophy: of vagina or urethra P sychologic: functional depression E ndocrine: hyperglycemia or hypercalcemia R estricted mobility S tool impaction

D rugs : hypnotics, sedatives, anticholinergic agents, diuretics, adrenergic agents

D elirium : or altered mental status

I nfection

A trophy: of vagina or urethra

P sychologic: functional depression

E ndocrine: hyperglycemia or hypercalcemia

R estricted mobility

S tool impaction

Urge Incontinence Strong desire to void without the ability to suppress the urinary loss Results from overactivity of the detrusor resulting in uncontrollable bladder contractions There is loss related to a particular activity of exposure and is the most common type of incontinence noted in elderly Frequently complicates central disorders: Parkinson's, Alzheimer's, CVA and brain tumor Also noted with bladder disorders: outlet obstruction, carcinoma in situ and infection

Strong desire to void without the ability to suppress the urinary loss

Results from overactivity of the detrusor resulting in uncontrollable bladder contractions

There is loss related to a particular activity of exposure and is the most common type of incontinence noted in elderly

Frequently complicates central disorders: Parkinson's, Alzheimer's, CVA and brain tumor

Also noted with bladder disorders: outlet obstruction, carcinoma in situ and infection

Stress Incontinence Urinary loss with physical activity or sudden increases in abdominal pressure A deficiency of the bladder outlet Result from hypermobility of urethra and bladder neck in women or from intrinsic damage in either sex

Urinary loss with physical activity or sudden increases in abdominal pressure

A deficiency of the bladder outlet

Result from hypermobility of urethra and bladder neck in women or from intrinsic damage in either sex

Reflex Incontinence Related to urge incontinence Manifested by the precipitous loss of urine with no sense of urgency Noted in patients with suprasacral spinal cord lesions

Related to urge incontinence

Manifested by the precipitous loss of urine with no sense of urgency

Noted in patients with suprasacral spinal cord lesions

Overflow Incontinence Caused by chronic retention of urine with small volumes being frequently voided May result from detrusor hypocontractility: seen in Tabes Dorsalis, diabetes mellitus or Vitamin B12 deficiency May also result from bladder outlet obstruction caused by prostatic or urethral pathology with subsequent bladder decompensation

Caused by chronic retention of urine with small volumes being frequently voided

May result from detrusor hypocontractility: seen in Tabes Dorsalis, diabetes mellitus or Vitamin B12 deficiency

May also result from bladder outlet obstruction caused by prostatic or urethral pathology with subsequent bladder decompensation

Continuous Incontinence Total and unabated leakage of urine unrelated to activity Identified when a fistula of the urinary tract is present The most common etiology for urinary tract fistula in woman is prior hysterectomy

Total and unabated leakage of urine unrelated to activity

Identified when a fistula of the urinary tract is present

The most common etiology for urinary tract fistula in woman is prior hysterectomy

Mixed Category of Incontinence More than one type of incontinence may be present Especially in the elderly An adult male may have both overflow incontinence due to prostatic obstruction and neurogenic bladder dysfunction secondary to diabetic neuropathy or cerebrovascular insufficiency

More than one type of incontinence may be present

Especially in the elderly

An adult male may have both overflow incontinence due to prostatic obstruction and neurogenic bladder dysfunction secondary to diabetic neuropathy or cerebrovascular insufficiency

Diagnosis & Management of Urinary Incontinence by Type Retropubic suspension Needle bladder neck suspension Anterior vaginal repair Sling procedures Artificial sphincter urethrolysis Estrogen therapy Phenylpropanolamine (hcl) (PPA) Pseudo-ephedrine hcl Imipramine (Tofranil-PM) Provocative stress test (Direct visualization) Tests for bladder neck mobility UPP or leak point pressure Simple Multichannel CMG Stress Incontinence Surgical Thx Drug Thx DX studies Type of UI

Retropubic suspension

Needle bladder neck suspension

Anterior vaginal repair

Sling procedures

Artificial sphincter

urethrolysis

Estrogen therapy

Phenylpropanolamine (hcl) (PPA)

Pseudo-ephedrine hcl

Imipramine (Tofranil-PM)

Provocative stress test

(Direct visualization)

Tests for bladder neck mobility

UPP or leak point pressure

Simple Multichannel CMG

Diagnosis & Management of Urinary Incontinence by Type Augmenta-tion intestino-cystoplasty or urinary diversion Bladder denervation Subtrigonal or transvesical phenol injection Doxazosin mesylate (Cardura) Flavoxate hcl L-Hyoscyamine (Levbid) Imipramine hcl (Tofranil-PM) Oxybutynin (Ditropan) Propantheline bromide Tamsulosin hcl (Flomax) Terazoxin hcl (Hytrin) Terodiline hcl (Micturin) Tolterodine tartrate (Detrol) Simple or multi-channel CMG with or without EMG Video-Urodynamic Simple or multi-channel cysto-metry Urge incontinence Surgical Thx Drug Thx Dx Studies Type of UTI

Augmenta-tion intestino-cystoplasty or urinary diversion

Bladder denervation

Subtrigonal or transvesical phenol injection

Simple or multi-channel CMG with or without EMG

Video-Urodynamic

Simple or multi-channel cysto-metry

Diagnosis & Management of Urinary Incontinence by Type Cutting suspending sutures from previous Endoscopic needle bladder neck suspension Urethrolysis (remobilization of periurethral adhesions) with or without resuspension Doxazosin mesylate (Cardura) Terazoxin hcl (Hytrin) Tamsulosin hydrochloride (Flomax) Post void residual volume Uroflowmetry Voiding CMG with EMG Cystourethroscopy Videourodynamics Overflow Incontinence Surgical Thx Drug Thx DX studies Type of UI

Cutting suspending sutures from previous Endoscopic needle bladder neck suspension

Urethrolysis (remobilization of periurethral adhesions) with or without resuspension

Doxazosin mesylate (Cardura)

Terazoxin hcl (Hytrin)

Tamsulosin hydrochloride (Flomax)

Post void residual volume

Uroflowmetry

Voiding CMG with EMG

Cystourethroscopy

Videourodynamics

Diagnosis & Management of Urinary Incontinence by Type Urinary diversion Dicyclomine hcl L-Hyoscyamine (Levbid) Oxybutin (Ditropan) IV-urography US Cystography Urethrography Cystourethroscopy Serial cystometro-gram Urodynamic voiding flow Sphincter EMG Urethral pressure profile studies Neurogenic Bladder Surgical Thx Drug Thx DX studies Type of UI

Dicyclomine hcl

L-Hyoscyamine (Levbid)

Oxybutin (Ditropan)

IV-urography

US

Cystography

Urethrography

Cystourethroscopy

Serial cystometro-gram

Urodynamic voiding flow Sphincter EMG

Urethral pressure profile studies

Diagnosis & Management of Urinary Incontinence by Type Therapy is directed toward identifying and treating the specific type of incontinence present Excretory urography Voiding Cystourethro-graphy Retrograde urethrography Cystoscopy Cystometro-gram Urethral pressure profile Mixed incontinence Drug Therapy & Surgical Thx DX studies Type of UI

Therapy is directed toward identifying and treating the specific type of incontinence present

Excretory urography

Voiding Cystourethro-graphy

Retrograde urethrography

Cystoscopy

Cystometro-gram

Urethral pressure profile

Diagnosis & Management of Urinary Incontinence by Type Surgical excision of fistulous tract Urinary diversion Excretory urography Voiding cystourethro-graphy Vaginoscopy Urethro-cystoscopy Urinary fistulas Artificial sphincter Residual urine Total incontinence Artificial sphincter Post-prostatectomy Incontinence Surgical Thx Drug Thx DX studies Type of UI

Surgical excision of fistulous tract

Urinary diversion

Excretory urography

Voiding cystourethro-graphy

Vaginoscopy

Urethro-cystoscopy

Diagnosis & Management of Urinary Incontinence by Type psychotherapy Alpha-adrenergic Anticholinergic Diagnosis can be established only after all other causes of Urinary Incontinence are ruled out Psychogenic incontinence Surgical Thx Drug Thx DX studies Type of UI

Alpha-adrenergic

Anticholinergic

Treatment Options for Stress, Urge and Mixed Urinary Incontinence: continued Neuromuscular Electrical Stimulation: Electrical stimulation of the pudendal nerve causes contraction of the pelvic floor and periurethral muscles. InterStim Continence Control Therapy: involves electrical stimulation of the sacral nerves via a totally implantable system

Neuromuscular Electrical Stimulation:

Electrical stimulation of the pudendal nerve causes contraction of the pelvic floor and periurethral muscles.

InterStim Continence Control Therapy:

involves electrical stimulation of the sacral nerves via a totally implantable system

Patient & Family Education Avoidance of cigarette smoking Teaching Pelvic Muscle Exercise to symptomatic and asymptomatic younger and older women and to men who undergo prostate surgery Instruct in proper lifting techniques to avoid abdominal strain Encourage Frequent voiding Encourage the use of protective undergarments and bedcovers

Avoidance of cigarette smoking

Teaching Pelvic Muscle Exercise to symptomatic and asymptomatic younger and older women and to men who undergo prostate surgery

Instruct in proper lifting techniques to avoid abdominal strain

Encourage Frequent voiding

Encourage the use of protective undergarments and bedcovers

Appropriate Referral and Follow-ups The FNP should consider minimal invasive, nonsurgical therapies first for those with stress, urge, and mixed UI These include behavioral therapies and judicious use of medications Refer to specialists if further assessment is necessary or if appropriate treatments are unavailable

The FNP should consider minimal invasive, nonsurgical therapies first for those with stress, urge, and mixed UI

These include behavioral therapies and judicious use of medications

Refer to specialists if further assessment is necessary or if appropriate treatments are unavailable

Research Study Purpose: to determine if there was a difference in pelvic floor muscle strength and reports of incontinence between women involved in high impact athletics and women who were relatively sedentary The subjects were nulliparous women age 18-25 divided into 2 groups: Grp I consisted of 20 women athletes who exercised a maximum of 6 hours/wk Grp II: 15 women who exercised 1 hr/wk Methods: Pelvic floor muscle strength was measured using EMG biofeedback via surface electrodes Results: the athletic group was found to have significantly stronger pelvic floor muscle strength, p=.025.

Study Purpose: to determine if there was a difference in pelvic floor muscle strength and reports of incontinence between women involved in high impact athletics and women who were relatively sedentary

The subjects were nulliparous women age 18-25 divided into 2 groups:

Grp I consisted of 20 women athletes who exercised a maximum of 6 hours/wk

Grp II: 15 women who exercised 1 hr/wk

Methods: Pelvic floor muscle strength was measured using EMG biofeedback via surface electrodes

Results: the athletic group was found to have significantly stronger pelvic floor muscle strength, p=.025.

Research: continued 49% of the entire sample reported incontinence with daily activities. No difference was found in pelvic floor strength in subjects who reported incontinence compared to subjects with no report of incontinence. Conclusions: although athletes had stronger pelvic floor muscles, they had no less report of urinary incontinence. Across the entire sample, those who reported incontinence did not have significantly weaker pelvic floor muscles than those with no report of incontinence This study suggested that pelvic floor strength is often not a predictor of incontinence

49% of the entire sample reported incontinence with daily activities.

No difference was found in pelvic floor strength in subjects who reported incontinence compared to subjects with no report of incontinence.

Conclusions: although athletes had stronger pelvic floor muscles, they had no less report of urinary incontinence.

Across the entire sample, those who reported incontinence did not have significantly weaker pelvic floor muscles than those with no report of incontinence

This study suggested that pelvic floor strength is often not a predictor of incontinence

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