This document discusses urinary incontinence in the elderly. It defines incontinence and notes that its prevalence increases with age, affecting more women than men. Types of incontinence include stress, urge, overflow, and functional. Evaluation involves history, exam, urinalysis and residual urine measurement to identify reversible causes and guide management. Management includes behavioral techniques, drug therapy, surgery, and catheters depending on the underlying causes. Pelvic floor muscle training and prompted voiding are effective non-drug interventions for some patients.
Presentation, diagnosis and treatment of urinary incontinence (UI). Includes discussion of Stress, Urge, Mixed, Overflow types of UI, Urodynamic testing, Pelvic floor exercise, and Medical vs Surgery treatment options.
Much of the content is in the notes section beneath each slide, or in embedded videos, which are visible only when the slides are downloaded and opened in powerpoint.
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding Uirinary incontinence / Bladder Incontinence, and its management. Highly recommended for II B.Sc Nursing Students
Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem.
Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void
Presentation, diagnosis and treatment of urinary incontinence (UI). Includes discussion of Stress, Urge, Mixed, Overflow types of UI, Urodynamic testing, Pelvic floor exercise, and Medical vs Surgery treatment options.
Much of the content is in the notes section beneath each slide, or in embedded videos, which are visible only when the slides are downloaded and opened in powerpoint.
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding Uirinary incontinence / Bladder Incontinence, and its management. Highly recommended for II B.Sc Nursing Students
Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem.
Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void
A benign (not cancer) condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine. Also called benign prostatic hyperplasia and BPH.
Urinary incontinence and pelvic organ prolapseDR MUKESH SAH
Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80 percent of women with pelvic floor dysfunction [1]. While these conditions are often concurrent, one may be mild or asymptomatic, which makes selection of the optimal surgical procedure(s) challenging. Prolapse repair can unmask urinary incontinence in previously continent women or worsen existing SUI symptoms [2].
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How to critically appraise a journal article on accuracy of a diagnostic test. This presentation spans issues regarding directness, validity, applicability and individualization. Also included are how to process information on sensitivity, specificity, likelihood ratios, predictive values and decision thresholds
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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2. Definition and Epidemiology
Urinary incontinence
Involuntary loss of urine in sufficient amount or
frequency to be a social and/or health problem
Increases with age
Women (30%)> men (15%)
As much as 60% among nursing home
elderly
3. Jackson, RA et al. 2004. Urinary
Incontinence in Elderly Women: Findings
From the Health, Aging, and Body
Composition Study. Obstet Gynecol 104:
301–7.
4. 21% reported incontinence at least weekly
42% reported predominantly urge
incontinence and 40% reported stress
Nearly twice as many white women as
black women (27% versus 14%, P < .001)
5. Factors associated with urge incontinence
white race (odds ratio OR 3.1, 95% confidence
interval CI 2.0–4.8)
diabetes treated with insulin (OR 3.5, 95% CI
1.6 –7.9)
depressive symptoms (OR 2.7, 95% CI 1.4 –
5.3)
current oral estrogen use (OR 1.7, 95% CI 1.1–
2.6)
arthritis (OR 1.7, 95% CI 1.1–2.6)
decreased physical performance (OR 1.6 per
point on 0–4 scale, 95% CI 1.1–2.3)
6. Factors associated with stress
incontinence
chronic obstructive pulmonary disease (OR 5.6,
95% CI 1.3–23.2)
white race (OR 4.1, 95% CI 2.5– 6.7)
current oral estrogen use (OR 2.0, 95% CI 1.3–
3.1)
Arthritis (OR 1.6, 95% CI 1.0 –2.4)
high body mass index (OR 1.3 per 5 kg/m2,
95% CI 1.1–1.6).
8. Urination is a complex process and
incompletely understood
Influence by higher centers in the
brainstem, cerebral cortex and cerebellum
Cerebral cortex predominantly inhibitory
Brainsterm facilitates urination
9. Urination reflex centered in the sacral
micturition center
Afferent pathway (somatic and autonomic)
carry bladder filling info to the spinal cord
Sympathetic tone closes bladder neck and
inhibits parasympathetic tone (bladder dome
relaxes)
Pelvic muscle tone maintained also inhibits
parasympathetic tone
On urination, the reverse occurs
10. Normal urination is a dynamic process
During filling, pressure remains low (<15 cm)
First urge usually at 150-250 cc
Normal bladder capacity 300-600cc
Detrussor muscle contracts and exceeds
urethral resistance urine flow
11. Basic Causes
Urologic, neurologic, psychological and
functional factors may contribute
↓bladder capacity, ↑residual urine,
↑prevalence of involuntary bladder
contractions
In 40-75% of incontinent elderly
But also 5-30% of continent elderly
12. Involuntary bladder contractions +
impaired mobility a substantial
proportion of incontinent elderly
Decline in bladder outlet and urethral
resistance in women
Relate to laxity of pelvic muscle due to
childbirth, obesity, deconditioned muscles, and
hysterectomy
13. In men, related to prostatic enlargement
Associated nocturia, low urine flow rate and
detrussor instability leads to overflow and/or
urge incontinence
In both sexes, detrussor hyperactivity with
impaired contractility
14. Acute and reversible causes
Acute incontinence
Sudden onset, related to acute illness or
iatrogenesis and subsides once cause is
resolved
Persistent incontinence
Unrelated to an acute cause and persist over
time
15. Condition Management
Conditions affecting lower urinary
tract
UTI Antibiotics
Atrophic vaginitis/urethritis Topical estrogen
Postprostatectomy Behavioral, avoid more surgery
Stool impaction Disimpaction, fiber intake, etc.
Drug side effects Discontinue or change drug therapy
Increased urine production
Metabolic (hyperglycemia, Treat DM, treat cause of hypercalcemia
hypercalcemia)
Excess fluid intake Reduce intake of diuretic fluids
Volume overload Medical and supportive therapy
Impaired ability or willingness to
reach toilet
Delirium Diagnosis or treatment of cause
Chronic illness or immobility Regular toileting, environment alteration
Appropriate therapy
psychological
17. 2 basic abnormalities in these types
Failure to store urine
Failure to fully empty the bladder
18. Definition Causes
Stress Weakness of pelvic floor muscles and
Involuntary loss of urine with urethral hypermobility
increases in abdominal pressure Bladder outlet or urethral sphincter weakness
(e.g. coughing) Postprostatectomy
Urge Detrussor hyperactivity, isolated or with the
leakage of urine due to inability to following: local genitourinary condition, CNS
delay voiding after sensation of disorders
bladder fullness is perceived
Overflow Anatomic obstruction
Urine leakage from mechanical Acontractile bladder due to DM or SCI
forces on an overdistended bladder Detrusor-sphincter dyssynergy associated
or other effects of urinary retention with MS or other suprasacral spinal lesions
on bladder and sphincter function Medication effect
Functional Severe dementia and other neurological
Associated with inability to toilet disorders
due to impaired cognition or Depression
physical functioning and hostility
environmental barriers or
psychological unwillingness
19. Evaluation
Includes thorough history, PE, urinalysis
and postvoid residual determination
Objectives
Identify potentially reversible conditions
Identify conditions that require further
diagnostic test or urologic/gynecologic
evaluation
Develop a management plan
20. All patients
History, PE, urinalysis, postvoid residual determination
Selected patients
Lab studies
Urine culture, urine cytology, serum glucose and calcium, renal
function tests, renal ultrasound
Gynecologic evaluation
Urologic evaluation
Cystourethroscopy
Urodynamic tests
Simple
• Observation of voiding
• Cough test for stress incontinence
• Simple cystometry
• Urine flowmetry (for men)
Complex
• Multichannel cystometrogram
• Pressure-flow study
• Leak point pressure
• Urethral pressure profilometry
• Sphincter electromyography
• videourodynamics
21. Patient history should also include
Characteristic of incontinence: timing,
frequency, amount
symptoms of voiding difficulty: hesitancy,
intermittent voiding, straining to void
Symptoms of stress vs urge incontinence
22. PE should include
Abdominal, rectal, genital exam
Exam of lumbosacral innervation
In women, examine for POP, inflammation suggestive of
atrophic vaginitis
Cough test
Leakage with coughing documents stress incontinence
Delayed leakage (>3 seconds after) indicates cough-
induced bladder contraction
Mobility and mental status
In patients with nocturia, examine for CHF or venous
insufficiency
23. Urinalysis
Clear relationship between incontinence and
UTI
Controversial for asymptomatic bacteriuria
No benefit in treating nursing home elderly with
stable bacteriuria
May be reasonable to treat initially in non-
institutionalized patients
24. Postvoid determination
May be done using UTZ
Done within a few minutes of a spontaneous
(continent or incontinent) void
<100 cc in the absence of straining generally
reflect adequate bladder emptying
>200 cc is abnormal
25. Criteria Definition Rationale
History
Recent lower urinary tract or Surgery or irradiation within Structural abnormality related
pelvic surgery/iiradiation the past 6 months to the procedure
Recurrent symptomatic UTI 3 or more symptomatic Structural abnormality
episodes in 12 months predisposing to UTI
Physical Examination
Marked POP Prominent cystocele Abnormality may underlie the
descending entire height of pathophysiology of
vaginal vault with coughing incontinence; may benefit
on speculum exam from surgery
Gross enlargement on DRE; Evaluation to exclude cancer
Prostatic enlargement or induration or assymetry of
possible cancer lobes
Postvoid residual
Diffuculty inserting 14F Unable to pass through, Anatomick block of the
straight catheter requiring more force or urethra or bladder
larger, stiffer catheter
Residual >200cc Anatomic or neurogenic
obstruction
26. Criteria Definition Rationale
Urinalysis
Hematuria >5 RBCS per HPF in the Pathology of urinary tract
absence of UTI should be excluded
Therapeutic Trial
Failure to respond Persistence of symptoms Urodynamic evaluation
after adequate trial
27. Management
Acute incontinence in elderly in acute care
Catheterization
Toilet accessibility or substitutes
Bed pads or diapers
Causes or contributing factors should be treated
Supportive measures
Education
Environment manipulation
Avoidance of iatrogenesis
Modification of fluids and diuretics
Skin care
28. Behavioral interventions
May be patient-dependent or caregiver-
dependent
Goal of the former is to restore normal voiding
and continence
The latter is to keep patient and environment
dry
29. Patient-dependent interventions
Require a functional and motivated patient and
a skill trainer
Relies on education, counselling and frequent
patient contact
Kegel exercises are effective for stress, urge or
mixed incontinence
3-5 sets of 10 contractions throughout the day, each
contraction 3-10 seconds in duration
30. Biofeedback
Use recordings of bladder, rectal or vaginal pressure
or electrical activity to train patients to contract pelvic
floor muscles with the abdominal muscles relaxed
Limited by requirement for equipment and trained
personel; may also be invasive and unacceptable
Bladdder training
Uses the pelvic muscle exercises and strategies to
manage urgency
Persistence of voiding difficulties despite the
protocol should prompt urologic referral
31. Hay-Smith EJC, and C. Dumoulin. Pelvic
floor muscle training versus no treatment,
or inactive control treatments, for urinary
incontinence in women. Cochrane
Database of Systematic Reviews 2006,
Issue 1. Art. No.: CD005654. DOI:
10.1002/14651858.CD005654
32. To determine the effects of pelvic floor muscle
training for women with urinary incontinence in
comparison to no treatment, placebo or sham
treatments, or other inactive control treatments.
403 women in six trials of varying age and types
of incontinence
Use of PFMT lead to more reports of cure
Greater benefit in younger populations
Studies heterogenous and needs further
investigation
33.
34. Caregiver-dependent interventions
Prevent incontinence episodes
Motivated caregivers are essential
Includes scheduled toileting, habit training and
prompted voiding
Scheduled toileting
Putting the patient to toiletting at scheduled intervals
regardless of expressed desire to void
Habit training
A schedule of toileting based on patient’s pattern of
continent voids and incontinent episodes
35. Prompted voiding
Involves focusing the patient’s attention on their
bladders and prompting the patient to attempt
voiding and giving feedback by personal interaction
37. Drug Treatment
Prescribed in conjunction with one or
more behavioral interventions
For urge incontinenceanticholinergic
and bladder smooth muscle relaxants
60-70% reduction in incontinence episodes
Systemic anticholinergic side effects
(constipation, dry mouth, urinary retention);
drug-induced delirium in patients with dementia
38. Stress incontinencecombination of α-agonist
and estrogen
Pseudoephedrine most commonly used
Appropriate for patients
With mild to moderate stress incontinence
No major anatomic abnormality like cystocele
No contraindication to these drugs, e.g. poorly controlled
hypertension
Estrogen (topical or oral) combined with α-agonists also
effective in women with atrophic vaginitis and urethritis
0.5-1.0 g vaginal cream@HS x 1-2 months
39. May combine several drug classes for
mixed incontinence
Drug therapy for chronic overflow
incontinence not usually effective
40.
41.
42. Surgery and periurethral injection
Elderly women with stress incontinence
who are
Unresponsive to nonsurgical treatment
With significant degree of pelvic organ prolapse
(POP)
Range from periurethral collagen injections and
neck suspension to sling procedures
Periurethral injection for those with intrinsic
urethral weakness
43. Indicated in men whose incontinence is
associated with outflow obstruction
Complete retention
Those with significant residuals causing recurrent
UTI and hydronephrosis
Decision should be based on degree of
symptomatology, benefits and risks
44. Catheters and Catheter Care
3 basic types
External catheters
Intermittent straight catheterization
Chronic indwelling catheterization
45. External catheters
In males, consists of a form of condom
Increased risk of developing symptomatic
infections
For intractable incontinence in males without
retention and are physically dependent
Safety and effectiveness in females is not well
document in the elderly population
46. Intermittent catheterization
Can be done 2-4x daily
Goal is to keep residual urine to <300 cc
Straight catheter should be kept clean (not
necessarily sterile)
Practical and reduces risk of symptomatic
infection compared to chronic catheterization
Presence of anatomic abnormalities increase
risk of infection in the elderly
Risk of nosocomial infection also high in
institutional settings
47. Chronic indwelling catheterization
Indications
Urinary retention causing persistent overflow
incontinence, cannot be corrected surgically or
medically and cannot be managed practically by
intermittent catheterization
Wounds or ulcers contaminated by urine
Patient preference
Care of terminally ill or severely impaired patients in
whom bed and clothing changes are disruptive or
uncomfortable
49. Fecal Incontinence
Less common
Unusual in elderly patients who are
continent of urine
30-50% of institutionalized patients with
urinary incontinence also have fecal
incontinence
52. Evaluation
Detailed history
PE should include perineal examination and
DRE
Done on left lateral or decubitus position
Examine for hemorrhoids, patulous anus (indicates
denervation), anal deformities or anal dermatitis
Test for excessive perineal descent or rectal
prolapse by asking patient to strain
Test for anocutaneous reflex
Examination of the rectal vault
53. Diagnostic Testing
Anorectal manometry-assess sphincter tone
and strength
Anorectal ultrasound-assess structural integrity
EMG-rules out denervation
Barium proctography
Dynamic pelvic MRI
54. General Measures
Incontinence pads
Barrier preparations like zinc oxide
Topical antifungals for perineal fungal infections
55.
56. Biofeedback
To improve perception of rectal sensation and
responsiveness of the rectal sphincter
However most studies have imprecise
endpoints and lacked sham controls
No superiority over conservative measures
No difference between instrumental and non-
instrumental biofeedback
57. Surgical methods
Anal sphincteroplasty
Effective for acute fecal incontinence; uncertain
effectivity and durability in chronic incontinence
May have failure rates as high as 50% after 5 years
Antegrade colonic irrigation by a
cecostomy/appendicostomy
Optimal for those with neurogenic fecal incontinence
and anorectal deformities
Can be complicated by stenosis and infection
58. Surgical replacement using surrounding
muscles and implantation of a stimulator
(dynamic graciloplasty)
Pelvic floor muscle repair
Diverting colostomy
Sacral nerve stimulation