disability and incontinence patient assessment patient management
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Disability and Incontinence
Patient assessmentPatient management
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Incontinence is more common in disabled
Major effect on QoL
Major economic burden
Increasing issue as survival improves
Leads to isolation, depression and death
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Overall management
Individual patient focussed
Coordinated multidisciplinary
Community based
Realistic
Cost effective
Ongoing care
Improved QoL, Independence
…small interventions can lead to major improvements……
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Urinary Incontinence
Physical declineGeneral decline
Vicious cycle
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Causes of Incontinence
SUI Stress Incontinence : 50%UUI Urge Incontinence : 20%MUI Mixed Incontinence: 30%
Higher UUI in Disabled
Non Urinary tractAgeingReduced mobilityPoly pharmacyIatrogenicPsychogenicCognitive impairment
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Causes of Incontinence
• D Delirium• I Infection• A Atrophic vaginitis• P Psychogenic• P Pharmacologic• E Excess urine• R Restricted mobility• S Stool impaction
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Assessement
• Systematic• History• Examination• Investigations• Diagnosis / define goals• Treatment• Follow up
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History
• General: Medical, systems, social supports, environmental
Specific: Urinary symptoms, Incontinence severity, current management.
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Examination
• General : Mobility, IQ/ cognition, BMI, Hand function
• Specific : Focused neurology, Abdominal, Pelvic floor ( Prolapse / Incontinence ), Rectal ( Constipation )
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Investigations
• MSU : Haematuria, UTI• Bloods : Creatinine, Glucose, Ca++• Flow and Residual• Bladder diary [ 24 hrs vs 3 days ] Think Compliance
and cooperation• QoL Score ICIQ ( useful - not validated )
• Renal US• Urodynamics: Rarely required ( pre op )
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Diagnosis and management plan
• Patient/ care giver expectation• Ability to deliver• Know local referral pathways
AdditionalChronic pain: adds to difficultyHaematuria : referralUTI : Treat and reviewProlapse : Refer
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Levels of evidence
Grades of recommendation
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Outcome objectives
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Management strategy
• Clinical / physical• Drugs• Environmental• Behavioral / Social• Rehabilitate• Integrate support
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Success in caregiver management
• Under pinning: Life long love…..
• Problem solve: careful observation
• Consequences: role change, emotional change, financial change, sleep, social isolation, reduced intimacy
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Management UUI
• General: • Scheduled void [ b ], restrict fluids [ b ], stop
smoking [ c ], avoid caffeine [ a ]• Specific: • Bladder retraining [ a ] 70%• Anticholinergics [ a ] 70% ( low dose, not in
retention , glaucoma ) ; new B3 agonist
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Management UUI
• Neuromodulation: Sacral vs Post tibial [ a ] 60 – 80% expensive, intensive required expertise
• Botox: [ a ] 75% expensive, repeated 6 – 12 monthly, may cause retention
• Catheter: patient preference depends on mobility
• Augmentation: rarely required
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Management SUI : Female
• General: timed void [b ], reduce caffeine [ a ], reduce weight [ b ], reduce fluids [ b ], reduce smoking [ b ].
• Specific: Pelvic floor exercises [ a ] 30% , oestrogen cream [ c ] 30%, surgery [ a ].
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Sling procedures for female SUI
Grade A evidence75 – 90% cure10 yrs durable
First choiceSimilar outcomes in disabled / elderly
Low risk retention
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Management Male SUI
Majority Post RRPWait 6 – 12 monthsAUSACC coverage in NZ90% dry or 1 security pad
Male sling for lower volume incontinence60% effective
Long term catheter or diversion
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Management mixed UI
• Manage predominant symptoms first in step wise manner
• Lower success
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Summary
• Listen and set realistic goals• “3 day trial” and review• Modify plan if required• Refer if complex or fail
Remember…. A small intervention can lead to a major improvement…..