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Nursing Management on Male Urinary Incontinence

VIEWS: 60 PAGES: 30

									                                                                                           Urinary Continence Mechanisms

                                                                                 Stable detrusor
           Nursing Management on                                                 Competent bladder neck
           Male Urinary Incontinence                                             Intact external sphincter
                                                                                  mechanism

     TO Hoi Chu
     Nurse Specialist (Urology)
     Division of Urology / Department of Surgery
     Queen Elizabeth Hospital




             Types of Urinary Incontinence
                                                Overflow                           Common Causes of Bladder Problems
Urge                                             Bladder pressure
   urine loss                                    overcomes urethral        URGE & OVERACTIVE BLADDER:

    accompanied by                                pressure only at          occurs when the bladder contracts when it
                                                                            shouldn’t, due to an unstable bladder problem.
                                                  very high bladder
    urgency resulting                             volume
    from abnormal
    bladder                                 Mixed
                                                                            STRESS: occurs when increased pressure on the bladder
    contractions                               combination of stress       can’t be supported by weak pelvic floor muscles.
                                                and urge incontinence
Stress
   urine loss resulting               Functional
    from sudden increased                 Factors outside the
                                                                            OVERFLOW: occurs when there is blockage in the urethra
    intra-
    intra-abdominal                        Bladder or Urethra, e.g.         or the bladder is damaged and can’t properly contract.
                                           Cognitive Impairment,
    pressure (eg, laugh,                   Chronic Functional Disability,
    cough, sneeze)                         Psychological Impairment,
                                           Environmental Barriers




                                                                                                                                     1
                                                 Overactive Bladder (OAB)

                                     Prevalence
                                      16% men (16% of them have urine leaks)

                                         more common after 64

                                      17% women (55% have urine leaks)

                                         more common after 44




                  Morbidity of OAB          Assessment of patient’s symptoms

   falls & fractures                   number of pads used
   depression                          nocturia
   UTI & skin infection                fluid intake
                                        frequency-volume chart
                                        Risk factors: alcohol, caffeine, diuretics




                                                                                      2
               Frequency-volume chart
                                                                             Treatment of OAB

                                                             Eliminating underlying cause
                                                             Bladder training
                                                             Drug therapy
                                                             Surgery




                                                      咖啡咽來源           類型             份量                毫克

              Eliminate underlying cause              咖啡              釀造             5 oz              100-
                                                                                                       100-164

                                                                      即溶             5 oz              50-
                                                                                                       50-75

                                                                      脫除咖啡因          5 oz              2-4
   UTI / bladder stone
   Reduce caffeine and alcohol use                   茶               1-分鐘釀造         5 oz              20-
                                                                                                       20-34
      e.g. coffee, tea, sodas, chocolate,                            3-分鐘釀造         5 oz              39-
                                                                                                       39-50
       medications, alcohol                                           5-分鐘釀造         5 oz              39-
                                                                                                       39-50
      Caffeine: acts as a local irritant and as a                    冰茶             12 oz             67-
                                                                                                       67-76
       diuretic                                       巧克力飲品           巧克力奶           5 oz              2-15

      Alcohol: a local irritant and powerful                         熱巧克力           5 oz              2-15

       diuretic, ethanol relaxes the pelvic floor ,   汽水              可樂             12 oz             46

       sedation, delirium, and immobility                             健怡可樂           12 oz             46

   Fluid management                                  巧克力甜品           蛋糕                     9”
                                                                                     1/16 of 9” cake   14

                                                                      雪糕             2/3 cup           5

                                                      巧克力糖果           牛奶巧克力          1 oz              1-15

                                                                      深巧克力           1 oz              20




                                                                                                                 3
                                                                                 Caffeine: Practice Implications
                  Caffeine Intake: Evidence
      Following caffeine intake, women with detrusor                     Reducing or restricting caffeine intake, especially in
       overactivity showed detrusor pressure with                          those with high daily intakes
       bladder filling, while continent women did not                     (> 5 drinks/day), may be helpful in reducing UI
                                                                          Besides coffee, tea, colas, other soda, some water
      Women with detrusor overactivity had higher                         products, and drugs contain caffeine
       caffeine intake than women without diagnosis,                      Taper caffeine slowly to avoid migraine-type headache
       even after controlling for age and smoking



WHO, Second International Consultation on Incontinence, 2001




                        Fluid management                                                 Bladder retraining

     Drink water excessively worsen irritative bladder
      symptoms
     Minimize their fluid intake to unacceptable levels,
      thinking that if they drink less, they will experience less
      incontinence                                                  Deferment technique
     Concentrated urine may lead to bladder irritation and
      actually worsen urge incontinence
     In addition, dehydration contributes to constipation
     Restrict fluids after dinnertime reduces nocturia,
      nighttime bed-wetting




                                                                                                                                    4
               Behavioral Treatment
                                                                                                                              Bladder Training
             Multi-component Programs
 Pelvic   floor muscle training (PFMT)
                                                                                   Patient education
 Home     practice and exercise
                                                                                   Scheduled voiding
 Voiding   schedules                                                              regimen

 Urge    suppression strategies                                                   Urge control
                                                                                   strategies
 Self-monitoring   (bladder diaries)
                                                                                   Self-monitoring
 Fluid   and diet management
                                                                                   Reinforcement
 Encouragement     (motivation)
                                                                           Wilson PD et al. International Consultation on Incontinence.
                                                                           2002;10c:572-624.




             Efficacy of Bladder Training                                                                               Scheduling Regimen

       Scheduled voiding                                                            Initial voiding interval - one hour
       Progressive lengthening of interval                                          Occurs during waking hours only
        between voids
                                                                                     Avoid voiding off schedule
       Requires cognitive ability
                                                                                     Increase voiding interval by 30 minutes per
       Incontinent episodes reduced by 57%
                                                                                      week if schedule well-tolerated
       Volume of urine loss reduced by 54%


                               Fantl, et.al., JAMA; 265(5):609-13, 1991.




                                                                                                                                                 5
            Urgency Control Techniques                                Urge Suppression Strategy

                                                                  Stop and stay still
         Mind games
         Distract to another task or activities                  Squeeze pelvic floor muscles
         Deep breathing exercise to relax bladder
                                                                  Relax rest of body
         Self-statements (affirmations)
         Pelvic floor muscle contractions                        Concentrate on suppressing urge
         Timing
                                                                  Wait until the urge subsides

                                                                  Walk to bathroom at normal pace




                                                                                                     No
                     Timed Voiding                                                                Ditropan

   For less mobile /mentally impaired
   Caregiver prompts the patient to void every 1 to 3 hours
    before they feel an urge to void
   Keeping bladder volumes below urge trigger volume thus
    avoiding incontinence
   Voiding diaries or urodynamic studies can be used to
    estimate this volume and appropriate voiding frequency

   In small uncontrolled studies,
      85% improvement rate in institutionalized male
       patients (Sogbein & Awad, 1982)
      79% improvement in female outpatients (Godex, 1994)
                                                                                                   Given
                                                                                                  Ditropan




                                                                                                             6
                                                                                                                                Stress Urinary Incontinence after
                        OAB & LUTS relationship
                                                                                                                                     Radical Prostatectomy
   Overactive bladder (OAB) contractions are present in                                                                Some degree of Stress Urinary
    about 60% of men with LUTS and correlate strongly with
                                                                                                                         Incontinence
    irritative voiding symptoms.
                                                                                                                        Part of the urinary sphincter resected
   However, overactive bladder contractions resolve in most                                                            Teach PFME as indicated, urine
    patients after surgery.
                                                                                                                         containing devices e.g. drip collector

   Only about 1/4 patients who have OAB before treatment
    retain the problem afterward.



McConnell et al., 1994. McConnell J, Barry M, Bruskewitz R, et al: Benign prostatic hyperplasia: Diagnosis and
                                                                                                                                      DIFFERENT DEGREE OF DAMAGE
   treatment. Clinical Practice Guidelines, Number 8. M. Rockville, MD, Agency for Health Care Policy and                             TO SPHINCTER CAN OCCUR
   Research, Public Health Service, U.S. Department of Health and Human Services, 1994.




                     Pelvic floor muscle exercise                                                                                   Pelvic floor muscle exercise

       5% ~ 34% urinary incontinence following post
        transurethral resection of prostate (TURP)                                                                   Burgio et al 2006
       8% ~56% men report urinary incontinence 1 year
        following RRP                                                                                                pre-
                                                                                                                     pre-op, prostatectomy, behavioural training
       Distressing condition                                                                                          significantly decreased:
       Deeply disturbing                                                                                                    time to continence
       Deter resumption of beneficial physical activities                                                                                                  6-
                                                                                                                              severe / continual leakage at 6-month 5.9% vs 19.6%
       Deter the return to employment                                                                                       self reported urine loss w coughing 22.0% vs 51.1%
       Negative impact on quality of life                                                                                   self reported urine loss w sneeze 26.0% vs 48.9%
       Behavioural interventions ( Pelvic floor muscle exercise)                                                            self reported urine loss w getting up from lying down
                       58-
        demonstrated 58-81% improvement on urinary                                                                            14.0% vs 31.9%
        incontinence following prostatectomy, persisting up to
        12 years
                                                                                                 Burgio et al 1989
                                                                                                Meaglia et al 1990




                                                                                                                                                                                      7
                                                                                                                       Patient urinary incontinence journey
                     Pelvic floor muscle exercise
                                                                                                                                   following RRP
 Filocam et al 2005, early pelvic floor rehabilitation
    treatment for post-prostatectomy incontinence                                                            Smither et al. 2007
                                                                                                              203 consecutive patients underwent radical
    74% of patients performing PFME were                                                                      prostatectomy by a single surgeon between 03/98 &
     continent at 3 months                                                                                     08/03.
                                                                                                              pelvic floor exercises (verbally and with hand-out) pre-
    30% of patients who did not perform PFME were                                                             operatively and again at the time of catheter removal, 2
     continent                                                                                                 weeks post-operatively.
                                                                                                              mean follow up was 118 weeks.



Filocam MT, Marzi VL, Del Popolo G, Cecconi F, Marzocco M, Tosto A, Nicita G: Effectiveness of early        Quantifying the natural history of post-radical prostatectomy incontinence using objective pad test data.
     pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Uorl 2005, 48:734-38.      Anna R Smither, Michael L Guralnick, Nancy B Davis and William A See. BMC Urology 2007, 7:2




           Patient urinary incontinence journey                                                                        Patient urinary incontinence journey
                       following RRP                                                                                               following RRP
    Majority of patients experienced incontinence
     immediately after catheter removal at 2 weeks
    Most patients who achieved continence did so by 18
     weeks post-op.
    Patients continue to improve out to 1 year with greater
     than 90% having minimal leakage by International
     Continence Society criteria.




Quantifying the natural history of post-radical prostatectomy incontinence using objective pad test data.
   Anna R Smither, Michael L Guralnick, Nancy B Davis and William A See. BMC Urology 2007, 7:2              Quantifying the natural history of post-radical prostatectomy incontinence using objective pad test data.
                                                                                                               Anna R Smither, Michael L Guralnick, Nancy B Davis and William A See. BMC Urology 2007, 7:2




                                                                                                                                                                                                                        8
                      Mechanism of PFME                                                   Pelvic floor muscle exercise

   Contraction of the puborectalis lifts the urethra,                        How to Identify your Pelvic Floor Muscles
    enabling the external urethra sphincter to
    contract against it to prevent urine flow (Myers,                            Sit or lie comfortably with muscles of your thighs,
                                                                                  buttocks and abdomen relaxed.
    1991; De Ridder, 2005).
                                                                                 Tighten the ring of muscle around the back passage
   Contraction of the pelvic floor also triggers an                              as if you are trying to control diarrhoea or wind. Relax
    inhibitory spinal cord reflex that reduces bladder                            it.
    sensitivity and suppresses involuntary bladder                               While you are passing urine, trying to stop the flow
    contractions (Stein et al., 1994; Bo and                                      mid-
                                                                                  mid-stream, then restarting it.
    Berghmans, 2000).                                                            If your technique is correct, each time that you tighten
                                                                                  your pelvic floor muscles you may feel the base of
                                                                                  your penis move up slightly towards your abdomen.




        Doing Pelvic Floor Muscle Exercises                                               Pelvic floor muscle exercise
       Tighten and draw in strongly the muscles around the anus and
        the urethra all at once. Lift them up inside.
                                                                              Make the Exercises a Daily Routine
       Try and hold this contraction strongly as you count to ten, then
        release slowly and relax for 10 seconds.                               Tighten your pelvic floor muscles also while you are getting up
                                                                                from a chair, coughing or lifting
                                                                      in
        Repeat ("squeeze and lift") and relax. It is important to rest in      assist themselves in regaining control
        between each contraction.
                                                                               Good results take time, takes several weeks to see improvement
       Repeat this as many times as you are able up to a maximum of           When you have recovered control of your bladder, you should
        10 squeezes. Make each tightening a strong, slow and controlled
        contraction.                                                            continue doing the at least once a day for life.

       Now do five to ten short, fast, but strong contractions, pulling up   Other Tips to Help Your Pelvic Floor
        and immediately letting go.
                                                                               Avoid constipation and prevent any straining during a bowel
       Do this whole exercise routine 10 times every day.                      movement.
       You can do it in a variety of positions - lying, sitting, standing,                               hay-
                                                                               Seek medical advice for hay-fever, asthma or bronchitis to
        walking.                                                                reduce sneezing and coughing.
                                                                               Keep your weight within the right range for your height and age.
       While doing the exercises:
            DO NOT hold your breath.                                          Share the lifting of heavy loads.
            DO NOT push down instead of squeezing and lifting up.




                                                                                                                                                   9
             Pelvic Muscle Assessment
                                                                             Neuromuscular Electro-Stimulation
               modified Oxford Scale
                                                                     Neuromuscular Electro-Stimulation is an
                                                                      addition to PFME in the rehabilitation of
                                                                      weakened pelvic muscles and can be used
                                                                      in junction with biofeedback or PFME
                                                                     Goal: Help identify and augment pelvic
                                                                      muscle contraction
                                                                     Beneficial for both men and women
                                                                     Stimulation must be performed for a
                                                                      minimum of 4 weeks and continue PFE
                                                                      after the treatment




              Contraindications for                                           Use of Electrical Stimulation for
        Neuromuscular Electro-Stimulation                                   Strengthening Pelvic Floor Muscles
   On-demand pace makers                                                  Vaginal or anal surface electrodes
   Urinary retention
                                                                           May help stress incontinence, although physiological
   Urethral obstruction
                                                                            reasons unclear
   Impaired cognitive function / Dementia
   Pelvic cancer                                                          Possibly educates patients to contract muscles
   Complete denervation of the pelvic floor (will not respond)
   Unstable or serious cardiac arrhythmia
   Pregnancy or planning/attempting pregnancy
   Broken/irritated peri-anal skin
   Rectal bleeding
   Active infection (UTI/vaginal)
   Unstable seizure disorder
   Swollen, painful hemorrhoids




                                                                                                                                   10
Electrostimulation of the pelvic floor musculature                                           Neuromuscular Electro-Stimulation
    Transform fast twitch muscle fibers into slow twitch muscle
     fibers
    Recommendation:  20 weeks training                                                Failed as a result of wrong positioning of the electrodes,
                                                                                         local fibrosis, and the natural plasticity of the nervous
                 (American college of Sports Medicine 1990)                              system
    Almost no complications
                                                                                     Complications:
                        Recommendations                                               infection (2%)
    In patients with incomplete denervation of the pelvic floor                      superficial wound dehiscence (10%)
     muscle and the striated sphincter, electrostimulation via                        erosion of the extension cable towards the skin (1%)
     anal or vaginal plugs performed over months, may be an                           pain (10%)
     option to improve pelvic floor function, thus improve
                                                                                      lead problem (38%)
     incontinence.
    The incompleteness of the lesion should be as such that
     the patient is able to contract voluntary the pelvic floor
     even if this is weak (Grade C/D)
                              3rd International Consultation on Incontinence, 2005




                      Parameters of ES                                                                  Parameters of ES

        Waveform
        Current intensity                                                           -                             pain-
                                                                                         Aim to produce maximal pain-free contraction
        Ramping of impulses                                                             perceptible by individual
        Pulse frequency
                                                                                     -                                           one’
                                                                                         The intensity is increased according to one’s
        On/Off timing
                                                                                         tolerance




                                                                                                                                                      11
                   Parameters of ES                                                  Parameters of ES

                  (10-
    Lower ranges (10-15Hz) has a calming effect on the               On”      Off”
                                                                     “On” and “Off” timing
    detrusor muscle →inhibited bladder contractions
      used for those with urge UI;                              -    On”
                                                                     “On” time is the amount of time that the electrical current
                   (50Hz)→
    Higher ranges (50Hz)→optimum for urethral closure and            is delivered to the muscles
    builds strength                                              -    Off”
                                                                     “Off” time is the amount of time when there is no
      used for those with stress UI                                 electrical current to the muscle, allowing it to recover




                    Precaution of ES                                              Pressure Biofeedback

                                   30mins→
    Apply stimulation not more than 30mins→muscle fatigue           Treatment of stress, urge and
   Observe for any signs of skin and mucosal irritation prior       mixed incontinence
    to use                                                          A form of PFMs rehabilitation
   Observe any compliant of discomfort during and after the        An electronic device made of an
                                                                     inflatable intravaginal or rectal
    procedure                                                        probe
                                                                    Connected to a manometer
                                                                    Biofeedback is often used as an
                                                                     audiovisual instructional aid and
                                                                     method of evaluating progress




                                                                                                                                   12
                Pressure Biofeedback                                         Advantages of Biofeedback

   Help to control external sphincter by measuring the           A useful tool for teaching a correct pelvic muscle
    actions of the PFMs                                            contraction
   Feedback information to the person                            Can increase motivation and adherence
   The information is stored, processed and fed back to the
    person in the form of sound, light or images
   Position: lying, standing, sitting




    Contraindication of Pressure Biofeedback                          Precautions of Pressure Biofeedback

   Allergic to natural rubber latex                               Examine any signs of skin and mucosal irritation prior to
   Client’
    Client’s anatomy that make proper probe insertion               use
    difficult or impossible                                        Examine the product prior to use
   Any infection of the bladder or vagina or                      Examine any signs of deterioration such as tears, cuts or
                                           dysuria,
    Symptoms of infection such as itching, dysuria, sores or        discoloration
    fever                                                          Examine any air leak of the latex balloon
   Pregnant or ? pregnant




                                                                                                                                13
          Instructions for Pressure Probe                                Instructions for Pressure Biofeedback

   The probe should be cleaned before & after                        Spread a light coating of lubricating gel
   Equalize the air pressure in the probe before use                 Insert the lubricated probe into the vagina or anus
                                          one-
    Insert the tip of the syringe into the one-way valve on the       Inflate the probe by positioning the front edge of the
    end of the probe tubing                                            rubber tip of the plunger at the appropriate mark
   Remove the syringe and replace the plunger                               vaginal probe: 15cc
                                                                             anal probe: 5cc




      Instructions for Pressure Biofeedback                              Instructions for Pressure Biofeedback

   Hold the plunger firmly in this position                          The force of the PFMs contractions is measured by the
   Attach the probe to the appropriate port of the equipment          marking
   When the ‘work’ light is on, ask the client to squeeze
                work’                                                 When the ‘rest’ light is ‘on’, ask client to relax the PFMs
    pelvic floor muscles                                              Client can adjust the PFE exercises pattern so that the
   The light will give client feedback that she/he controls the       exercises are performed correctly
    correct muscles




                                                                                                                                     14
      Instructions for Pressure Biofeedback                                                           Absorbent products

   Following use, remove the probe from the port and                                Do not use absorbent products instead of definitive
    deflate the probe                                                                 interventions to decrease or eliminate urinary incontinence.
   Check the client any discomfort during and after the                             Early dependency on absorbent pads may be a deterrent to
    procedure                                                                         achieving continence, providing the wearer a false sense of
   Observe any skin or mucosal irritation after removal of                           security.
    probe
                                                                                     Chronic use of absorbent products may lead to inevitable
   Wash the probe with mild soap and water to remove any                             acceptance of the incontinence condition, which removes
    surface debris,                                                                   the motivation to seek evaluation and treatment.
   and disinfect with Cidex for clinic use
                                                                                     In addition, improper use of absorbent products may
                                                                                      contribute to skin breakdown and urinary tract infections.
                                                                                     Thus, appropriate use, meticulous care, and frequent pad or
                                                                                      garment changes are needed when absorbent products are
                                                                                      used.




         External appliances: Condom catheter

   CC still has a role in controlling urinary incontinence in
    neurologic male patients (LOE 3)
   Long-term use may cause bacteriuria, but it does not
    increase the risk of UTI when compared to other                                   Non-latex            self-adhesive          inflatable
    methods of bladder management. (LOE 3)
   Complications may be less if applied properly with good
    hygiene care, frequently change of the CC and
    maintenance of low bladder pressures. (LOE 3)
   Special attention should be paid to people with dementia
    (LOE 3)
                           3rd International Consultation on Incontinence, 2005


                                                                                      Latex                  Detachable tip      For retracted penis




                                                                                                                                                       15
External appliances:
     Condom catheter                                            External appliances:
                                                                     Condom catheter
   60 SCI using condom catheter
   >50% positive urine culture                                       Penetrating / non-penetrating lesions
    In which 56% tissue invasion by                                   Due to fastener or proximal hard roller ring
    bacteria
                                                                      Compressive effect              (Nanninga & Rosen 1975)
        (Newman & Price 1985)                                         Chronic dermatitis
   Incomplete emptying                                               Irritative or allergic reaction
   High RU                                                           SCI patient w/ bil hydronephrosis due to condom
   Bladder overdistension                                             catheter fasten strap
   Urine stasis inside condom                                        Resolved when the strap is removed (Pidde &Little,
    catheter                                                           1994)
   Urine leakage




                External appliances:                                    External appliances : Condom catheter
            Condom catheter Complications                        Recommendations (All grades of recommendation: B/C)
                                                                  To have better control of leakage, a more secure CC
                                                                   should be used, and patients should be educated and
                                                                   cooperative.
    If skin lesion
                                                                  To prevent latex allergy, a silicone CC should be used and
    Remove CC, resume IC / urethral catheter                      serological examination of latex-specific IGE is
    Till skin is dry & healed, to reapply CC                      recommended in addition to patient history to better
                                                                   identify patients at risk.
    Allergic dermatitis
                                                                  To prevent compressive effects, choose proper size CC
    Remove CC, topical steroid           (Harmon et al 1995)      with self- adhesive.
                                                                  To prevent infection, a daily change of the CC could help.

                                                                  To prevent bladder and upper tract damage, regular
                                                                   bladder emptying with low bladder pressures and low post
                                                                   void residual should be persued.
                                                                                            3rd International Consultation on Incontinence, 2005




                                                                                                                                                   16
                                                              Penile Compression Devices and absorbent products
                   External appliances

    Penile Compression Devices
     Cunningham clamp
     Continence penile cuff

                                                                                         Cunningham clamp     continence penile cuff




                                                                    skin care products                  drip collector




           Overflow urinary incontinence

   Bladder pressure overcomes urethral pressure only at
    very high bladder volume
   Diabetes cystopathy
   CROU
   BPH, urethral stricture, detrusor-sphincter dyssynergia
   Significant PVR leading to overflow incontinence, UTI,
    urinary tract stone formation, bladder diverticulum
    obstructive uropathy




                                                                 BPH potential complications




                                                                                                                                       17
        Two routes of urinary catheterisation




Urethral




                                                18
                                                            Indwelling transurethral catheter

         Two routes of urinary catheterisation       Complications
                                                      Alteration of body image
                                                      Feeling of dependence
                                                      Pain & discomfort
                                                      Bacterial biofilm, UTI acute &
                                                       chronic
                                                      Encrustation, blockage,
                                                       bladder & renal stone
Suprapubic                                           Infection: para-urethral
                                                       abscess, urethritis, prostatitis,
                                                       epididymo-orchitis, cystitis
                                                      Urethral trauma & bleeding,
                                                       fistula, urethral stricture




        Indwelling transurethral catheter                        Catheter-associated UTI
                                                                        (CAUTI)
 Complications
  Catheter induced detrusor
   spasm, urine bypass, catheter                 •     10-15 % of all hospitalised patients have indwelling
   expulsion                                           urethral catheters
  Urethral sphincter erosion                                                    Stamm, 1975
  Bladder neck incompetence                                                     Fincke & Friedland, 1976
  Balloon deflation problem,
   problematic removal
                                                 •     ~ 40 % of all hospital-acquired infections occur in the
  Balloon self-deflation
                                                       urinary tract
  Bladder carcinoma
                                                                                Stamm, 1975
  100%-silicon catheter balloon
   cuffing
  Anaphylaxis & allergy




                                                                                                                 19
               Catheter-associated UTI
                                                                                                       Bacterial biofilms
                      Incidence
                                                                     Bacterial biofilms
   Single sterile catheterisation
                                                                     part bacterial matter and part
     • Healthy outpatients                         0.5 – 1 %
                                                                      crystals
     • Hospitalised patients -

         Male                                        5%
         Female                                   10 – 20 %

   Longer duration of catheterisation          5 % per day

                                                                     Stickler, D., Ganderton, L., King. J., Nettleton, J., & Winters, C. (1993). Proteus mirabilis biofilms and the
                                                                          encrustation of urethral catheters. Urological Research, 21, 407–411.
                                                                                                                                       407–
                  AUA Update Series 21:292, 2002




                                                                                                           Urethral erosion
                                       2 hrs primary
                                       adherence of               2
                                                                                                                                                                                1 yr
                                     bacteria on 100%-         months
                                                                                                                                                                               long
                                       Silicon Foley            long
                                                                                                                                                                               term
                                                                term
                                                                                                                                                                               Foley
                                                               Foley




                                                                2 yr                                                                                                             2 yr
    Bacterial Biofilm                                          long                                                                                                             long
                                                               term                                                                                                             term
       (18 hrs later)                                                                                                                                                           Foley
                                                               Foley
    on 100%-Silicon
               Foley




                                                                                                                                                                                        20
               Urethral erosion                                   Encrustation




                                                          Encrusted blocked Foley catheter



              2 yr long term Foley


                                                    Encrusted blocked Suprapubic Stamey catheter




      Effect between different water rate                        Catheter valve
                on Encrustation




720cc/24 hr      2160cc/24 hr        4320cc/24 hr




                                                                                                   21
                     Time to catheter blockage                                                                              Encrustation
after 46 hr of operation in urine infected with Proteus
  mirabilis                                                                                               Encrustation always forms when urine is
                                                                                                           concentrated
                                                                                                          so a high fluid intake, spread evenly throughout
                                                                                                           the day, is important to decrease encrustation




 Sabbuba NA. Stickler DJ. Long MJ. Dong Z. Short TD. Feneley RJ. Does the valve regulated release
 of urine from the bladder decrease encrustation and blockage of indwelling catheters by crystalline
 proteus mirabilis biofilms? Journal of Urology. 173(1):262-6, 2005 Jan




                                                                                                                Indwelling transurethral catheter
                              Catheter selection                                                                    Implications for practice
 All silicone catheters are preferred
                                                                                                       100%-
                                                                                                       100%-silicon catheter is      Maintain closed drainage
  least irritation
                                                                                                       preferable                    system
  bigger lumens (Burr et al 1993),
                                                                                                       Sterile materials & aseptic   Educate patients on
    because it has a thinner wall
                                                                                                       technique                     catheter care
                                                                                                       Smaller catheter & balloon    Change siliconised latex
 Small sized catheters and balloon are                                                                                               catheters 1 – 2 weeks
   preferred
  Fr 12 ~ 14 with a 5 ~ 10 mL balloon                                                                 Routine catheter care                  100%-
                                                                                                                                     Change 100%-silicon
  increases patient comfort                                                                                                         catheter 2 - 4 weeks
  decreases blockage to the periurethral
                                                                                                       Secure catheter properly      Catheterize only when
   glands                                                                                                                            necessary
  decreases the risk of urethral erosion




                                                                                                                                                                22
          Indwelling transurethral catheter                                  Intermittent catheterization

                        Long-term use                             Purpose: regular complete emptying of the
   Urethral trauma, unacceptable (Andrews et al 1988)             bladder and to resume normal bladder
                                                                   storage
   Urine bypass upon catheter spasm                              With intermittent catheterization:
                            (Fenely 1983, Lindan et al 1987)         no need to leave the catheter in the LUT
   Urine leakage due to blockage caused by encrustation              all the time
   Patulous & non-functioning urethra                               avoiding complications of indwelling

   Reduced bladder capacity & compliance                             catheterization
                                                                     prevent bladder overdistension in order
                                   (Chancellor et al 1994)            to avoid complications and to improve
                                                                      urological conditions




                                                                                                                 23
Tiemann-tip or coude-tip catheter easy negotiating                 Intermittent catheterization
  urethra for post TURP change or urethral false
                     passage
                                                          1st line of treatment in neurogenic bladder
                                                          Preferable method
                                                          Less complications
                                                          Better outcome
                                                          Effective & safe in short-term & long-term use
                                                                     (2nd International Consultation on Incontinence, 2nd Edition, 2002)




                Post-micturition dribble                            Post-micturition dribble

   Used for the symptom when men                     Aetiology
    experience an involuntary loss of urine            failure of the bulbocavernosus muscle (which circles the
    immediately after they finish passing urine,        bulbar urethra) to contract by reflex action after
    usually after leaving the toilet (Abrams et al,     micturition and to evacuate urine from this portion of the
    2002).                                              urethra (Feneley, 1986)
   It is neither stress dependent (due to             This reflex is known as the urethrocavernosus reflex
    exertion) nor due to bladder dysfunction            (Shafik and El-Sibai, 2000).
    (Wille et al, 2000)                                Its failure may occur as a result of surgery, neurological
   should be distinguished from terminal               conditions or weak pelvic floor muscles.
    dribble, which occurs at the end of                Urine remaining in the bulbar portion of the urethra will
    micturition (Shah, 1994).                           then dribble out on movement.
   The condition can be a nuisance and cause
    embarrassment.




                                                                                                                                           24
       Treatment for Post-micturition dribble                                                    Treatment for Post-micturition dribble

   Paterson et al (1997) conducted a single-blind                                          Urethral milking: after urinating, to place his fingers
    randomised controlled trial comparing pelvic floor muscle                                behind the scrotum and gently massage the bulbar
                                                                                             urethra in a forwards and upwards direction in order to
    exercises with bulbar urethral massage (urethral milking).                               ‘milk’ the remaining urine from the urethra
   49 men (36-83 years) not undergone surgery on the
    bladder, urethra or prostate gland                                                      They found that men who practised pelvic floor
   RCT: pelvic muscle exercise, urethral milking or                                         exercises were almost twice as likely to have reduced
                                                                                             urine loss than the urethral milking group and both these
    counselling                                                                              interventions were more effective than counselling alone.
   followed up the treatment specific to their group for 12
    weeks. At 5, 9 and 13 weeks, urine loss was assessed



 PATERSON J, PINNOCK CB, MARSHALL VR. Pelvic floor exercises as a treatment for post-    PATERSON J, PINNOCK CB, MARSHALL VR. Pelvic floor exercises as a treatment for post-
    micturition dribble. British Journal of Urology 1997; 79(6) pp 892-897.                 micturition dribble. British Journal of Urology 1997; 79(6) pp 892-897.




What is an artificial urinary sphincter (AUS) ?
                                                                                                                           Benefits of AUS

AUS is made up of three parts:
                                                                                            The largest single-institution series in children
   an inflatable cuff fits around urethra                                                   demonstrates:
      at bladder neck or bulbous urethra
                                                                                               a total continence rate of 86%
      exert enough pressure on the urethra to
       allow bladder to hold urine                                                             a revision rate of 25%

   a control pump
      implanted in scrotum / labia majora                                              Herndon CD, Rink RC, Shaw MB, Simmons GR, Cain MP, Kaefer M. The Indiana experience with
                                                                                            artificial urinary sphincters in children and young adults. J Urol. Feb 2003;169(2):650-4; discussion
                                                                                            654.
   a pressure regulating balloon (reservoir)
                           ping-
      about the size of a ping-pong ball
      placed in body behind pubic bone




                                                                                                                                                                                                    25
                       AUS device durability                                                                                    AUS is implanted all inside the body
                                                                                                                       Implanted in an operating theatre
   5-year survival rate is 67% ~ 90%                                                                                  Under spinal or general anesthesia
                                                                                                                       Two small incisions on groin and perineum
   10-year survival rate is 66%                                                                                       No external appliances
                                                                                                                       It will not change the body looks because the AUS is all
                                                                                                                        inside the body                                Groin
                                                                                                                                                                                                              incision


                                                                                                              Perineal
Venn, S.N., Greenwall, T.J., & Mundy, A.R. (2000). The long-term outcome of artificial urinary                    incision
     sphincter. The Journal of Urology, 164, 702-707.
Elliott, D.S., & Barrett, D.M. (1998b). Mayo clinic long-term analysis of the functional durability of the
     AMS 800 artificial urinary sphincter: A review of 323 cases. The Journal of Urology, 159, 1206-
     1208.
Smith, J.J., & Barrett, D.M, (2002). Implantation of the artificial genitourinary sphincter. In P.C. Walsh,
     A.B. Retik, E.D. Vaughn, & A.J. Wein (Eds.), Campbell's urology (8th ed.) (pp. 1187-1194).
     Philadelphia: Saunders.




                          Pre-operative education                                                                            DOs and DON’Ts before implant surgery
Teach patient how to:
                                                                                                                    If allergy to iodine, make sure to tell the doctor
   identify different parts of a sample                                                                               iodine is often used for skin disinfection
    AUS and their function
                                                                                                                    Don’t shave groin or perineum 2 weeks before the surgery
   cycle a sample AUS                                                                                               because skin nicks may result in higher chance of getting
   intermittent self catheterization if                                                                             infection which may result in removal of infected AUS
    concomitant overflow
    incontinence is present                                                                                         The pubic hair should only be shaved in operating theatre
                                                                                                                     just prior to the implant surgery
   deactivate the cuff if urethral
    catheterization or instrumentation
    is necessary
                                                                                                                    Elliott, D.S., & Barrett, D.M. (1998). The Mayo Clinic long term analysis of the functional durability
                                                                                                                                                                                      cases.
                                                                                                                         of the AMS 800 Artificial Urinary Sphincter: A review of 323 cases. journal of Urology, 259(4),
                                                                                                                         1206-
                                                                                                                         1206-1208.




                                                                                                                                                                                                                             26
         DOs and DON’Ts before implant surgery                                                                  What will be expected after the surgery?

   Cleanse bowel the night before surgery by laxatives like                                                May have some soreness in perineum
    fleet enema
                                                                                                            In some patients a chronic pain associated with device
   Disinfect body esp. the genital area with an antibacterial                                               have been reported
    soap like Betadine bath
                                                                                                            A urinary catheter will be in place and drains urine from
   For females, vaginal douching will be used in the                                                        bladder
    morning of the surgery                                                                                     Helps healing from operation
                                                                                                               Will be removed before discharge home
   These will help lower the chance of getting an infection

Elliott, D.S., & Barrett, D.M. (1998). The Mayo Clinic long term analysis of the functional durability
                                                                  cases.
     of the AMS 800 Artificial Urinary Sphincter: A review of 323 cases. journal of Urology, 259(4),
     1206-
     1206-1208.




          What will be expected after the surgery?                                                               DOs and DON’Ts after implant surgery
   Initially GSI may be improved transiently to a certain
    degree because of operated site swelling which narrows                                                  Gently pull down AUS pump once each day to prevent
    the urethra                                                                                              upward migration during the capsule-forming period

   As swelling gradually subside, return of GSI is anticipated                                             Wear loose-fitting clothing and undergarments

   Don’t be panic, because the AUS is not yet activated until                                              Avoids prolonged sitting, it may put unnecessary
    the operated site is healed                                                                              pressure on the perineum where the cuff is placed

   The AUS will be activated by a Urologist or Urology Nurse                                               If scrotum is swelling, ice therapy and scrotal support
                                                                                                             may help
   Then you will be taught how to cycle the AUS
                                                                                                            Avoid constipation to prevent straining, more roughage
   Instruct patient not to manipulate the AUS for 6 weeks                                                   and water intake, stool softener may be prescribed
    until activation is permitted




                                                                                                                                                                         27
      When will the AUS be started working ?                                When will the AUS be started working ?
                                                                   On the 6-8 weeks follow-up visit
   The AUS will not be activated (inflated) until operated          the AUS will be activated (inflated) if healed
    site healed in 6-8 weeks after the operation                     teach patient to

                                                                         identify different parts of AUS and their function
   Need to keep using incontinence pads during this period
                                                                         how to cycle the AUS

                                                                         deactivate the cuff if urethral catheterization or
                                                                          instrumentation is necessary
                                                                     release of the deactivation valve may require greater
                                                                      pressure than that used to cycle the device
                                                                     assess the micturition ability by

                                                                         uroflowmetry

                                                                         post void residual urine volume by BladderScan




     Realistic expectations after AUS working                                   Special things to do following AUS
                                                                      Wear a Medic-Alert bracelet alerts AUS implanted
   An AUS does make urine control better, but it may not             Avoid horseback riding and bicycle riding, which may put
    stop all urine leakage esp. on strenuous exercise or               unnecessary pressure a pump
    severe coughs
                                                                      Avoid trauma or injury to the pelvis, perineum or lower
   Empty the bladder before sports or strenuous exercise to           abdomen, such as impact injuries associated with sports
    avoid or reduce GSI                                                    this damage may result in the malfunction of the device
                                                                            and may necessitate surgical correction including
   AUS is not a lifetime implant                                           replacement of the device
                                                                      Choose activities wisely
                                                                      Good habit to emptying bladder on a regular basis, every
                                                                       2-3 hours

                                                               Elliott DS, Barrett DM, Gohma M, Boone TB. Does nocturnal deactivation of the artificial urinary
                                                                    sphincter lessen the risk of urethra atrophy?. Urology. Jun 2001;57(6):1051-4.




                                                                                                                                                                  28
                  Special things to do following AUS                                                                          Special things to do following AUS

   AUS should be deactivated before any urethral catheterization                                                  Activation is accomplished by a firm and sustained
    or instrumentation otherwise an erosion may result                                                              squeeze of the pump, allowing the deactivation pin to
                                                                                                                    "pop" into the activated position.
   To deactivate the device
      squeeze the pump several times to empty the fluid from the                                                  If inadvertently locks the button when the cuff is closed,
       cuff with a slight indentation appearance                                                                    urinary retention occurs
      push the button to lock the cuff open
      it is important to leave a slight indentation in the pump bulb                                              Conversely, if the button is locked when the cuff is open,
       to ensure that there is enough fluid in the pump for                                                         persistent incontinence occurs
       reactivation
                                                                                                                   Patients should be instructed on the locking mechanism to
                                                                                                                    understand and be able to respond to these problems




                  Special things to do following AUS                                                                          Special things to do following AUS

       Good practice in teaching patient’s spouse or significant                                              As with any prosthetic implantation, patients should take
        other to know how to operate the AUS if it became                                                        prophylactic antibiotics prior to dental or surgical
        necessary                                                                                                procedures to avoid hematogenous seeding

       If dry at night, nighttime deactivation of cuff may reducing
        the risk of tissue ischemia, urethral atrophy,& urethral cuff
        erosion

       Prolonged sitting & chairs with hard seats should be
        avoided to prevent unnecessary pressure on the cuff
                                                                                                                   Smith, J.J., & Barrett, D.M, (2002). Implantation of the artificial genitourinary sphincter. In P.C.
        Elliott DS, Barrett DM, Gohma M, Boone TB. Does nocturnal deactivation of the artificial urinary               Walsh, A.B. Retik, E.D. Vaughn, & A.J. Wein (Eds.), Campbell's urology (8th ed.) (pp. 1187-
             sphincter lessen the risk of urethra atrophy?. Urology. Jun 2001;57(6):1051-4.                            1194). Philadelphia: Saunders.
        Smith, J.J., & Barrett, D.M, (2002). Implantation of the artificial genitourinary sphincter. In P.C.
             Walsh, A.B. Retik, E.D. Vaughn, & A.J. Wein (Eds.), Campbell's urology (8th ed.) (pp. 1187-
             1194). Philadelphia: Saunders.




                                                                                                                                                                                                                          29
Thank you




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