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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 30
"Nursing Management on Male Urinary Incontinence"