Urinary Continence Mechanisms  Nursing Management on Male Urinary Incontinence   Stable detrusor Competent bladder neck Intact external sphincter mechanism TO Hoi Chu Nurse Specialist (Urology) Division of Urology / Department of Surgery Queen Elizabeth Hospital Types of Urinary Incontinence Overflow Urge  Stress   Bladder pressure overcomes urethral pressure only at very high bladder volume urine loss accompanied by urgency resulting from abnormal bladder contractions urine loss resulting from sudden increased intraintra-abdominal pressure (eg, laugh, cough, sneeze) Common Causes of Bladder Problems URGE & OVERACTIVE BLADDER: occurs when the bladder contracts when it shouldn’t, due to an unstable bladder problem. Mixed  combination of stress and urge incontinence STRESS: occurs when increased pressure on the bladder can’t be supported by weak pelvic floor muscles. Functional  Factors outside the Bladder or Urethra, e.g. OVERFLOW: occurs when there is blockage in the urethra or the bladder is damaged and can’t properly contract. Cognitive Impairment, Chronic Functional Disability, 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    falls & fractures depression UTI & skin infection Assessment of patient’s symptoms      number of pads used nocturia fluid intake frequency-volume chart Risk factors: alcohol, caffeine, diuretics 2 Frequency-volume chart Treatment of OAB     Eliminate underlying cause    UTI / bladder stone Reduce caffeine and alcohol use  e.g. coffee, tea, sodas, chocolate, medications, alcohol  Caffeine: acts as a local irritant and as a diuretic  Alcohol: a local irritant and powerful diuretic, ethanol relaxes the pelvic floor , sedation, delirium, and immobility Fluid management Eliminating underlying cause Bladder training Drug therapy Surgery 咖啡咽來源類型份量毫克咖啡釀造 5 oz 100100-164 即溶 5 oz 5050-75 脫除咖啡因 5 oz 2-4 1-分鐘釀造 5 oz 2020-34 3-分鐘釀造 5 oz 3939-50 5-分鐘釀造 5 oz 3939-50 冰茶 12 oz 6767-76 巧克力奶 5 oz 2-15 熱巧克力 5 oz 2-15 可樂 12 oz 46 健怡可樂 12 oz 46 蛋糕 1/16 of 9” 9” cake 14 雪糕 2/3 cup 5 牛奶巧克力 1 oz 1-15 深巧克力 1 oz 20 茶巧克力飲品汽水巧克力甜品巧克力糖果 3 Caffeine: Practice Implications Caffeine Intake: Evidence  Following caffeine intake, women with detrusor overactivity showed detrusor pressure with bladder filling, while continent women did not  Women with detrusor overactivity had higher caffeine intake than women without diagnosis, even after controlling for age and smoking    Reducing or restricting caffeine intake, especially in those with high daily intakes (> 5 drinks/day), may be helpful in reducing UI Besides coffee, tea, colas, other soda, some water products, and drugs contain caffeine Taper caffeine slowly to avoid migraine-type headache WHO, Second International Consultation on Incontinence, 2001 Fluid management      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 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 Bladder retraining Deferment technique 4 Behavioral Treatment Multi-component Programs  Pelvic floor muscle training (PFMT)  Home practice and exercise  Voiding  Urge schedules suppression strategies  Self-monitoring  Fluid (bladder diaries) and diet management  Encouragement Bladder Training Patient education Scheduled voiding regimen Urge control strategies Self-monitoring Reinforcement (motivation) Wilson PD et al. International Consultation on Incontinence. 2002;10c:572-624. Scheduling Regimen Efficacy of Bladder Training  Scheduled voiding  Initial voiding interval - one hour  Progressive lengthening of interval between voids  Occurs during waking hours only  Avoid voiding off schedule  Requires cognitive ability Incontinent episodes reduced by 57%   Increase voiding interval by 30 minutes per  Volume of urine loss reduced by 54% week if schedule well-tolerated Fantl, et.al., JAMA; 265(5):609-13, 1991. 5 Urgency Control Techniques       Mind games Distract to another task or activities Deep breathing exercise to relax bladder Self-statements (affirmations) Pelvic floor muscle contractions Timing Timed Voiding      Urge Suppression Strategy  Stop and stay still  Squeeze pelvic floor muscles  Relax rest of body  Concentrate on suppressing urge  Wait until the urge subsides  Walk to bathroom at normal pace No 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 Radical Prostatectomy OAB & LUTS relationship  Overactive bladder (OAB) contractions are present in about 60% of men with LUTS and correlate strongly with irritative voiding symptoms.  However, overactive bladder contractions resolve in most patients after surgery.  Only about 1/4 patients who have OAB before treatment retain the problem afterward.  Some degree of Stress Urinary Incontinence  Part of the urinary sphincter resected  Teach PFME as indicated, urine containing devices e.g. drip collector DIFFERENT DEGREE OF DAMAGE TO SPHINCTER CAN OCCUR McConnell et al., 1994. McConnell J, Barry M, Bruskewitz R, et al: Benign prostatic hyperplasia: Diagnosis and treatment. Clinical Practice Guidelines, Number 8. M. Rockville, MD, Agency for Health Care Policy and 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) 8% ~56% men report urinary incontinence 1 year following RRP Distressing condition Deeply disturbing Deter resumption of beneficial physical activities Deter the return to employment Negative impact on quality of life Behavioural interventions ( Pelvic floor muscle exercise) demonstrated 5858-81% improvement on urinary incontinence following prostatectomy, persisting up to 12 years Burgio et al 2006 prepre-op, prostatectomy, behavioural training significantly decreased:      time to continence severe / continual leakage at 66-month 5.9% vs 19.6% self reported urine loss w coughing 22.0% vs 51.1% self reported urine loss w sneeze 26.0% vs 48.9% self reported urine loss w getting up from lying down 14.0% vs 31.9% Burgio et al 1989 Meaglia et al 1990 7 Pelvic floor muscle exercise Filocam et al 2005, early pelvic floor rehabilitation treatment for post-prostatectomy incontinence  74% of patients performing PFME were continent at 3 months  30% of patients who did not perform PFME were continent Filocam MT, Marzi VL, Del Popolo G, Cecconi F, Marzocco M, Tosto A, Nicita G: Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Uorl 2005, 48:734-38. Patient urinary incontinence journey following RRP    Patient urinary incontinence journey following RRP Smither et al. 2007  203 consecutive patients underwent radical prostatectomy by a single surgeon between 03/98 & 08/03.  pelvic floor exercises (verbally and with hand-out) preoperatively and again at the time of catheter removal, 2 weeks post-operatively.  mean follow up was 118 weeks. 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 Patient urinary incontinence journey 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   Contraction of the puborectalis lifts the urethra, enabling the external urethra sphincter to contract against it to prevent urine flow (Myers, 1991; De Ridder, 2005). Contraction of the pelvic floor also triggers an inhibitory spinal cord reflex that reduces bladder sensitivity and suppresses involuntary bladder contractions (Stein et al., 1994; Bo and Berghmans, 2000). Pelvic floor muscle exercise How to Identify your Pelvic Floor Muscles  Sit or lie comfortably with muscles of your thighs, buttocks and abdomen relaxed.  Tighten the ring of muscle around the back passage as if you are trying to control diarrhoea or wind. Relax it.  While you are passing urine, trying to stop the flow midmid-stream, then restarting it.  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  Tighten and draw in strongly the muscles around the anus and the urethra all at once. Lift them up inside.  Try and hold this contraction strongly as you count to ten, then release slowly and relax for 10 seconds.  Repeat ("squeeze and lift") and relax. It is important to rest in in between each contraction.  Repeat this as many times as you are able up to a maximum of 10 squeezes. Make each tightening a strong, slow and controlled contraction.  Now do five to ten short, fast, but strong contractions, pulling up and immediately letting go.  Do this whole exercise routine 10 times every day.  You can do it in a variety of positions - lying, sitting, standing, walking.  While doing the exercises:   DO NOT hold your breath. DO NOT push down instead of squeezing and lifting up. Pelvic floor muscle exercise Make the Exercises a Daily Routine Tighten your pelvic floor muscles also while you are getting up from a chair, coughing or lifting  assist themselves in regaining control  Good results take time, takes several weeks to see improvement  When you have recovered control of your bladder, you should continue doing the at least once a day for life.  Other Tips to Help Your Pelvic Floor Avoid constipation and prevent any straining during a bowel movement.  Seek medical advice for hayhay-fever, asthma or bronchitis to reduce sneezing and coughing.  Keep your weight within the right range for your height and age.  Share the lifting of heavy loads.  9 Pelvic Muscle Assessment modified Oxford Scale Neuromuscular Electro-Stimulation  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 Neuromuscular Electro-Stimulation              On-demand pace makers Urinary retention Urethral obstruction Impaired cognitive function / Dementia Pelvic cancer 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 Use of Electrical Stimulation for Strengthening Pelvic Floor Muscles  Vaginal or anal surface electrodes  May help stress incontinence, although physiological reasons unclear  Possibly educates patients to contract muscles 10 Electrostimulation of the pelvic floor musculature    Transform fast twitch muscle fibers into slow twitch muscle fibers Recommendation:  20 weeks training (American college of Sports Medicine 1990) Almost no complications Recommendations  In patients with incomplete denervation of the pelvic floor muscle and the striated sphincter, electrostimulation via anal or vaginal plugs performed over months, may be an option to improve pelvic floor function, thus improve 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) Neuromuscular Electro-Stimulation  Failed as a result of wrong positioning of the electrodes, local fibrosis, and the natural plasticity of the nervous system Complications: infection (2%)  superficial wound dehiscence (10%)  erosion of the extension cable towards the skin (1%)  pain (10%)  lead problem (38%)  3rd International Consultation on Incontinence, 2005 Parameters of ES      Waveform Current intensity Ramping of impulses Pulse frequency On/Off timing Parameters of ES - - Aim to produce maximal painpain-free contraction perceptible by individual The intensity is increased according to one’ one’s tolerance 11 Parameters of ES   Lower ranges (10(10-15Hz) has a calming effect on the detrusor muscle →inhibited bladder contractions  used for those with urge UI; Higher ranges (50Hz)→ (50Hz)→optimum for urethral closure and builds strength  used for those with stress UI Parameters of ES  “On” On” and “Off” Off” timing - “On” On” time is the amount of time that the electrical current is delivered to the muscles “Off” Off” time is the amount of time when there is no electrical current to the muscle, allowing it to recover - Precaution of ES    Apply stimulation not more than 30mins→ 30mins→muscle fatigue Observe for any signs of skin and mucosal irritation prior to use Observe any compliant of discomfort during and after the procedure Pressure Biofeedback      Treatment of stress, urge and mixed incontinence A form of PFMs rehabilitation An electronic device made of an inflatable intravaginal or rectal probe Connected to a manometer Biofeedback is often used as an audiovisual instructional aid and method of evaluating progress 12 Pressure Biofeedback     Help to control external sphincter by measuring the actions of the PFMs Feedback information to the person The information is stored, processed and fed back to the person in the form of sound, light or images Position: lying, standing, sitting Advantages of Biofeedback   Contraindication of Pressure Biofeedback      Allergic to natural rubber latex Client’ Client’s anatomy that make proper probe insertion difficult or impossible Any infection of the bladder or vagina or Symptoms of infection such as itching, dysuria, dysuria, sores or fever Pregnant or ? pregnant A useful tool for teaching a correct pelvic muscle contraction Can increase motivation and adherence Precautions of Pressure Biofeedback     Examine any signs of skin and mucosal irritation prior to use Examine the product prior to use Examine any signs of deterioration such as tears, cuts or discoloration Examine any air leak of the latex balloon 13 Instructions for Pressure Probe     The probe should be cleaned before & after Equalize the air pressure in the probe before use Insert the tip of the syringe into the oneone-way valve on the end of the probe tubing Remove the syringe and replace the plunger Instructions for Pressure Biofeedback    Instructions for Pressure Biofeedback     Hold the plunger firmly in this position Attach the probe to the appropriate port of the equipment When the ‘work’ work’ light is on, ask the client to squeeze pelvic floor muscles The light will give client feedback that she/he controls the correct muscles Spread a light coating of lubricating gel Insert the lubricated probe into the vagina or anus Inflate the probe by positioning the front edge of the rubber tip of the plunger at the appropriate mark vaginal probe: 15cc anal probe: 5cc Instructions for Pressure Biofeedback    The force of the PFMs contractions is measured by the marking When the ‘rest’ light is ‘on’, ask client to relax the PFMs Client can adjust the PFE exercises pattern so that the exercises are performed correctly 14 Instructions for Pressure Biofeedback      Following use, remove the probe from the port and deflate the probe Check the client any discomfort during and after the procedure Observe any skin or mucosal irritation after removal of probe Wash the probe with mild soap and water to remove any surface debris, and disinfect with Cidex for clinic use Absorbent products  Do not use absorbent products instead of definitive interventions to decrease or eliminate urinary incontinence.  Early dependency on absorbent pads may be a deterrent to achieving continence, providing the wearer a false sense of security.  Chronic use of absorbent products may lead to inevitable acceptance of the incontinence condition, which removes the motivation to seek evaluation and treatment.  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 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) Non-latex self-adhesive inflatable 3rd International Consultation on Incontinence, 2005 Latex Detachable tip For retracted penis 15 External appliances: Condom catheter        60 SCI using condom catheter >50% positive urine culture In which 56% tissue invasion by bacteria (Newman & Price 1985) Incomplete emptying High RU Bladder overdistension Urine stasis inside condom catheter Urine leakage External appliances: Condom catheter Complications      If skin lesion Remove CC, resume IC / urethral catheter Till skin is dry & healed, to reapply CC Allergic dermatitis Remove CC, topical steroid (Harmon et al 1995) External appliances: Condom catheter        Penetrating / non-penetrating lesions Due to fastener or proximal hard roller ring Compressive effect (Nanninga & Rosen 1975) Chronic dermatitis Irritative or allergic reaction SCI patient w/ bil hydronephrosis due to condom catheter fasten strap Resolved when the strap is removed (Pidde &Little, 1994) External appliances : Condom catheter 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.  To prevent latex allergy, a silicone CC should be used and serological examination of latex-specific IGE is recommended in addition to patient history to better identify patients at risk.  To prevent compressive effects, choose proper size CC 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 skin care products continence penile cuff 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 Complications  Alteration of body image  Feeling of dependence  Pain & discomfort  Bacterial biofilm, UTI acute & chronic  Encrustation, blockage, bladder & renal stone  Infection: para-urethral abscess, urethritis, prostatitis, epididymo-orchitis, cystitis  Urethral trauma & bleeding, fistula, urethral stricture Two routes of urinary catheterisation Suprapubic Catheter-associated UTI (CAUTI) Indwelling transurethral catheter Complications  Catheter induced detrusor spasm, urine bypass, catheter expulsion  Urethral sphincter erosion  Bladder neck incompetence  Balloon deflation problem, problematic removal  Balloon self-deflation  Bladder carcinoma  100%-silicon catheter balloon cuffing  Anaphylaxis & allergy • 10-15 % of all hospitalised patients have indwelling urethral catheters Stamm, 1975 Fincke & Friedland, 1976 • ~ 40 % of all hospital-acquired infections occur in the urinary tract Stamm, 1975 19 Catheter-associated UTI Incidence    Single sterile catheterisation • Healthy outpatients • Hospitalised patients  Male  Female 0.5 – 1 %  Bacterial biofilms part bacterial matter and part crystals 5% 10 – 20 % Longer duration of catheterisation  5 % per day AUA Update Series 21:292, 2002 2 hrs primary adherence of bacteria on 100%Silicon Foley Bacterial Biofilm (18 hrs later) on 100%-Silicon Foley Bacterial biofilms Stickler, D., Ganderton, L., King. J., Nettleton, J., & Winters, C. (1993). Proteus mirabilis biofilms and the encrustation of urethral catheters. Urological Research, 21, 407– 407–411. Urethral erosion 2 months long term Foley 1 yr long term Foley 2 yr long term Foley 2 yr long term Foley 20 Urethral erosion Encrustation Encrusted blocked Foley catheter 2 yr long term Foley Encrusted blocked Suprapubic Stamey catheter Effect between different water rate on Encrustation 720cc/24 hr 2160cc/24 hr Catheter valve 4320cc/24 hr 21 Time to catheter blockage after 46 hr of operation in urine infected with Proteus mirabilis Encrustation   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 Catheter selection All silicone catheters are preferred  least irritation  bigger lumens (Burr et al 1993), because it has a thinner wall Small sized catheters and balloon are preferred  Fr 12 ~ 14 with a 5 ~ 10 mL balloon  increases patient comfort  decreases blockage to the periurethral glands  decreases the risk of urethral erosion Indwelling transurethral catheter Implications for practice 100%100%-silicon catheter is preferable Sterile materials & aseptic technique Smaller catheter & balloon Maintain closed drainage system Educate patients on catheter care Change siliconised latex catheters 1 – 2 weeks Routine catheter care Change 100%100%-silicon catheter 2 - 4 weeks Secure catheter properly Catheterize only when necessary 22 Indwelling transurethral catheter      Long-term use Urethral trauma, unacceptable (Andrews et al 1988) Urine bypass upon catheter spasm (Fenely 1983, Lindan et al 1987) Urine leakage due to blockage caused by encrustation Patulous & non-functioning urethra Reduced bladder capacity & compliance (Chancellor et al 1994) Intermittent catheterization   Purpose: regular complete emptying of the bladder and to resume normal bladder storage With intermittent catheterization:  no need to leave the catheter in the LUT all the time  avoiding complications of indwelling catheterization  prevent bladder overdistension in order to avoid complications and to improve urological conditions 23 Tiemann-tip or coude-tip catheter easy negotiating urethra for post TURP change or urethral false passage Intermittent catheterization      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     Used for the symptom when men experience an involuntary loss of urine immediately after they finish passing urine, usually after leaving the toilet (Abrams et al, 2002). It is neither stress dependent (due to exertion) nor due to bladder dysfunction (Wille et al, 2000) should be distinguished from terminal dribble, which occurs at the end of micturition (Shah, 1994). The condition can be a nuisance and cause embarrassment. Post-micturition dribble Aetiology  failure of the bulbocavernosus muscle (which circles the bulbar urethra) to contract by reflex action after micturition and to evacuate urine from this portion of the urethra (Feneley, 1986)  This reflex is known as the urethrocavernosus reflex (Shafik and El-Sibai, 2000).  Its failure may occur as a result of surgery, neurological conditions or weak pelvic floor muscles.  Urine remaining in the bulbar portion of the urethra will then dribble out on movement. 24 Treatment for Post-micturition dribble     Paterson et al (1997) conducted a single-blind randomised controlled trial comparing pelvic floor muscle exercises with bulbar urethral massage (urethral milking). 49 men (36-83 years) not undergone surgery on the bladder, urethra or prostate gland RCT: pelvic muscle exercise, urethral milking or counselling 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 postmicturition dribble. British Journal of Urology 1997; 79(6) pp 892-897. Treatment for Post-micturition dribble  Urethral milking: after urinating, to place his fingers behind the scrotum and gently massage the bulbar urethra in a forwards and upwards direction in order to ‘milk’ the remaining urine from the urethra  They found that men who practised pelvic floor exercises were almost twice as likely to have reduced urine loss than the urethral milking group and both these interventions were more effective than counselling alone. PATERSON J, PINNOCK CB, MARSHALL VR. Pelvic floor exercises as a treatment for postmicturition dribble. British Journal of Urology 1997; 79(6) pp 892-897. What is an artificial urinary sphincter (AUS) ? AUS is made up of three parts:  an inflatable cuff fits around urethra  at bladder neck or bulbous urethra  exert enough pressure on the urethra to allow bladder to hold urine  a control pump  implanted in scrotum / labia majora  Benefits of AUS  The largest single-institution series in children demonstrates:  a total continence rate of 86%  a revision rate of 25% 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)  about the size of a pingping-pong ball  placed in body behind pubic bone 25 AUS device durability AUS is implanted all inside the body   5-year survival rate is 67% ~ 90%  10-year survival rate is 66%     Implanted in an operating theatre Under spinal or general anesthesia Two small incisions on groin and perineum No external appliances It will not change the body looks because the AUS is all inside the body Groin incision Venn, S.N., Greenwall, T.J., & Mundy, A.R. (2000). The long-term outcome of artificial urinary 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, 12061208. 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. Perineal incision Pre-operative education Teach patient how to:  identify different parts of a sample AUS and their function  cycle a sample AUS  intermittent self catheterization if concomitant overflow incontinence is present  deactivate the cuff if urethral catheterization or instrumentation is necessary DOs and DON’Ts before implant surgery  If allergy to iodine, make sure to tell the doctor  iodine is often used for skin disinfection  Don’t shave groin or perineum 2 weeks before the surgery because skin nicks may result in higher chance of getting infection which may result in removal of infected AUS  The pubic hair should only be shaved in operating theatre just prior to the implant surgery Elliott, D.S., & Barrett, D.M. (1998). The Mayo Clinic long term analysis of the functional durability of the AMS 800 Artificial Urinary Sphincter: A review of 323 cases. cases. journal of Urology, 259(4), 12061206-1208. 26 DOs and DON’Ts before implant surgery  Cleanse bowel the night before surgery by laxatives like fleet enema  Disinfect body esp. the genital area with an antibacterial soap like Betadine bath  For females, vaginal douching will be used in the morning of the surgery  These will help lower the chance of getting an infection What will be expected after the surgery?  May have some soreness in perineum  In some patients a chronic pain associated with device have been reported  A urinary catheter will be in place and drains urine from bladder  Helps healing from operation  Will be removed before discharge home Elliott, D.S., & Barrett, D.M. (1998). The Mayo Clinic long term analysis of the functional durability of the AMS 800 Artificial Urinary Sphincter: A review of 323 cases. cases. journal of Urology, 259(4), 12061206-1208. 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 the urethra  Gently pull down AUS pump once each day to prevent 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 the operated site is healed  Avoids prolonged sitting, it may put unnecessary 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   Instruct patient not to manipulate the AUS for 6 weeks until activation is permitted Avoid constipation to prevent straining, more roughage and water intake, stool softener may be prescribed  27 When will the AUS be started working ? When will the AUS be started working ?   The AUS will not be activated (inflated) until operated site healed in 6-8 weeks after the operation  Need to keep using incontinence pads during this period On the 6-8 weeks follow-up visit  the AUS will be activated (inflated) if healed  teach patient to  identify different parts of AUS and their function  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    An AUS does make urine control better, but it may not stop all urine leakage esp. on strenuous exercise or severe coughs Special things to do following AUS  Wear a Medic-Alert bracelet alerts AUS implanted  Avoid horseback riding and bicycle riding, which may put unnecessary pressure a pump  Avoid trauma or injury to the pelvis, perineum or lower abdomen, such as impact injuries associated with sports Empty the bladder before sports or strenuous exercise to avoid or reduce GSI  AUS is not a lifetime implant this damage may result in the malfunction of the device and may necessitate surgical correction including 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  AUS should be deactivated before any urethral catheterization or instrumentation otherwise an erosion may result  To deactivate the device  squeeze the pump several times to empty the fluid from the cuff with a slight indentation appearance  push the button to lock the cuff open  it is important to leave a slight indentation in the pump bulb to ensure that there is enough fluid in the pump for reactivation Special things to do following AUS  Good practice in teaching patient’s spouse or significant other to know how to operate the AUS if it became necessary  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 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. 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. 11871194). Philadelphia: Saunders. Special things to do following AUS  Activation is accomplished by a firm and sustained squeeze of the pump, allowing the deactivation pin to "pop" into the activated position.  If inadvertently locks the button when the cuff is closed, urinary retention occurs  Conversely, if the button is locked when the cuff is open, persistent incontinence occurs  Patients should be instructed on the locking mechanism to understand and be able to respond to these problems Special things to do following AUS As with any prosthetic implantation, patients should take prophylactic antibiotics prior to dental or surgical procedures to avoid hematogenous seeding 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. 11871194). Philadelphia: Saunders. 29 Thank you 30