1. Urinary Incontinence 1 / 18 Fletcher T. Penney, MD Medical University of South Carolina Department of Medicine

2. Outline 2 / 18 Introduction Outpatient Inpatient

3. Learning Objectives 3 / 18 Characteristics of primary types of incontinence Initial workup/management of incontinence Importance of removing foley catheters Valid indications for inpatient foley catheters

4. Outline 4 / 18 Introduction Outpatient Inpatient

5. Patient Screening Medical Asst. Ask: Circle Yes or No YesNo “Do you ever leak urine/water when you don't want to? “Does it bother you enough to discuss various options?” YesYesNo URINARY INCONTINENCE 5 / 18

6. Patient Screening 6 / 18 RESIDENT Answer: Circle Yes or No Is urine leakage Acute or worsening?YesNo Chronic?YesNo Type of Incontinence (answer all that apply) Stress?YesNo Overflow?YesNo Urge?YesNo

7. Types of Urinary Incontinence 7 / 18 Urge Stress Overflow Mixed

8. Urge Incontinence 8 / 18 Loss of urine with sensation of urgency Low post-void residual Detrusor overactivity Anticholinergic therapy

9. Stress Incontinence 9 / 18 Loss of urine with exertion, sneeze, cough Low post-void residual Kegel exercises, surgery

10. Overflow Incontinence 10 / 18 Loss of urine in setting of bladder outlet obstruction High post-void residual BPH Intermittent catheterization, treat cause

11. Mixed Incontinence 11 / 18 Some episodes of incontinence are consistent with urge incontinence, and some with stress incontinence Common in older women need to determine underlying cause(s)

12. Outline 12 / 18 Introduction Outpatient Inpatient

13. MUSC - Early Catheter Discontinuation Protocol 13 / 18 Nurse-Driven Protocol Encourage early removal of foley catheters when appropriate Should be assessed every 24 hrs by nursing If no justification for a catheter exists, it can be removed by the nurse Physician should be contacted if there is any doubt

14. Valid Indications for Foley Catheters 14 / 18 urinary tract obstruction neurogenic bladder urologic study or surgery on contiguous structures sacral pressure ulcer (stage III or IV) with incontinence end-of-life care prolonged surgery with general or spinal anesthesia trauma fluid challenge in acute renal insufficiency intake and output monitoring AND critically ill/unable to collect urine lumbar epidural in place continuous bladder irrigation acute renal failure with anuria or oliguria

15. What Isn’t a Valid Indication? 15 / 18 Nonobstructive renal insufficiency Transferred from ICU Patient request Confusion Incontinence

16. Risks of Foley Catheters 16 / 18 3–10% daily rate of bacteriuria 10–25% of these patients will develop symptoms of UTI 3% will develop bacteremia 42% of patients report it was uncomfortable 48% said it was painful 61% said it restricted their ADLs Saint, S., Lipsky, B. A., & Goold, S. D. (2002). Indwelling urinary catheters: a one-point restraint? Annals of internal medicine, 137(2), 125–127.

17. Other Key Points 17 / 18 Studies show that physicians are frequently unaware whether their patients have a foley catheter in place High risks for unnecessary catheters include admission from the ED and transfer from the ICU to the floor.

18. Foley Tracking 18 / 18 We’re working on a workflow to notify Gen Med team attendings when their patients have foley catheters