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Geriatric Medicine

__ million adults suffer with a form of urinary incontinence 12
4 consequences of urinary incontinence psychological, physical, social, economic
__ innervation maintains tone in the bladder floor somatic
6 requirements for continence bladder must be able to store urine, must effectively empty, pt ability to use toilet, adequate cognitive ability, motivation, absence of environmental barriers to toilet
posterior urethral angle (90-100 degrees) is reduced secondary to birth, anterior vaginal surgery, or prolapse of urogenital structures, in: pelvic prolapse (may cause incontinence)
reduction of what hormone may cause urinary incontinence in women estrogen
neurological causes of urinary incontinence suprasacral lesions, sacral spinal lesions, UMN lesions, dementia
anatomical changes of GU tract associated with aging bladder capacity reduced (by 40% in 90yo), residual urine increases, decreased bladder outlet/urethral resistance, increased laxity of pelvic structures secondary to decreased estrogen, increased size of prostate
does normal aging cause incontinence? No
reversible causes of urinary incontinence (DIAPERS) Delerium, infection, atrophic urethritis/vaginitis, pharmaceuticals, psychological, excessive urine output, restricted mobility, stool impaction
6 meds that may be associated with urinary incontinence diuretics, sedatives/antidepressants, narcotics, antihistamines, calcium channel blockers
4 categories of urinary incontinence urge (most common), stress, , functional, overflow (least common)
Urethral incompetence (intra-abdominal pressure > urethral pressure) stress incontinence
4 causes of stress incontinence weak pelvic muscle, internal organ prolapse, urethral / bladder neck hypermobility (test pos if >30 degree rotation), intrinsic sphincter deficiency
3 symptoms of stress incontinence Loss of small amount of urine with cough or sneeze, laughing or changing of position. No leakage when supine. Sensation of pelvic heaviness
6 treatments for stress incontinence topical estrogens (atrophic vaginitis), phenylpropanolamine (increased urethral resistance), kegel exercises, biofeedback, wt loss if obese, surgical interventions (sling procedure, anterior vaginal repair, pessary)
Detrusor muscle hyperactivity (assoc with hyperreflexia or sphincter dysfunction) = urge incontinence
4 symptoms of urge incontinence the need to void comes too quickly to reach the toilet. loss of large amount of urine. frequent voiding. loss of urine with the sound of water running or waiting to use the toilet
4 treatments of urge incontinence Restrict fluids in PM, meds rather than surgery, bladder relaxants (antispasmodics, anticholinergics). Antibiotics/antiseptic meds
incontinence due to chronic urinary retention +/- outflow obstruction (failure to empty bladder) = overflow incontinence
4 causes of overflow incontinence anatomical obstruction (enlarged prostate, urethral strictures, cystocele, stool obstruction). Contractile bladder secondary to DM. Neurogenic bladder secondary to spinal cord injury or MS. Anticholinergic meds
4 symptoms of overflow incontinence report of incomplete emptying of bladder. dribbling of urine. painful abdomen. unaware of urine loss.
treatment for overflow incontinence Alpha blockers/reductase inhibitors. Prostate resection. Balloon dilation of urethra. Crede maneuver. Scheduled toileting. Suprapubic cath or intermittent caths (keep bladder amount <400cc)
Due to factors outside urinary tract (cognitive or physical impairment or environmental barriers) = functional incontinence
treatment of functional incontinence Reschedule meds, decrease use of hypnotics/EtOH, avoid anticholinergics. Easy access to toilet, easy to remove clothing. Scheduled/prompt toileting.
4 indications for indwelling catheter Retention causing symptomatic infxn; renal dysfunction; persistent overflow incontinence; comfort care for terminally ill patients; ST for pressure ulcers or skin wounds; inability to adequately turn/change pt
3 risks/problems w/ urinary catheters May cause chronic bacteriuria, bladder stones, bladder cancers. Iatrogenic hypospadias. Overdistention of the bladder
Incontinence diagnostic studies UA/UCC. Voiding cystogram. PVR (if >150mL in male, get renal US to r/o hydronephrosis)
Antispasmodic meds oxybutynin or tolteridine (antimuscarinic agents)
Detrusor instability tx bladder training & Kegels
Overflow incontinence (obstruction) med bethanechol
Overflow due to BPH: meds prazosin, terazosin, finasteride
Incontinence: DRIP drugs/delirium; restricted mobility, retention; infxn/inflam/impaction; polyuria
Incontinence: PE distended bladder, lg prostate, uterine prolapse, cystocele, rectocele, mass/impaction; neuro: CVA, spcord dz, cog impairment
urge incontinence: causes usu invol detrusor activity, poss rel to CVA, dementia, PD, spcord injury
incontinence dx testing ua, PVR (postvoid residual)(usu via cath) >200 mL; renal labs
Created by: Adam Barnard Adam Barnard