URINARY ELIMINATION DISORDERS

URINARY ELIMINATION DISORDERS

·

1.Adult Bedwetting (Enuresis)

Nocturnal enuresis or bedwetting is the involuntary release of
urine during sleep. Bedwetting can be a symptom of bladder
control problems like incontinence or overactive bladder or more
severe structural issues, like an enlarged prostate or bladder
cancer.
 CAUSES OF ENURESIS
HORMONAL CAUSES
The body produces an antidiuretic hormone at night called ADH,
which slows the kidney's production of urine while you sleep. In
people with enuresis, this hormone is not produced in significant
enough quantities to slow the production of urine, which often
leads to bedwetting. This can be a symptom of both Type I and
Type II Diabetes.
NEUROLOGICAL CAUSES
People who suffer enuresis can also have a smaller functional bladder
capacity, meaning the amount of urine they can hold before the bladder
sends a signal to the brain that it's full is smaller than average. Coupled
with overactive bladder or bladder instability, this can lead to bedwetting.

STRUCTURAL CAUSES
Enuresis can also be a symptom of problems in the urethra, prostate or
pelvis, including urinary tract infection, urinary tract stones, enlarged
prostate, prostate cancer and bladder cancer.
MEDICATION AND DIET
Bedwetting can be a side effect of certain insomnia
medications and drugs taken for psychiatric purposes like
Thioridazine, Clozapine and Risperidone. Bladder irritants
such as alcohol and caffeine can also contribute to bladder
instability and act as diuretics to increase the production of
urine.
TREATMENT:

BEHAVIORAL TREATMENT

· Monitoring Fluid Intake: The first step towards preventing bedwetting is

limiting the intake of fluids in the afternoon and evening, which creates a
decrease in the amount of urine produced at night. Reduce or avoid caffeine
and alcohol intake, which act as diuretics and increase the likelihood of
accidents.

· Bladder Volume Control: This technique attempts to increase bladder

capacity in those with smaller functional bladders. Training involves drinking
large amounts of fluid during the day and refraining from urinating for as long as
possible to increase functional bladder capacity.
· Bedwetting Alarm System: Wet-detection alarms can be used in
underwear or on the bed itself to vibrate or give off sound when
bedwetting occurs. This wakes you and allows you to stop the flow of
urine and finish in the restroom. Eventually, the body conditions itself to
wake before the urge to urinate gets too strong.
· Waking: Setting a random alarm each night to get up and urinate may
be helpful in preventing bedwetting. Avoid setting an alarm at the same
time each evening in case your body becomes accustomed to emptying
at a set time each night.
MEDICATION
Medication can be an effective treatment for enuresis, but only for as long as it is taken. Medication
only deals with the symptoms rather than the underlying causes of bedwetting, so it's recommended
that you try behavioral treatments as well. The most common medications mimic the hormone ADH,
slowing production of urine in the kidneys and lessening the instances of bedwetting.

IMIPRAMINE (antidepressant)
This type of drug is thought to work one of several ways:
● by changing the child's sleep and wakening pattern
● by affecting the time a child can hold urine in the bladder or
● by reducing the amount of urine produced.

Desmopressin Acetate --DDAVP is a man-made copy of a normal body chemical that controls urine production. The therapeutic
benefit of DDAVP might be due to a reduction in the overnight production of urine or possibly to an effect on arousal

Anticholinergic drugs, such as oxybutynin (Ditropan) or hyosyamine (Levsinex), reduce or stop bladder contractions and
increase bladder capacity. Anticholinergics may be helpful for children who have daytime wetting due to bladder contractions
and/or small bladder capacity
SURGERY
Surgery should only be considered once other non-invasive options have been exhausted.
Talk to your health care professional about other options before choosing surgery.

· Sacral Nerve Stimulation: Sacral nerve roots are stimulated, causing decreased
activity in the bladder muscles, which helps the muscle to relax and not contract constantly.
This form of surgery is recommended if you also have moderate to severe urge
incontinence.

· Clam Cytoplasty: The bladder is cut open and a patch of intestine added to increase
bladder capacity and reduce bladder instability.

· Detrusor Myectomy: A portion of the exterior muscle surrounding the bladder is

removed, strengthening bladder contractions and reducing the number
2. Urinary incontinence — the loss of bladder control — is a
common and often embarrassing problem. The severity ranges from
occasionally leaking urine when you cough or sneeze to having an urge to
urinate that's so sudden and strong you don't get to a toilet in time.
· Though it occurs more often as people get older, urinary incontinence
isn't an inevitable consequence of aging.

Symptoms:
Many people experience occasional, minor leaks of urine. Others may lose
small to moderate amounts of urine more frequently.
Types of urinary incontinence include:

· Stress incontinence. Urine leaks when you exert pressure on your bladder
by coughing, sneezing, laughing, exercising or lifting something heavy.

· Urge incontinence. You have a sudden, intense urge to urinate followed by

an involuntary loss of urine. You may need to urinate often, including
throughout the night. Urge incontinence may be caused by a minor condition,
such as infection, or a more-severe condition such as a neurologic disorder or
diabetes.
· Overflow incontinence. You experience frequent or constant
dribbling of urine due to a bladder that doesn't empty completely.

· Functional incontinence. A physical or mental impairment

keeps you from making it to the toilet in time. For example, if you
have severe arthritis, you may not be able to unbutton your pants
quickly enough.

· Mixed incontinence. You experience more than one type of

urinary incontinence.
Urinary incontinence isn't a disease, it's a symptom. It can be caused

by everyday habits, underlying medical conditions or physical

problems. A thorough evaluation by your doctor can help determine
what's behind your incontinence.
Temporary urinary incontinence
Certain drinks, foods and medications may act as diuretics —
stimulating your bladder and increasing your volume of urine. They
include:

· Alcohol

· Caffeine

· Carbonated drinks and sparkling water

· Artificial sweeteners

· Chocolate

· Chili peppers

· Foods that are high in spice, sugar or acid, especially citrus fruits

· Heart and blood pressure medications, sedatives, and muscle relaxants

· Large doses of vitamin C

Urinary incontinence may also be caused by an easily treatable medical condition, such
as:

· Urinary tract infection. Infections can irritate your bladder, causing you to have strong
urges to urinate, and sometimes incontinence.

· Constipation. The rectum is located near the bladder and shares many of the same nerves.
Hard, compacted stool in your rectum causes these nerves to be overactive and increase
urinary freque

Urinary incontinence can also be a persistent condition caused by underlying physical problems
or changes, including:

· Pregnancy. Hormonal changes and the increased weight of the fetus can lead to stress incontinence.
· Childbirth. Vaginal delivery can weaken muscles needed for bladder
control and also damage bladder nerves and supportive tissue, leading to a
dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum
or small intestine can get pushed down from the usual position and
protrude into the vagina. Such protrusions can be associated with
incontinence.

· Changes with age. Aging of the bladder muscle can decrease the
bladder's capacity to store urine. Also, involuntary bladder contractions
become more frequent as you get older.
· Menopause. After menopause women produce less estrogen, a hormone that
helps keep the lining of the bladder and urethra healthy. Deterioration of these
tissues can aggravate incontinence.

· Hysterectomy. In women, the bladder and uterus are supported by many of the
same muscles and ligaments. Any surgery that involves a woman's reproductive
system, including removal of the uterus, may damage the supporting pelvic floor
muscles, which can lead to incontinence.

· Enlarged prostate. Especially in older men, incontinence often stems from

enlargement of the prostate gland, a condition known as benign prostatic
hyperplasia.
· Prostate cancer. In men, stress incontinence or urge incontinence can be
associated with untreated prostate cancer. But more often, incontinence is a side
effect of treatments for prostate cancer.

· Obstruction. A tumor anywhere along your urinary tract can block the normal flow
of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses
that form in the bladder — sometimes cause urine leakage.

· Neurological disorders. Multiple sclerosis, Parkinson's disease, a stroke, a brain

tumor or a spinal injury can interfere with nerve signals involved in bladder control,
causing urinary incontinence.
· Diagnostic tests:
Urinalysis. A sample of your urine is checked for signs of infection, traces of blood or other
abnormalities.

· Bladder diary. For several days you record how much you drink, when you urinate, the amount of
urine you produce, whether you had an urge to urinate and the number of incontinence episodes.

· Post-void residual measurement. You're asked to urinate (void) into a container that measures
urine output. Then your doctor checks the amount of leftover urine in your bladder using a catheter or
ultrasound test. A large amount of leftover urine in your bladder may mean that you have an obstruction
in your urinary tract or a problem with your bladder nerves or muscles.
Risk factors:
Factors that increase your risk of developing urinary incontinence include:

· Gender. Women are more likely to have stress incontinence. Pregnancy,

childbirth, menopause and normal female anatomy account for this difference.
However, men with prostate gland problems are at increased risk of urge and
overflow incontinence.

· Age. As you get older, the muscles in your bladder and urethra lose some of
their strength. Changes with age reduce how much your bladder can hold and
increase the chances of involuntary urine release.
· Being overweight. Extra weight increases pressure on your bladder and
surrounding muscles, which weakens them and allows urine to leak out when
you cough or sneeze.

· Smoking. Tobacco use may increase your risk of urinary incontinence.

· Family history. If a close family member has urinary incontinence, especially

urge incontinence, your risk of developing the condition is higher.

· Other diseases. Neurological disease or diabetes may increase your risk of

incontinence.
Complications:
Complications of chronic urinary incontinence include:

· Skin problems. Rashes, skin infections and sores can develop from
constantly wet skin.

· Urinary tract infections. Incontinence increases your risk of repeated

urinary tract infections.

· Impacts on your personal life. Urinary incontinence can affect your social,
work and personal relationships.
NEUROGENIC DISORDER
 AMYOTROPHIC LATERAL SCLEROSIS
Amyotrophic lateral sclerosis (a-my-o-TROE-fik LAT-ur-ul skluh-ROE-sis), or ALS, is a progressive nervous system
disease that affects nerve cells in the brain and spinal cord, causing loss of muscle control.

ALS is often called Lou Gehrig's disease, after the baseball player who was diagnosed with it. Doctors usually don't
know why ALS occurs. Some cases are inherited.

ALS often begins with muscle twitching and weakness in a limb, or slurred speech. Eventually, ALS affects control of
the muscles needed to move, speak, eat and breathe. There is no cure for this fatal disease, and the treatment is
symptomatic.

The cause of the disease may be related to an excess of glutamate, a chemical responsible for relaying messages
between the motor neurons. As the disease progresses, muscle weakness and atrophy develop until flaccid
quadriplegia develops. Eventually the respiratory muscles become affected, leading to respiratory compromise,
pneumonia and death.
Causes

ALS affects the nerve cells that control voluntary muscle movements such as walking and talking
(motor neurons). ALS causes the motor neurons to gradually deteriorate, and then die. Motor
neurons extend from the brain to the spinal cord to muscles throughout the body. When motor
neurons are damaged, they stop sending messages to the muscles, so the muscles can't
function.

ALS is inherited in 5% to 10% of people. For the rest, the cause isn't known.

Researchers continue to study possible causes of ALS. Most the

Symptoms

Signs and symptoms of ALS vary greatly from person to person, depending on which neurons
are affected. Signs and symptoms might include:

● Difficulty walking or doing normal daily activities

● Tripping and falling
● Weakness in your leg, feet or ankles
● Hand weakness or clumsiness
● Slurred speech or trouble swallowing
● Muscle cramps and twitching in your arms, shoulders and tongue
● Inappropriate crying, laughing or yawning
● Cognitive and behavioral changes
Early CLinical Manifestations of Amyotrophic Lateral Sclerosis

1. Tongue Atrophy
2. Weaknes of the arms and hands
3. Beginning muscle atrophy of the arms
4. Fasciculations ( Twitching ) of the face
5. Nasa quality of speech
6. Dysarrthria ( slurred speech )
7. Dysphagia ( difficulty swallowing )
8. Fatigue while talking
ALS often starts in the hands, feet or limbs, and then spreads to other
parts of your body. As the disease advances and nerve cells are
destroyed, your muscles get weaker. This eventually affects chewing,
swallowing, speaking and breathing.

There's generally no pain in the early stages of ALS, and pain is

uncommon in the later stages. ALS doesn't usually affect your bladder
control or your senses.
Risk factors

Established risk factors for ALS include:

● Heredity. Five to 10 percent of the people with ALS inherited it (familial ALS). In most
people with familial ALS, their children have a 50-50 chance of developing the disease.
● Age. ALS risk increases with age, and is most common between the ages of 40 and
the mid-60s.
● Sex. Before the age of 65, slightly more men than women develop ALS. This sex
difference disappears after age 70.
● Genetics. Some studies examining the entire human genome found many similarities
in the genetic variations of people with familial ALS and some people with noninherited
ALS. These genetic variations might make people more susceptible to ALS.
Environmental factors, such as the following, might trigger ALS.

Smoking. Smoking is the only likely environmental risk factor for ALS. The risk seems
to be greatest for women, particularly after menopause.

Environmental toxin exposure. Some evidence suggests that exposure to lead or

other substances in the workplace or at home might be linked to ALS. Much study has
been done, but no single agent or chemical has been consistently associated with
ALS.

Military service. Studies indicate that people who have served in the military are at
higher risk of ALS. It's unclear what about military service might trigger the
development of ALS. It might include exposure to certain metals or chemicals,
traumatic injuries, viral infections, and intense exertion
Complications

As the disease progresses, ALS causes complications, such as:

Breathing problems

Over time, ALS paralyzes the muscles you use to breathe. You might need a device to help you breathe at night,
similar to what someone with sleep apnea might wear. For example, you may be given continuous positive airway
pressure (CPAP) or bilevel positive airway pressure (BiPAP) to assist with your breathing at night.

Some people with advanced ALS choose to have a tracheostomy — a surgically created hole at the front of the neck
leading to the windpipe (trachea) — for full-time use of a respirator that inflates and deflates their lungs.

The most common cause of death for people with ALS is respiratory failure. On average, death occurs within three to
five years after symptoms begin. However, some people with ALS live 10 or more years.
Speaking problems

Most people with ALS develop trouble speaking. This usually starts as occasional, mild slurring of words, but
becomes more severe. Speech eventually becomes difficult for others to understand, and people with ALS
often rely on other communication technologies to communicate.

Eating problems

People with ALS can develop malnutrition and dehydration from damage to the muscles that control
swallowing. They are also at higher risk of getting food, liquids or saliva into the lungs, which can cause
pneumonia. A feeding tube can reduce these risks and ensure proper hydration and nutrition.

Dementia

Some people with ALS have problems with memory and decision-making, and some are eventually diagnosed
with a form of dementia called frontotemporal dementia.
Diagnosis

Amyotrophic lateral sclerosis is difficult to diagnose early because it can mimic other neurological
diseases. Tests to rule out other conditions might include:

Electromyogram (EMG). Your doctor inserts a needle electrode through your skin into
various muscles. The test evaluates the electrical activity of your muscles when they contract
and when they're at rest.
Abnormalities in muscles seen in an EMG can help doctors diagnose or rule out ALS. An
EMG can also help guide your exercise therapy.

Nerve conduction study. This study measures your nerves' ability to send impulses to
muscles in different areas of your body. This test can determine if you have nerve damage or
certain muscle or nerve diseases.
MRI. Using radio waves and a powerful magnetic field, an MRI produces detailed images of
your brain and spinal cord. An MRI can reveal spinal cord tumors, herniated disks in your
neck or other conditions that might be causing your symptoms.

Blood and urine tests. Analyzing samples of your blood and urine in the laboratory might
help your doctor eliminate other possible causes of your signs and symptoms.

Spinal tap (lumbar puncture). This involves removing a sample of your spinal fluid for
laboratory testing using a small needle inserted between two vertebrae in your lower back.

Muscle biopsy. If your doctor believes you may have a muscle disease rather than ALS,
you might undergo a muscle biopsy. While you're under local anesthesia, a small portion of
your muscle is removed and sent to a lab for analysis
Medications

The Food and Drug Administration has approved two drugs for treating ALS:

Riluzole (Rilutek). Taken orally, this drug has been shown to increase life
expectancy by three to six months. It can cause side effects such as dizziness,
gastrointestinal conditions and liver function changes. Your doctor will monitor your
blood counts and liver functions while you're on the drug.

Edaravone (Radicava). This drug, given by intravenous infusion, has been shown to
reduce the decline in daily functioning. Its effect on life span isn't yet known. Side
effects can include bruising, headache and shortness of breath. This medication is
given daily for two weeks a month.
doctor might also prescribe medications to provide relief from other symptoms, including:

Muscle cramps and spasms

Constipation

Fatigue

Excessive saliva and phlegm

Pain

Depression

Sleep problems

Uncontrolled outbursts of laughing or crying

INTERVENTIONS:

1. Care is directed toward the treatment of symptoms

2. Monitor respiratory status
3. Provide respiratory treatments
4. Prepare to initiate respiratory support
5. Assess for complications of immobility
6. Provide the client and family with support
Therapies

Breathing care. You'll eventually have more difficulty breathing as your muscles
weaken. Doctors might test your breathing regularly and provide you with devices to
assist your breathing at night.
You can choose mechanical ventilation to help you breathe. Doctors insert a tube in a
surgically created hole at the front of your neck leading to your windpipe
(tracheostomy that connects to a respirator.

Physical therapy. A physical therapist can address pain, walking, mobility, bracing
and equipment needs that help you stay independent. Practicing low-impact exercises
can help maintain your cardiovascular fitness, muscle strength and range of motion
for as long as possible.
Regular exercise can also help improve your sense of well-being. Appropriate
stretching can help prevent pain and help your muscles function at their best.
A physical therapist can also help you adjust to a brace, walker or wheelchair and
might suggest devices such as ramps that make it easier for you to get around.

Occupational therapy. An occupational therapist can help you find ways to

remain independent despite hand and arm weakness. Adaptive equipment can
help you perform activities such as dressing, grooming, eating and bathing.
An occupational therapist can also help you modify your home to allow
accessibility if you have trouble walking safely.
Speech therapy. A speech therapist can teach you adaptive techniques to make your speech
more understandable. Speech therapists can also help you explore other methods of
communication, such as an alphabet board or pen and paper.
Ask your therapist about the possibility of borrowing or renting devices such as tablet computers
with text-to-speech applications or computer-based equipment with synthesized speech that can
help you communicate.

Nutritional support. Your team will work with you and your family members to ensure you're
eating foods that are easier to swallow and meet your nutritional needs. You might eventually
need a feeding tube.

Psychological and social support. Your team might include a social worker to help with
financial issues, insurance, and getting equipment and paying for devices you need.
Psychologists, social workers and others may provide emotional support for you and your family.
References:

1. Medical-Surgical Nursing ( Vol. 1 ) by: Ignatavicius and Workman 6th Ed. 2010

pp : 171-211

2. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing: 14th Ed. Vol.1

By: Janice L. Hinkle and Kerry H. Cheever, 2018 . pp- 283-286,

259-264,

3. Saunders Comprehensive Review for NCLEX-RN exam. 3rd Ed. by Linda Anne Silvestri. 2002, pp. 83-107
4. Slideshare from Internet-- fluid and electrolyte and acid base balance/Imbalance
5. Internet sources : Fluid and Electrolytes and fluid and acid- base balance and imbalance
6. Amyotrophic lateral sclerosis (ALS) - Diagnosis and treatment ... www.mayoclinic.org ›
7.