Incontinence when the bladder is underactive

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OWM often addresses overactive bladder (OAB). After a few moments on Twitter updating whom we follow, I came across an organization that deals with just the opposite — ie, underactive bladder — where patients lose bladder control because they cannot pass urine. We have touched on this in the past, but I felt it was worth revisiting.

Underactive bladder (like some forms of overactive bladder) may be due to a condition called neurogenic bladder, where the nerves that control the holding or release of urine do not function properly. The messages that make the brain aware of a full bladder and that it is time to urinate are disrupted, so the bladder continues to fill but the person is unable to pass urine. Urine pressure in the bladder overcomes the sphincter muscle's ability to hold it, and urine leaks out.

This condition may occur in men and women and may be attributed to injury, diseases that affect the nervous system (eg, polio, syphilis, multiple sclerosis), diabetes, acute infections, genetic nerve problems, or heavy metal poisoning. Persons with neurogenic bladder can experience urine leakage or retention, damage to the tiny blood vessels in the kidney, and bladder or ureter infection.

Patients with the condition may need to use catheterization in order to drain the bladder — ie, a thin tube is inserted through the urethra and into the bladder. Clean intermittent catheterization (CIC) is an on-demand approach. An alternative is an indwelling Foley catheter placed in the bladder for extended periods. When the patient’s bladder and sphincter muscle do not work in tandem, the problem can be addressed surgically. Urinary diversion and bladder augmentation can divert the urine or enlarge the bladder to help protect the kidneys and keep patients continent.

Lesson: incontinence can just as likely be caused by not being able to go as it is by going too much.

Adapted from a Columbia University Medical Center posting

Visual validation

« Show me some skin… with care

Visual validation

June 5, 2013 by ostomywoundmanagement | Edit

I’m going to make this personal. I just returned from my annual check-up with one of my (increasing) stable of physicians. I have been a patient of Dr. B’s for 39 years — through three “successful” pregnancies, several breast scares, and a hysterectomy. Obviously, not all fun times, but overall positive outcomes. As many doctors as I’ve had to see through the years, he remains my favorite. Why? Because he validates my concerns and celebrates my health.

Today’s visit started by his smiling at me and saying with genuine admiration, You REALLY look good. Do you know nice that is? To look eye-to-eye at a health professional who isn’t buried in drop-down files on the EMR or going through the motions with a foot out the exam room door? Who I’m sure is assessing my health status, not just tossing compliments because by meeting my gaze, this doctor also has been known to see through my upbeat (or not so much) demeanor and ask what’s up.

I know as a journal OWM repeatedly beseeches clinicians to treat the whole person, not just the hole in the person, and to avoid minimizing patient concerns. Just know that this is a mental as well as a physical health issue. Please, notice us patients. We are far greater than the sum of our imperfect parts.

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Does diabetes preclude participation?

There's lots of buzz right now about the Patriots dropping a player because he has diabetes. The litigious among us — and what seems to be the common knee-jerk reaction to the announcement — have their noses in the air, sniffing out a potential lawsuit for discrimination. Now it's diabetes. What could be next? One of the conversation threads notes that the player's condition can be kept in check with exercise and weight loss. The former is no problem. But football players need their bulk. A conundrum is born.

I'm curious for those in our circle to weigh in (pun intended). Is dropping Love (the player with type 2 diabetes) grossly unfair or in everyone's best interests? Could his sugar be sufficiently regulated with diet and meds? Are the comorbidities of diabetes (neuropathy et al) enough of a concern in a younger person? Would the wounds he is certain to endure on the gridiron become a challenge to heal?

The football leagues have certain relevant regulations. But what do the health experts say?

Leave eschar alone

Remember how as a child your mother told you “not to pick”? As a mom myself, I think it had more to do with the fingernails-on-a-chalkboard reaction to that repetitive action and the subsequent blood than the notion that the scar was protecting the boo-boo from further damage and infection and it best be left alone.

Wound care specialists, however, know (and subsequently, related guidelines have been developed) that eschar/necrotic tissue keeps a wound covered and helps facilitate healing. Concern that eschar prohibits accurate assessment for the most part is assuaged by the realization that if no other signs of trouble are present (such as warmth, redness, and the like) that herald infection or suggest debridement is warranted, the “dead” tissue is best left undisturbed. Obviously, there are exceptions, but the rule of thumb (more accurately, the rule of foot) with regard to heel wound eschar should be: Leave it alone.

Care to debate?

When wound care sucks

It is no surprise that I — the Hoover/Oreck queen of my family — have more than an abiding interest in anything with the word vacuum in its name. Plus, the concept vacuum-assisted therapy was just beginning to really take off when I took the reins of Ostomy Wound Management.

Through the years, OWM has provided numerous articles and supplements on negative pressure wound therapy (NPWT). Morykwas and Argenta published their groundbreaking article on the use of subatmospheric pressure in wound care in 1997, but according to Miller’s¹ aggressive search, their concept is predated in Russian medical literature by 11 years. However, despite NPWT's 20-plus year history, and although the visual makes sense, no one is completely sure why sucking backwards on a tightly adhered dressing helps heal a wound. Current thinking is that NPWT promotes wound healing by 1) removing exudate from wounds to help establish fluid balance, 2) providing a moist wound environment, and 3) removing slough — this to potentially decrease wound bacterial burden, edema, and third-space fluids; increase blood flow and growth factors; and promote white cells and fibroblasts.^1,2 But NPWT research mostly involves one specific company’s product, and randomized, controlled trials are somewhat lacking. Plus, the 411 from patients isn’t always positive: NPWT treatment, as well as the post-treatment process of extracting the foam dressing of the manufacturer most associated with the wound vac,³ is painful.⁴

Which makes me wonder if this is why the brouhaha surrounding NPWT 5 to 10 years ago is diminished. Or maybe wound vac-ing has become an established part of wound care, lessening the din. After all, KCI was touted for providing its negative pressure prowess in the post-earthquake relief efforts in Haiti. Various studies show different products and dressings (for example, medicinal honey⁵) are used concomitantly to enhance treatment and counter negative side effects. Clinicians are rethinking the amount of pressure needed.⁶ What do Morykwas and Argenta think about the product size, mobility, and dressing options now available? What do you think?  

Great articles from OWM on NPWT include:

1.     Negative Pressure Wound Therapy: "A Rose by Any Other Name"

2. Negative Pressure Wound Therapy Achieved by Vacuum-Assisted Closure: Evaluating the Assumptions

3. Can You Help?: Making the Dressing Changing Process Less Painful

4. Managing Wound Pain in Patients with Vacuum-Assisted Closure Devices

5. Active Leptospermum Honey and Negative Pressure Wound Therapy for Nonhealing Postsurgical Wounds

6. The Effect of Intermittent and Variable Negative Pressure Wound Therapy on Wound Edge Microvascula

Intertrigo: skin is also a concern in obesity

Say what you will about recent concern that obesity is a disease and not a lifestyle choice, the number of overweight and morbidly overweight persons in the world is increasing. This pandemic affects healthcare providers challenged to manage the comorbid conditions resulting from obesity, payors seeking responsible ways to finance care, and society in general. Airlines (Samoa, the most prominent example) want to charge by weight; some companies require the purchase of an extra seat for the bigger among us. A popular reality show follows the struggles of a select few to embrace healthy eating and exercise habits.

But food, activity, and public opinion are but a few of the issues. Persons with areas of adjacent excessive skin folds are susceptible to intertrigo, a bacterial, fungal, or viral infection that develops as a result of inflammation when skin rubs against skin. Common areas are the inner thighs, genitalia, armpits, under the breasts, the underside of the belly, behind the ears, and the web spaces between the toes and fingers. Usually appearing as red and raw, intertrigo may itch, ooze, and feel sore. You can read more about intertrigo at: 

Intertrigo in the Obese Patient: Finding the Silver Lining
An Overview of Dermatological Conditions Commonly Associated with the Obese Patient

The Braden Scale: A Dynamic Tool?

The Braden Scale is a fixture in wound care circles that helps clinicians predict pressure ulcer risk. It is also the source of growing controversy. The problem seems to be that with continually increasing use, practitioners are discovering its limitations. A February 2012 article provides a meta-analysis of its use in surgical patients and upcoming articles in OWM will reflect on its ability to accurately assess risk among ICU patients. Some studies are finding that the overall Braden Scale score is not as informative as particular subscores.

The Braden Scale has been tweaked for use in children (the Braden-Q). As we discover more about pressure ulcer risk factors (eg, serum albumin levels may not provide dependable implication for risk), it is not unreasonable to anticipate clinicians making further modifications to this tried-and-true tool in wound care.