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Retention, Infection, Prevention

Posted Feb 19 2009 6:06pm
An ounce of prevention is worth a pound of cure.            -  Henry de Bracton 

     My daily work setting has changed.  I am still in my office for a very limited number of patients each week, taking ONLY pelvic pain and TMJ patients, but the majority of my day is now seeing homebound patients through a Home Health Agency.  It is different.  Challenging.  But different.

     This population has a real, constant concern about urinary tract infections (UTI's).  Chronic UTI's make you feel awful, subdue the immune system, are painful and frustrating, and for a lot of people cause incontinence.  The intense urgency felt with a UTI, combined with the physical debility of these people, can make every hurried trip to the bathroom a potential disaster.  An accidental leak can be humiliating, not to mention difficult to clean up, if you are alone.  Being in wet clothing can cause skin break down or irritation.  The frequent trips to the bathroom also increase the person's risk for falling.  Another sad fact is that incontinence is the number one reason that elderly people end up in assisted living facilities.  It is often just too much for the patient and family to deal with. 

 Why so many UTI's?  Retention is often a factor.  For the purpose of this post, I want to sort of reframe the word "retention".  Usually when a medical person says "retention" we all think "complete loss of the ability to void."  Potentially life threatening stuff.  Here, I will use retention as the "loss of the ability to void completely."  When you do not empty the bladder with each void, you end up with a residual volume of old urine sitting in your bladder.  Anyone that has ever emptied a potty chair or urinal knows how quickly urine can become nasty.  Imagine that just hanging out in your bladder, growing bacteria and disease - ugh, right?

So - the best way to prevent infection is to make sure the bladder empties.  For the next several tips, the person taking charge of the situation must have fairly normal mental capacity, so if the patient is in early or middle stages of dementia (Altzheimer type illnesses) these tips will require supervision. 
  •  Check the meds.  Many medication used for "mood elevation" list retention as a potential side effect.  Even if the person is not suffering that particular side effect, none of these tips will cause problems, and you may be able to prevent future UTI's. 
 
  • Do NOT strain to urinate, I cannot emphasize this enough.  Not only is it bad for the pelvic floor (which  I post about alot), the val salva (straining) maneuver can cause a person to pass out - especially if there are heart, blood pressure, or respiratory problems.
 
  •  Try to "double void."  After urinating, stand up.  Wait for a few seconds, then sit back down and relax.  Not a great idea if balance is an issue, but good for people that are stable on their feet.

  • "Passive void"  After urinating, apply pressure to the bladder, by pushing in and down just above the pubic bone with your hands.  When you are pushing as deeply as possible, lean forward over you hand, and relax your lower body.  The official instructions for this kind of void has patients pushing in with their thumbs; most of my patients have arthritic hands or are simply not strong enough.  I usually have them place their hands over the top of each other, or use their fist to push in.  This does not work well for people with active UTI's, pressure over the bladder is painful.  Wait until the infection is gone before beginning this.

  • Relaxing the pelvic floor.  A small step stool placed under the feet while sitting on the toilet is an excellent way to relax the pelvic floor.  This will make voids and bowell elimination easier (a full bowell puts pressure on the bladder - very uncomfortable for a UTI patient).  This is especially helpful if the patient has a raised toilet seat to help them get up and down easily.  Big WARNING:  Small movable stools are hazards for people that are unstable (balance), have reduced mental capacity, or are generally very weak.  If any of these apply to the patient involved, the care giver MUST supervise trips to the bathroom, so that the stool is removed and safely out of the way before the person tries to get up, and when maneuvering to sit down.

I hope some of these tips help.  If you have additional information - please feel free to post a comment!
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