Page 93 Complete Your CE Test Online - Click Here assess the older patient for urinary incontinence since this is a problem that can be treated, reduced, and sometimes, eliminated. There are several types of urinary incontinence [9]: ● ● Stress incontinence occurs when urine is involuntary expelled when a person laughs or coughs. The muscles of the pelvic floor or urethral sphincter are not strong enough to control the loss of urine. ● ● Overflow incontinence occurs when the bladder muscles stretch beyond their ability to contract or when the urethra is blocked. ● ● Urge incontinence occurs when there are strong, unexpected contractions of the bladder muscles and the internal sphincter cannot hold the urine in the bladder. ● ● Functional incontinence is due to causes not associated with the urinary system. For example, the older adult may not be able to get to a bathroom in time to avoid incontinence, or he may be physically unable to reach a bathroom by himself. Another example is that of the adult whose cognition is impaired and does not recognize the need to void. Treatment interventions include bladder training. Bladder training involves training the bladder to hold gradually increasing amounts of urine by extending the time between trips to the bathroom. Pelvic floor exercises, also referred to as Kegel exercises, may also be helpful. A general exercise program may also help to strengthen appropriate muscles. Bladder irritants include spicy foods, carbonated beverages, caffeine, and alcohol [9]. There are also a number of protective undergarments that can be worn to protect clothing, stop odor, and decrease embarrassment [9,13]. Urinary tract infections Margaret is 80 years old and enjoys an active life. She volunteers at her church and participates in many social activities at her local senior citizens’ center. Over the past six months she has seen her nurse practitioner twice for urinary tract infections. Upon tactful questioning, Margaret admits that she drinks very little fluid throughout the day because of incontinence problems. She is afraid of being embarrassed if she “has an accident” in public. Margaret is not alone in her fears. Older adults are especially vulnerable to urinary tract infections (UTI). Many of them deliberately reduce their fluid intake to avoid incontinence. Inadequate fluid intake increases the risk for UTIs [9,13]. UTIs in older adults are often asymptomatic, with only sudden confusion as a symptom. Antibiotic therapy may be prescribed, although, in some asymptomatic cases, no treatment may be initiated [9]. Nursing consideration: Geriatric patients may not exhibit the typical signs and symptoms of UTIs such as burning sensations when voiding. In older adults, the most common symptoms of UTI are often lethargy and changes in mental status [13]. Tips to prevent UTIs include [13]: ● ● Maintain adequate hydration. Void promptly when the urge to urinate occurs. Don’t wait a long time between voiding. ● ● Wipe from front to back after going to the bathroom. ● ● Avoid using products such as douches, perfumes and scented powders over or around the genital areas as these can irritate the urethra. Benign prostatic hyperplasia Benign prostatic hyperplasia (BPH) affects about half of men between 51 and 60 years of age and 90% of men over 80 [9]. Signs and symptoms include: decreased urinary stream and force; feeling of incomplete bladder emptying; frequency and urgency; dribbling; incontinence; difficulty initiating voiding; and, at times, hematuria [13]. The only effective treatment is surgical removal of the prostate tissue. Such tissue is always biopsied to rule out malignancy. Issues related to reproductive organs Age-related changes in the reproductive system include [9]: ● ● Decreased libido. ● ● Breast tissue atrophy. ● ● Diminished ejaculation in men, and the need for more time and stimulation to reach arousal. ● ● Increased incidence of erectile dysfunction in men. ● ● Drastically decreased estrogen levels in women leading to vaginal dryness and possibly painful sexual intercourse. ● ● Increased facial hair in women. ● ● Increased length of time for arousal in women. These changes do not prevent older adults from having a satisfying sex life. It is important to assess sexuality as part of physical assessment. For more detailed information about sexual assessment and interventions see the section on Sexual Assessment presented earlier in this educational program. Malignancies Bladder cancer Bladder cancer is fairly common in older adults, with men nearly four times as likely as women to develop this malignancy. Symptoms are similar to UTI. The first symptom is often painless hematuria [13]. As with other cancers, the treatment depends on the stage of the disease and its exact location. Prostate cancer The incidence of prostate cancer in men is even higher than that of bladder cancer [9]. Symptoms are usually not evident until the disease is advanced. That is why it is so important to have a prostate examination as part of the annual physical exam. Symptoms include lower back pain, difficulty initiating urination, dribbling, retention of urine, and hematuria [13]. Radiation is used to treat locally invasive lesions. Surgery and hormone therapy may also be used in conjunction with radiation therapy [13]. Nursing consideration: Since early recognition is critical to successful treatment, encourage all male patients to have a prostate examination as part of their annual physical exam. Some older men may refuse the exam or neglect to have an annual physical. Be sure to explain the importance of preventive healthcare! Common gynecological malignancies in older women Uterine cancer Uterine, breast, and ovarian malignancies are more common in older women than in younger women. Cervical cancer is more common in young and middle-aged women, but can occur at any age. Vulvar cancer is not common in any age group [9]. Uterine cancer is the most common gynecological cancer in older women. Obesity and prolonged exposure to estrogen due to early menarche combined with late menopause or never having been pregnant are risk factors for endometrial cancer. Hormone replacement therapy without progestin is also a risk factor [9]. The most common symptom is bleeding from the vagina after menopause. Other signs and symptoms include weight loss and pain, but these do not appear until the disease is advanced [13]. Treatment of uterine cancer includes surgery, which is generally a total abdominal hysterectomy. Hormonal therapy, radiation therapy, and chemotherapy in various combinations are generally part of the treatment regimen [13]. Ovarian cancer Seventy-five percent of ovarian cancer cases occur in women over 55. Unfortunately, prognosis is often poor, especially in older women. There is not a screening test at this time. The CA-125 blood test for tumor markers does exist; however, it is not recommended as a screening tool for ovarian cancer because there are no data to support that such screening would decrease mortality [9]. Ovarian cancer is the leading cause of gynecological deaths in the U.S. [13]. Symptoms are generally vague and include abdominal discomfort, dyspepsia, feelings of bloat, urinary frequency, abdominal distention, and weight loss [9,13]. Treatment includes removal of the uterus, ovaries, fallopian tubes, and omentum. Aggressive therapy is usually indicated including chemotherapy and, sometimes, radiation [13].