Chapter 26: Urinary Function & Aging

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome back to The Deep Dive.

We are doing something a little specialized today.

We are.

We're pulling a specific chapter from Gerontologic Nursing Chapter 26 to be exact, and we're treating this like the ultimate last minute lecture.

That's right.

We know a lot of you listening might be nursing students, you know, cramming for an exam, or maybe you're a practicing nurse who just realized, wait, I need a serious refresher on how the aging body handles fluids.

Yeah, exactly.

So we're skipping the fluff.

We're diving straight into the text.

The topic today is urinary function.

And I know the immediate reaction for a lot of people is, okay, plumbing, pipes and tanks.

Let's just get this over with.

But when you actually read this material, and we've gone through every page of this chapter, you realize that urinary health is, well, it's basically the gatekeeper for independence in older adults.

It is the difference between living at home and living in a facility.

And that's not an exaggeration.

The text explicitly highlights that urinary incontinence UI is one of the strongest independent predictors for nursing home admission.

It's so often the breaking point for families, they can handle the confusion, they can handle mobility issues, but the incontinence, that's often the straw that breaks the camel's back.

The text threw a number at us that I had to double check because it just seemed too high.

The estimated cost of urinary incontinence, we're talking direct care, supplies, laundry, all of it, is upwards of $65 billion per year.

It's a staggering amount of money, but the human cost is higher.

Oh, for sure.

We're talking about skin breakdown, pressure ulcers, falls, and this profound social isolation.

People stop going to church.

They stop visiting their grandkids.

They stop leaving the house.

They stop leaving the house because they are terrified of having an accident in public.

It just shrinks their world.

So our mission today is to decode this chapter.

We need to understand the anatomy, the different types of incontinence, because they are definitely not all the same.

Not at all.

And most importantly, the nursing interventions that actually work.

And I want to start by busting the biggest myth in this entire field.

I think I know which one you're going for.

The idea that getting old means you wet your pants.

It's just inevitable, you know, like gray hair or wrinkles.

That is the single most dangerous misconception we fight in geriatrics.

Incontinence is not a normal part of aging.

Let's be crystal clear about that.

If you are a nurse and you see an 85 -year -old patient leaking urine, and you think, well, they're 85, that's just how it is, you are missing a treatable condition.

You are effectively giving up on them.

And there's a nuance, but here, the text does differentiate between disease and normal age -related changes.

The machinery does change, right?

So if it's not normal to leak, what is normal?

The system changes in ways that make you more susceptible to incontinence.

Even if incontinence itself isn't normal.

Think of it like an older car.

An old car isn't guaranteed to break down, but the hoses are worn, the seals are drier, so it can't handle the same stress as a new one.

Let's look under the hood then.

What are the specific physiological shifts mentioned in the chapter?

So first, look at the bladder capacity.

In a younger adult, the bladder can hold quite a bit, let's say 500 or 600 ml, before sending that I -need -to -go signal.

As we age, that capacity shrinks.

The tank gets smaller.

You might only hold,

say, 250 or 300 ml.

So the tank is smaller.

What about the muscle surrounding it?

The detrusor muscle, it gets twitchy.

The text describes an increase in involuntary bladder contractions.

It spasms when you don't want it to.

And that leads to urgency.

Exactly.

You don't just need to go.

You need to go right now.

There's less warning time.

And then you have to look at the kidney's role in this.

The text mentions that the aging kidney handles fluid differently at night.

Yes.

In a younger person, kidney function slows down at night so you can sleep.

In older adults, that rhythm flattens out.

So they produce more urine at night than a younger person would.

Which brings us to the term nocturia.

Right.

Nocturia is waking up one or more times during the night to void.

Now, here's a clinical pearl from the text.

Okay.

Getting up once a night is considered a normal age -related change.

It's annoying, but it's physiological.

But when it's two, three, four times...

Then it becomes a pathology.

And it becomes a massive safety hazard.

Think about the mechanics of an 85 -year -old waking up at 3 a .m.

Yeah.

They're groggy.

Maybe the room is dark.

Their blood pressure might drop when they stand up.

That's orthostatic hypotension.

And now they are rushing because of that bladder urgency we talked about.

That is a recipe for a hip fracture.

It is the number one scenario for falls in the home.

Yeah.

So managing nocturia isn't just about sleep quality.

It is a critical fall prevention strategy.

What about the gender specific changes?

The text splits this up pretty clearly between men and women.

For women, the story is largely hormonal.

When estrogen levels drop after menopause, the tissues of the urogenital tract change significantly.

The urethral mucosa, the lining it thins out and becomes friable.

Friable means it tears or bleeds easily.

And the pelvic floor muscles, which act like a hammock supporting the bladder, lose their tone and bulk.

So there's less structural support to keep the urethra closed.

The exit valve is weaker.

Correct.

For men, it's usually the opposite problem.

The prostate gland, which sits right at the base of the bladder wrapped around the urethra, tends to

enlarge.

This is benign prostatic hypertrophy or BPH.

So instead of a loose valve, they have a clamped valve.

Roughly speaking, yes.

The enlarged prostate obstructs the flow.

It forces the bladder to work harder to push urine out, which can actually cause the bladder muscle to thicken and become less elastic over time.

It just creates a cycle of retention and overflow.

Okay.

So that's the baseline.

That is the susceptibility you mentioned.

Now let's talk about when it actually breaks down.

The text categorizes incontinence into two big buckets, acute and chronic,

or as the text sometimes calls it, transient and persistent.

I like transient.

I do too, because it implies we can fix it.

And you usually can't.

Acute or transient incontinence is sudden onset.

If a patient has been dry their whole life and suddenly starts wetting the bed on Tuesday, that's a red flag.

That is acute incontinence.

And it almost always has a specific reversible cause.

The text provides a checklist for this.

Box 26 to 1.

I've seen students use mnemonics for this, but let's walk through the list provided in the chapter, because this is where the detective work starts for the nurse.

Absolutely.

The first thing you look for is infection.

A urinary tract infection, a UTI, will cause inflammation and urgency.

You treat the UTI with antibiotics and the incontinence stops.

Simple as that.

Then you look at mobility.

Right.

Did they break a leg?

Are they restrained?

Are they in a new environment where the bathroom is just too far away?

If they can't get to the bathroom physically, they will be incontinent, but their bladder is actually working fine.

Fecal impaction is another big one on the list, which it sounds counterintuitive.

How does constipation cause urinary incontinence?

It's anatomy.

The colon and the bladder are neighbors.

A rectum packed with hard stool physically pushes against the bladder and the urethra.

Oh, okay.

It can block the outflow, leading to overflow, or it can irritate the bladder nerves, causing urgency.

You clear the impaction, you fix the bladder.

And then there are metabolic issues like uncontrolled diabetes.

High blood sugar causes polyuria, excessive urination.

The kidneys are trying to dump the sugar and they drag water with it.

So if you're making three liters of urine a day, you're going to have a hard time holding it no matter how strong your sphincter is.

But the biggest category, and we always seem to come back to this, is medications.

Always check the meds.

It is the first rule of geriatrics.

What are the specific offenders here?

The text lists quite a few.

Well, diuretics are the obvious one.

You give someone Lasix, you are telling your body to dump water.

If you give it at 6 p .m., don't be surprised if they wet the bed at 10 p .m.

But sedatives are also huge, benzodiazepines or sleep aids.

If the patient is too sedated to wake up when their bladder signal is full, they will wet the bed.

What about the drugs that affect the muscle toe itself?

Anticholinergics.

These are tricky because we sometimes use them to treat incontinence.

But in the wrong patient or at the wrong dose, they cause urinary retention.

They paralyze the bladder muscle.

The bladder fills up until it overflows.

Calcium channel blockers, used for blood pressure, can do the same thing by relaxing the smooth muscle of the bladder.

So the takeaway for acute incontinence is don't reach for a diaper, reach for the patient's chart,

find the cause.

Be a detective.

If it's new, it's likely reversible.

Now let's shift to the chronic types.

These are the ones that persist over time.

The text breaks this down into five categories.

And understanding the difference is crucial because the treatment for one might be the exact wrong thing for another.

Absolutely.

Let's start with the most common one in older adults, urge incontinence.

Urge incontinence is often associated with the diagnosis of overactive bladder.

The hallmark here is the warning time or rather the lack thereof.

The patient feels a sudden intense need to urinate and they often leak before they can make it to the toilet.

This is the key in the door syndrome, isn't it?

Yes.

That's a classic trigger.

You get home, you put your key in the lock and your bladder's basms.

Hearing running water is another one.

Touching cold water, it's a neuromuscular disconnect where the bladder contracts involuntarily.

And the accidents are usually a large volume.

Moderate to large, yes.

They soak their clothes.

It's not just a dribble.

Okay.

Contrast that with stress incontinence.

Stress incontinence is mechanical.

It's a plumbing failure.

The pressure inside the abdomen increases coughing, sneezing, laughing, lifting a heavy box.

And that pressure overrides the resistance of the urethra.

So urge is a muscle spasm.

Stress is a weak valve.

Perfectly put.

Stress incontinence is much more common in women, usually related to that estrogen loss we discussed or damage from childbirth years ago.

Okay.

It's actually rare in men unless they've had prostate surgery that damaged the sphincter mechanism.

Then we have overflowing incontinence.

The name seems pretty descriptive.

It is.

The bladder is like a balloon that is blown up too tight.

It's full, distended, but the patient can't empty it completely.

So the pressure builds until a little bit of urine just leaks out to relieve the pressure.

It's constant dribbling, not a gush.

And this is dangerous because that stagnant urine sitting in the bladder is a breeding ground for bacteria.

Exactly.

This is usually caused by an obstruction like the enlarged prostate in men or a weak bladder muscle, which we see in diabetic neuropathy.

The bladder just gives up pushing.

The fourth type is functional incontinence, and this one is heartbreaking because the urinary tract works fine.

Physically, yes, the kidneys make urine, the bladder holds it, the sphincter works, but the person cannot navigate the environment to void appropriately.

This is the patient with severe arthritis who takes, you know, 10 minutes to walk to the bathroom.

Or the patient with Parkinson's who can't undo their zipper or buttons fast enough.

Or, and this is a big one, the patient with dementia, who simply doesn't recognize the sensation of needing to go or can't find the bathroom.

And finally,

mixed incontinence.

Which is exactly what it sounds like, a combination.

In the community, it's often a mix of urge and stress.

In nursing homes, we see a lot of mixed urge and functional.

They have an overactive bladder and they can't walk fast.

Wow.

That is a very difficult combination to manage.

So we have the types.

Now, how do we out which one our patient has?

The text calls this the nursing assessment.

And it starts with the interview.

But we have to be sensitive.

The text points out that embarrassment is a massive barrier.

Yeah, I'd imagine.

Patients hide this.

They use pads.

They drink less water.

They stay home.

They won't volunteer this information.

You have to ask.

But you can't just say, do you wet yourself?

No, you need to be specific and clinical.

Ask about the symptoms we just discussed.

Do you ever lose urine when you cough or sneeze?

That checks for stress.

Do you ever a sudden strong urge and can't make it to the toilet?

That checks for urge.

Do you feel like you empty your bladder completely?

It checks for overflow.

Exactly.

The text emphasizes a specific tool called the bladder diary.

It's figure 26, 10 to 2.

Is this practical in the real world?

It is the gold standard.

If you ask a patient,

how often do you go?

They will guess.

And they will usually be wrong.

A bladder diary captures real data over three days.

So what's on it?

When do they drink?

What do they drink?

When do they avoid?

When did they leak?

It helps you spot patterns.

Exactly.

You might see that every day at 10 a .m.

they have coffee and at 11 a .m.

they have an urge accident.

Okay, now we know caffeine is a trigger.

Or you see they are dry all day but wet the bed every night.

That points to nocturia or fluid management issues.

There's also a physical assessment component.

We talked about the 15 -foot test.

I love this because it requires zero equipment.

It's a brilliant functional test.

You position the patient 15 feet from a toilet.

You tell them to go.

Then you just watch.

What are you looking for?

How long does it take them to stand up?

How's their gait?

Can they maneuver through the doorway?

Can they manage their clothing?

It instantly tells you if there's a functional component.

Right.

If the bladder is fine but it takes them five minutes to undo their belt, the intervention isn't a pill.

It's elastic waistbands or velcro pants.

The text also mentions provocation tests.

This sounds a bit mean.

It sounds aggressive but it's necessary for diagnosis.

We need to see the leak to understand it.

So we ask the patient to stand with a full bladder and cough.

If they squirt urine, that's a positive stress test.

We might listen to running water to see if it triggers a spasm.

And we have to check for retention.

The post -void residual or PVR?

Yes.

In the old days, we'd have to catheterize them to check this which introduces infection risk.

Right.

Now we have portable ultrasound bladder scanners.

You scan them right after they pee.

If there's more than 100 ml left in there, that suggests retention or overflow incontinence.

Okay.

We've assessed.

We've diagnosed.

Now what do we do?

Section four is nursing interventions.

And I'm happy to see that pills and surgery are not at the top of the list.

No.

Lifestyle modification is always the first line of defense.

And the first conversation is always about fluid intake.

I imagine most patients think, if I leak, I should stop drinking water.

It is the intuitive response.

And it is completely wrong.

Restricting fluids leads to dehydration, obviously.

But it also produces concentrated dark acidic urine.

And that concentrated urine irritates the bladder lining.

Which triggers more spasm.

Exactly.

It makes urge incontinence worse.

Plus, dehydration causes constipation.

And we already know a full bowel pushes on the bladder.

So the nurse's job is to convince them to drink more, aiming for 1 .5 to 2 liters a day.

But to be smart about when and what they drink.

So front load the fluids.

Yes.

Drink plenty during the day, but taper off after dinner to help with the nighttime waking.

Oh.

And cut the irritants.

Like what?

Caffeine is a double threat.

It's a diuretic, makes more urine, and the stimulant makes the bladder twitch.

Alcohol is similar.

Artificial sweeteners can also be triggers for some people.

Weight loss helps, too.

Less weight means less pressure on the pelvic floor.

Let's talk about the exercises.

Everyone has heard of kegels, but I feel like most people do them wrong.

Most people do.

They squeeze their buttocks or their thighs or their abs.

That does nothing for the pelvic floor.

Box 26 -3 gives the specific instructions.

The first step is just identifying the muscle.

The text suggests stopping the stream of urine while voiding.

But, and this is a huge warning, only do that once or twice to find the muscle.

Do not do it as an exercise.

Why not?

Stopping the flow repeatedly can cause urine reflux back into the kidneys or teach the bladder to retain urine.

It is a teaching tool, not the workout.

Once they find the muscle, what's the regimen?

It's a workout.

You don't get biceps by lifting a weight once.

You need 45 repetitions a day, three sets of 15.

Hold for 10 seconds, rest for 10 seconds.

And you need to do them lying down, sitting, and standing to train the positions.

That requires a cognitively intact patient.

What about our patients with dementia?

You can't tell them to squeeze their pelvic floor.

No.

For them, the intervention is external.

It's on the caregiver.

We use prompted voiding or scheduled toileting.

How is that different from just taking them to the bathroom every two hours?

The difference is the interaction.

In standard scheduled toileting, you just take them.

In prompted voiding, described in Box 26 -5, you engage them.

So you talk to them.

You ask them to focus on their bladder.

You ask, are you wet or dry?

You praise them if they're dry.

Then you ask, do you want to use the toilet?

It's about building awareness and positive reinforcement.

Yes.

Research shows this significantly reduces incontinence episodes compared to just standard care.

But the key is the positive feedback.

Never, ever scold a patient for being wet.

Right.

It destroys their dignity and causes anxiety, which makes incontinence worse.

I want to touch on devices before we move to the kidneys.

Specifically catheters.

The Tex seems to have a very strong opinion on indwelling or Foley catheters.

It's not just an opinion.

It's a patient safety mandate.

An indwelling catheter is a direct highway for bacteria to enter the bladder.

Catheter -associated urinary tract infections, CODIs, are a massive source of hospital -acquired sepsis.

So when is it appropriate?

Box 26 -6 lists the very narrow indications.

Acute urinary retention that you can't fix otherwise.

To he'll heal a stage three or four pressure ulcer that keeps getting contaminated by urine.

Okay.

Or for comfort care in a terminally ill patient.

It's not for the convenience of the nursing staff.

Never.

If you are placing a catheter because you are tired of changing the bedsheets, you are putting that patient's life at risk.

That is malpractice in my book.

Point taken.

Let's zoom out.

We've been talking about the bladder, but we need to talk about the stream factory.

The kidneys.

Section five deals with a renal function.

The kidneys age too.

They shrink.

We lose nephrons, which are the filtering units.

By age 80, the blood flow to the kidneys is cut in half compared to a 30 -year -old.

That sounds dramatic.

Does that mean everyone gets kidney failure?

No, because the kidneys have a huge reserve capacity.

You could live with one kidney, right?

So you can live with reduced function.

But, and this is the key, older kidneys lose their adaptability.

They can't handle stress well.

If an older person gets dehydrated or has a sudden drop in blood pressure or takes a toxic drug, the kidneys crash much faster than a young person's would.

There is a specific concept in the text regarding creatinine that I found fascinating.

It's a drug safety alert.

This is one of the most important takeaways for nursing pharmacology.

We usually measure kidney function by looking at serum creatinine in a blood test.

Creatinine is a waste product from muscle breakdown.

Okay.

So high creatinine means the kidneys aren't siltering it out, which is bad.

Correct.

However, older adults often have sarcopenia muscle wasting.

Right.

They lose muscle mass.

They have very little muscle mass.

So they aren't producing much creatinine to begin with.

So their creatinine level might look low or normal on the lab report.

But their kidney function is actually terrible.

The normal lab value is a lie.

If you do the based on that normal creatinine, you might overdose the patient because their kidneys aren't actually clearing the drug.

So what should we look at?

You have to look at the GFR glomerular filtration rate, which is a calculation that accounts for age.

That is a critical distinction.

Always look at the GFR.

Now let's distinguish between the two types of failure, acute and chronic.

Acute kidney injury, or AKI, is a sudden attack.

It happens over hours or days.

The text groups the causes into three buckets.

Prerenal, intrinsic, and postural.

Let's break those down.

Prerenal means before the kidney.

Right.

The problem isn't the kidney.

It's the blood flow to the kidney.

Dehydration, heart failure, severe shock.

The pump isn't priming the filter.

Intrinsic means inside the kidney.

Damage to the tissue itself.

This is usually toxins, antibiotics like gentamicin, contrast dye from a CT scan, or unmanaged infections.

Impostural is after the kidney.

Obstruction, a kidney stone, a tumor, or that enlarged prostate we talked about.

The urine can't get out, so it backs up and damages the kidney.

So the good news about AKI is that if you fix the cause, hydrate them, stop the toxic drug, remove the blockage, the kidney often recovers.

Chronic kidney disease, CKD, is a different beast, though.

CKD is permanent.

It's damage lasting more than three months.

It's usually caused by long -term diabetes or hypertension.

The text outlines five stages based on the GFR.

Stage one is mild damage.

Stage five is end -stage renal disease, where you need dialysis or a transplant to survive.

And the nursing management for CKD is incredibly complex.

It's not just pills, it's a lifestyle overhaul.

It's very restrictive.

They need strict blood pressure control, under 130 over 80.

Tight blood sugar control.

And the diet is tough, low protein, low sodium, low potassium, low phosphorus.

Imagine telling an older adult they can't eat meat, bananas, dairy, or salt.

Yeah, that's every thing.

It significantly impacts quality of life, and monitoring for symptoms like edema or itching periodists is key.

We are in the home stretch here.

We need to cover a few specific conditions listed in section six.

Let's start with UTIs, but specifically the concept of asymptomatic bacteria urea.

This feels like a major shift in practice.

Is.

We used to think urine should be sterile.

If we found bacteria, we treated it.

But we now know that many older adults have bacteria living in their bladder all the time.

They have over 100 ,000 colony forming units, but they have zero symptoms.

No burning, no pain, no fever.

Nothing.

This is called asymptomatic bacteria urea.

And the current guideline is, do not treat.

That feels counterintuitive to a lot of nurses.

There's bugs, kill them.

But if you treat them, you are just killing the weak bacteria and leaving the superbugs.

You are breeding MRSA and VRE, and you risk giving the patient C,

diff diarrhea from the antibiotics.

You only treat if there are symptoms.

But clinical pearl here, the symptoms in older adults are weird, aren't they?

They are.

An 80 year old might not get a fever or burning.

Their only symptom might be sudden confusion,

delirium, or they start falling.

Or they become incontinent suddenly.

If mental status changes, check the urine.

Moving to bladder cancer, what is the one red flag everyone needs to memorize?

Painless hematuria.

Blood in the urine without pain.

If you see that, especially in a smoker, and smoking is the number one risk factor for bladder cancer,

it needs a workup immediately.

And finally, let's revisit the prostate issues.

BPH versus prostate cancer.

BPH is mechanical.

It's benign.

It causes those obstructive symptoms, hesitancy, weak stream, dribbling.

We treat it with alpha blockers like Tamsulosin or Flomax, which relaxes the muscle, or surgery like a to roto -router the blockage out.

And prostate cancer.

It's the most common cancer in men.

The risk is significantly higher for African American men.

Screening is done with the PSA blood test and the digital rectal exam.

It's usually slow growing, but early detection is key.

And for nurses, the care often happens after the treatment.

Yes.

Prostate surgery or radiation often leaves men with erectile dysfunction or urinary incontinence.

Supporting them through the psychological impact of that is a huge part of the role.

We have covered a massive amount of ground today.

From the physiology of the aging bladder to the nuances of checking a GFR versus creatinine.

We have.

It's a dense chapter.

If you had to distill this down,

what is the one thing you want our listeners to take back to their next shift?

I want to go back to the idea of functional incontinence.

We label it as a type of incontinence, but really it's often a failure of the environment.

If a patient is wet because no one answered the call light, or because the bathroom was cluttered, or because their walker was out of reach,

that is not a bladder problem.

That is a care problem.

That's powerful.

As a nurse, you aren't just managing fluids and pills.

You are the architect of their environment.

You are the one who ensures their dignity is preserved.

Ask yourself,

is the patient failing to hold their urine, or are we failing to get them to the toilet?

A critical question to end on.

Thank you for listening to this deep dive into urinary function.

Go forth, assess your patients, check those meds, and advocate for their dignity.

We'll see you on the next one.