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LY-JN-QT

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Abstract

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the brain-gut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray. It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response. Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus. Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4(+) lymphocytes. The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

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national center for biotechnology information

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Stress and the gastrointestinal tract - PubMed

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Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathw ...

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Introduction to emesis

Vomiting can also be referred to as emesis, and consists of the following stages:

Nausea
Nausea is an unpleasant sensation of wanting to vomit, and is often associated with cold sweat, pallor, salivation, loss of gastric tone, duodenal contraction, and the reflux of intestinal contents into the stomach. Nausea generally precedes vomiting, but can occur by itself. The system that brings about the loss of gastric tone, of gastric relaxation, is the efferent part of the long loop intestinal reflex that relaxes the gut during food intake.

Retching
Retching is a strong involuntary effort to vomit, and usually follows nausea. During retching, the abdominal muscles, chest wall and diaphragm all contract without any expulsion of gastric contents.

Vomiting
Vomiting is the forceful expulsion of the contents of the gastrointestinal system out through the mouth. From an evolutionary perspective, it is thought to have evolved as a defense mechanism of the body, serving a protective function to rid the body of noxious substances that have been ingested, rather than allowing them to be retained and absorbed by the intestine.
Contrary to popular belief, the stomach itself does not actively expel its contents during vomiting. The stomach, oesophagus, and their relevant sphincters are all in fact relaxed during vomiting. Most of the force that expels the contents arises from the contraction of the diaphragm, which is the major respiratory muscle, and the abdominal muscles, which are the muscles involved in active expiration.

Symptoms of emesis

The symptoms of emesis include:

Profuse salivation;

Sweating;

Elevated heart rate;

Pallor;

Nausea; and

Retching movements.

Causes of nausea and vomiting

The following table highlights the major and most common causes of nausea and vomiting:

Mechanisms of emesis

The mechanisms of emesis can be divided into three components:

1. Afferent inputs go to the central nervous system (CNS), relaying the signals of emetic stimuli;

2. These signals are received, recognised, and centrally processed. They then form integrated emetic efferent signals coming from the CNS;

3. These motor and chemical efferent pathways relay signals that lead to the coordinated respiratory, gastrointestinal and abdominal muscle expulsive actions of vomiting.

Central nervous system control
There are two medullary centres of vomiting in the brain known as the sensory " chemoreceptor trigger zone (CTZ)" and the integrative centre.
Chemoreceptor trigger zone (CTZ)
The CTZ is located in the medulla of the brain. It has a defensive blood-brain barrier for detecting circulating toxins in the blood and cerebrospinal fluid (CSF), and is sensitive to a number of circulating emetic agents, including morphine, intravenous copper sulphate, and certain circulating metabolic emetic agents associated with uraemia, infections and radiation. When activated, the CTZ does not initiate vomiting itself, but relays stimuli to the integrative vomiting centre which produces the actual act of emesis.

Integrative vomiting centre
The integrative vomiting centre coordinates activities of the nearby neural structures to produce a complex patterned response, resulting in the processing and action of the vomiting reflex. The centre is located in the medulla. The motor component of the vomiting centre is controlled by both somatic and autonomic systems, meaning that both voluntary and involuntary systems are involved in the process. Their inputs are coordinated by the vomiting centre.
Somatic efferent pathways control respiratory and abdominal musculature, and visceral efferent components mediating changes in gastric tone and motility, while salivation, pallor and sweating are autonomic epiphenomena. The autonomic nervous system is not essential for the mechanical act of vomiting, but the activation of efferent nerves of the abdominal organs in the emetic process is proportional to the duration and intensity of the nausea that accompanies the process.

Afferent pathways
The vomiting centre is predominantly activated by three different mechanisms:

1. By nervous impulses from the stomach, intestinal tract, and other portions of the body, resulting in a reflexive activation;

2. By stimulation from the higher brain centres;

3. By the chemoreceptor trigger zone (CTZ) sending impulses.

Afferent impulses may also arise from other sites, such as unpleasant sights and odours, as well as severe parietal pain. The most common afferent pathways are in the viscera, or abdominal organs. Vomiting can be provoked by occlusion of the coronary vessels, distension of the intestine, and irritation of the gastrointestinal mucosa. In the gastrointestinal tract, mechanoreceptors in the intestinal wall are activated by abnormal contractions, distension or physical damage. Potentially harmful chemical stimuli can also activate chemoreceptors located in the intestinal wall. These receptors then release information to the vomiting centre.

Efferent pathways
The neural pathways involved in the motor act of vomiting are associated mainly with the phrenic nerve to the diaphragm, the spinal nerves to the abdominal and intercostal muscles, efferent visceral autonomic fibres to the gut, and the viscera efferent fibres to parts of the voluntary muscles of the pharynx and larynx. The vomiting reflex is mediated by both the autonomic and somatic systems, and consists of two phases:

1. Prodomal phase (pre-ejection): Relaxation of gastric muscles followed by small intestinal retrograde peristalsis;

2. Ejection phase: Comprises of retching and vomiting including expulsion of gastric contents.

Stimuli for vomiting

Pain, sight, smell, taste, emotion
The experience of these sensations leads to information sent to the higher centres in the brain, and then information relayed to the vomiting centre and CTZ via chemicals that transmit information to the brain, hence the name ' neurotransmitters'. The one that is most commonly responsible is acetylcholine, or Ach. Neurotransmitters stimulate and activate the vomiting reflex through the afferent pathways previously described.

Motion sickness
Motion sickness is due to labyrinth stimulation. The labyrinth is a part of the inner ear involved in balance and perception of movement. Labyrinth stimulation leads to impulses passing along the vestibular nerve to the central nervous system, where it activates the CTZ to produce emesis. Neurotransmitters such as histamine or Ach are also released to the CTZ, which itself can releases chemicals such as dopamine and serotonin (5HT) that go on to stimulate the vomiting centre, which releases Ach, which then leads to the feelings of nausea and actions of vomiting.

Opioid medications
Opioids such as codeine, morphine, pethidine, fentanyl, methadone, oxycodon, and tramadol can cause nausea and vomiting through a number of different possible mechanisms such as stimulation of CTZ, increased vestibular sensitivity, gastric stasis, or impaired intestinal motility and constipation.

Cancer therapy
Chemotherapy
Cytotoxic drugs cause stimulation of 5-HT3-receptors peripherally and possibly centrally on the CTZ. This in turn will cause the release of the aforementioned chemical transmitters dopamine and 5HT, which trigger the vomiting centre and cause the release of Ach, thereby leading to induction of nausea and vomiting. Chemotherapy-induced nausea and vomiting can affect the quality of life and result in dehydration, weight loss and malnutrition.
There are three types of emesis following cytotoxic chemotherapy:

1. Acute emesis: symptoms occurring within the first 24 hours after chemotherapy;

2. Delayed emesis: symptoms occurring after 24-48 hours after last dose of chemotherapy;

3. Anticipatory emesis: a conditioned response in patients who have developed significant chemotherapy-induced nausea and vomiting during previous cycle of therapy.

Delayed emesis as well as acute emesis is a particular problem with high-dose of cisplatin and other agents such as doxorubicin. However, in up to 75% of patients, this can be prevented or alleviated by using correct anti-nausea and anti-vomiting drugs, known as anti-emetics.
Generally, for management of chemotherapy-induced nausea and vomiting a combination of anti-emetic drugs is used. For instance, dopamine antagonists, such as metoclopramide (Maxolon), and serotonin antagonists, such as palonosetron (Aloxi) and granisetron (Kytril), are used together with a corticosteroid, such as dexamethasone, to match the strengths of chemotherapy agents.
In up to 75% of patients, this can be completely prevented by using correct anti-nausea and anti-vomiting drugs, known as anti-emetics. Nausea and vomiting are particular problems with some agents such as doxorubicin and others that contain platinum. Usually a combination of anti-emetic drugs is used. For example, metoclopramide and serotonin antagonists are used in combination with a steroid to match the strengths of chemotherapy agents.
R adiotherapy
Whether radiation therapy causes nausea and vomiting depends on the part of the body being treated, the amount of radiation given, and how often the treatment is given.
When the area of the body being treated includes a large part of the abdomen, specifically, the small intestine (or small bowel), there is a greater chance of nausea and vomiting occurring. About 50% of the people with cancer who receive standard doses (180 to 200 centiGray) of radiation to their abdomen will have nausea and vomiting. These symptoms can occur 1 to 2 hours after treatment and can last for several hours.
Of those being treated with total body radiation therapy, used in bone marrow transplants, about 60% to 90% will develop nausea and vomiting if not given medicines to prevent nausea and vomiting. These people may also receive high doses of chemotherapy to prepare for the transplant.
The combination of radiation therapy and chemotherapy increases the chance of nausea and vomiting. People who receive one large dose of radiation therapy have a greater chance of nausea and vomiting than those who receive radiation therapy in smaller doses.

Hormonal changes during pregnancy
Symptoms of nausea and vomiting are common during the first trimester of the stages of pregnancy. The exact mechanisms of pregnancy-induced nausea and vomiting still is not clear, however it is thought that elevated level of pregnancy hormones can play a role in inducing nausea and vomiting. Adequate hydration should be advised. Dietary modification such as small, frequent, high-carbohydrate, low-fat meals may help.

Post-operative nausea and vomiting (PONV)
PONV is a result of several potential factors such as:

The types of anaesthetic agents used such as inhaled gases and/or medications, such as morphine;

The type and the site of operation such as operations around the ear and inner ear, eyes, mouth and some abdominal surgery;

The age of the patient; for instance young adults and the elderly are more susceptible to PONV;

The gender of the patient; females are more susceptible to PONV;

Patients with co-existing conditions such as those who are overweight and/or obese, diabetic, pregnant or suffering from hypothyroidism.

It is evident that some surgeries due to the above factors may trigger the release of 5HT from enterochromaffin-like cells in the visceral mucosa and initiate the emesis reflex and its accompanying feeling of nausea. Some risk factors that can predispose you to getting nausea and vomiting following a surgical procedure:

Age: Younger patients and the elderly are more at risk of having post-operative nausea and vomiting;

Gender: Women tend to suffer more than men do.

Nutrition: People who are overweight or obese have a much higher risk of getting nausea and vomiting after a surgery. It is a condition that patients must fast before surgery, as contents in the stomach puts you at a much higher risk of vomiting after a surgery or at least feeling nauseous;

Past history: If you have previously had nausea and vomiting after a surgical procedure and/or you suffer from motion sickness makes you more susceptible to getting nausea and vomiting after an operation;

Cancer therapy: Patients undergoing chemotherapy and radiotherapy are more likely to suffer as well;

Anaesthetic and surgical factors: Sometimes certain types of anaesthetic agents (such as inhaled gases) and medications (such as morphine) can lead to nausea and vomiting. Some surgical factors such as operations around the ear and inner ear, eyes, mouth and some abdominal surgery increase the risk of you getting nausea and vomiting afterwards.

All steps will be taken by the anaesthetists and doctors caring for you to prevent post-operative nausea and vomiting, however, in some instances, it can not be prevented and they will give you medications to ease the discomfort.

The ingested toxin substances such as alcohol can induce life-saving physiological response to these circulating foreign particles. The CTZ is relatively permeable, enabling the circulating substance or mediators to act directly on this centre. Activation of this centre is followed by release of the aforementioned chemical transmitters dopamine and 5HT, which trigger the vomiting centre and cause the release of Ach, thereby leading to induction of nausea and vomiting.

Throat/stomach
Stimulation of parts of the throat and/or stomach can lead to nerve and chemical transmitter release of information to an area of the spinal cord and brain (known as the nucleus of the solitary tract), which goes on to trigger the vomiting centre and the cascaded of nausea and vomiting through Ach release.

Consequences of vomiting

Severe and prolonged vomiting can cause the following harmful consequences:

Dehydration, which can be lethal, especially in children;

Protracted vomiting may result in starvation, malnutrition and vitamin deficiency;

Severe post-operative vomiting can increase bleeding, aspiration pneumonia, and induce the re-opening of surgical wounds as a result of involuntary muscle contractions associated with vomiting;

Metabolic alkalosis.

Metabolic alkalosis
Metabolic alkalosis is a reduction in plasma concentrations of [H⁺] cause by a relative deficiency of noncarbonic acids. Under normal circumstances, Hydrochloric acid (HCl) is secreted into the lumen of the stomach during digestion. During this secretion, bicarbonate (HCO ₃⁻) is added. The HCO ₃⁻ is usually neutralised by H⁺ as the gastric secretions are gradually reabsorbed. As a result, there is no net addition of HCO ₃⁻ to plasma overall. Vomiting results in a loss of acidic gastric juices from the digestive tract, so that there is an abnormal loss of H⁺ from the body, and hence a loss of reabsorbed H⁺ to neutralise the extra HCO ₃⁻ added to the plasma during gastric HCl secretion. This leads to an acid-base disturbance associated with an increase in HCO ₃⁻ and a decrease in H⁺, hence the metabolic alkalosis.

Management and treatment of nausea and vomiting

1. Identify the pathway by which each cause triggers the vomiting reflex;

2. Identify the chemical transmitter involved in the identified pathway;

3. Choose a drug that is able to act as a preventer of this reflex pathway;

4. Appropriate drug delivery (e.g. as a tablet, as an injection). The route of administration depends on the state and condition of the patient. Drugs in rectal or parental form are necessary where oral medication is not tolerated or is contraindicated such as after major surgery;

5. Try to optimise the dose of the medication (usually start with the recommended dose).

If the underlying cause of the nausea and vomiting is unable to be identified, control of the symptoms should be established. It is also important to correct for electrolyte, fluid, and/or nutrient deficiencies.

Antiemetic medications
Dopamine antagonists
The members of this class of antiemetics are metoclopramide (Maxolon) and prochlorperazine (Stemitil). Metoclopramide has anti-dopamine action, which stimulates motility of the upper gut without stimulating the gastric, biliary or pancreatic secretions. Its exact mechanism is still unclear, however it is thought that metoclopramide may sensitize the tissues to the action of ACH. On the other hand, prochlorperazine has several activities such as anti-dopamine action, alpha-adrenoreceptor antagonism, weak anticholinergic, antihistamine and serotonin antagonism actions. Thereby its mechanisms of action give prochlorperazine strong antiemetic and antipsychotic properties.
Antihistamines
An example of this class of antiemetics is promethazine. Promethazine is a long acting antihistamine with sedative and anticholinergic properties that enhance the antiemetic activity.
5HT3 antagonists
5HT3 antagonists are mainly used to prevent or treat nausea and vomiting following cancer chemotherapy, radiotherapy or surgery. The members of this class of antiemetic are palonosetron (Aloxi), granisetron (Kytril), ondansetron, dolasetron and tropisetron. These medicines are potent antiemetic and highly selective antagonists of 5HT3 receptors. Because 5HT3 receptors are located peripherally on vagal nerve terminals and centrally in the CTZ, antagonism of this receptor is an effective method of preventing nausea and vomiting.
Anticholinergics
An example of this class of antiemetics is hyoscine, which is a belladonna alkaloid. Hyoscine has anti-spasmodic and anti-motility effect on the gut by inhibiting the activity of ACH.

Dietary management of nausea
Nausea with or without vomiting is a common side effect of surgery, chemotherapy, radiation therapy, and biological therapy. Nausea can prevent you from eating enough food and maintaining your nutritional intake and weight.
Dietary strategies to manage nausea include:

Discuss anti nausea (antiemetic) medications with your doctor;

Avoid eating 1-2 hours before your treatment if this makes nausea worse. Try to 'catch up' after treatment;

Avoid foods that:

are fatty/greasy/fried;

are spicy or hot;

have strong odours.

Eat small amounts more frequently and eat slowly;

Eat before you get hungry, because hunger can make feelings of nausea stronger;

Avoid eating in a room that is stuffy, too warm, or has cooking odors that might disagree with you;

Sip cold clear fluids (e.g. cordial, flat gingerale, lemonade, diluted fruit juices, icy poles and jelly). This is particularly important if you are vomiting to prevent dehydration;

Have foods and drinks at room temperature or cooler; hot foods may add to nausea;

Rest after meals, because activity may slow digestion. It's best to rest sitting up for about an hour after meals;

Choose stomach-friendly foods, such as toast, crackers, yoghurt, creamed rice, oatmeal, boiled potatoes, rice, noodles, steamed/baked skinned chicken, canned peaches or other soft, bland fruits and vegetables, carbonated drinks that have gone flat;

If vomiting persists after a day or two, contact your doctor or treatment centre. Contact them sooner if you feel very unwell.

Article kindly reviewed by:
The DAA WA Oncology Interest Group
and
Food4Health (Helen Baker Dietitian-APD)

References

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2. Cummins AJ. The physiology of symptoms: III. Nausea and vomiting. Am J Dig Dis. 1958;3(10):710-21. [Abstract]

3. Davis CJ, Lake-Bakaar GV, Grahame-Smith DG (eds). Nausea and Vomiting: Mechanisms and treatment. Berlin: Springer-Verlag; 1986. [Book]

4. Golembiewski J, Chernin E, Chopra T. Prevention and treatment of postoperative nausea and vomiting. Am J Health Syst Pharm. 2005 Jun 15;62(12):1247-60. [Abstract]

5. Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Book]

6. Longmore M, Wilkinson I, Rajagopalan SR. Oxford Handbook of Clinical Medicine (6th edition). Oxford: Oxford University Press; 2004. [Book]

7. Anzemet (dolasetron mesylate) [online]. St Leonards, NSW: MIMS Online; 20 November 2006 [cited 18 October 2007]. Available from: [URL Link]

8. Kytril (granisetron) [online]. St Leonards, NSW: MIMS Online; 2007 [cited 18 October 2007]. Available from: [URL Link*

9. Maxolon (metoclopramide hydrochloride) [online]. St Leonards, NSW: MIMS Online; 2007 [cited 18 October 2007]. Available from: [URL Link]

10. Onsetron (ondansetron) [online]. St Leonards, NSW: MIMS Online; 27 December 2006 [cited 18 October 2007]. Available from: [URL Link]

11. Stemetil (prochlorperazine) [online]. St Leonards, NSW: MIMS Online; 2007 [cited 18 October 2007]. Available from: [URL Link]

12. Saladin KS. Anatomy and Physiology: The unity of form and function (3rd edition). New York: McGraw-Hill; 2004. [Book]

13. Sherwood LS. Human Physiology: From cells to systems (5th edition). Belmont, CA: Brooks-Cole, Cengage Learning; 2004. [Book]

14. Nausea and vomiting. [online]. Melbourne, VIC: Therapeutic Guidelines; 2006 [cited 25 September 2007]. Available from: [URL Link]

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Nausea and Vomiting (Emesis) - HealthEngine Blog

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Vomiting can also be referred to as emesis, and consists of three stages: nausea is an unpleasant sensation of wanting to vomit; retching is a strong involuntary effort to vomit; and vomiting is the forceful expulsion of the stomach's contents through the mouth.

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https://www.nature.com/articles/nrdp201624

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https://pathways.nice.org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-disease

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Gastroenteritis is a nonspecific term used to describe a condition in which there is a combination of nausea, vomiting, diarrhoea and abdominal pain. The term is usually taken to mean those of infectious origin. See also the separate article Gastroenteritis in Children.

Gastroenteritis is caused by a variety of viral (eg, norovirus, rotavirus and adenovirus), bacterial (eg, Campylobacter spp., Escherichia coli O157, Salmonella spp., Shigella spp., or toxins from Staphylococcus aureus, Bacillus cereus or Clostridium perfringens) and parasitic pathogens (eg, Cryptosporidium spp., Entamoeba histolytica (amoebiasis) or Giardia lamblia).

About 20% of the UK population develop infectious intestinal disease each year.

Viral infections cause 30-40% of gastroenteritis cases in industrialised countries. The figure is higher for children. Norovirus is the most common cause of viral infectious gastroenteritis in adults in England and Wales. Adenovirus and rotavirus are much less common in teenagers than in younger children.

The 2014 Ebola virus outbreak is one of the largest Ebola outbreaks in history and the first in West Africa.

The causative agent for most cases of gastroenteritis is never isolated and the responsible agent never diagnosed. Management is not usually dependent upon cause.

Risk factors

Poor personal hygiene and lack of sanitation increase the incidence.

A compromised immune system leaves the patient vulnerable to gastroenteritis - eg, AIDS.

Achlorhydria increases risk, especially for Salmonella spp. and Campylobacter spp. Achlorhydria may also result from acid-suppressing drugs.

Infection may arise from poorly cooked food, cooked food that has been left too long at room temperature or from uncooked food such as shellfish. Insufficient reheating of food not only fails to kill bacteria but may speed up multiplication and increase the bacterial load ingested. Even if reheating of cooked food kills bacteria, enterotoxins such as staphylococcal exotoxin, are not destroyed.

The history may well give an indication of cause. The incubation period for viruses is usually about a day, for bacillary dysentery a few hours to four days and for parasites seven to ten days.

Epidemics in this country are usually caused by a rotavirus but norovirus is a common cause of 'winter vomiting'.

Bloody diarrhoea should arouse suspicion of bacterial infection, especially E. coli O157 or, after return from an exotic location, it may be E. histolytica. Salmonella spp. is also a possibility.

Pyrexia in adults often suggests an invasive organism as the cause, although many other illnesses can induce fever and diarrhoea, especially in children who generally are febrile with any type of infective gastroenteritis.

Check temperature, blood pressure, pulse rate and and respiratory rate.

Perform a thorough abdominal examination, particularly to consider other possible diagnoses - eg, appendicitis.

Assess for features of dehydration:

Mild dehydration: lassitude, anorexia, nausea, light-headedness, postural hypotension.

Moderate dehydration: apathy, tiredness, dizziness, muscle cramps, dry tongue, sunken eyes, reduced skin elasticity, postural hypotension (systolic blood pressure >90 mm Hg), tachycardia, oliguria.

Severe dehydration: profound apathy, weakness, confusion (leading to coma), shock, tachycardia, marked peripheral vasoconstriction, systolic blood pressure <90 mm Hg, oliguria or anuria.

Stool investigations - microscopy (include ova, cysts and parasites), culture and sensitivity:

A stool sample should be sent for microbiological investigation if:

There is blood and/or mucus in the stool.

The patient is immunocompromised.

Sending a stool sample should be considered if:

The patient has recently been abroad to anywhere other than western Europe, North America, Australia or New Zealand.

The diarrhoea has not improved by day seven.

There is uncertainty about the diagnosis of gastroenteritis.

Unwell patients may need blood tests - eg, FBC, renal function and electrolytes.

Other tests will depend on the clinical scenario - eg, bowel distension requires imaging.

Not all diarrhoea or vomiting is gastroenteritis and other causes must be considered. The following list is far from complete; however, it gives some other causes of diarrhoea or vomiting but not usually both. See also the separate article Chronic Diarrhoea in Adults.

Arrange emergency admission to hospital if the patient is vomiting and unable to retain oral fluids, or there are features of shock or severe dehydration.

Other factors when considering admission include recent foreign travel, older age, poor home circumstances and low level of support, fever, bloody diarrhoea, abdominal pain and tenderness, faecal incontinence, diarrhoea lasting more than ten days, co-existing medical conditions and drug therapy (eg, systemic steroids, angiotensin-converting enzyme (ACE) inhibitors, diuretics).

Both dysentery and food poisoning are notifiable diseases. The laboratory may report the isolation to the relevant authority but it is better to duplicate notification than to overlook it. Notification is a statutory duty.

There is little evidence on the use of oral rehydration salt (ORS) solution in adults in developed countries. For adults able to maintain their fluid intake, ORS solution does not provide any benefits in terms of reducing the duration of diarrhoea or the number of stools. ORS solution should be used as a treatment option in people who are frail or very elderly

Consumption of solid food should be guided by appetite. The person should eat small, light meals and avoid fatty, spicy, or heavy food. There is little evidence on any benefit of fasting or dieting for the treatment of acute diarrhoea.

Measures to prevent spread of infection - eg, hands should be washed thoroughly, towels and flannels should not be shared, soiled clothing and bedlinen should be washed separately from other clothes, at the highest temperature they will tolerate, and toilet seats, flush handles, wash hand basin taps, surfaces and toilet door handles should be cleaned at least daily with hot water and detergent.

Advise exclusion from work or other institutional settings until at least 48 hours after the person is free from diarrhoea and vomiting. Longer periods of exclusion may be required.

Antidiarrhoeal drugs are not usually necessary for the management of gastroenteritis. Antimotility drugs may be useful for symptomatic control in adults with mild-to-moderate diarrhoea - for example, if quicker resolution of diarrhoea would enable the person to continue essential activities. Loperamide is the antimotility drug of choice. Antimotility drugs should be avoided if there is blood and/or mucus in the stools, or high fever.

Antibiotics are not recommended for adults with acute diarrhoea of unknown pathology but may be appropriate when gastroenteritis is due to a known bacterial or protozoal cause.

Anti-emetics are not usually necessary for the primary care management of gastroenteritis.

The aims of management may be summarised as to identify the extent of dehydration and to treat accordingly and to educate patients in the management and prevention of gastroenteritis - eg, hand washing.

Dehydration and electrolyte disturbance.

Haemolytic uraemic syndrome (HUS), which is rare. HUS is characterised by acute kidney injury, haemolytic anaemia and thrombocytopenia. It occurs mostly in young children and the elderly.

Reactive complications - eg, arthritis, carditis, urticaria, erythema nodosum, conjunctivitis and reactive arthritis. They are associated with Salmonella spp., Campylobacter spp., Yersinia enterocolitica and Shigella spp. infections. There are usually no reactive complications associated with viral or parasitic gastroenteritis.

Systemic invasion by Salmonella spp. may cause endovascular infections and localised infections in bones, joints, meninges, or in the gallbladder.

Toxic megacolon caused by fulminant colitis is rare.

Guillain-Barré syndrome is associated with a number of viruses, especially cytomegalovirus (CMV), but Campylobacter jejuni has been the most commonly isolated pathogen in several studies.

Malnutrition.

Intractable diarrhoea: may (rarely) require long-term parenteral nutrition.

Irritable bowel syndrome.

Secondary lactose intolerance

Reduced absorption of drugs such as anticonvulsants or oral contraceptives may occur.

The risk of complications from gastroenteritis is greatest at the extremities of life, in people with concurrent chronic disease and in those who are immunocompromised. Complications include:

Usually there is an uneventful recovery. Risk is greatest at the extremes of life and in those with immunocompromise. In England and Wales between 2001-2006, 20% of deaths in persons >65 years of age caused by infectious intestinal disease other than Clostridium difficile were associated with norovirus infection.

In developing countries, gastroenteritis is a leading cause of death. In November 2014, the total reported number of deaths in West Africa due to the Ebola virus was 5,420.

Meats should be properly cooked. Vegetables and salads should be thoroughly washed before eating.

Uncooked meats should be kept separate from cooked and ready-to-eat food, to avoid cross-contamination.

Chopping boards, knives and other utensils should be washed thoroughly in hot soapy water immediately after handling any raw meat.

Hands should be washed before handling different food items and eating or drinking and after going to the toilet or handling pets. Effective use of hand washing could prevent many cases.

Infants, the elderly and those with immunological compromise are more likely to have more severe disease and to require admission to hospital for rehydration. In severe cases hypovolaemic shock and even death can occur.

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Gastroenteritis in Adults and Older Children

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Gastroenteritis is a nonspecific term used to describe a condition in which there is a combination of nausea, vomiting, diarrhoea and abdominal pain. The term is usually taken to mean those of infectious origin. See also the separate article Gastroenteritis in Children.

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Food poisoning means getting sick from eating food with poisonous stuff in it. But not usually the kind of poisons used by the killer in an Agatha Christie story. Usually the poison comes from some type of germ.

Many types of germs can cause food poisoning, including bacteria, viruses and parasites. Common culprits include:

You are more likely to pick up food poisoning if you are not careful about how you store and handle food, and about what and where you eat or drink.

The main symptom is diarrhoea, often with being sick (vomiting) as well. Diarrhoea is defined as "loose or watery stools (faeces), usually at least three times in 24 hours". Blood or mucus can appear in the stools with some infections.

Crampy pains in your tummy (abdomen) are common. Pains may ease for a while each time you pass some diarrhoea.

You may feel hot one minute and cold and shivery the next, and achy all over. These are symptoms of a high temperature (fever) which sometimes develops along with the tummy symptoms.

If vomiting occurs, it often lasts only a day or so but sometimes longer. Diarrhoea often continues after the vomiting stops and commonly lasts for several days or more. Slightly loose stools may persist for a week or so further before a normal pattern returns. Sometimes the symptoms last longer.

The vomiting and diarrhoea usually start hours or a very few days after eating the infected food. Afterwards, you often feel drained and washed out for a few days, while you regain your appetite and 'oomph'.

Symptoms of lack of fluid in the body

Diarrhoea and vomiting may cause lack of fluid in the body (dehydration). Consult a doctor quickly if you suspect you are becoming dehydrated. Mild dehydration is common and is usually easily reversed by drinking lots of fluids. Severe dehydration can be fatal unless quickly treated because the organs of your body need a certain amount of fluid to function.

Symptoms of dehydration in adults include:

Tiredness.

Dizziness or light-headedness.

Headache.

Muscle cramps.

Sunken eyes.

Passing less urine.

A dry mouth and tongue.

Weakness.

Becoming irritable.

Symptoms of severe dehydration in adults include:

Profound loss of energy or enthusiasm (apathy).

Weakness.

Confusion.

A fast heart rate.

Producing very little urine.

Coma - may occur.

Severe dehydration is a medical emergency and immediate medical attention is needed.

Dehydration in adults is more likely to occur in:

Elderly or frail people.

Pregnant women.

People with severe diarrhoea and vomiting. In particular, if you are not able to replace the fluid lost with enough drinks.

When do I need to seek medical advice?

You should seek medical advice if:

You think that you are becoming dehydrated.

You are vomiting a lot and can't keep fluids down at all.

You have blood in your stools (poo) or you vomit up blood.

You have severe tummy pain.

You have severe symptoms, or if you feel that your condition is becoming worse.

You have a high temperature (fever), which doesn't settle with medicines such as paracetamol, or which hangs about for three days or more.

Your symptoms are not settling; for example, vomiting for more than 1-2 days, or diarrhoea that does not start to settle after 3-4 days.

Your infection was caught abroad.

You are elderly or have an underlying health problem such as diabetes, epilepsy, inflammatory bowel disease, kidney disease.

You have a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, HIV infection.

You are pregnant.

You suspect that you may have contracted food poisoning from eating restaurant or takeaway food.

There are any other symptoms that you are concerned about.

Food poisoning is common and most of us will recognise the scenario. You ate something that looked (or smelled) a little dodgy, or you were abroad in a country where it isn't safe to drink the water, and you had a salad. Washed in the water you know you shouldn't drink. A few hours later you get tummy ache, and you are being sick (vomiting) and running backwards and forwards to the toilet. There are pet names for it in different parts of the world: Delhi belly, Kathmandu quickstep, Montezuma's revenge, Karachi crouch. But you can pick it up pretty much anywhere, including your own home.

Campylobacter is the most common germ (bacterium) that causes food poisoning in the UK. Other germs (bacteria) that can cause food poisoning include:

Some germs (viruses), such as norovirus or rotavirus, can contaminate food and cause food poisoning.

Parasites
These are another type of microbe. Parasites are living things (organisms) that live within, or on, another organism. Examples include cryptosporidium, Entamoeba histolytica and giardia parasites. Food poisoning caused by parasites is more common in the developing world.

In the UK, a common cause of food poisoning is Toxoplasma gondii. This is a parasite that lives in the bowels of a number of animals, including cats. Food poisoning can occur if food or water is contaminated with the stools (faeces) of infected cats, or if raw or undercooked meat from another animal carrying the parasite is eaten. The infection is known as toxoplasmosis. Symptoms of this type of food poisoning include swollen lymph glands and sometimes a skin rash.

Toxins and chemicals
Poisons (toxins) produced by bacteria can also contaminate food, as well as the bacteria themselves. For example, the bacterium Staphylococcus aureus can contaminate ice cream and its toxins can lead to food poisoning. The bacterium Bacillus cereus can contaminate rice. If contaminated rice is reheated and eaten, the toxins produced can lead to food poisoning.

Certain types of fish (including shark, marlin, swordfish and tuna) contain high levels of the chemical mercury. Eating these types of fish is not normally a problem for most people - it does not cause gastroenteritis or food poisoning. But pregnant women are advised to avoid eating shark, marlin and swordfish and to limit tuna. This is because a high level of mercury can damage the developing nervous system of an unborn baby.

Oily fish may be contaminated by chemicals called polychlorinated biphenyls. Again, this does not usually cause a problem or food poisoning for most people. However, you should limit the amount of oily fish you eat in pregnancy because of possible effects of these chemicals on a developing baby. Public Health England recommends no more than two portions of oily fish a week.

Note: this is a general leaflet about food poisoning. There are separate leaflets that give more details about some of the different microbes that cause food poisoning.

How does food become contaminated?

Contamination of food can occur because of problems in food production, storage or cooking. For example:

How does water become contaminated?

Water can become contaminated with bacteria or other microbes usually because human or animal stools (faeces) get into the water supply. This is particularly a problem in countries with poor sanitation. In such countries, food may also be washed and prepared using contaminated water. So, for example, in countries with poor sanitation, you should always avoid:

Most people will recognise food poisoning from their typical symptoms. If symptoms are mild, you do not usually need to seek medical advice or receive specific medical treatment.

However, in some circumstances, you may need to seek medical advice when you have food poisoning (see below about when to seek medical advice). The doctor may ask you questions about recent travel abroad or any ways that you may have eaten or drunk contaminated food or water. The doctor will also usually check you for signs of lack of body fluid (dehydration). They may check your temperature, pulse and blood pressure. They may also examine your tummy (abdomen) to look for any tenderness.

Your doctor may ask you to collect a stool (faeces) sample. This can then be examined in the laboratory to look for the cause of the infection. A stool sample is not always needed. Your doctor is likely to suggest one in certain situations, such as:

If you have recently been abroad.

If you are very unwell.

If you have blood or pus in your stools.

If your diarrhoea is not settling after a week.

If you have recently been in hospital or had antibiotic treatment.

If you have another medical condition, particularly one which affects your immune system.

If the doctor is not sure you have food poisoning or a gut infection (gastroenteritis).

If your job involves handling food.

The reason a stool sample is not always needed is that in many cases knowing what germ you have does not make any difference to the treatment you need. Most cases of food poisoning get better on their own even before the stool test result is back.

If you are very unwell, you may need admission to hospital. If this is the case, further investigations may be needed such as blood tests, scans or a lumbar puncture. This is to look for spread of the infection to other parts of your body.

If you think your infection may have come from food at a particular restaurant or shop then inform your local Environmental Health Office. (Find them via the Food Standards Agency website's Report a food problem page.) This is so that the business can be checked out by environmental health officers. Further actions may be taken if there is a problem with their food hygiene practices. This will hopefully help to reduce the chance that other people will get food poisoning. If your doctor suspects or confirms that you have food poisoning, they are also required by law to report this.

Symptoms often settle within a few days or so as your immune system usually clears the infection. Occasionally, admission to hospital is needed if symptoms are severe, or if complications develop (see below).

The following are commonly advised until symptoms ease:

Fluids - have lots to drink

The aim is to prevent lack of body fluid (dehydration), or to treat dehydration if it has developed. ( Note: if you suspect that you are dehydrated, you should contact a doctor.)

As a rough guide, drink at least 200 mls after each watery stool (each bout of diarrhoea).

This extra fluid is in addition to what you would normally drink. For example, an adult will normally drink about two litres a day but more in hot countries. The above '200 mls after each watery stool' is in addition to this usual amount that you would drink.

If you are sick (vomit), wait 5-10 minutes and then start drinking again but more slowly. For example, a sip every 2-3 minutes but making sure that your total intake is as described above.

You will need to drink even more if you are dehydrated. A doctor will advise on how much to drink if you are dehydrated.

For most adults, fluids drunk to keep hydrated should mainly be water. Also, ideally, include some fruit juice and soups. It is best not to have drinks that contain a lot of sugar, such as cola or pop, as they can sometimes make diarrhoea worse.

Rehydration drinks are recommended for people who are frail, or over the age of 60, or who have underlying health problems. They are made from sachets that you can buy from pharmacies. (The sachets are also available on prescription.) You add the contents of the sachet to water. Rehydration drinks provide a good balance of water, salts, and sugar. The small amount of sugar and salt helps the water to be absorbed better from the gut (intestines) into the body. They do not stop or reduce diarrhoea. Do not use home-made salt/sugar drinks, as the quantity of salt and sugar has to be exact.

Eat as normally as possible

It used to be advised to 'starve' for a while if you had food poisoning. However, now it is advised to eat small, light meals if you can. Be guided by your appetite. You may not feel like food and most adults can do without food for a few days. Eat as soon as you are able - but don't stop drinking. If you do feel like eating, avoid fatty, spicy or heavy food at first. Plain foods such as wholemeal bread and rice are good foods to try eating first.

Medication

Antidiarrhoeal medicines are not usually necessary. Your body is doing its best to get rid of the germ for you, and you will recover more quickly if you let it do so. However, a medicine called loperamide may be advised in some situations. For example, to help you over a special event such as a wedding, or if you have difficulty reaching the toilet quickly. Loperamide works by slowing down your gut's activity and it can reduce the number of trips that you need to make to the toilet. You can buy loperamide from pharmacies. The adult dose of loperamide is two capsules at first. This is followed by one capsule after each time you pass some diarrhoea, up to a maximum of eight capsules in 24 hours. You should not take loperamide for longer than five days.

Note: although loperamide is usually safe, there have been reports of very serious gut problems developing in some people who have taken loperamide. These problems were mainly in people who had severe inflammation of the gut. So, do not use loperamide or any other antidiarrhoeal medicine if you pass blood or mucus with the diarrhoea or if you have a high temperature (fever). Also, people with certain conditions should not take loperamide. Pregnant women should not take loperamide. Therefore, to be safe, read the leaflet that comes with the medicine.

Paracetamol or ibuprofen is useful to ease a high temperature or headache.

In some cases, your doctor may ask for a sample of the diarrhoea. This is sent to the laboratory to look for infecting germs (microbes such as bacteria, parasites, etc). A course of antibiotic medicine is sometimes needed when the germ is identified. Examples where antibiotics might be needed include:

If symptoms are very severe

If the infection is not improving as expected. For example, if symptoms are still persisting after one week.

If you are older than 50 with confirmed infection with salmonella.

If you have other medical conditions, such as problems with your heart valves, and have confirmed salmonella infection.

If you have blood in your diarrhoea and have confirmed shigella infection.

If your immune system is not working as well as normal - for example, due to chemotherapy or if you have an illness such as AIDS.

Infections with some specific germs, usually those acquired abroad, are usually treated with antibiotics. For example, infection with giardia, or amoebic infection.

Complications are uncommon in the UK. Those who are older are more likely to develop complications. Complications are also more likely if you have an ongoing (chronic) condition such as diabetes or if your immune system is not working normally. (For example, if you are taking long-term steroid medication or you are having chemotherapy treatment for cancer.) Possible complications include the following:

Salt (electrolyte) imbalance and lack of fluid (dehydration) in your body. This is the most common complication. It occurs if the salts and water that are lost in your stools (faeces), or when you are sick (vomit), are not replaced by you drinking adequate fluids. If you can manage to drink plenty of fluids then dehydration is unlikely to occur, or is only likely to be mild, and will soon recover as you drink. Severe dehydration can lead to a drop in your blood pressure. This can cause reduced blood flow to your vital organs. If dehydration is not treated, your kidneys may be damaged. Some people who become severely dehydrated need a 'drip' of fluid directly into a vein. This requires admission to hospital. People who are elderly or pregnant are more at risk of dehydration.

Reactive complications. Rarely, other parts of your body can 'react' to an infection that occurs in your bowels. This can cause symptoms such as joint inflammation (arthritis), skin inflammation and eye inflammation (either conjunctivitis or uveitis).

Spread of infection to other parts of your body such as your bones, joints, or the meninges that surround your brain and spinal cord. This is rare. If it does occur, it is more likely if diarrhoea is caused by salmonella infection.

Persistent diarrhoea syndromes may rarely develop:

Irritable bowel syndrome is sometimes triggered by a bout of food poisoning.

Lactose intolerance can sometimes occur for a period of time after food poisoning. This is known as 'secondary' or 'acquired' lactose intolerance. Your bowel (intestinal) lining can be damaged by an episode of bowel infection. This leads to lack of a chemical (enzyme) called lactase that is needed to help your body digest a sugar called lactose that is in milk. Lactose intolerance leads to bloating, tummy (abdominal) pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the bowel lining heals. It is more common in children than in adults.

Haemolytic uraemic syndrome is another potential complication. It is rare and is usually associated with food poisoning caused by a certain type of E. coli infection. It is a serious condition where there is anaemia, a low platelet count in the blood and kidney failure. It is more common in children. If recognised and treated, most people recover well.

Guillain-Barré syndrome may rarely be triggered by campylobacter infection. This is a condition that affects the nerves throughout your body and limbs, causing weakness and sensory problems. See the separate leaflet called Guillain-Barré syndrome for more details.

Reduced effectiveness of some medicines. During an episode of food poisoning, certain medicines that you may be taking for other conditions or reasons may not be as effective. This is because the diarrhoea and/or vomiting means that reduced amounts of the medicines are taken up (absorbed) into your body. Examples of such medicines are those for epilepsy, diabetes and contraception. Speak with your doctor or practice nurse if you are unsure of what to do if you are taking other medicines and have food poisoning.

The Foods Standards Agency in the UK has identified the '4 Cs' to help prevent food poisoning:

Cleanliness

Cooking

Make sure that you cook food thoroughly, especially meat. This will kill germs (bacteria). Food should be cooked right through and be piping hot in the middle.

If you are reheating food, it needs to be cooked right through and be piping hot in the middle.

Don't reheat food more than once.

Chilling

Food that needs to be chilled or refrigerated should be. If food is left out of the fridge, bacteria may multiply to levels that can cause food poisoning.

Your fridge needs to be kept between 0°C and 5°C. Also, don't leave the door open unnecessarily.

Cool leftover food quickly and then refrigerate. Taking it out of the cooking pot and putting it into a shallow container can speed up the cooling process.

Cross-contamination

This occurs when bacteria pass from foods (commonly, raw foods) to other foods. It can occur if:

Foods touch directly.

One food drips on to another.

Your hands or utensils or equipment such as knives or chopping boards touch one food and then another.

It is important to:

Preventing the spread of food poisoning to others

Some infections causing diarrhoea and vomiting are very easily passed on from person to person. If you have diarrhoea, the following are also recommended to prevent the spread of infection to others:

Wash your hands thoroughly after going to the toilet. Ideally, use liquid soap in warm running water but any soap is better than none. Dry properly after washing.

Don't share towels and flannels.

Don't prepare or serve food for others.

Regularly clean the toilets that you use. Wipe the flush handle, toilet seat, bathroom taps, surfaces and door handles with hot water and detergent at least once a day. Keep a cloth just for cleaning the toilet (or use a disposable one each time).

Stay off work, college, etc, until at least 48 hours after the last episode of diarrhoea or vomiting.

Food handlers: if you work with food and develop diarrhoea or vomiting, you must immediately leave the food-handling area. For most, no other measures are needed, other than staying away from work until at least 48 hours after the last episode of diarrhoea or vomiting. Some special situations may arise and sometimes longer time off is needed. If in doubt, seek advice from your employer or GP.

If the cause of food poisoning is known to be (or suspected to be) a germ called cryptosporidium, you should not swim in swimming pools for two weeks after the last episode of diarrhoea.

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Food Poisoning in Adults - Symptoms, Causes and Treatment

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Food poisoning means getting sick from eating food with poisonous stuff in it. But not usually the kind of poisons used by the killer in an Agatha Christie story. Usually the poison comes from some type of germ. Many types of germs can cause food poisoning, including bacteria, viruses and parasites.

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GI secretions include enzymes and fluids which aid in the liberation of nutrients from food, as well as mucus which facilitates transport of food down the alimentary tract. The nature of the secretions change in the different segments of the GI tract and each are discussed individually below along with their regulation.

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Structure of the stomach.

Food starts to be digested and absorbed in the stomach, although absorption is mostly limited to water, alcohol and some drugs. The stomach is an expandable, muscular bag, and it keeps swallowed food inside it by contracting the muscular pyloric sphincter. Food can stay in the stomach for 2 hours or more. Food is broken down chemically, by gastric juice, and mechanically, by contraction of the three layers of smooth muscle in the muscular externa layer. The broken up food at the end of this process is called chyme.

Gastric juice is secreted by gastric mucosal glands, and contains hydrochloric acid, mucus, and proteolytic enzymes pepsin (which breaks down proteins), and lipase (which breaks down fats).

When the stomach is empty, and not distended, the lining is thrown up into folds called rugae. After eating, these folds flatten, and the stomach is able to distend greatly.

The stomach has three anatomical regions:

1. cardiac, which contains mucous secreting glands (called cardiac glands) and is closest to the oesophagus

2. fundus, the body or largest part of the stomach which contain the gastric (fundic) glands

3. pyloric, which secretes two types of mucus, and the hormone gastrin.

Compare the glands present in these three regions.

The pyloric region ends at the pyloric sphincter. This sphincter relaxes when the formation of chyme is completed, and the chyme is squirted into the duodenum.

When you've worked through the three regions of the stomach, test your knowledge.

Layers of the stomach.

This shows an image through the wall of the body of the stomach at low power. You should be able to identify the three major layers seen here - the mucosa, submucosa and muscularis externa.

The mucosa is full of gastric glands and pits, and there is a prominent layer of smooth muscle - the muscularis mucosa. The contraction of this muscle helps to expel the contents of the gastric glands.

The muscularis externa layer has three layers of muscle. An innner oblique layer , a middle circular and an external longitudinal layer. The contraction of these muscle layers help to break up the food mechanically.

Now look at this eMicroscope showing the layers.
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This image may also be viewed with the Zoomify viewer.

Oesophageo-gastric junction.

The structure of the oesophagus was covered in the topic 'oral'. The oesophagus forms a junction with the stomach, which is called the oesophageo-gastric junction.

The photograph on the right hand side shows this junction.

Can you identify the oesophageo-gastric junction, where the oesophagus ends, and the stomach begins? This region of the stomach is called the 'cardiac' region. How does the mucosa in this region change?

Gastric Glands in the fundus (body) of the stomach

The epithelium of the mucosa of the fundus and body of the stomach forms invaginations called gastric pits. The lamina propria contains gastric glands, which open into the bases of the gastric pits. These glands are responsible for the synthesis and secretion of the gastric juice.

The lining epithelium of the stomach, and gastric pits is entirely made up of mucous columnar cells. These cells produce a thick coating of mucus, that protects the gastric mucosa from acid and enzymes in the lumen. Even so, these cells have to be replaced after 4-6 days.

This diagram shows the structure of a gastric gland, a simple tubular gland.

The isthmus and neck contain dividing cells (stem cells) immature cells and maturing neck mucous cells. The mature cells move up to replace the surface mucous cells. These mucous cells are very pale staining.

Parietal (oxyntic) cells are also concentrated in the isthmus region, but also found in the base and neck of the glands. These are large pale staining cells with a central spherical nucleus. Can you identify them in these sections? (They have a 'fried egg' appearance). Parietal cells make hydrochloric acid, and intrinsic factor, which is needed for absorption of vitamin B12 in the terminal ileum.

Chief/Peptic/zymogenic cells are found in the bases of gastric glands. They have a stongly basophilic granular cytoplasm, as they have lots of rER for production of peptin, which is secreted (as precursor pepsinogen), and basally located nuclei.

Neuroendocrine cells in the bases of the glands secrete serotonin and other hormones.

Look at this high power image of the gastric mucosa from the fundus (main body of the stomach) showing the numerous gastric pits. Can you identify Parietal cells and Peptic cells, surface mucous cells, gastric pits, and the base of the pits.

Now take a look at this eMicroscope of the gastric pits and glands in the fundus.
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This image may also be viewed with the Zoomify viewer.

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Food starts to be digested and absorbed in the stomach, although absorption is mostly limited to water, alcohol and some drugs. The stomach is an expandable, muscular bag, and it keeps swallowed food inside it by contracting the muscular pyloric sphincter. Food can stay in the stomach for 2 hours or more.

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affect of stress on the digestive system 

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affect of stress on the digestive system 

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How does our body react to stress?

Is it really any coincidence that London seems to be full of stressed people suffering with digestive problems and lack of sleep?

The pace of life, the volume of people and the daily demands in a busy city are a good example of what happens when we are exposed to constant stressors.

In actual fact, it makes no difference what is causing the stress, the real problem is the chain reaction of stress hormones released in the body as it physically prepares to fight against, or flee from any perceived threat:

Blood is diverted to the brain, heart, lungs and muscles, which will need to work well to get you out of danger

The heart beat speeds up to pump blood more effectively round the body to these areas

Blood is diverted away from the digestive tract, as stopping for a picnic shouldn't really be on the agenda when there's a life and death situation going on

Breathing speeds up to get oxygen supplies to the muscles as quickly as possible

Sweat levels go up to stop the body from overheating

Blood sugar levels go up dramatically so that glucose is available to feed the brain and muscles

Blood vessels constrict.

The overall effect is higher blood pressure, digestive problems, anxiety, tense muscles and palpitations. If your body is flooded with stress hormones continuously, these symptoms worsen.

What happens to the digestive system when we are stressed?

Under normal circumstances our digestive system should be able to go about its daily task of mixing, contracting and absorbing, to help break down our food and begin extracting the nutrients and vitamins that we require for good health.

However, when stress hormones are flooding our body, our digestive system effectively shuts down, causing our digestive muscles to contract more or less frequently, our gastric secretions and stomach acid levels to increase or decrease and our healthy gut bacteria to change composition.

At the very time we need to slow down, breathe, rest and digest, we bolt our food, eat on the run and make life even harder on our digestion.

What are the digestive symptoms we are likely to experience?

Fewer digestive secretions are made to help us digest food (causing more wind, bloating and nausea)

Stomach acid levels can increase (causing acid reflux, pain and inflammation)

The digestive contractions can increase or decrease (diarrhoea, constipation, spasm, etc.)

These symptoms also leave us open to compromised immunity (with at least 70% of our immune cells in our gut), infection, and further impact on our mood.

The brain in the gut or Enteric Nervous System

The important link between the gut and the brain also needs to be mentioned. We have all heard of 'gut feelings' or 'having butterflies' in certain situations.

This is thought to be due to the Enteric Nervous System (ENS) or the 'brain in the gut' linking digestive function to mood and vice versa. The ENS is two thin layers of more than 100 million nerve cells lining our gastrointestinal tract from oesophagus to rectum.

A highway of nerves runs directly from our actual brain to our digestive system, and messages flow in both directions between the two.
Did you know?
95 percent of the body's serotonin (a hormone that helps control mood, sleep, appetite) is found in the digestive system, not the brain.

The ENS may trigger big emotional shifts experienced by people coping with irritable bowel syndrome (IBS) and functional bowel problems such as constipation, diarrhoea, bloating, pain and stomach upset.

image: https://www.northwestpharmacy.com/healthperch/gut-health/

" For decades, researchers and doctors thought that anxiety and depression contributed to these problems. But our studies and others show that it may also be the other way around," explains Jay Pasricha, M.D., director of the Johns Hopkins Center for Neurogastroenterology, whose research on the enteric nervous system has gained international attention. Researchers are finding evidence that irritation in the gastrointestinal system may send signals to the central nervous system (CNS) that trigger mood changes.

" These new findings may explain why a higher-than-normal percentage of people with IBS and functional bowel problems develop depression and anxiety," Pasricha says. " That's important, because up to 30 to 40 percent of the population has functional bowel problems at some point. "

How can we help ourselves?

If you notice any change in digestive function, do consult with your GP or healthcare provider. They will be able to ask certain questions and arrange any applicable tests to help determine the cause. If stress is considered to be the main culprit, addressing the source of the stress should naturally be a priority.

Talking therapies

' Talking therapies' which involve working with a qualified therapist to find better ways to deal with stress should not be underestimated. Methods such a CBT, which addresses intrusive and unwanted thought patterns can be particularly helpful, and have been shown to improve symptoms of irritable bowel syndrome by up to 70 percent in some people, over a period of a few months.

Listen to your gut

Given the link between the gut and the brain we can be wired to react to certain foods, and may feel better avoiding them. Have you ever felt tired, nauseous, or a little "fuzzy" after a meal? If so, your enteric nervous system may be reacting to something you ate. Pay attention to how you feel after eating. If it helps you to keep track, try writing a food diary for a few weeks or consult with a nutritional therapist. ( www.bant.org.uk)

Balanced diet

The body is always working towards balance and this is a sensible way to approach what we eat. The digestive system appreciates a healthy, whole food, well-balanced diet. When under stress we may instinctively reach for extremes in sugar, fat, caffeine, alcohol and processed foods but this can just exacerbate the stress cycle and digestive dysfunction.
Eating mindfully
If our Sympathetic Nervous System (the part of nervous system in charge of 'fight or flight') has been in overdrive, we need to counterbalance the effects by switching on our Parasympathetic Nervous System (the part of the nervous system in charge of 'rest and digest').

Copyright© 2007 Pearson Education, Inc, publishing as Benjamin Cummings

One of the ways we can do this is to aim for the experience of mindful eating rather than refuelling. In other words, rather than grabbing food and eating on the run, we endeavour to take time to sit down, relax and enjoy our food.

Chew, chew and chew some more

If we could only change one thing, my recommendation would be to chew, chew and chew some more. As our digestion expert Ali says, ' Don't bolt your food down. If it hardly touches the sides as it goes down, the chances are the digestive system won't be ready for it and all sorts of mayhem will break out. Try chewing each mouthful 20 times for a while and surprise yourself with how much better your digestive tract feels.'

The process of chewing not only helps to break down food into digestible particles but also produces digestive enzymes through saliva. The more we chew, the easier on our stomach and small intestine and the better we are likely to digest, avoiding unpleasant symptoms.

image: https://www.fix.com/blog/mindfulness-techniques-to-reduce-stress/

Avoid drinking with meals

When we drink fluid with a meal we dilute our natural digestive enzymes and potentially wash down the food before it has been properly broken down. To maximise digestive potential, stick to drinking 20 or 30 minutes before or after a meal.

Exercise

Moderate exercise is one of the best ways to manage stress and maintain healthy digestion. Physical activity relieves tension and stimulates the release of those feel good chemicals called endorphins which naturally improve our mood.

According to studies a post-meal walk can speed up the rate at which food moves through the stomach as well as decreasing blood sugar and lowering cardiovascular risk.

Relaxation therapy

People who have stress-related digestive problems often benefit from relaxation therapies such as yoga, meditation, hypnosis, progressive muscle relaxation, and even soothing music. IBS sufferers have been found to experience a significant reduction in pain and bloating through practising these techniques.

Bowel Essence and Bitters

As an IBS sufferer, two of my favourite ways to tackle digestive dysfunction are flower essences and bitters.

I was introduced to Bowel Essence during a particularly stressful time in my life and was advised that this flower essence combination may help relieve emotionally triggered digestive issues. Its significant impact surprised me and, needless to say, it has been a constant companion ever since!

Bitter herbs were also a revelation to me in their ability to improve digestive function, assimilation and elimination. Anyone suffering with digestive issues can benefit from including bitter foods in the diet, such as chicory, dandelion root coffee, artichoke, watercress, rocket, etc.

A tincture of bitters such as Digestisan in a little water, 20 minutes or so before meals, can also be such a helpful formula for those needing the extra digestive support.

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How does stress impact our digestive system?

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Is it really any coincidence that London seems to be full of stressed people suffering with digestive problems and lack of sleep? The pace of life, the volume of people and the daily demands in a busy city are a good example of what happens when we are exposed to constant stressors.

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What if Jonah’s symptoms had come on after a course of co-amoxiclav?

This introduces the concept of antibiotics causing disruption of normal flora producing a niche for infection with pathogens such as C. difficile (antibiotic-associated diarrhoea)

What if Jonah diarrhea had occurred after he had come home from a holiday abroad? This would make you think of travel associated diarrhea.  Send stool sample to lab with details of where the patient has travelled, for how long etc and request tests for a wider range of pathogens e.g. helminths and protozoa.

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Case 3 Patient details

They have been prompted to ask the following:

What information would you want to gather? How would you phrase the questions?

What clinical examination would you decide to do?

What blood tests might you order?

What other tests might you order?

History of presenting complaint:
Yi has had the pain on 3 occasions in the last couple of months. Normally the pain lasts 1 – 2 hours and is 3/10 in intensity. It occurs after eating, especially fatty food and she describes the pain as gripping and coming in waves.

The pain is in the stomach area and under right breast (epigastric / right upper quadrant region). Her pain today is also felt in the right shoulder. There is no lower abdominal pain (hypogastric / R or L iliac fossa regions).

Systemic enquiry:
Appetite, swallowing: normal. She has vomited once. Her bowels are normal. No bloating.

Past medical history: Nil of note

Drug history: Nil
Allergies: Nil

Social History:
She doesn’t smoke, drink or take recreational drugs. Yi is married, works in an office and has one son.

On examination:
temp= 37.5, pulse rate 88, blood pressure 105/72. Other vital signs normal.

Abdomen: soft, tender in upper right quadrant region. Nil masses found and bowels sounds normal.

Investigations:

Full blood count: Normal (performed to look for infection

Renal function tests: Normal (performed to assess level of hydration, drug safety),

Liver function test: Higher end of normal range (performed to look for jaundice / liver dysfunction)

C-reactive protein: Higher end of normal (Performed to look for inflammation/infection),

Amylase: Normal (to look for pancreatitis)

Ultrasound Abdomen: Fluid filled gallbladder. At least 3 mobile small gallstones seen. Slight thickening (indicating likely previous inflammation) of the gallbladder wall. Liver, spleen, kidney normal.

ECG, Chest x-ray: Normal

Diagnosis: gallstones causing biliary colic (pain caused by the cystic duct being blocked temporarily by a gallstone)

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BA-QT-FF

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BB-PQ-JR

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https://www.amboss.com/us/knowledge/Muscarinic_antagonists#Z84a7b3381d10a12ff0f5ed39bc9030f2

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We'd like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services.

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We use some essential cookies to make this website work. We'd like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services. We also use cookies set by other sites to help us deliver content from their services.

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preventing embarrassment during consultations  

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preventing embarrassment during consultations  

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This article, the second in a six-part series on communication skills, a discusses the barriers to effective communication and how to overcome them

Abstract

Competing demands, lack of privacy, and background noise are all potential barriers to effective communication between nurses and patients. Patients’ ability to communicate effectively may also be affected by their condition, medication, pain and/or anxiety. Nurses’ and patients’ cultural values and beliefs can also lead to misinterpretation or reinterpretation of key messages. This article, the second in a six-part series on communication skills, suggests practical ways of overcoming the most common barriers to communication in healthcare.

Citation: Ali M (2017) Communication skills 2: overcoming barriers to effective communication Nursing Times; 114: 1, 40-42.

Author: Moi Ali is a communications consultant, a board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care, and a former vice-president of the Nursing and Midwifery Council.

This article has been double-blind peer reviewed

Scroll down to read the article or download a print-friendly PDF here

Click here to see other articles in this series

Read Moi Ali’s comment

Introduction

It is natural for patients to feel apprehensive about their health and wellbeing, yet a survey in 2016 found that only 38% of adult inpatients who had worries or fears could ‘definitely’ find someone in hospital to talk to about them (Care Quality Commission, 2017). There are numerous barriers to effective communication including:

Time constraints;

Environmental issues such as noise and privacy;

Pain and fatigue;

Embarrassment and anxiety;

Use of jargon;

Values and beliefs;

Information overload.

Time constraints

Time – or lack of it – creates a significant barrier to communication for nurses (Norouzinia et al, 2016). Hurried communication is never as effective as a leisurely interaction, yet in pressured workplaces, nurses faced with competing demands may neglect the quality of communication. It is important to remember that communication does not need to be time-consuming – a smile, hello, or some ‘small talk’ about the weather may suffice. Even when there is no pressing news to tell individual patients, taking the time to get to know them can prepare the ground for difficult conversations that may need to take place in the future.

In a pressured ward or clinic, conversations between patients and nurses may be delayed or interrupted because of the needs of other patients – for example, they may need to respond to an emergency or pain relief. This can be frustrating for patients who may feel neglected. If interruptions occur it is important to explain to patients that you have to leave and why. Arranging to return within a specified time frame may be enough to reassure them that you are aware that their concerns are important (Box 1).

Box 1. Making time for communication

Nurse Amy Green was allocated a bay of four patients and two side wards for her shift. Halfway through the morning one of her patients in a side ward became very ill and Amy realised that she needed to spend a lot of time with him. She quickly visited her other patients to explain what was happening, and reassured them that she had not forgotten about them. She checked that they were comfortable and not in pain, asked them to ring the call bell if they needed her, and explained that she would return as soon as she could. The patients understood the situation and were reassured that their immediate needs had been assessed and they were not being neglected.

Environmental factors

You may be so familiar with your surroundings that you no longer notice the environmental factors that can create communication difficulties. Background noise in a busy clinic can affect patients’ ability to hear, and some may try to disguise this by nodding and ‘appearing’ to hear. If you think your patient has hearing problems, reduce background noise, find a quiet corner or step into a quiet side room or office. Check whether your patient uses physical aids, such as hearing aids or spectacles and that these are in working order.

Noise and other distractions can impede communication with patients with dementia and other cognitive impairments, who find concentration challenging. If you have to communicate an important message to a patient with poor concentration, it is useful to plan ahead and identify the best place and time to talk. It can be helpful to choose a time when you are less busy, without competing activities such as medicine rounds or meal times to interrupt your discussion.

Patients may be reticent to provide sensitive personal information if they are asked about their clinical history within earshot of other people, such as at a busy reception desk or in a cubicle with just a curtain for privacy. It is important to avoid asking sensitive questions where others may hear patients’ replies. Consider alternative ways of gathering pertinent information, such as asking the patient to complete a written form – but remember that some patients struggle with reading and writing or may need the form to be provided in a different language or have someone translate for them.

Pain and fatigue

We often need to gain important information from patients when they are acutely ill and distressed, and symptoms such as pain can reduce concentration. If you urgently need to gather information, it is important to acknowledge pain and discomfort: “I know that it is painful, but it’s important that we discuss.”

Patients may also be tired from a sleepless night, drowsy after an anaesthetic or experiencing the side-effects of medicines. Communicating with someone who is not fully alert is difficult, so it is important to prioritise the information you need, assess whether it is necessary to speak to the patient and ask yourself:

Is this the best time for this conversation?

Can my message wait?

Can I give part of the message now and the rest later?

When patients cannot give their full attention, consider whether your message could be broken down into smaller pieces so there is less to digest in one go: “I will explain your medication now. I’ll return after lunch to tell you about how physiotherapy may help.” Ask if they would like any of the information repeated.

If you have to impart an important piece of information, acknowledge how the patient is feeling: “I know that you’re tired, but …”. Showing empathy can build rapport and make patients more receptive. It may also be useful to stress the need to pay attention: “It’s important that you listen because …”. Consider repeating the message: “It can be difficult to take everything in when you’re tired, so I just wanted to check that you’re clear about …”. If the communication is important, ask the patient to repeat it back to you to check it has been understood.

Embarrassment and anxiety

Would you feel comfortable undressing in front of a complete stranger, or talking about sex, difficult family circumstances, addictions or bowel problems? Patients’ and health professionals’ embarrassment can result in awkward encounters that may hamper effective communication. However, anticipating potential embarrassment, minimising it, and using straightforward, open communication can ease difficult conversations. For example, in a clinic, a patient may need to remove some clothes for an examination. It is important to be direct and specific. Do not say: “Please undress”, as patients may not know what to remove; give specific instructions: “Please remove your trousers and pants, but keep your shirt on”. Clear directions can ease stress and embarrassment when delivered with matter-of-fact confidence.

Patients may worry about embarrassing you or themselves by using inappropriate terms for anatomical parts or bodily functions. You can ease this embarrassment by introducing words such as “bowel movements” or “penis” into your questions, if you think they are unsure what terminology to use. Ambiguous terms such as “stool”, which have a variety of everyday meanings, should be avoided as they may cause confusion.

Many patients worry about undergoing intimate procedures such as bowel and bladder investigations. Explain in plain English what an examination involves, so that patients know what to expect. Explaining any side-effects of procedures – such as flatulence or vomiting – not only warns patients what to expect but reassures them that staff will not be offended if these occur.

Box 2 provides some useful tips on dealing with embarrassment.

Box 2. Managing embarrassment

Look out for signs of embarrassment – not just obvious ones like blushing, but also laughter, joking, fidgeting and other behaviours aimed at masking it

Think about your facial expressions when communicating with patients, and use positive, open body language such as appropriate eye contact or nodding

Avoid disapproving or judgmental statements by phrasing questions carefully: “You don’t drink more than 10 glasses of wine a week, do you?” suggests that the ‘right’ or desired answer is ‘no’. A neutral, open question will elicit a more honest response: “How many glasses of wine do you drink in a typical week?”

Some patients are reluctant to ask questions, seek clarification or request that information be repeated for fear of wasting nurses’ time. It is important to let them know that their health or welfare is an integral part of your job. They also need to know that there is no such thing as a silly question. Encourage questions by using prompts and open questions such as: “You’re bound to have questions – are there any that I can answer for you now?”; “What else can I tell you about the operation?”. It is also possible to anticipate and address likely anxieties such as “Will it be painful?”; “Will I get better?”; or “Will I die?”.

Jargon

Jargon can be an important communication aid between professionals in the same field, but it is important to avoid using technical jargon and clinical acronyms with patients. Even though they may not understand, they may not ask you for a plain English translation. It is easy to slip into jargon without realising it, so make a conscious effort to avoid it.

A report on health literacy from the Royal College of General Practitioners (2014) cited the example of a patient who took the description of a “positive cancer diagnosis” to be good news, when the reverse was the case. If you have to use jargon, explain what it means. Wherever possible, keep medical terms as simple as possible – for example, kidney, rather than renal and heart, not cardiac. The Plain English website contains examples of healthcare jargon.

Box 3 gives advice on how to avoid jargon when speaking with patients.

Box 3. Avoiding jargon

Avoid ambiguity: words with one meaning for a nurse may have another in common parlance – for example, ‘acute’ or ‘stool’

Use appropriate vocabulary for the audience and age-appropriate terms, avoiding childish or over-familiar expressions with older people

Avoid complex sentence structures, slang or speaking quickly with patients who are not fluent in English

Use easy-to-relate-to analogies when explaining things: “Your bowel is a bit like a garden hose”

Avoid statistics such as “There’s an 80% chance that …” as even simple percentages can be confusing. “Eight in every 10 people” humanises the statistic

Values, beliefs and assumptions

Everyone makes assumptions based on their social or cultural beliefs, values, traditions, biases and prejudices. A patient might genuinely believe that female staff must be junior, or that a man cannot be a midwife. Be alert to patients’ assumptions that could lead to misinterpretation, reinterpretation, or even them ignoring what you are telling them. Think about how you can address such situations; for example explain your role at the outset: “Hello, I am [your name], the nurse practitioner who will be examining you today.”

It is important to be aware of your own assumptions, prejudices and values and reflect on whether they could affect your communication with patients. A nurse might assume that a patient in a same-sex relationship will not have children, that an Asian patient will not speak good English, or that someone with a learning disability or an older person will not be in an active sexual relationship. Incorrect assumptions may cause offence. Enquiries such as asking someone’s “Christian name” may be culturally insensitive for non-Christians.

Information overload

We all struggle to absorb lots of facts in one go and when we are bombarded with statistics, information and options, it is easy to blank them out. This is particularly so for patients who are upset, distressed, anxious, tired, in shock or in pain. If you need to provide a lot of information, assess how the patient is feeling and stick to the pertinent issues. You can flag up critical information by saying: “You need to pay particular attention to this because …”.

Box 4 provides tips on avoiding information overload.

Box 4. Avoiding information overload

Consider suggesting that your patient involves a relative or friend in complex conversations – two pairs of ears are better than one. However, be aware that some patients may not wish others to know about their health

Suggest patients take notes if they wish

With patients’ consent, consider making a recording (or asking whether the patient wishes to record part of the consultation on their mobile phone) so they can replay it later or share it with a partner who could not accompany them

Give written information to supplement or reinforce the spoken word

Arrange another meeting if necessary to go over details again or to provide further information

Conclusion

It is vital that all nurses are aware of potential barriers to communication, reflect on their own skills and how their workplace environment affects their ability to communicate effectively with patients. You can use this article and the activity in Box 5 to reflect on these barriers and how to improve and refine your communication with patients.

Box 5. Reflective activity

Think about recent encounters with patients:

What communication barriers did you encounter?

Why did they occur?

How can you amend your communication style to take account of these factors so that your message is not missed, diluted or distorted?

Do you need support to make these changes?

Who can you ask for help?

Key points

Nurses need to be aware of the potential barriers to communication and adopt strategies to address them

Environmental factors such as background noise can affect patients’ ability to hear and understand what is being said to them

Acute illness, distress and pain can reduce patients’ concentration and their ability to absorb new information

Anticipating potential embarrassment and taking steps to minimise it can facilitate difficult conversations

It is important to plan ahead and identify the best place and time to have important conversations

Also in this series

Communication skills 1: benefits of effective communication for patients

Communication skills 3: non-verbal communication

Communication 4: the influence of appearance and environment

Communication 5: effective listening and observation skills

Communication skills 6: difficult and challenging conversations

Care Quality Commission (2017) 2016 Inpatient Survey: Statistical Release.

Norouzinia R et al (2016) Communication barriers perceived by nurses and patients. Global Journal of Health Science; 8: 6, 65-74.

Royal College of General Practitioners (2014) Health Literacy: Report from an RCGP-led health literacy workshop.

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Communication skills 2: overcoming the barriers to effective communication | Nursing Times

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Abstract Competing demands, lack of privacy, and background noise are all potential barriers to effective communication between nurses and

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Page Owner - Sadaf Tanveer as part of the One Page Project

Identifying the classification of urinary incontinence can help to guide treatment, however, an individual could exhibit symptoms from more than one of the classifications.

Urinary incontinence (symptom): Complaint of involuntary loss of urine.

Stress urinary incontinence: Complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing.

Urgency urinary incontinence: Complaint of involuntary loss of urine associated with urgency.

Mixed urinary incontinence: Complaint of involuntary loss of urine associated with urgency and also effort or physical exertion or on sneezing or coughing.

Urgency: Complaint of a sudden, compelling desire to pass urine which is difficult to defer.

Overactive bladder (OAB, Urgency) syndrome: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.

Urinary incontinence remains a worldwide problem, affecting both males and females, across different cultures and races. As mentioned above, the world wide prevalence is difficult to determine due to differences in definitions used, population surveyed, survey type, response rate, age, gender, availability and efficacy of health‐care, and other factors.

The pelvic floor is made up of the muscles, ligaments, and fascial structures that act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra-abdominal pressure.

The pelvic floor muscles refer to the muscular layer of the pelvic floor. It includes the levator ani, striated urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus.

The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles. During increased intra-abdominal pressure, the pelvic floor muscles must contract to provide support. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing involuntary loss of urine or rectal contents. The pelvic floor muscles must also relax in order to void.

[9]

Stress urinary incontinence:

Urethral hypermobility: increases in intra-abdominal pressure (eg, from coughing or sneezing) with insufficient support of the pelvic floor musculature and vaginal connective tissue to the urethra and bladder neck can lead to incontinence.

Pregnancy and vaginal birth, post-partum, obesity, chronic cough, chronic heavy lifting and constipation: if there is an increase in abdominal pressure that is greater than the opposing force of the pelvic floor muscles, it can result in stress incontinence

Intrinsic sphincteric deficiency (ISD): this results from a loss of intrinsic urethral mucosal and muscular tone that normally keeps the urethra closed, it can occur in presence or absence of urethral hypermobility and with minimal abdominal pressure.

Urgency urinary incontinence:

This may be secondary to neurologic disorders (eg, spinal cord injury), bladder abnormalities, increased or altered bladder microbiome, or may be idiopathic.

Overactive bladder:

This could be due to neuropathic, an infection (i.e. urinary tract infection), weak pelvic floor muscles, diet (i.e. consumption of diuretics), medications, excess weight

Mixed Incontinence:

Individuals can present with more than one type of incontinence

For example stress incontinence and/or urge incontinence might be "masked" by an overactive bladder (frequenting the washroom often to avoid leakage).

Risk Factors

Risk factors for urinary incontinence (UI)

Age

The prevalence and severity of UI increases with age.

Age may not be an independent risk factor, when studies have controlled for co-morbidities.

Obesity

This is a strong risk factor for UI. Additionally, weight reduction is associated with improvement or resolution of symptoms, particularly with stress urinary incontinence.

Parity

Increasing parity is a risk factor for UI, however, nulliparous women also report bothersome UI.

Mode of delivery

Women who have had a vaginal delivery have an increased risk of UI, however, cesarean delivery does not protect women from UI.

Family history

This may be a risk factor for UI, particularily with urge incontinence and overactive bladder.

Other

Conditions such as diabetes, stroke, and depression are associated with an increased risk of UI.

A large portion of women with urinary stress incontinence can be diagnosed from clinical history alone. In a systematic review performed in 2006, little evidence was found to support the use of urinary diaries, and pad-tests although these measures are common diagnostic assessments used in physical therapy.

Clinical history taking compared with multi-channel urodynamics was found to have 0.92 sensitivity and 0.56 specificity for the diagnosis of urinary stress incontinence based on the presence of stress incontinence symptoms.

Modified Oxford grading system:

0 - no contraction

1 - flicker

2 - weak squeeze, no lift

3 - fair squeeze, definite lift

4 - good squeeze with lift

5 - strong squeeze with a lift

Palpation of the pelvic floor muscles per the vagina in females and per the rectum in male patients.

P - power, may use the Modified Oxford grading scale
E - endurance, the time (in seconds) that a maximum contraction can be sustained
R - repetition, the number of repetitions of a maximum voluntary contraction
F - fast contractions, the number of fast (one second) maximum contractions
ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening

The 1 hour pad test was found to have 0.94 sensitivity and 0.44 specificity for diagnosing any leakage compared with multi-channel urodynamics. The 48 hour pad-test was found to have 0.92 sensitivity and 0.72 specificity for the diagnosis of urinary stress incontinence.

While the 48 hour pad test is better used in clinical research due to it's high reproducibility, the 1-hour pad test is the standardized method in a clinical setting.

The test involves the patient wearing a pre-weighed pad, next the patient drinks 500 ml of sodium-free liquid in < 15 minutes, resting, after which he/she exercises for 30 minutes. The exercise would include activities such as walking, climbing up and down a flight of stairs, standing up from sitting, coughing vigorously, running on the spot for 1 minute. The pad is then re-weighed and the resulting measurement given in grams of urine lost.

Urinary (Voiding) Diary

One study found a scale derived from a 7 day diary was 0.88 sensitive and 0.83 specific for the diagnosis of detrusor overactivity in women. The National Institute for Diabetes and Digestive and Kidney Diseases provides clinicians with a easy to use Bladder Diary pdf that may be used in clinical practice.

Pelvic Floor Muscle Training (PFMT)

This brief video gives a good run down on how to teach pelvic floor exercises.

The pelvic floor muscles are known as the levator ani, made up of the pubococcygeus - puborectalis complex. Those muscles form a sling around the anorectal junction. They are made up of both Type I (slow-twitch) and Type II (fast-twitch) fibers. The majority are Type I (about 70%) which provide sustained support and are fatigue resistant. The remaining Type II fibers provide the quick compressive forces necessary to oppose leakage during increased abdominal pressure. A contraction of the pelvic floor muscles also causes a reflex inhibition of the detrusor muscle.

A non-controlled trial studying the effects of a home-based pelvic floor muscle training and bladder training in women with urinary incontinence showed that combined pelvic floor muscle training and bladder training decreased the symptoms and improved the quality of life.

Pelvic floor muscle training (PFMT) performed during pregnancy helps to decrease the short-term risk of urinary incontinence in women without prior incontinence. A meta-analysis that included randomised or quasi-randomised trials on pregnant or postnatal women, found that women assigned to antenatal PFMT had a significant decrease in the rate of urinary incontinence at up to three months postpartum.

A systematic review including randomised or quasi-randomised trials on primiparous or multiparous pregnant or postpartum women found that PFMT during pregnancy and after delivery can prevent and treat urinary incontinence. The authors recommended a supervised training protocol following strength-training principles, emphasizing close to maximum contractions and lasting at least 8 weeks.

A Randomized Controlled Trial in women with stress urinary incontinence suggests that the Pelvic floor Muscle Training and Extracorporeal Magnetic Innervation are effective in improving the stress urinary incontinence and quality of life in women. Another randomized control study suggested better outcomes with a combined training of PFMT and Transversus Abdominis muscle than with PFMT alone in patients with stress urinary incontinence. However, the training was more effective in the group of women who had lesser than three vaginal births.

A study examining the training parameter for strengthening the pelvic floor found the most effective protocol to consists of digital palpation combined with biofeedback monitoring and vaginal cones, including 12 week training parameters, and ten repetitions per series in different positions.

Behavioral Therapy

Bladder Training

The information gathered from the bladder diary is used to guide decision making for bladder re-training, including a voiding schedule if necessary to increase the capacity of the bladder for people with frequency issues. Bladder training attempts to break the cycle by teaching patients to void on a schedule, rather than in response to urgency. Urge suppression techniques are taught, such as distraction and relaxation. It is also important to teach the patient to contract the pelvic floor to cause detrusor inhibition. A voluntary contraction of the pelvic floor muscles helps increase pressure in the urethra, inhibit detrusor contractions, and control urinary leakage.

Multi-channel urodynamics testing is the gold standard for making a condition-specific diagnosis. This testing is typically done in secondary care, not in primary care or physical therapy.

A systematic review published in the Annals of Internal Medicine in 2008 found good evidence that pelvic floor muscle training and bladder training resolved urinary incontinence in women. However, the effects of electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy were inconsistent.

The study suggests surface electromyographic (sEMG) assisted biofeedback training and Pilates exercises have positive outcomes on the pelvic floor muscles in women with stress urinary incontinence.

Physiopedia's Clinical Guidelines: Pelvic Health Page

Pelvic Physiotherapy - to Kegel or Not?

This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.

View the presentation

1. Messelink B, Benson T, Berghmans B, Bo K, Corcos J, Fowler C, Laycck J, Huat-Chye Lim P, van Lunsen R, Lycklama a Nijeholt G, Pemberton J, Wang A, Watier A, Van Kerrebrocck P. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn 2005;24:374-380.

2. Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa RP. Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence. Neurourol Dynam 2006;25:674-683.

3. Krhut J, Zachoval R, Smith PP, Rosier PF, Valanský L, Martan A, Zvara P. Pad weight testing in the evaluation of urinary incontinence. Neurourology and urodynamics. 2014 Jun;33(5):507-10.

4. Burgio KL. Current perspectives on management of urgency using bladder and behavioral training. J Am Academy Nurse Pract 2004;16:4-7.

5. Payne CK. Behavioral therapy for overactive bladder. Urology 2000;55:3-6.

6. Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008;148:459-474.

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Page Owner - Sadaf Tanveer as part of the One Page Project Identifying the classification of urinary incontinence can help to guide treatment, however, an individual could exhibit symptoms from more than one of the classifications. Urinary incontinence (symptom): Complaint of involuntary loss of urine.

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factors influencing people accessing health care

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factors influencing people accessing health care

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NEED FOR HEALTH-CARE SERVICES

Health status and the need for health-care services to improve or maintain health are major determinants of health-care utilization. The World Health Organization states that health is determined by a person's individual characteristics and behaviors, physical environment, and socioeconomic environment ( WHO, 2017). People's individual characteristics include their biology and genetics, such as inherited diseases and conditions that require medical care. The prevalence of those conditions differs by sex, age, race and ethnicity, employment status, and other factors. Physical environments can affect health because of pollutants or other environmental health hazards. Individual behaviors, such as smoking or lack of exercise and overeating, also cause health conditions that require health care ( ODPHP, 2017a). Recent attention to social determinants of health, such as education, economic stability, community safety, and availability of adequate housing and healthful food, has shown that they correlate with healthier populations ( ODPHP, 2017a). People who have unmet social needs are more likely to be frequent ED users, to have repeat "no-shows" for medical appointments, and to have poorer glycemic and cholesterol control than those who are able to meet their needs ( Thomas-Henkel and Schulman, 2017).

How need affects differential health-care utilization by specific populations of interest is discussed below with reference to poverty and its correlates and geographic area of residence, race and ethnicity, sex, age, language spoken, and disability status. Ideally, need should be the major determinant of health-care utilization, but other factors clearly have an effect. One of those factors is the ability to access care-including whether it is available, timely and convenient, and affordable ( Figueroa et al., 2017).

ACCESS TO HEALTH CARE

Access to health care is defined as having timely use of personal health services to achieve the best possible health outcome ( IOM, 1993). Access requires gaining entry into the health-care system, getting access to sites of care where patients can receive needed services, and finding providers who meet the needs of patients and with whom patients can develop a relationship based on mutual communication and trust ( AHRQ, 2010). Clinicians note that timely access to health care is important inasmuch as it might enable patients and physicians to prevent illness, control acute episodes, or manage chronic conditions, any of which could avoid exacerbation or complication of health conditions ( NCHS, 2017b).

There are many ways to think of access, and the term access is often used to describe factors or characteristics that influence one's initial contact with or use of services. Anderson and Newman (2005) present a framework of health-care utilization that includes predisposing factors, enabling factors, and magnitude of illness. More recently Levesque et al. (2013) defined access to health care by presenting five dimensions of accessibility: approachability, acceptability, availability and accommodation, affordability, and appropriateness. They saw access as the opportunity to identify health-care needs; to reach, obtain, or use health-care services; and to have the need for services fulfilled. Access can be seen as a continuum: even if care is available, many factors can affect ease of access to it, for example, the availability of providers who will accept a person's insurance (including Medicaid), ease in making an appointment with a given provider, the ability of a patient to pay for care (even if a patient is insured, due to cost-sharing copayments and deductibles), and the difficulty of arranging transportation to and from healthcare facilities ( AHRQ, 2010, MACPAC, 2016). Some of those issues are discussed below.

Ability and Propensity to Use Services

People cannot access care if it does not exist in their geographic area, or if providers will not treat them because of insurance or other issues. Rural areas in particular have been identified as lacking a sufficient supply of specialty physicians and, in particular, mental health-care providers ( Meit et al., 2014; Douthit et al., 2015).

Assuming that services are available, access to care might be impeded by other barriers. One is inadequate transportation, either because travel time is excessive, because no public transportation is available and the person does not have a car or other alternative transportation, or because the cost of transportation is prohibitive. Providers might refuse to see patients because no appointment times are open, or because they do not accept patients' insurance. Providers might be unable to communicate with patients because of language issues, or their offices might not be accessible to people with disabilities. Excessive wait times to obtain appointments or to see providers at their places of service might also deter use ( MACPAC, 2016; NCHS, 2016).

Insurance and Ability to Pay for Services

Access to health care is tied to the affordability of health insurance. Financial barriers to care, particularly among low-income people and the uninsured, have been greater in the United States than in other high-income countries ( Davis and Ballreich, 2014; Squires and Anderson, 2015). According to a 2013 Commonwealth Fund survey of adults in 11 high-income countries, the United States ranks last on measures of financial access to care ( Schoen et al., 2013). The Kaiser Commission on Medicaid and the Uninsured notes that people who lack insurance coverage have worse access than people who are insured, and 20 percent of uninsured adults in 2015 went without needed medical care because of cost ( KFF, 2016). The lack of health insurance has been identified as an important driver of health-care disparities ( IOM, 2002).

Uninsured people who are 18-64 years old are more likely than those who have Medicaid or private coverage to report difficulties in affording needed medical care and prescription drugs, and are more likely than the insured to delay or forgo them because of cost ( KFF, 2016). During 2004-2014, uninsured adults were 4-5 times more likely than those who had private coverage and 1.5-3.0 times more likely than those who had Medicaid to report difficulty in medical care and prescription access. For adults who had Medicaid, medical care access problems were stable until 2008 and then decreased through 2014. For those who had private insurance, medical care access problems increased until 2009 and then decreased through 2014 ( NCHS, 2016). For the uninsured, problems with medical care and prescription access increased until 2010 and 2009, respectively, and then were stable for medical care and decreased through 2014 for prescriptions. Prescription access problems were stable in 2004-2014 for those who had private insurance but decreased for adults who had Medicaid ( NCHS, 2016).

Having insurance coverage does not mean that coverage is adequate or is not associated with burdensome cost-sharing through premium payments, copayments, and deductibles ( Lavarreda et al., 2011; Fang et al., 2016). Surveys have categorized underinsured people as those who say they have insurance but are worried about medical bills, who are paying them off over time, or who have not obtained selected types of health-care services because of cost.

A study by Magge et al. (2013) estimated that more than one-third of low-income adults were underinsured (defined as spending more than 5 percent of household income on medical care) and that 8 percent and 13 percent deferred or delayed obtaining medical care or prescription medications, respectively ( Magge et al., 2013). Avoiding or delaying medical care correlates strongly with coverage under a high-deductible health plan (in which a person must make a substantial out-of-pocket [OOP] contribution before insurance payment begins) and with depression, poor perceived health, or poverty. However, it is relatively independent of the percentage of income spent on OOP costs, so the percentage of income spent on OOP costs by itself is a poor measure of health-care unaffordability. People who spend a small percentage of their income on health care might be extremely burdened by their health-care plan when financial concerns prevent access to health care ( Kielb et al., 2017). Current evidence also suggests that high-deductible health plans are associated with lower health-care costs as a result of a reduction in the use of health-care services, including appropriate services ( Agarwal et al., 2017).

DIFFERENCES IN HEALTH-CARE UTILIZATION ASSOCIATED WITH SELECTED CHARACTERISTICS

Ideally, utilization of health-care services reflects a need for care, but that is not the case, for several reasons. Many factors affect health-care utilization independently of need and are reflected in differences, some of which are remediable, among population groups. Some of these factors are related to biologic or environmental differences among groups, such as disproportionate residence in polluted environments, access to healthful food and adequate housing, and education associated with effective use of health care. Others are related to differences in access, such as health insurance coverage or income needed to obtain services, ease of obtaining services, and discriminatory practices of providers.

Race and Ethnicity

Racial and ethnic disparities are found in many sectors of American life. Black people, people of Hispanic origin, American Indians, Pacific Islanders, and some Asian Americans might be disproportionately represented in the lower socioeconomic ranks, in lower-quality schools, and in poorer-paying jobs ( IOM, 2002). Racial residential segregation is a key mechanism through which racism produces and perpetuates social disadvantage. Black and Latino adults are more likely to live in disadvantaged neighborhoods and to have inadequately resourced schools, which yield lower educational attainment and quality ( Braveman et al., 2014). Those factors can result in some racial and ethnic minorities experiencing higher rates of chronic and disabling illnesses, infectious diseases, and higher mortality than white Americans. Minority populations have more difficulty than the majority population in locating a "usual source" of medical care, and black and Hispanic adults report greater difficulty than whites in obtaining medical care at a consistent location ( IOM, 2002; AHRQ, 2010).

Black adults have earlier onset of multiple illnesses, greater severity and more rapid progression of diseases, higher levels of comorbidity and impairment throughout the life course, and higher mortality than whites up to the age of 65 years. Similar patterns are evident in American Indians, Pacific Islanders, Asian populations of low socioeconomic status, and US-born Latinos ( Williams and Wyatt, 2015).

A recent report by the Kaiser Family Foundation (2016) on health and health care by race and ethnicity found that disparities in health and health care continue to pose a persistent challenge in the United States. Among their findings are the following:

Some 41 percent of nonelderly people living in the United States are nonwhite.

Nonwhite people face substantial disparities in access to and utilization of health care.

Black, American Indian, and Alaska Native adults fare worse than whites on most of the measures of health status and outcomes that were examined.

Nonelderly Hispanic, black, American Indian, and Alaska Native adults remain much more likely than whites to be uninsured despite coverage gains under the ACA.

Lack of insurance, more than any other demographic or economic barrier, adversely affects the quality of health care received by minority populations ( OMH, 2011). In the United States, black and Hispanic people have disproportionately lower income and higher rates of uninsurance, which might result in poorer health outcomes and different health-care utilization trends. In 2015, the percentage of people who lacked health insurance coverage for the entire calendar year was 9.1 percent or 29.0 million ( USCB, 2016). Non-Hispanic whites had the lowest uninsured rate, 6.7 percent; blacks and Asian people had rates of 11.1 percent and 7.5 percent, respectively; and people of Hispanic origin had the highest rate, 16.2 percent. From 2014 to 2015, the overall rate of health insurance coverage increased in people of Hispanic origin by 3.6 percentage points, in Asian people by 1.9 percentage points, and in non-Hispanic white people by 0.9 percentage points.

During that period, the trend in lack of coverage varied by racial and ethnic group. From 1999 to June 2015, among people 18-64 years old, people of Hispanic origin had the highest percentage without coverage (27.2 percent in the first 6 months of 2015), and non-Hispanic white adults had the lowest except in the first 6 months of 2015, when non-Hispanic Asian adults had the lowest percentage. The difference between the highest and lowest percentages of people 18-64 years old who did not have health insurance among the four racial and ethnic groups narrowed from 1999 to June 2015. The difference was 24.9 percentage points in 1999 (adults of Hispanic origin compared with non-Hispanic white adults) and 19.9 percentage points in the first 6 months of 2015 (adults of Hispanic origin compared with non-Hispanic Asian adults) ( NCHS, 2016).

Chen et al. (2016) examined racial and ethnic disparities in health-care access and utilization after the ACA health insurance mandate was fully implemented in 2014. They used the 2011-2014 National Health Interview Survey (NHIS) to examine changes in health-care access and utilization. They noted that the full implementation of the ACA (year indicator, 2014) was associated with substantial reductions in the probabilities of being uninsured, delaying necessary care, and forgoing necessary care, with an increase in the probability of having physician visits compared with the reference year (2011).

A systematic review of 37 studies examined the extent and measurement of racism in health-care providers ( Paradies et al., 2014). A number of databases and electronic journal collections were searched for articles published in 1995-2012 (including Medline, CINAHL, PsycInfo, and Sociological Abstracts). The search included published reports (in English) of empirical studies of any design that measured or discussed racism in health-care providers. The studies used a number of measurement approaches and dealt primarily with physicians in the United States. Of the 37 studies, 26 found statistically significant evidence of racist beliefs, emotions, or practices among health-care providers. A 2015 "Perspective" in the New England Journal of Medicine ( Ansell and McDonald, 2015) noted evidence that physicians hold stereotypes that are based on patients' race that can influence clinical decisions. The authors stated that despite physicians' and medical centers' best intentions to be equitable, black-white disparities persist in patient outcomes, medical education, and faculty recruitment.

A 2002 Institute of Medicine report, Unequal Treatment, reviewed hundreds of studies of age, sex, and racial differences in medical diagnoses, treatments, and health outcomes. It concluded that black people received less effective care than white people for each disease studied even after matching for socioeconomic factors and insurance status. It found evidence of the role of bias, stereotyping, and prejudice in perpetuating racial and health disparities. Multiple factors contribute to racial disparities in health-care access and utilization, but unconscious bias on the part of medical professionals might contribute to deficits in the quality of care.

The more recent annual National Healthcare Quality and Disparities Report ( QDR) provides an overview of the quality of health care received by the US population and highlights continued disparities in care that are experienced by different racial and socioeconomic groups ( AHRQ, 2017). The 2016 QDR states that disparities were getting smaller from 2000 through 2014-2015 but that disparities persist, especially for poor and uninsured populations. Furthermore, although 20 percent of measures show disparities decreasing for black people and people of Hispanic origin, most disparities have not changed more than a small amount for any racial and ethnic groups. More than half the measures show that poor and low-income households had worse care than high-income households; more than 40 percent of the measures show that middle-income households had worse care than high-income households. Nearly two-thirds of the measures show that uninsured people had worse care than privately insured people.

Sex

Women overall have higher health-care utilization than men. Although it had been thought that women receive health care primarily during child-bearing years for reproductive health, many health-care utilizations occur during and after menopause for such issues as cardiovascular disease and osteoporosis ( Owens, 2008). Other studies have shown that women make more primary care visits and receive more diagnostic services, screening services, diet and nutrition counseling, and sexual health care than men even though men generally have higher rates of obesity and cardiovascular problems ( Salganicoff et al., 2014).

Among people 18-64 years old, women have higher rates of disability and self-reported fair or poor health status. Among all people 18 years and older, women are more likely to delay or not receive care, or to not receive prescription drugs, because of cost. Women are more likely to have a health-care visit in a given year, to have 10 or more visits, and to have a hospitalization or ED visit ( NCHS, 2017b). Those findings indicate that although women utilize health-care resources at greater rates, health-care needs go unmet.

Working Age Adults

The average retirement age in the United States in 2013 was 64 years for men and 62 years for women ( Munnell, 2015). However, because of disability or for other reasons, many workers leave the workforce before Social Security retirement age or before they become eligible for pensions or vested savings.

There is no question that increased functional limitations and consequent health-care utilization occurs in people as they age; that is true for working-age people and for older adults ( NCHS, 2017b). There has also been an increase in rates of health-care utilization and functional limitation in people 45-64 years old ( Freid et al., 2012). About 4 percent of people who were 18-44 years old had self-reported heart disease compared with about 12 percent of people 45-64 years old; corresponding rates of cancer were 2 percent and 7 percent, respectively. Almost one-fourth of people 18-44 years old reported low back pain compared with 35 percent of people 45-64 years old ( NCHS, 2017b). Rates of self-reported disability among working-age adults and mental illness among all people 18 years and older have remained stable in recent years ( Ahrnsbrak et al., 2017; NCHS, 2017b).

Spoken Language

Many Americans in racial and ethnic minorities experience language barriers and have low or no proficiency in speaking, reading, or comprehending English. In a health-care setting, those barriers can present serious challenges to both patients and providers. A systematic review of studies of language barriers in health care for Latino populations showed that access to care, quality of care, and health status all suffer as a result of language barriers. If a patient does not speak the language of his or her health-care provider, multiple adverse effects on the patient's health care might occur. For example, a patient's inability to understand a provider's diagnosis or treatment plan can lead to poor patient satisfaction, poor compliance, and underuse of services ( Timmins, 2002).

Flores (2006) examined language barriers to health care in the United States and noted that some 49.6 million Americans speak a language other than English at home, and 22.3 million have low English proficiency, speaking English less than "very well" according to self-ratings. From 1990 to 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million, and the number with low English proficiency grew by 7.3 million. Many patients who need medical interpreters have no access to them. According to one study, in 46 percent of ED cases that involved patients who had low English proficiency, no interpreter was used ( Baker et al., 1996). Few clinicians receive training in working with interpreters; only 23 percent of US teaching hospitals provide any such training, and most of them make it optional ( Flores, 2006).

Patients who face language barriers are less likely than their English-speaking counterparts to have a usual source of medical care, receive fewer preventive services, and have a greater likelihood of nonadherence to medication prescriptions. Psychiatric patients who encounter language barriers are more likely than others to receive a diagnosis of a severe psychopathologic condition-but are also more likely to leave the hospital against medical advice. Such patients are less likely than others to return for followup appointments after visits to an ED, and they have higher rates of hospitalization and drug complications ( Flores, 2006).

Income and Poverty

Income correlates highly with risk factors for chronic disease: for example, people who have lower family income have higher rates of heart disease, stroke, diabetes, or hypertension, and have four or more common chronic conditions ( NCHS, 2017b). People in families whose income is less than 200 percent of the federal poverty level are more likely to be obese and to smoke cigarettes than wealthier people. Adults who live in poverty are also more likely to have self-reported serious psychologic distress, as measured by a series of questions about their perceived mental health.

Economic resources (such as income and wealth) enable access to material goods and services, including health-care services. In 2009-2010, people of all racial and ethnic groups who were 18-64 years old and had a family income below 200 percent of the poverty level were more likely than those who had higher family income to delay seeking or not to receive needed medical care because of cost ( NCHS, 2012). From 2000 to 2010, the percentage of people 18-64 years old who did not get or delayed seeking needed medical care during the preceding 12 months because of cost increased in all family income groups. During that period, the percentage who had unmet needs for medical care decreased as family income increased from below 200 percent of the poverty level to 400 percent or more of the poverty level. Failure to receive needed medical care because of cost was equally likely in families below the poverty level and those whose income was 100-199 percent of the poverty level.

More recent findings indicate that in 2014 28.6 percent of adults who were living under the poverty level had one or more ED visits compared with 13.5 percent of adults who were at 400 percent of the poverty level, and 8.1 percent of adults under the poverty level had at least one hospitalization compared with 3.8 percent of adults at 400 percent of the poverty level. Despite the high utilization of health-care services by low-income people, adults under the poverty level reported greater rates of not receiving or of delaying medical care, obtaining prescription drugs, and receiving dental care because of costs than adults who were at 400 percent of the poverty level. Thus, health-care needs of those under the poverty level are still being unmet despite their higher utilization of emergency and hospital services ( NCHS, 2017b).

Geography

The extent of urbanization has been shown to be associated with health-care utilization in several ways, including the correlation of residents' sociodemographic characteristics with need, risk factors, and access to care. Communities that differ in urbanization differ in their demographic, environmental, economic, and social characteristics, and those characteristics correlate with the magnitude and types of health problems that the communities face. For example, more-urban counties tend to have more health-care providers per capita, and residents of more-rural counties often live farther from health-care resources.

Most studies have compared aggregated magnitude of urbanization-primarily metropolitan compared with nonmetropolitan areas. However, a few studies have compared utilization by more granular urbanization groupings: metropolitan geographic areas, inner cities of large metropolitan areas, fringes of large cities (sometimes called suburbs), and small metropolitan areas; and two categories of nonmetropolitan areas, namely, large rural areas that contain small population centers and rural areas that contain very small population centers ( Ingram and Franco, 2014). Those studies show some differences by magnitude of urbanization, but other differences are more pronounced between suburban fringe areas of cities (which tend to have higher average income) and other areas.

Sociodemographic and Characteristics

Residents of rural areas differ from residents of urban areas in a number of important characteristics that correlate with health-care utilization. Rural residents have low incomes: 17 percent of rural workers earn less than the poverty level ($11,490 per year for an individual) compared with 14.6 percent of urban workers ( Mueller et al., 2014). They are more likely to classify themselves as white. The greatest racial and ethnic diversity was found in central counties of large metropolitan areas. In 2010, the population of central counties nationwide was 27 percent Hispanic origin, 17 percent non-Hispanic black, 9 percent non-Hispanic Asian or Pacific Islander, 2 percent people identifying with multiple races, and less than 1 percent non-Hispanic or American Indian or Alaska Native (AI/AN) origin. All those groups except AI/ANs were less likely to live in nonmetropolitan counties than in central counties. Among all regions, fringe counties of large metropolitan areas (suburban areas) had the lowest concentration of people in poverty in 2011 (9-13 percent). The proportions of the populations in poverty in all other urbanization levels were comparable.

Risk Factors

Rural residents have a higher percentage of several risk factors associated with poorer health than urban residents. For example, self-reported obesity rates vary by urbanization and increase with increasing rurality. In 2010-2011, people living in central counties of large metropolitan areas nationwide had the lowest age-adjusted prevalence of obesity, and women in the most rural counties had the highest ( Meit et al., 2014). In people 20 years old and over, urbanization patterns in ischemic heart disease (IHD) death rates differed by region. In the South, 2008-2010 IHD death rates were lowest in fringe counties of large metropolitan areas and more than 25 percent higher in the most rural counties. In the Midwest, IHD death rates were highest in the most rural counties.

For the United States as a whole, limitation of activity due to chronic health conditions in adults is more common in nonmetropolitan counties than in large metropolitan counties. In all regions except the Midwest, the rate of activity limitation due to chronic health conditions in both men and women generally increases as rurality increases.

Utilization

Using the more aggregated metropolitan/nonmetropolitan grouping, data show that adults who live in nonmetropolitan areas are more likely to report having 10 or more visits to doctors' offices, visits to EDs, or home visits in the preceding year than are people who live in metropolitan areas ( NCHS, 2017b). In particular, they have higher rates of ED visits. Nonmetropolitan residents have a slightly higher rate of at least one hospital stay during the year and a similar rate of two or more hospital stays ( NCHS, 2017b). Inpatient hospital discharge rates of people 18-64 years old were higher in small metropolitan counties than in metropolitan and nonmetropolitan counties. The average length of stay was highest in central counties of large metropolitan areas ( Meit et al., 2014).

Access

Douthit et al. (2015) conducted a literature review of the provision of health care and access in rural areas of the United States. Their findings indicate a reluctance to seek health care because of cultural and financial constraints, which are often compounded by a scarcity of services, a lack of trained physicians, insufficient public transportation, and poor availability of broadband Internet services. Rural residents were found to have poorer health than urban residents, and rural areas had more difficulty in attracting and retaining physicians than their urban counterparts.

The urbanization pattern of the supply of physicians and other providers depends on specialty. However, physician supply generally decreases steadily as rurality increases both nationally and regionally. The National Center for Health Statistics (2017b) NHIS found that in 2015, about 10 percent of people who were 18-64 years old had difficulty in accessing needed medical care, which included experiencing delays or not receiving needed care because of cost. The difficulty varied by region: people in the South and the Midwest had the most difficulty, and those in the Northeast and West had the least ( NCHS, 2017b).

Urban and rural locations differ in transit options, which affects whether patients can access care. Syed et al. (2013) studied issues of cost, availability of transit, distance to healthcare providers, and travel burden by time and distance. Their literature review found that transportation barriers affect health-care access in as little as 3 percent or as much as 67 percent of the population, depending on the area. Their findings collectively suggest that lack or inaccessibility of transportation might be associated with less health-care utilization, lack of regular medical care, and missed appointments.

Residents of central counties of large metropolitan areas and nonmetropolitan counties have similarly high percentages of residents who lack health insurance. In general, central counties of large metropolitan areas often have the most adverse health measures in the Northeast and Midwest, and nonmetropolitan counties tend to fare the worst in the South and West ( Meit et al., 2014). Including all income levels, fringe counties of large metropolitan areas had the largest proportion of privately insured people less than 65 years old in each of the four regions. The coverage gaps in rural America exist in large part because rural Americans have less access to private insurance. Only 64 percent of rural employers offer their workers health insurance compared with 71 percent in urban areas ( Coburn et al., 2009). The prevalence of such jobs as farming and contracting means that self-employment is more prevalent in rural America. Not only are the self-employed in all parts of the country insured at lower rates than wage earners, but the self-employed in rural America are insured at even lower rates than the self-employed in urban areas.

Geographic markets also differ with respect to managed care penetration, payer involvement, and state and local oversight ( Horwitz and Nichols, 2011; Colla et al., 2016). Physicians in rural areas receive 20 percent of their revenue from Medicaid compared with 17 percent for physicians in urban areas ( Bailey, 2012). Up to 84 percent of rural physicians accept new Medicaid patients compared with 65 percent of urban physicians ( UnitedHealth Center for Reform & Modernization, 2011).

Geographic Practice Patterns

Variation in surgical rates by geographic area, particularly hospital referral regions, is high and represents both gaps in outcomes research and poor patient decision quality. Outcomes differ from place to place even when patient differences are controlled for. The Dartmouth Atlas Project has conducted extensive research designed to examine local differences in practice patterns ( Goodney et al., 2015). It used the hospital referral regions as the geographic unit of study. In 2007 and 2011, rates of bariatric surgery in Medicare beneficiaries varied by a factor of more than 20 and rates of therapeutic endovascular interventions by a factor of more than 6. The rate of open leg bypass surgery was 4.1 per 1,000 Medicare beneficiaries who had diabetes and peripheral artery disease; this rate varied from under 2 to more than 9 procedures per 1,000 people among hospital referral regions.

In 2013, the Institute of Medicine report Variation in Health Care Spending: Target Decision Making, Not Geography evaluated geographic variation in magnitude and growth of health-care spending by people in the United States who have Medicare, Medicaid, private insurance, or no insurance. The report presented findings of analyses of traditional, fee-for-service Medicare (and to a smaller extent Medicare Advantage, or Part C) and commercial insurance. It noted that because of methodologic challenges and data limitations, it did not include separate analyses of variation in the Medicaid and uninsured populations, although estimates of spending by those two groups are included in the area-wide estimates of total healthcare spending. The report's findings are instructive in examining geographic determinants of health-care use:

Geographic variation in spending and utilization persists among geographic units and health-care services and over time.

After adjustment for differences in the age, sex, and health status of beneficiaries, geographic variation in spending on both Medicare and commercial insurance is not further explained by other beneficiary demographic factors, insurance plan factors, or market-level characteristics. In fact, after controlling for all factors measurable within the data used for the analysis, much of the variation remains unexplained.

Variation in spending and utilization remains as units of analysis get progressively smaller (hospital referral regions, hospital service area, hospital, practice, and individual provider). Hospital referral region-level quality is not consistently related to spending or utilization by either Medicare beneficiaries or the commercially insured.

PEOPLE WITH DISABILITIES

Disability is a multidimensional concept. Some health conditions associated with disability result in poor health and extensive health-care needs, but others do not. The disabled population is clinically diverse. Some members have multiple chronic conditions that are stable with treatment and will persist for years; others have extreme functional limitations. Some have mostly severe, persistent behavioral health challenges; others have conditions that are greatly exacerbated by social factors such as lack of housing, food, and supportive personal relationships ( Krahn et al., 2015; Meade et al., 2015; Blumenthal et al., 2016). The committee's use of the word disability will vary with the literature that it reviewed.

The term disability implies that there are limitations in a person's ability to function in one or more ways. But types of impairment also differ substantially and might more or less limit a person's ability to function. They might:

Impair a person's body structure or function, or mental functioning; examples of impairment are loss of a limb, loss of vision, and memory loss.

Limit activity, such as difficulty seeing, hearing, walking, or problem-solving.

Restrict participation in normal daily activities, such as working, engaging in social and recreational activities, and obtaining health-care and preventive services ( ODPHP, 2017b).

Disability can be caused by or be related to genetic disorders, injuries, illness, or environmental exposures. Disabilities can be temporary, progressive, or intermittent. Thus, it is difficult to generalize about the relationship between disability and health-care utilization without targeting specific causes, diseases, or conditions. However, people who have disabilities have the same general health-care needs as everyone else, and therefore need access to healthcare services ( WHO, 2017).

Some diseases or conditions associated with disability are common; others are rare. For example, in 2015 one-fourth of people who were 18-64 years old reported difficulty in performing a basic activity, and 12.5 percent reported complex-activity limitation ( NCHS, 2017b).

Without adjustment, population rates of seven selected disabilities among all adults (not limited to working-age adults) increased substantially from 1998 to 2011. The absolute percentage change was greatest for movement difficulties, from 19.3 percent in 1998 to 23.3 percent in 2011. After separate adjustments for trends in age, race and ethnicity, and body mass index distributions, six disability types continued to show increased rates over time; the exception was sensory disabilities. Poor education, poverty, and unemployment remained associated with disability ( Iezzoni et al., 2014). People who report disability are at higher risk for poor health outcomes such as obesity, hypertension, falls-related injuries, and mood disorders, including depression ( An et al., 2015; Krahn et al., 2015; Meade et al., 2015; CDC, 2017).

People with disabilities use more health-care services than people who do not, in part because they have greater need for medical and health services to treat their conditions ( NCHS, 2017b). One-third of adults who had disabilities had at least one ED visit in 2015, compared to 13 percent of adults who had no disability. Some 29 percent of people who had disabilities had 10 or more visits to doctors or EDs or had home health-related visits compared with 8 percent of adults who had no disability ( NCHS, 2017b).

People who have disabilities also face a number of barriers to access to health care that are specific to their individual limitations in function ( Lagu et al., 2014; Meade et al., 2015). The barriers include physical access and absence of working elevators or ramps, automatic doors, hallways and doors wide enough to accommodate wheelchairs, and accessible parking; policies that discriminate against people with disabilities and the absence of policies in place and enforced that are designed to accommodate people with disabilities; and lack of accommodation for barriers to communication, including large print materials, sign language interpreters, and staff who are willing to try to communicate with impaired patients during scheduling or other interactions.

SUMMARY AND CONCLUSIONS

The health-care delivery system has undergone much change in the past few decades: new and improved drugs, devices, procedures, tests, and imaging machinery have changed patterns of care and sites where care is provided. The growth in ambulatory surgery has been influenced by improvements in anesthesia and analgesia and by the development of noninvasive or minimally invasive techniques. New and improved, and less invasive, procedures are available to treat people for a number of previously untreatable conditions in a variety of new sites of care, and even in physicians' offices. New drugs can cure disease or prolong survival of disease, although often at increased cost or with increased utilization. However, the availability of newer and improved types of health-care services does not mean that they are equally available to all Americans.

People use health-care services to diagnose, cure, or ameliorate disease or injury; to improve or maintain function; or even to obtain information about their health status and prognosis. Many factors affect health-care utilization, including need. The need for services affects differential use of health utilization for specific populations. Ideally, need is the major determinant of health-care utilization, but other factors clearly have an impact. They include poverty and its correlates, geographic area of residence, race and ethnicity, sex, age, language spoken, and disability status. The ability to access care-including whether it is available, timely and convenient, and affordable-affects health care utilization.

For people who have disabilities, accessing health care can be demanding. Many factors facilitate and hinder access to needed health care. Disability correlates with increased health-care utilization, and people who have disabilities often have worse overall health status, are poorer, and have a higher prevalence of poor health behaviors such as smoking and obesity. They also have poorer overall access because of provider discrimination, provider failure to make accommodations, and inadequate communication with providers.

REFERENCES

Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. The Milbank Quarterly. 2005;83(4) [ CrossRef]

Freid VM, Bernstein AB, Bush MA. Multiple chronic conditions among adults aged 45 and over: Trends over the past 10 years. NCHS Data Brief. 2012;(100):1-8. [ PubMed: 23101759 ]

IOM (Institute of Medicine). Access to Health Care in America. Washington, DC: National Academy Press; 1993.

NCHS. Health, United States, 2011: With special feature on socioeconomic status and health. Hyattsville, MD: National Center for Health Statistics (US); 2012. Health, United States. [ PubMed: 22812021 ]

NCHS. Health, United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: National Center for Health Statistics (US); 2016. Health, United States. [ PubMed: 27308685 ]

NCHS. Health, United States, 2016: With chartbook on long-term trends in health. Hyattsville (MD): National Center for Health Statistics (US); 2017b. Health, United States. [ PubMed: 28910066 ]

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Factors That Affect Health-Care Utilization

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The committee was tasked with identifying factors that influence a person's use of health-care services, including poverty and level of urbanization. This chapter will address those factors. The committee has organized the beginning of the chapter around individual and societal determinants of health-care utilization, including factors that affect the need for care, the propensity to use services, and barriers to the use of services.

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The number of non-native English speakers in the United States now includes over 60 million people - nearly triple the number from just three decades ago. Spanish and Chinese are the most popular foreign languages spoken in U.S. homes.

With nearly one-in-five Americans speaking another language at home, medical professionals are bound to come across patients with whom it is difficult to communicate. Employing a medical interpreter is vital for situations like this, but it's not just the interpreter who matters. You can play an active role in helping to make your non-English speaking patients more comfortable by following these six tips:

1. Learn a few polite expressions

A simple 'good morning' or 'thank you' in the patient's native language will go a long way toward improving your relationship and building trust.

2. Avoid slang

Use standard English to make sure your explanations and instructions will be understood correctly.

3. Keep it simple

The shorter the explanation, the better. Aim for words and phrases that are simple to understand and easily translated. Long explanations could lead the interpreter to summarize your words in a way that doesn't fully express what you're trying to say. At the same time, be careful not to patronize your patient!

4. Speak in full sentences

You may think it's helpful to stop mid-sentence to allow the translator to catch up, but doing so may put information out of context and lead to a confusing or inaccurate oral translation.

5. Be culturally sensitive

Topics such as death, sexuality and women's health must be addressed with care and respect. Also be careful about making jokes that might not translate well (or appropriately) into your patient's native language.

6. Look at the interpreter

It's very important to stay engaged while the interpreter is translating your words. Don't look through charts, talk to others in the room or stare out the window. Instead, signal your interest by facing the interpreter while they're talking.

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6 Tips for Communicating with Non-English Speaking Patients

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The number of non-native English speakers in the United States now includes over 60 million people - nearly triple the number from just three decades ago. Spanish and Chinese are the most popular foreign languages spoken in U.S. homes. With nearly one-in-five Americans speaking another language at home, medical

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Anticholinergic drugs, MOA and side effects

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Anticholinergic drugs, MOA and side effects

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Large doses- excitement, restlessness, hallucinations, agitation, medullary paralysis, coma and death

Large doses- excitement, restlessness, hallucinations, agitation, medullary paralysis, coma and death
Atropine has minimal action on ventricles which are innervated by adrenergic fibres
Adequate dose of atropine can suppress many type of reflex vagal cardiac slowing or asystole as occurring due to inhalation of irritant vapors stimulation of carotid sinus , pressure in eye balls, peritoneal stimulation, or injection of contrast medium during cardiac catheterization it can also negate cardiac slowing due to drugs like anticholinesterases, digpxin,

Secretions like sweat, salivary, nasal, throat, bronchial, gastric, lacrimal etc.

Secretions like sweat, salivary, nasal, throat, bronchial, gastric, lacrimal etc.
The action of atropine on urinary bladder is useful in relieving the urinary spasm due to inflammation, surgery, and certain neurogenic conditions,. Overactive bladder is a neurogenic bladder disorder.

Absorption: Atropine, scopolamine other tertiary amines well absorbed from the gut and across conjunctival membranes, if prepared in a suitable vehicle, these can be absorbed by the transdermal route example scopolamine transdermal patch
Distribution:
except quaternary compounds rest drugs are widely distributed, scopolamine rapidly and fully distributed in CNS and has greater effects than most of the other antimuscarinic drugs
Metabolism:
50% atropine & 80 % scopolamine metabolized by liver as conjugates . Some animal species as black rabbits are resistant to atropine actions because they possess specific enzyme, atropine esterase which degrades atropine faster than in human
Half life of atropine is 3 hours the effects of atropine decline rapidly in all organs except eye where the effects last about 72 hours or more

Physostigmine preferred over neostigmine

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Large doses- excitement, restlessness, hallucinations, agitation, medullary paralysis, coma and death Large doses- excitement, restlessness, hallucinations, agitation, medullary paralysis, coma and death Atropine has minimal action on ventricles which are innervated by adrenergic fibres Adequate dose of atropine can suppress many type of reflex vagal cardiac slowing or asystole as occurring due to inhalation of irritant vapors stimulation of carotid sinus , pressure in eye balls, peritoneal stimulation, or injection of contrast medium during cardiac catheterization it can also negate cardiac slowing due to drugs like anticholinesterases, digpxin, Secretions like sweat, salivary, nasal, throat, bronchial, gastric, lacrimal etc.

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9 Tips to Put Embarrassed Patients at Ease

Inside: Patients may be reluctant to share embarrassing health issues - here's what you can do to lessen the stigma.
When it comes to treating health issues, there are plenty of opportunities for patients to be embarrassed.

Whether a patient needs help finding a front-end product for a condition he considers embarrassing or filling a prescription for a condition that she might be shy about, embarrassment can be a hurdle for many patients when seeking treatment. If patients are ashamed about their condition they might neglect the issue, decide to not fill their script, or leave your pharmacy altogether.

Don't risk losing patients to embarrassment. Here are nine things you can do to help patients who are embarrassed.

1. Have a consultation area

Put patients at ease by designating a private consultation area in your store. Make this an area where patients can discuss potentially embarrassing conditions or uncomfortable questions with you.

Create a space in your pharmacy with privacy, so patients feel comfortable speaking openly, without the fear of being overheard or interrupted. When patients know that you have this space, they'll be more comfortable coming to your pharmacy with any embarrassing issues.

2. Approach the patient

Some patients might just be too embarrassed to approach you. Maybe they think their question is frivolous, or perhaps they feel uncomfortable interrupting one of your employees.

If a patient appears to be struggling or confused, make the first move. Start the conversation by asking if there is anything you can do to help, or just telling the patient that you would be happy to discuss the merits and features of various products.

Ask questions to find out why the patient is visiting the pharmacy. You may have to ask a few follow-up questions to get to the heart of the matter, so keep the questions non-judgmental. Even if a patient isn't willing to open up right then, they will hopefully recognize they can come to you in the future.

3. Build a strategic front-end layout

Design your front end to minimize embarrassment.

Keep possibly embarrassing products, such as fungus cream, away from high-traffic aisles and waiting areas. That way, people can select their product without other patients walking around or standing nearby.

Also, make sure your sections are clearly marked with signs, so patients don't have to ask for directions to sections of potentially embarrassing products.

4. Show empathy

Being empathetic with your patients can help make them feel less embarrassed.

Reassure patients by reminding them that everybody has to deal with embarrassing issues and that you're here to help. By acknowledging you realize the situation is uncomfortable, you can take the pressure off.

Don't try to break the ice by making a joke or poking fun. You might think it lessens the tension, but your patient might think you're making fun of them.

If you're comfortable, you can even share a story about how you've personally dealt with an embarrassing situation.
Editor's picks

5. Use positive body language

Your body language can help make patients with embarrassing conditions feel more at ease.

When patients share information about a medical condition that might be embarrassing, make sure you don't look surprised, or make any gestures that would signal that you're uncomfortable. Instead, work on nodding your head, maintaining eye contact, and smiling while reassuring the patient that you can help.

On the other hand, negative body language will signal to patients that you are not really listening or aren't invested in what they are telling you - which is hugely discouraging when they are sharing something that makes them feel vulnerable.

Avoid body language that signals you are "closed off," like crossing your arms, fidgeting, or putting your head in your hands.

6. Don't talk down

You're coming into these embarrassing conversations with a lot more knowledge than your patients have. Resist the temptation to deluge them with information that they didn't ask for.

Giving patients too much information may come off as condescending and give them the impression that you aren't really listening to their problem.

If patients get up the courage to ask you about something embarrassing, they want a solution, not a lecture. Be direct and avoid using jargon to get them the answers they need quickly and pleasantly.

7. Actively listen

Awkward or embarrassing conversations are the perfect time to deploy your active listening skills.

In addition to using positive and open body language, you can show your patients that you are giving them your full attention by repeating what they've said. This practice also gives them a chance to correct or clarify and ensure that you're on the same page.

Ask questions to make the conversation flow in both directions instead of putting all the pressure on your patient to convey what they are experiencing.

When the conversation is over, make a point to state the conclusion that you've settled on together and ensure your patient feels confident with the solution.

8. Don't let the conversation stutter

Don't let the conversation peter out before the patients' problem has been resolved. Studies have shown that brief pauses in the conversation - sometimes thought of as "awkward silences" - actually do have a negative impact on how the conversation unfolds.

The more silences you run into, the more uncomfortable the conversation will become, and it will become more difficult to get to the root of the patient's problem. And even if you do solve the problem, patients won't walk away with a positive impression after a stilted conversation.

Use your active listening skills as a way to keep things moving.

9. Call for backup

Recognize that you may not always be the best person for a specific difficult conversation.

Especially if they are dealing with a sex-specific problem, a female patient may be more comfortable speaking with a female staff member and a male patient may be more comfortable speaking with a male staff member.

While it may not be possible in every situation, when you're dealing with particularly a tight-lipped patient, see if you can match them up with a staff member they can speak to and feel less self-conscious.

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9 Tips to Put Embarrassed Patients at Ease - PBA Health

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9 Tips to Put Embarrassed Patients at Ease Inside: Patients may be reluctant to share embarrassing health issues - here's what you can do to lessen the stigma. When it comes to treating health issues, there are plenty of opportunities for patients to be embarrassed.

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The main muscles responsible for holding the urine in when a person doesn't want to urinate are the pelvic floor muscles.

Ideally, these muscles allow a person to release urine when they're ready. However, some people have weakened pelvic floor muscles. As a result, they may leak urine or have difficulty controlling the flow of their urine.

While there are many treatments for an overactive bladder or affected bladder control, one approach is to perform pelvic floor exercises. These exercises are aimed to strengthen the pelvic floor muscles and, ideally, the bladder.

The pelvic floor muscles go around the urethral opening, vagina, and rectum in women. Like all exercises, they require frequent practice to strengthen the muscles and keep them strong.

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Ideally, the pelvic floor muscles hold urine in until a person is ready to urinate.

Doctors often recommend Kegel exercises as a means to strengthen the muscles that support the bladder and keep it closed.

This can improve a person's ability to start and stop their urine stream.

However, the pelvic floor muscles can be difficult to target through Kegels. That's why it's important to first complete an exercise to identify these muscles. People can follow these steps to do so:

While preparing to urinate, focus on stopping the urine stream. People should think carefully about tightening only the muscles that stop their urine stream, not on other nearby muscles such as the legs, buttocks, or stomach.

Also focus on the sensation of the pelvic floor muscles pulling inward, stopping the urine stream or at least slowing it. Men will see the penis and scrotum move slightly when the proper muscles are tightened.

Once a person has identified the proper pelvic floor muscles, they can focus on performing Kegel exercises twice daily.

To perform the exercise, people should:

squeeze the same muscles used to stop the flow of urine

hold for 3 seconds

release the muscles

repeat this action 25 times

As the muscles get stronger, a person can increase the frequency to 25 to 50 repetitions for two to three times each day.

People who practice Kegel exercises should refrain from attempting to perform them while urinating, other than to practice initially "finding" the muscles. Kegels while urinating can affect a person's ability to completely empty their bladder, which could potentially lead to a bladder infection.

In addition to Kegel exercises, there are other methods to target the pelvic floor muscles. Examples include the following two exercises:

Short contractions

A doctor can help someone identify their pelvic floor muscles if they are having trouble.

Short contractions work the fast-twitch muscles located in the pelvic floor. Instead of focusing on holding the muscle contraction, the goal for this exercise is to tighten the muscles as quickly as possible, then release the muscles.

To perform short contractions, people should:

Take a deep breath in and exhale while tightening the pelvic floor muscles as fast as possible, imagining they are lifting the muscles upward.

Inhale while releasing the pelvic floor muscle contraction.

Repeat the exercise 10 times and complete a total of three sets.

People should aim to complete the exercises twice a day.

Long contractions

Long contractions are intended to help a person ultimately achieve a pelvic floor contraction that lasts 10 seconds.

To perform, people should tighten the pelvic floor muscles and hold the contraction as long as possible. A person may have to start at 3 seconds, then increase over time. Repeat for 10 repetitions of three sets.

The National Association For Continence recommend performing the short and long contractions in the same exercise period.

The exercises may take about 3 to 6 months before a person may see a noticeable difference. To continue to challenge the muscles, people can try performing the exercises in different positions, such as when sitting, standing, or lying down.

An inability or difficulty controlling urine flow is known as urinary incontinence. There are many reasons why urinary incontinence may occur, some of which may respond to exercises for bladder control.

There are a variety of reasons why someone would be unable to control their bladder, including pregnancy and childbirth, which can weaken the muscles.

Examples can include:

pregnancy and childbirth, which can stretch and weaken the pelvic floor muscles

long-term constipation, which can place added pressure on the bladder

long-term urinary tract infections or inflammation of the urinary tract

weight gain that places extra pressure on the bladder

surgery to the vagina in women or prostate surgery in men

While exercises for bladder control can be very effective in reducing the incidence of urinary incontinence and leakage, they are unfortunately often performed incorrectly. As a result, a person may find them ineffective in treating loss of bladder control.

Specialists can help a person learn how to properly perform these exercises. An example is a pelvic floor specialist. These specialists are usually physical therapists who obtain additional certifications in pelvic floor therapy.

Ideally, completing exercises for bladder control will allow a person to go longer between bathroom visits and experience fewer incidences of incontinence.

Are there gender differences in exercises for overactive bladder?

Both men and women can experience overactive bladder and urinary incontinence and benefit from exercises. However, women traditionally have greater difficulty singling out the muscles that should be tightened to strengthen the pelvic floor.

When this is the case, a doctor or pelvic floor therapist can use certain tools to help a woman identify the appropriate muscles. One example is a vaginal cone, which can be inserted into the vagina. If a woman is correctly tightening the pelvic floor muscles, the cone will stay in place.

Another option is biofeedback, which involves inserting a pressure sensor into the vagina. When a woman is correctly contracting the pelvic floor muscles, the pressure sensor will read at an expected level. A doctor can also use biofeedback for men by inserting the pressure sensor into the rectum.

Exercises are an excellent, nonsurgical way to work to relieve overactive bladder and incontinence symptoms. These exercises can be used as a complementary therapy to additional treatments that can be used to treat incontinence.

Examples include:

Dietary changes: Reducing the intake of foods known to cause bladder irritation and reducing fluid intake before a person goes to bed can reduce the incidence of overactive bladder, especially at night.

Medications: Medications can reduce spasms that cause the bladder to excessively contract and relax. Examples of these medications include oxybutynin, solfienacin, or tolterodine.

Surgery: If a person's symptoms do not respond to non-invasive treatments, surgeries to repair pelvic organs can help. Other surgical approaches can vary based on the likely cause of a person's incontinence.

If overactive bladder or poor bladder control affect a person's quality of life, they should seek medical treatment.

Sometimes, nerve damage can cause urinary problems.

Common causes include:

Nerve damage can lead to an overactive bladder or poor bladder control, leading to urinary incontinence and possibly urine retention. Urine retention increases the risk of a kidney or bladder infection.

Treatments include bladder training, electrical stimulation, medications, and, in severe cases, surgery.

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Bladder control: Kegel and pelvic floor exercises

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The main muscles responsible for holding the urine in when a person doesn't want to urinate are the pelvic floor muscles. Ideally, these muscles allow a person to release urine when they're ready. However, some people have weakened pelvic floor muscles. As a result, they may leak urine or have difficulty controlling the flow of their urine.

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https://www.healthline.com/health/anticholinergics

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https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problem/art-20046597#:~:text=Drink%20more%20of%20your%20fluids,from%20foods%20such%20as%20soup

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Includes a section on the psychological impacts of UTIs

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Abstract

Urinary tract infections (UTIs) are the most common outpatient infections, with a lifetime incidence of 50−60% in adult women. This is a narrative review aimed at acting as an introduction to the epidemiology and burden of UTIs. This review is based on relevant literature according to the experience and expertise of the authors. The prevalence of UTI increases with age, and in women aged over 65 is approximately double the rate seen in the female population overall. Etiology in this age group varies by health status with factors such as catheterization affecting the likelihood of infection and the pathogens most likely to be responsible. In younger women, increased sexual activity is a major risk factor for UTIs and recurrence within 6 months is common. In the female population overall, more serious infections such as pyelonephritis are less frequent but are associated with a significant burden of care due to the risk of hospitalization. Healthcare-associated UTIs (HAUTIs) are the most common form of healthcare-acquired infection. Large global surveys indicate that the nature of pathogens varies between the community and hospital setting. In addition, the pathogens responsible for HAUTIs vary according to region making adequate local data key to infection control. UTIs create a significant societal and personal burden, with a substantial number of medical visits in the United States every year being related to UTIs. European data indicate that recurrent infections are related to increased absenteeism and physician visits. In addition, quality of life measures are significantly impacted in women suffering from recurrent UTIs. Data suggest that nonantimicrobial prophylactic strategies offer an opportunity to reduce both the rate of UTIs and the personal burden experience by patients.

Keywords: burden of disease, epidemiology, urinary tract infections

Introduction

The following narrative review is based on presentations from the 2° Foro en Infecciones Urinarias Recurrentes (FIUR2) symposium, a Latin American forum to discuss current trends and challenges in treating recurrent urinary tract infections (UTIs). The literature herein was compiled based on a nonsystematic review of the current literature and the expertise of the authors/presenters.

Understanding the different classifications of UTIs is essential when considering their epidemiology. Broadly, UTIs are classified based on their location in the urinary tract, the presence of relevant complicating factors, and the presence or absence of symptoms. Definitions of some of the major categories of UTIs, based on the most recent German guidelines, are summarized in .

Table 1.

Uncomplicated UTI

A UTI where there are no relevant functional or anatomical abnormalities in the urinary tract, no relevant kidney function impairment, and no relevant concomitant diseases promoting the UTI or risk of developing serious complications

Acute uncomplicated cystitis

A lower UTI in which the acute symptoms involve only the lower urinary tract, for example, urgency, painful voiding (dysuria), pollakiuria, and pain above the symphysis

Acute uncomplicated pyelonephritis

An upper UTI with persistent symptoms including flank pain, flank tenderness, or fever (>38°C)

Asymptomatic bacteriuria

A positive urine culture (>10 ⁵ colony-forming units/ml) in the absence of urinary symptoms

Recurrent uncomplicated UTIs

A recurrent UTI refers to the occurrence of ⩾2 symptomatic episodes within 6 months or ⩾3 symptomatic episodes within 12 months

UTI epidemiology

Uncomplicated UTIs

UTIs are the most common outpatient infections in the United States (US). With the exception of a spike in young women aged 14−24 years old, the prevalence of UTIs increases with age. The prevalence in women over 65 years of age is approximately 20%, compared with approximately 11% in the overall population. Between 50% and 60% of adult women will have at least one UTI in their life, and close to 10% of postmenopausal women indicate that they had a UTI in the previous year.

Etiology in older postmenopausal women varies depending on their health status, residential status (institutionalized or not), age, the presence of diabetes mellitus, history of/current catheterization, spinal cord dysfunction, and a history of antibiotic use. Most UTIs in noncatheterized older adults are caused by a single bacterial species. However, in the presence of structural abnormalities and catheterization, it is not unusual to isolate more than one species in the urine culture. The increased use of catheters and instrumentation in these patients predisposes them to UTIs caused by Gram-negative rods such as Proteus, Klebsiella, Serratia, and Pseudomonas. In patients with diabetes mellitus, infections caused by Klebsiella, Enterobacter, and Candida are more common.

The frequency of uncomplicated cystitis in young sexually active women in the US is approximately 0.5 episodes per person per year. The peak rate of uncomplicated UTIs occurs during the years of maximum sexual activity, usually between the ages of 18 and 39. Uncomplicated recurrent UTIs are also frequent in young women. After a first episode of a UTI, 27% of women have a confirmed recurrence within the next 6 months, and 2.7% have a second recurrence within the same period of time.

There are an estimated 250,000 cases of pyelonephritis annually in the US, with a higher frequency among females. In women aged 18−49 years, the estimated incidence of pyelonephritis is 28/10,000; 7% of cases require hospital admission. Cultural and genetic factors may influence prevalence (e.g. in South Korea 59/10,000 patients experience pyelonephritis). Recurrence is less common than with uncomplicated UTIs, with 9% of females and 5.7% of males having a second episode within a year.

Uropathogenic Escherichia coli ( E. coli) (UPEC) is the dominant infectious agent in both uncomplicated and complicated UTIs. Enterococcus spp. and Candida spp. are substantially more common in complicated infections, while Staphylococcus saprophyticus ( S. saprophyticus) is rare (). Infection with UPEC increases the likelihood of recurrence within 6 months.

Table 2.

Healthcare-associated UTIs

Infectious complications following urological procedures are a major issue, particularly in the context of increasing antimicrobial resistance. Over 4 million patients acquire healthcare-associated infections in the European Union every year, 20−30% of which are considered preventable. Healthcare-associated UTIs (HAUTIs) represent the largest subtype among all healthcare-associated infections. The prevalence of HAUTIs assessed in regional studies ranges from 12.9% in the US and 19.6% in Europe, to up to 24% in developing countries.

The large, ongoing Global Prevalence Study on Infections in Urology (GPIU study) aims to gain a global perspective on HAUTIs. Between 2003 and 2010, 19,756 patients were assessed, 9.4% of whom were diagnosed with a HAUTI (70.4% of whom were female). The mean age of the study group was 59 years, and 75% of UTIs were diagnosed via urine culture. Asymptomatic bacteriuria (ABU) was the most common diagnosis (27%), followed by cystitis (26%), pyelonephritis (20%), and urosepsis (10%). The dominant pathogen in all conditions was UPEC (39.7%), although it made up a lower proportion than in UTIs in general (); Enterococcus spp. (11.5%), Klebsiella spp. (11.1%), and Pseudomonas aeruginosa ( P. aeruginosa) (10.8%) comprised approximately one-third of infections. An Asian substudy of GPIU ( n = 6707) underlined some regional differences: while the overall prevalence was similar (9.8%), the breakdown of UTIs classifications differed; pyelonephritis was the most common diagnosis (30.7%), followed by cystitis (29.9%), ABU (17.9%), and urosepsis (11.1%).

Prevalence of UTIs in Latin America

Overall, regional data for Latin America are currently lacking. In a Colombian study including 226 pregnant women, ABU was found in 10.6% of participants; UPEC was the most common pathogen (25%), followed by Enterococcus faecalis ( E. faecalis) (20.8%). Another Columbian study showed a prevalence of acute UTIs for women and men, respectively, of 23.3% and 6.8%, and a prevalence of recurrent UTIs of 54.2% and 15.7%, respectively. In a third Colombian study ( n = 1959), UTI prevalence was 31%, and the major causative agents were E. coli (69%), Enterococcus spp. (11%), and Klebsiella spp. (8%).

A small Argentinian study ( n = 87) examined HAUTIs (48% of participants) and community-acquired UTIs (52% of participants). Again, UPEC was more common in the community-acquired UTI group (74%) than in the HAUTI group (47%). Klebsiella pneumoniae ( K. pneumoniae) and E. faecalis infection rates were 12% versus 20% and 5% versus 7% in the community and healthcare settings, respectively.

The burden of recurrent UTIs

The burden of recurrent UTIs has both personal and societal aspects. The societal burden includes the clinical and economic burden of the illness, and the personal burden includes social and psychological effects which have a negative impact on quality of life (QoL). The high prevalence of recurrent UTIs represents a modifiable determinant for both societal and personal burdens, hence the importance of disease prophylaxis. Consultations for UTIs represent between 1% and 6% of all medical visits (~7 million visits and ~US$1.6 billion annually). They are associated with a significant burden of morbidity and mortality in the elderly, among whom UTIs are most prevalent.

Recurrent UTIs are associated with symptoms of anxiety and depression. The sudden, rapid, and painful onset of a UTI is often a source of anxiety in patients. Feelings of guilt related to a patient's inability to perform their usual activities, or the impact of recurrent infections on their social activities, may lead to clinical symptoms of depression. The social impact of recurrent UTIs may be particularly marked in premenopausal, working women. Treatment of a UTI alone is often not enough to improve a patient's QoL. However, the often-neglected impact of therapy on QoL should be considered as part of treatment efficacy. In the elderly, the potential for a substantial impact on general health, including issues such as incontinence, is also associated with a significant psychological burden.

The personal and societal impacts of recurrent UTIs often overlap. For example, in cases where multiple urine cultures or imaging studies may be required, the diagnostic burden both affects QoL and has a substantial negative economic impact. Costs may be both direct and indirect: work absenteeism, for example, can impact both the economy and a patient's sense of wellbeing. Costs include those associated with medical visits (for ambulatory patients), prescriptions for antimicrobials, hospital expenses, nonmedical travel-related costs, days of sick leave due to the disease, and the treatment of related comorbidities.

The recent multinational web-based GESPRIT study assessed both the personal and economic burden of recurrent UTIs in Europe (Germany, Switzerland, Poland, Russia, and Italy). Adult women (⩾18 years of age) with a history of recurrent infection and who currently had an acute infection ( n = 1275) or had suffered an infection within the previous 4 weeks ( n = 666) completed an online questionnaire. Recurrent UTIs were associated with an economic burden due to both sick leave and physician visits. Participants also reported a significant impact on QoL as evaluated by the SF-12 v2 health survey. The majority of women surveyed (approximately 80%) reported having received treatment with antibiotics. Prophylaxis was frequently delayed beyond the point where recurrence was established (⩾3 UTIs in 12 months), and the behavioral measures used for prophylaxis were often ineffective.

Appropriate prophylaxis may have the potential to ameliorate the impact of recurrent UTIs on QoL. In a recently published open-label, multicenter, prospective trial, 699 patients with recurrent UTIs were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Leicester Impact Scale which measures QoL in patients with urological problems. At trial entry, 61.9% of the patients exhibited some degree of depression. Participants received prophylaxis with the bacterial lysate OM-89 daily for 90 days. At the end of the 6-month study, the frequency of UTIs decreased by 59.3% ( p ⩽ 0.0001), the total HADS score decreased by 32.1% ( p ⩽ 0.0001), and the Leicester Impact Scale score decreased by 44.0% ( p ⩽ 0.0001), compared with baseline measurements. These data suggest that effective utilization of prophylaxis has the potential to ease the burden of UTIs on both individual patients and society.

Conclusion

UTIs remain one of the most common forms of infection both in the community and, particularly, within the healthcare setting. HAUTIs are of significant concern and cause a substantial personal and societal burden due both to their prevalence, and to the ability of microbes to share resistance mechanisms. Studies focusing on understanding regional differences in UTI epidemiology are necessary, particularly in Latin America, where there is currently a paucity of data. The burden of UTIs on both individuals and society is multifactorial and is likely to increase in the context of antibiotic resistance. Both regional and national studies on the burden of UTIs remain an unmet need in Latin America.

Contributor Information

Martha Medina, Hospital Nacional Docente Madre-Niño San Bartolome, Lima, Perú.

Edgardo Castillo-Pino, Department of Obstetrics and Gynecology, School of Medicine, University of the Republic, Hospital de Clínicas, Av Italia, 11600 Montevideo, Uruguay.

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An introduction to the epidemiology and burden of urinary tract infections

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Urinary tract infections (UTIs) are the most common outpatient infections, with a lifetime incidence of 50−60% in adult women. This is a narrative review aimed at acting as an introduction to the epidemiology and burden of UTIs. This review is ...

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If you're wondering how to Kegel correctly, you have come to the right place. Pelvic floor exercises should be an important part of both men and women's daily exercise routine. Pelvic exercises strengthen the core muscles that support your pelvic organs such as your bladder, bowel and uterus, and a strong and healthy pelvic floor means no leaks, less chance of prolapse and greater intimate sensation for both you and your partner.

Pelvic floor exercises aren't a new thing - they were developed in 1948 by Dr Arnold Kegel (hence 'Kegel exercises') who realised the importance of strong pelvic muscles to help with prolapse, help with natural childbirth and prevent incontinence. Yet, 1 in 2 women don't know how to produce an effective pelvic floor muscle contraction.

How To Do Pelvic Floor Exercises For Women (A Step-by-Step Guide)

1. Slow Kegel Exercises - Sit, stand or lie with your knees slightly apart. Slowly tighten your pelvic floor muscles starting with your anus (as if you are trying not to pass wind - the biggest part of your pelvic floor muscle is located here), then tighten around your vagina, squeeze both areas and lift (or 'suck-up' your muscles) as hard as you can. Hold for the count of five, then relax, repeat 5 times.

2. Fast Kegel Exercises - As before (Anus/Vagina/Squeeze/Lift) but quickly for two seconds, then relax for two seconds. Repeat five times

3. Try to vary your Kegel exercising by alternating between 5 slow kegel pull-ups and 5 fast Kegels. Ideally for five minutes.

4. Ideally you should do your Kegels for about five minutes at least three times a day - if you have time try to do more. Preferably 6-10 times a day. It may take between 8-20 weeks to see improvement in your pelvic floor muscle strength.

"If you're not exercising them (pelvic floor muscles) the problem is you could start to become incontinent and the problem could get steadily worse... The good news is that if you do exercise them regularly you can prevent it."
Dr. Dawn

Pelvic Exercise Positions

When you're learning how to do pelvic floor exercises most guides will tell you that they can be done anywhere at any time - lying down, sitting or standing up. But is this really true? Everything in your body is connected, so the position you're in when exercising impacts how engaged each muscle group is. This applies to your pelvic floor! We've done some research into what the best position for Kegel exercises is, here's what we found out:

1

Lying Down

When you start doing kegels, particularly if it's to recover from surgery, you'll probably find it easiest to do them lying down. Lying down offers the least amount of resistance for your pelvic floor muscles, making it much easier to contract them.

Lie on your back with your legs stretched out. Relax and do a Kegel - if you're using a Kegel8, insert your probe before lying down or use the electrode pads on your lower back. If lying on your back is uncomfortable you can try lying on your side with your legs bent at an angle instead. As you get stronger you can try more strenuous positions like sitting up. This will increase the amount of resistance and help you to gradually do more intense and effective Kegels.

2

Standing Up

Most pressure is on your pelvic floor when standing, causing symptoms to worsen. If you suffer from stress incontinence, Kegel exercises are useful throughout the day to prevent leaks when sneezing, coughing or laughing. Pelvic floor physiotherapist, Sue Croft, advises that the best standing position for Kegels is with your feet hip-width apart with your toes pointing inwards. Making it easier to focus on your pelvic floor muscles rather than tensing your inner thighs [1].

Ensure you don't tense the glutes and abdominals. Working other muscles alongside your pelvic floor prevents full Kegel benefits. Contracting your abs too much puts a lot of pressure on your pelvic floor, causing painful spasms and potentially making conditions like prolapse worse.

3

Sitting Down

Our research on Kegel positions came up with a definite winner - sitting down. This position enables you to target the right muscles with the right amount of resistance, as it's midway between standing and sitting. The Australian Journal of Physiotherapy confirmed this in a 2006 study [2]. It looked at three different positions for pelvic floor exercise - slumped and supported by a backrest, upright but unsupported and very tall and unsupported. As the women in the study sat more upright, the level of activity in their pelvic floor muscles increased. Sitting up straight in a 'very tall' position was found to be the most effective position for Kegels.

How Long Do Kegel Exercises Take to Work?

Some women have such weak pelvic floor muscles, they are unable to even gently contract them effectively in order to strengthen them. This is common for women who have been pregnant, post-menopausal women and runners. What are the options if this sounds like you?

With manual Kegel exercises, it's hard to pinpoint when you will see improvement. Everyone will see results at different times and if you don't suffer with leaks or other signs of pelvic floor weakness, progress can be difficult to identify. And this is where 'giving up' comes in; but with Kegel8 it is easy to keep motivated!

See results

The Kegel8 Vaginal Cones are a complete at-home pelvic floor strengthening system that can give you fast, effective results in just 12 weeks. Designed with top UK physiotherapists and available on prescription, these cones allow you to target the correct muscles and exercise effortlessly.

The Kegel8 Vaginal Cones feature a unique indicator tail that shows you, in real time, whether you're exercising your pelvic floor muscles correctly or not. Simply squeeze and lift your muscles, and the tail waves down!

"My physio said that I would need these because they have resistance - something to squeeze against, with weight as well for best results. Love these, notice the difference already even after 2 weeks."
Review by Ginni

The Kegel8 Biofeedback Pelvic Trainer is like weighing scales are to your diet; without them you feel like you're getting nowhere but getting on them every day and watching that number drop with the pounds week on week keeps you going.

The Kegel8 Biofeedback Pelvic Trainer measures your squeeze giving you a Squeeze Scale™ score. Record your progress and watch your Squeeze Scale™ climb as you squeeze! You'll know you're doing it right and you'll know how effective your Kegel exercises are!

"The real bonus for me is to be able to see the results of what I am doing on the screen, it really encourages me to squeeze harder and get a higher reading. I am only on level 4 but I actually look forward to using it each time."
Review by happy lady

Get in the Kegel8 Habit for the Best Pelvic Floor Exercises

This is the biggest hurdle for many of us; finding the time or getting into the habit. So here are some handy tips on how to make your pelvic health a habit:

Kegel exercises should be an every day essential to your health, just like brushing your teeth... so why not do them at the same time, morning and night!

We can spend the majority of a day getting from A to B. Use this time wisely; every time you hit a red light - kegel, every time your bus comes to stop - kegel, every time your train is delayed - kegel!

You could use your favourite TV programme that you make sure you never miss; kegel during the opening credits, again during the ad breaks and then during the closing credits.

'Whistle while you work' - how about kegel while you work? Pick a chore: vacuuming, ironing, pot washing; and kegel while you do it!

These are all options but a simple must is the Kegel8 12 Week Exercise Plan - sign up for FREE and we'll send you a fortnightly email full of useful tips, pelvic health information and a kegel challenge to really keep you motivated!

Make it Easy with a Kegel Exerciser

The same as an ab belt will do for your stomach, an electronic pelvic exerciser will do the work for you! The Kegel8 Ultra 20 is the UK's No. 1 pelvic toner, with clinically proven programmes to ensure your pelvic floor is strong and healthy. Using neuromuscular electrical stimulation (NMES), Kegel8 ensures your kegel exercises are efficient by stimulating your pelvic floor muscles to contract in the right way; and of course, relax. In fact, there's even a programme designed specifically for relaxation, so if you do suffer with pelvic pain or muscle tightness, Kegel8 can train your muscles to relax and recover.

"The probe stimulates the muscles - the right muscles in the right way."
Dr. Chris Steele

Does Kegel Exercise Work for You? 5 Mistakes You Could Be Making

Now that you know how to Kegel, and the best position to do it in, it's time to make sure you're doing it properly! 1 in 2 women perform Kegel exercises incorrectly. The pelvic floor is complicated and it's easy to make a mistake without realising - we've got a list of the 5 most common mistakes we've come across and how to fix them...

1: Bearing Down Instead of Lifting

The most common mistake when it comes to Kegel exercising is that instead of correctly squeezing and lifting the pelvic floor muscles, you push and bear down on them, causing further strain. This can make weak pelvic floor symptoms even worse!

Instead, you should feel like your muscles are lifting upwards. Imagine your pelvic floor as an elevator - take your muscles upwards to each level.

2: Not Activating Every Muscle

Your urethra, vagina and anus are all part of your pelvic floor. A proper Kegel contracts these muscles together. It's common for people to think that they're doing a Kegel when they're actually just squeezing their bum cheeks!

If you're having a lot of trouble finding the right muscles, you'll benefit from using a Kegel8 Ultra 20 Electronic Pelvic Toner.

3: Contracting But Not Relaxing

A complete Kegel should involve total relaxation of your muscles at the end. Failing to relax can cause strain, muscle spasms and fatigue. It can also cause hypertonic muscles (muscles which are too tight) and an overly tight pelvic floor can lead to conditions like chronic pelvic pain and constipation.

Make sure that you are fully releasing your pelvic floor after each contraction. Count slowly to 5 and breathe in while you contract your muscles, and breathe out to a count of 5 while you're relaxing them.

4: Bad Posture

It's really easy to end up slouching if you sit down a lot during the day. This will cause bad back pain and other health problems, your pelvic floor included. Sitting up straight while you do Kegels makes them 24% more effective [2] as your torso is properly aligned and your pelvic floor can contract more efficiently.

A posture cushion can help you to perfect Kegels. Our Kegel8 Pelvic Floor Exercise Wedge Cushion has been specially designed with Kegels in mind.

5: Bracing Too Much

Contracting your abdominal muscles while you Kegel will lessen how effective they are. Activating your core muscles too much puts strain on your pelvic floor, especially if you suffer from a prolapse. Abdominal strain can also make your pelvic floor muscles spasm, leading to pelvic pain that can be life altering.

If you're having trouble avoiding this type of strain, a Kegel8 Biofeedback Pelvic Trainer will ensure that you are just activating your pelvic floor muscles and not your abs. Using a Kegel8 unit makes Kegels more effective as it isolates the pelvic floor muscles for you.

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If you're wondering how to Kegel correctly, you have come to the right place. Pelvic floor exercises should be an important part of both men and women's daily exercise routine.

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Video explaining how the nervous system is involved in micturition

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Video explaining how the nervous system is involved in micturition

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During your stay in hospital (or before you go into hospital, if it's a planned stay), hospital staff will discuss and plan with you:

how the doctor will decide when you're ready to leave hospital (be discharged)

when they think that will be

whether you will go home or somewhere else, such as a community hospital or care home (most people go home)

transport or any other arrangements

any support and care you might need

They will involve your family and carers if you want.

It helps to have a key safe at home, or to leave keys with family or friends.

What happens while you're in hospital

If you need care and support after you leave, staff will talk with you about how you can get this. They will work with social care staff, if necessary, to plan your short-term care.

If you're likely to have long-term health and care needs, social services will arrange a care needs assessment. This may occur while you're in hospital or in your home.

Preparing to go home from hospital

If you can manage on your own at home with a little help, hospital staff should make sure:

someone is taking you home or you have a taxi, transport from a voluntary organisation or hospital transport

you have any medicine or new equipment you need and know how to use it

they share information about your care with your GP

you know the next steps in your care and how to get help from the hospital

local voluntary organisations are there to support you for the first 2 days, if you need it

When you get home from hospital

Temporary care

If you have had a short illness or an operation, you might need care after hospital for a short time to get back to normal. This is called reablement, intermediate care, or aftercare.

The aim of this type of short-term care is to help you:

stay as independent as possible

avoid unnecessary hospital stays

Reablement care is free for up to 6 weeks.

Ongoing care

After you've had a chance to recover or have had reablement care (if you need it), your local council should assess your long-term health and care needs and help put a plan in place.

You may have to pay towards the costs of long-term care and support.

Find out about getting a needs assessment.

If at any time you feel your care isn't right, contact social services and ask for a review.

What to do if you're unhappy with your hospital discharge

You can complain if you're unhappy with your hospital discharge, or the discharge of someone you know.

For example, if:

the hospital plans to discharge you before you think it's safe

you don't think your discharge assessment was done correctly

Speak to the hospital staff who arranged your discharge.

It might help to get advice from the Patient Advice and Liaison Service (PALS) or the charity POhWER who can provide help with NHS health complaints.

Read more about how to complain to the NHS.

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Planning care before you leave hospital - Social care and support

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During your stay in hospital (or before you go into hospital, if it's a planned stay), hospital staff will discuss and plan with you: how the doctor will decide when you're ready to leave hospital (be discharged) when they think that will be whether you will go home or somewhere else, such as a community hospital or care home (most people go home) transport or any other arrangements any support and care you might need They will involve your family and carers if you want.

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Regulation of Micturition

Passing of urine is under parasympathetic control. Bladder afferents signals ascend through the spinal cord and then project to the pontine micturition centre and cerebrum. Upon the voluntary decision to urinate, neurones of the pontine micturition centre fire to excite the sacral preganglionic neurones.

There is subsequent parasympathetic stimulation to the Pelvic Nerve (S2-4) causing a release of ACh, which works on M 3 muscarinic ACh receptors on the detrusor muscle, causing it to contract and increase intra-vesicular pressure. The pontine micturition centre also inhibits Onuf's nucleus, with a resultant reduction in sympathetic stimulation to the internal urethral sphincter causing relaxation.

Finally, a conscious reduction in voluntary contraction of the external urethral sphincter from the cerebral cortex allows for distention of the urethra and the passing of urine. In the female, urination is assisted by gravity, while in the male, bulbospongiosus contractions and squeezing along the length of the penis helps to expel all of the urine.

Clinical Relevance - Urinary Retention

Urinary retention has a variety of causes:

Benign prostatic hyperplasia (BPH) - this is the most common cause

Nerve dysfunction

Infection

Constipation

Drugs - including anticholinergics, antidepressants and opioids.

Patients typically present with intermittent flow, straining, vesical tenesmus (the feeling of incomplete emptying of the bladder following urination) and hesitancy (a delay between trying to urinate and the flow beginning).

Complications include incontinence, nocturia (the need to urinate at night), pain, hypertension, high frequency, hydronephrosis (high vesical pressure can push urine back up ureters), kidney failure, sepsis. Retention leading to complete anuria (inability to pass urine) can cause the bladder to significantly stretch and possibly tear.

In an acute setting treatment includes urinary catheterisation, a prostatic stent or a suprapubic cystostomy can be used. Long-term patients' treatment is dependent on cause, with the most common cause, BPH, having pharmacological (alpha blocker, 5-alpha-reducatase inhibitor) and surgical (prostatectomy, transurethral resection of the prostate) treatment options.

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Micturition - Regulation - TeachMePhysiology

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Micturition (urination) is the process of urine excretion from the urinary bladder Most of the time, the bladder (detrusor muscle) is used to store urine. As it fills, the rugae distend and a constant pressure in the bladder (intra-vesicular pressure) is maintained. This is known as the stress-relaxation phenomenon.

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https://www.continence.org.au/life-incontinence/caring-someone/psychological-impact

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https://www.healthline.com/health/anticholinergics#warnings

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Urinary retention- inability to voluntarily urinate  

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CKD- chronic kidney disease kidney damage or decreased function for  =3 months 

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AKI - acute kidney injury, abrupt loss of kidney function, resulting in retention of urea, loss of EC volume electrolyte balance. Occurs in healthy and diseased kidneys 

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College of Pharmacy University of Sulaimani

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1 DIURETICS Dr. Hiwa K. Saaed PhD Pharmacology & Toxicology

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PW-FE-TO

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All samples should be midstream and collected in a clean sterile container.

Suprapubic aspiration or fresh catheter samples are ideal, but not always practical.

The gold standard method of testing is to remove a small volume of urine from the sterile container with a fresh sterile syringe, and then apply the removed urine to the dipstick. In this way, the remainder of the collected sample contents remains untouched by a potentially unsterile dipstick and so can be sent for laboratory analysis if required.

Hold the dipstick horizontally before reading.

These include:

Multistix®: suitable for screening for glycosuria only.

Micral-Test II® or Microalbustix®: detect microalbuminuria.

Multiple combination strips - five tests on each strip: detects blood, ketones, glucose, pH and protein.

Multiple combination strips - seven tests on each strip: tests for blood, ketones, glucose, pH, bilirubin, urobilinogen and protein.

Costs vary depending on how many substances can be detected and the supplier.

Colour

The colour of the urine can vary greatly. Normal urine varies from colourless to dark yellow. Various factors can affect urine colour.

Turbidity

Cloudy urine may be due to:

Contamination with vaginal mucus or epithelial cells.

Excess phosphate crystals precipitating in alkaline urine (no clinical significance).

Pyuria secondary to infection.

Chyluria (presence of chyle/lymph in the urine - usually secondary to filariasis).

Hyperuricosuria secondary to a diet high in purine-rich foods.

Lipiduria.

Hyperoxaluria.

One study has recently shown that Gram-negative organisms can be accurately identified directly from an inoculum prepared from centrifuged turbid urine specimens. This method permits the reporting of the complete results on urine specimens as early as eight hours after their arrival in the laboratory. The most important benefit is the faster pathogen identification and susceptibility data, which allow earlier selective antimicrobial therapy.

Odour

The normal odour is described as urinoid. In concentrated specimens this can be strong but does not imply infection, which has a more pungent smell. Alkaline fermentation causes an ammoniacal smell, and patients with diabetic ketoacidosis produce a urine that may have a sweet or fruity odour.

Other causes of abnormal odours are cystine decomposition (a sulphuric smell), gastrointestinal-bladder fistulae (a faecal smell), medications (eg, vitamin B6), and diet (eg, asparagus).

Specific gravity (SG) <1.008 is dilute and >1.020 is concentrated.

Increased SG is seen in conditions causing dehydration, glycosuria, renal artery stenosis, heart failure (secondary to decreased blood flow to the kidneys), inappropriate antidiuretic hormone secretion and proteinuria.

Some dipsticks give falsely high readings in the presence of dextran solutions and IV radiopaque dyes, but this varies, so check the manufacturer's leaflet.

Urine SG may have low specificity in many in some situations.

Decreased SG is seen in excessive fluid intake, renal failure, pyelonephritis, and central and nephrogenic diabetes insipidus .

False low readings are associated with alkaline urine (eg, a high-citrate diet).

The range is 4.5 to 8, but urine is commonly acidic (ie 5.5-6.5) due to metabolic activity.

Acidic urine (low pH) may be caused by diet (eg, acidic fruits such as cranberries) and uric acid calculi. Spot urine pH by dipstick is not an accurate method for evaluation of the patients with urolithiasis. Patients with alkaline urine are more prone to error with reliance on spot pH.

Urine pH generally reflects the blood pH but in renal tubular acidosis (RTA) this is not always the case. If the blood is more acidic than it should be and the urine less acidic than it should be then the possibility of RTA should be considered:

In type 1 RTA (distal) the urine and the blood are both acidic.

In type 2 (proximal) the urine is initially alkaline but becomes more acidic as the disease progresses.

Alkaline urine (high pH) is also seen with infection with urease-splitting organisms, and may be associated with the formation of stag-horn calculi.

See also the separate Haematuria article.

A positive test indicates either haematuria, haemoglobinuria or myoglobinuria.

Dipstick tests for the presence of haemoglobin with the degree of colour change directly related to amount present.

Free haemoglobin or myoglobin causes field change, whereas intact red blood cells (RBCs) are broken down on contact with the reagent pad and release local haemoglobin, producing a dot. These coalesce when >250 RBCs/ml.

False positive readings are most often due to contamination with menstrual blood; they are also seen with dehydration which concentrates the number of RBCs produced, and exercise.

False negative readings: captopril, vitamin C, proteinuria, elevated SG, pH less than 5.1 and bacteriuria.

Dipstick testing for haematuria is the best screening tool.

Prognostic significance of a positive test is very controversial - rates ranging from 0.5-6% of patients with a positive test have been found to have underlying significant pathology.

See also the separate Proteinuria article.

Healthy adults normally excrete 80-150 mg protein in urine daily. Normal urinary proteins include serum globulins, albumin, and proteins secreted by the nephron.

Proteinuria is defined as albumin:creatinine ratio >30 mg/mmol or albumin concentration >200 mg/L. Clinical proteinuria is indicated at greater than 0.5 g of protein per day (greater or equal to 250 mg/L on a test strip). The dipstick test is a widely used screening tool for albuminuria, as a marker for chronic kidney disease, but the albumin:creatinine ratio (ACR) has advantages over the test in sensitivity and quantification of levels.

Detectible proteinuria may be the first sign of renovascular, glomerular or tubulo-interstitial renal disease. Alternatively, it may be caused by overflow of abnormal proteins in diseases such as multiple myeloma.

Most dipstick tests will pick up albumin but may not detect low concentrations of Bence Jones' protein or gamma-globulins. Bence Jones' protein can be detected by a specific antibody test on a midstream sample, whilst urine gamma-globulins can be detected by urine electrophoresis.

False negatives: alkaline or dilute urine or when primary protein is not albumin. A more accurate method is to precipitate urinary proteins with 3% sulfosalicylic acid (detects at 2.5 mg/L and detects other proteins). If urine is negative on dipstick but strongly positive with sulfosalicylic acid, suspect multiple myeloma.

Persistent significant proteinuria detected by dipstick requires further assessment with 24-hour urinary protein excretion, urinary protein:creatinine ratio, microscopic examination of the urinary sediment, urinary protein electrophoresis, and assessment of renal function.

Microalbuminuria can be detected with Micral-Test II® or Microbumintest® but this should be followed by confirmation in the laboratory, since false positive results are common.

See also the separate Glycosuria article.

Nearly all glucose filtered by the glomeruli is reabsorbed in the proximal tubules and only undetectable amounts appear in urine in healthy patients. Above the renal threshold (10 mmol/L) glucose will appear in urine. The test relies upon reaction of glucose with glucose oxidase on dipstick to form hydrogen peroxide which causes colour change. This is specific to glucose and no other sugar.

Useful screen for diabetes mellitus.

False positive results: seen when high levels of ketones are present. Also seen in patients taking levodopa.

False negatives: seen where SG is elevated, in uricosuria and in patients taking ascorbic acid.

See also the separate Urinary Ketones article.

Ketones are not normally found in urine.

Dipstick tests for the presence of acetoacetic acid at 5-10 mg/dL but not acetone or beta-hydroxybutyric acid. The urine ketone level has been found to be negative in more than half of the patients whose capillary blood ketone level was positive which has implications for the management of diabetic ketoacidosis.

A positive test is associated with uncontrolled diabetes, pregnancy without diabetes, carbohydrate-free diets and starvation.

False trace results may be seen in highly pigmented urine and in patients taking levodopa.

Delay in testing a sample may result in a false negative result.

See also the separate Bilirubinuria article.

Unconjugated bilirubin is water-insoluble and not normally present in the urine.

Conjugated bilirubin only appears in urine in the presence of liver disease or obstruction of the bile ducts.

A small amount of urobilinogen is normally found in urine, but significant amounts suggest that further assessment for haemolytic and hepatocellular disease is indicated.

Urobilinogen levels can be increased in conditions associated with elevated nitrite levels (eg, UTIs).

Nitrites

This test relies on the breakdown of urinary nitrates to nitrites, which are not found in normal urine.

Many Gram-negative and some Gram-positive bacteria are capable of producing this reaction and a positive test suggests their presence in significant numbers (ie more than 10,000 per ml). A negative result does not rule out a UTI.

The reagent is highly sensitive to air exposure, which may cause a false positive response.

False negative results may be seen where:

Bladder incubation time is shortened (less than four hours).

There is absence of dietary nitrate.

There is presence of nitrate reductase-negative organisms (eg, some mycobacteria strains).

Urine SG is elevated.

The pH is less than 6.0.

There is presence of urobilinogen and urinary vitamin C.

Leukocyte esterase

This relies on the reaction of leukocyte esterase produced by neutrophils and a positive result suggests pyuria associated with UTI.

Isolated trace results may be of questionable significance, but repeated ones should not be ignored.

False positive results may be caused by contamination with vaginal discharge.

Elevated urine glucose or oxalic acid concentrations may reduce sensitivity, and this may also be seen in patients taking tetracycline or cefalexin.

Efficacy

A negative urine culture can be predicted by negative dipstick test results. Therefore dipstick testing may be a reliable predictor of negative urine culture. In this study the percentage of positive cultures was 17.5%. Nitrite had 28% sensitivity and 99% specificity, with positive and negative predictive values of 89% and 87%, respectively. Leukocyte esterase had 79% sensitivity and 84% specificity, with positive and negative predictive values of 51% and 95%, respectively. The combination of positive nitrite or positive leukocyte esterase tests had 85% sensitivity and 84% specificity, with positive and negative predictive values of 53% and 96%, respectively.

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investigations (bedside and laboratory tests and imaging)

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Urine Dipstick Analysis; Performing Urine Dipstick Analysis

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All samples should be midstream and collected in a clean sterile container. Suprapubic aspiration or fresh catheter samples are ideal, but not always practical. The gold standard method of testing is to remove a small volume of urine from the sterile container with a fresh sterile syringe, and then apply the removed urine to the dipstick.

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

If you believe you are seeing this page in error please contact us.

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. If you believe you are seeing this page in error please contact us.

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https://kidneyresearchuk.org/kidney-health-information/living-with-kidney-disease/how-can-i-help-myself/understanding-test-results/

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Chronic kidney disease leaflet with information on eGFR

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Chronic kidney disease leaflet with information on eGFR

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Learning Objectives

By the end of this section, you will be able to:

Identify the ureters, urinary bladder, and urethra, as well as their location, structure, histology, and function

Compare and contrast male and female urethras

Describe the micturition reflex

Describe voluntary and involuntary neural control of micturition

Rather than start with urine formation, this section will start with urine excretion. Urine is a fluid of variable composition that requires specialized structures to remove it from the body safely and efficiently. Blood is filtered, and the filtrate is transformed into urine at a relatively constant rate throughout the day. This processed liquid is stored until a convenient time for excretion. All structures involved in the transport and storage of the urine are large enough to be visible to the naked eye. This transport and storage system not only stores the waste, but it protects the tissues from damage due to the wide range of pH and osmolarity of the urine, prevents infection by foreign organisms, and for the male, provides reproductive functions.

Ureters - slender tube that carries urine to the bladder

Urinary Bladder - hollow organ that stores urine

o has a region called the trigone - area with 3 openings...two from the ureters and one to urethrea

o layer of transitional ET - allows stretching

Urethra - carries urine from bladder to outside of body

Micturition (Voiding) - act of emptying bladder

Urethra

The urethra transports urine from the bladder to the outside of the body for disposal. The urethra is the only urologic organ that shows any significant anatomic difference between males and females; all other urine transport structures are identical.

The urethra in both males and females begins inferior and central to the two ureteral openings forming the three points of a triangular-shaped area at the base of the bladder called the trigone (Greek tri- = "triangle" and the root of the word "trigonometry"). The urethra tracks posterior and inferior to the pubic symphysis (see Figure 1). In both males and females, the proximal urethra is lined by transitional epithelium, whereas the terminal portion is a nonkeratinized, stratified squamous epithelium. In the male, pseudostratified columnar epithelium lines the urethra between these two cell types. Voiding is regulated by an involuntary autonomic nervous system-controlled internal urinary sphincter, consisting of smooth muscle and voluntary skeletal muscle that forms the external urinary sphincter below it.

Female Urethra

The external urethral orifice is embedded in the anterior vaginal wall inferior to the clitoris, superior to the vaginal opening (introitus), and medial to the labia minora. Its short length, about 4 cm, is less of a barrier to fecal bacteria than the longer male urethra and the best explanation for the greater incidence of UTI in women. Voluntary control of the external urethral sphincter is a function of the pudendal nerve. It arises in the sacral region of the spinal cord, traveling via the S2-S4 nerves of the sacral plexus.

Male Urethra

The male urethra passes through the prostate gland immediately inferior to the bladder before passing below the pubic symphysis (see Figure 1b). The length of the male urethra varies between men but averages 20 cm in length. It is divided into four regions: the preprostatic urethra, the prostatic urethra, the membranous urethra, and the spongy or penile urethra. The preprostatic urethra is very short and incorporated into the bladder wall. The prostatic urethra passes through the prostate gland. During sexual intercourse, it receives sperm via the ejaculatory ducts and secretions from the seminal vesicles. Paired Cowper's glands (bulbourethral glands) produce and secrete mucus into the urethra to buffer urethral pH during sexual stimulation. The mucus neutralizes the usually acidic environment and lubricates the urethra, decreasing the resistance to ejaculation. The membranous urethra passes through the deep muscles of the perineum, where it is invested by the overlying urethral sphincters. The spongy urethra exits at the tip (external urethral orifice) of the penis after passing through the corpus spongiosum. Mucous glands are found along much of the length of the urethra and protect the urethra from extremes of urine pH. Innervation is the same in both males and females.

Bladder

The urinary bladder collects urine from both ureters. The bladder lies anterior to the uterus in females, posterior to the pubic bone and anterior to the rectum. During late pregnancy, its capacity is reduced due to compression by the enlarging uterus, resulting in increased frequency of urination. In males, the anatomy is similar, minus the uterus, and with the addition of the prostate inferior to the bladder. The bladder is partially retroperitoneal (outside the peritoneal cavity) with its peritoneal-covered "dome" projecting into the abdomen when the bladder is distended with urine.

View the University of Michigan WebScope to explore the tissue sample in greater detail.

The bladder is a highly distensible organ comprised of irregular crisscrossing bands of smooth muscle collectively called the detrusor muscle. The interior surface is made of transitional cellular epithelium that is structurally suited for the large volume fluctuations of the bladder. When empty, it resembles columnar epithelia, but when stretched, it "transitions" (hence the name) to a squamous appearance. Volumes in adults can range from nearly zero to 500-600 mL.

The detrusor muscle contracts with significant force in the young. The bladder's strength diminishes with age, but voluntary contractions of abdominal skeletal muscles can increase intra-abdominal pressure to promote more forceful bladder emptying. Such voluntary contraction is also used in forceful defecation and childbirth.

Micturition Reflex

Micturition is a less-often used, but proper term for urination or voiding. It results from an interplay of involuntary and voluntary actions by the internal and external urethral sphincters. When bladder volume reaches about 150 mL, an urge to void is sensed but is easily overridden. Voluntary control of urination relies on consciously preventing relaxation of the external urethral sphincter to maintain urinary continence. As the bladder fills, subsequent urges become harder to ignore. Ultimately, voluntary constraint fails with resulting incontinence, which will occur as bladder volume approaches 300 to 400 mL.

Normal micturition is a result of stretch receptors in the bladder wall that transmit nerve impulses to the sacral region of the spinal cord to generate a spinal reflex. The resulting parasympathetic neural outflow causes contraction of the detrusor muscle and relaxation of the involuntary internal urethral sphincter. At the same time, the spinal cord inhibits somatic motor neurons, resulting in the relaxation of the skeletal muscle of the external urethral sphincter. The micturition reflex is active in infants but with maturity, children learn to override the reflex by asserting external sphincter control, thereby delaying voiding (potty training). This reflex may be preserved even in the face of spinal cord injury that results in paraplegia or quadriplegia. However, relaxation of the external sphincter may not be possible in all cases, and therefore, periodic catheterization may be necessary for bladder emptying.

Nerves involved in the control of urination include the hypogastric, pelvic, and pudendal. Voluntary micturition requires an intact spinal cord and functional pudendal nerve arising from the sacral micturition center. Since the external urinary sphincter is voluntary skeletal muscle, actions by cholinergic neurons maintain contraction (and thereby continence) during filling of the bladder. At the same time, sympathetic nervous activity via the hypogastric nerves suppresses contraction of the detrusor muscle. With further bladder stretch, afferent signals traveling over sacral pelvic nerves activate parasympathetic neurons. This activates efferent neurons to release acetylcholine at the neuromuscular junctions, producing detrusor contraction and bladder emptying.

Ureters

The kidneys and ureters are completely retroperitoneal, and the bladder has a peritoneal covering only over the dome. As urine is formed, it drains into the calyces of the kidney, which merge to form the funnel-shaped renal pelvis in the hilum of each kidney. The hilum narrows to become the ureter of each kidney. As urine passes through the ureter, it does not passively drain into the bladder but rather is propelled by waves of peristalsis. As the ureters enter the pelvis, they sweep laterally, hugging the pelvic walls. As they approach the bladder, they turn medially and pierce the bladder wall obliquely. This is important because it creates an one-way valve (a physiological sphincter rather than an anatomical sphincter) that allows urine into the bladder but prevents reflux of urine from the bladder back into the ureter. Children born lacking this oblique course of the ureter through the bladder wall are susceptible to "vesicoureteral reflux," which dramatically increases their risk of serious UTI. Pregnancy also increases the likelihood of reflux and UTI.

The ureters are approximately 30 cm long. The inner mucosa is lined with transitional epithelium (Figure 4) and scattered goblet cells that secrete protective mucus. The muscular layer of the ureter consists of longitudinal and circular smooth muscles that create the peristaltic contractions to move the urine into the bladder without the aid of gravity. Finally, a loose adventitial layer composed of collagen and fat anchors the ureters between the parietal peritoneum and the posterior abdominal wall.

Chapter Review

The urethra is the only urinary structure that differs significantly between males and females. This is due to the dual role of the male urethra in transporting both urine and semen. The urethra arises from the trigone area at the base of the bladder. Urination is controlled by an involuntary internal sphincter of smooth muscle and a voluntary external sphincter of skeletal muscle. The shorter female urethra contributes to the higher incidence of bladder infections in females. The male urethra receives secretions from the prostate gland, Cowper's gland, and seminal vesicles as well as sperm. The bladder is largely retroperitoneal and can hold up to 500-600 mL urine. Micturition is the process of voiding the urine and involves both involuntary and voluntary actions. Voluntary control of micturition requires a mature and intact sacral micturition center. It also requires an intact spinal cord. Loss of control of micturition is called incontinence and results in voiding when the bladder contains about 250 mL urine. The ureters are retroperitoneal and lead from the renal pelvis of the kidney to the trigone area at the base of the bladder. A thick muscular wall consisting of longitudinal and circular smooth muscle helps move urine toward the bladder by way of peristaltic contractions.

Self Check

Answer the question(s) below to see how well you understand the topics covered in the previous section.

Critical Thinking Questions

1. Why are females more likely to contract bladder infections than males?

2. Describe how forceful urination is accomplished.

Glossary

anatomical sphincter: smooth or skeletal muscle surrounding the lumen of a vessel or hollow organ that can restrict flow when contracted

detrusor muscle: smooth muscle in the bladder wall; fibers run in all directions to reduce the size of the organ when emptying it of urine

external urinary sphincter: skeletal muscle; must be relaxed consciously to void urine

internal urinary sphincter: smooth muscle at the juncture of the bladder and urethra; relaxes as the bladder fills to allow urine into the urethra

incontinence: loss of ability to control micturition

micturition: also called urination or voiding

physiological sphincter: sphincter consisting of circular smooth muscle indistinguishable from adjacent muscle but possessing differential innervations, permitting its function as a sphincter; structurally weak

retroperitoneal: outside the peritoneal cavity; in the case of the kidney and ureters, between the parietal peritoneum and the abdominal wall

sacral micturition center: group of neurons in the sacral region of the spinal cord that controls urination; acts reflexively unless its action is modified by higher brain centers to allow voluntary urination

trigone: area at the base of the bladder marked by the two ureters in the posterior-lateral aspect and the urethral orifice in the anterior aspect oriented like points on a triangle

urethra: transports urine from the bladder to the outside environment

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By the end of this section, you will be able to: Identify the ureters, urinary bladder, and urethra, as well as their location, structure, histology, and function Compare and contrast male and female urethras Describe the micturition reflex Describe voluntary and involuntary neural control of micturition Rather than start with urine formation, this section will start with urine excretion.

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Leaflet for patients on information about urine colour and UTI symptoms

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Leaflet for patients on information about urine colour and UTI symptoms

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https://www.nhs.uk/conditions/kidney-disease/diagnosis/

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https://www.mayoclinic.org/tests-procedures/urinalysis/about/pac-20384907#:~:text=A%20dipstick%20test%20checks%20for,kidney%20or%20urinary%20tract%20disorder.

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National Institute of Diabetes and Digestive and Kidney Diseases

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View or Print All Sections

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

The NIDDK would like to thank
Steven A. Kaplan, M.D., Icahn School of Medicine at Mount Sinai

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View or Print All Sections This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public.

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anatomy of the bladder and muscles involved in urination

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anatomy of the bladder and muscles involved in urination

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Urine produced in the kidneys travels down the ureters into the urinary bladder. The bladder expands like an elastic sac to hold more urine. As it reaches capacity, the process of micturition, or urination, begins. Involuntary muscle movements send signals to the nervous system, putting the decision to urinate under conscious control.

1. The Two Urethral Sphincters Maintain Urinary Continence

The internal urethral sphincter and the external urethral sphincter both provide muscle control for the flow of urine. The internal sphincter is involuntary. It surrounds the opening of the bladder to the urethra and relaxes to allow urine to pass. The external sphincter is voluntary. It surrounds the urethra outside the bladder and must be relaxed for urination to occur.

2. The Bladder Expands As It Fills with Urine

The bladder is shaped like a pyramid when empty. It becomes more oval as it fills with urine and expands. A smooth muscle called the detrusor surrounds the bladder, and folds called rugae line the interior wall. These structures give the bladder elasticity and allow it to expand. The floor of the bladder includes a funnel-like region called the trigone, formed by the two ureteral orifices and the internal urethral sphincter. Urine flows into the bladder via the ureteral orifices and out through the internal sphincter.

3. Muscles of Micturition: The Detrusor and Urethral Sphincters

Micturition, or urination, is the act of emptying the bladder. When the bladder is full of urine, stretch receptors in the bladder wall trigger the micturition reflex. The detrusor muscle that surrounds the bladder contracts. The internal urethral sphincter relaxes, allowing for urine to pass out of the bladder into the urethra. Both of these reactions are involuntary. The external urethral sphincter is voluntary. It must be relaxed for urine to flow through the urethra and outside the body.

4. How Full Does the Bladder Get Before We Have to Urinate?

The bladder expands as urine flows in from the ureters, but there is a limit to the volume it can contain. At about 200 ml of urine, the detrusor muscle begins to contract and the internal urethral sphincter muscle begins to relax. This sends signals through the nervous system and creates the "urge" to urinate. If this urge is ignored, continence may be threatened. At about 500 ml, detrusor muscle contractions begin to force open the internal urethral sphincter. Unless the external urethral sphincter is powerful enough to prevent it, micturition (urination) will occur involuntarily.

5. Bladder Stretch Triggers the Nervous System to Initiate and Control Micturition

Smooth muscle stretch initiates the micturition reflex by activating stretch receptors in the bladder wall. This autonomic reflex causes the detrusor muscle to contract and the internal urethral sphincter muscle to relax, allowing urine to flow into the urethra. The stretch receptors also send a message to the thalamus and the cerebral cortex, giving voluntary control over the external urethral sphincter. We usually gain this control of urination between the ages of 2 and 3, as our brains develop.
Download Urinary System Lab Manual

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Urine produced in the kidneys travels down the ureters into the urinary bladder. The bladder expands like an elastic sac to hold more urine. As it reaches capacity, the process of micturition, or urination, begins. Involuntary muscle movements send signals to the nervous system, putting the decision to urinate under conscious control.

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NEPHRON Structure & Function Made Easy - Human Excretory System Simple Explanation.

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https://www.youtube.com/watch?v=i1iTLLDWnn0

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Anatomy and Function of kidney and nephron 

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Anatomy and Function of kidney and nephron 

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https://courses.lumenlearning.com/wm-biology2/chapter/kidney-function-and-physiology/

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https://www.myinnovo.com/uk/how-innovo-works/

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1. Sue finds that she leaks when she coughs or sneezes (instead of having to rush to the toilet)

What type of incontinence does she have?

Which anatomical structures are involved?

What factors might put her at risk of this?

How does this compare to urge incontinence?

Do you know what simple first steps might help her manage this?

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1. Sue was found to have an anterior vaginal wall prolapse?

What adjacent structures may be causing this?

What symptoms may this prolapse cause?

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1. Mr Kowalski had no family living nearby

Who might be visiting him, why and how often?

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1. Mr Kowalski was in found to be in urinary retention?

What clinical signs would be present?

What is the most likely cause?

What is the immediate management of urinary retention?

What intervention may be offered later?

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1. Mr Kowalski’s blood level of potassium is high?

What are the risks of this for Mr Kowalska?

What tests might be ordered immediately?

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1. What if Mr Kowalski spoke limited English?

How would ensure you obtained informed consent, take a history and make shared decisions?

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Did we answer all of the questions sufficiently?

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Did we answer all of the questions sufficiently?

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Did we answer all of the questions sufficiently?

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Did we answer all of the questions sufficiently?

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BC-AP-YK

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https://www.youtube.com/watch?v=e3fgzcXu7LE&t=166s

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https://www.mayoclinic.org/diseases-conditions/angina/symptoms-causes/syc-20369373

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BA-JU-SG

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948792/

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288985/

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HDL / LDL and how to test for cholesterol in blood

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Cholesterol is a type of lipid found in the blood and in the diet. It has many functions and is a structural part of all body cells. It is an essential component of brain and nerve tissue. Cholesterol is needed to form hormones, bile, and vitamin D. Many foods contain cholesterol, but primarily it is found in foods of animal origin. Some meats are higher in cholesterol than others.

The body needs cholesterol, but it produces all of the cholesterol that it needs. It is almost impossible to avoid consuming outside sources of cholesterol, but it is possible and advisable to limit cholesterol intake by avoiding foods high in cholesterol. Elevated levels of LDL in the blood can increase the risk of artery and heart disease.

The human body produces two types of cholesterol: low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

LDL: The Bad Cholesterol

LDL is cholesterol that usually enters the human body through consuming food that contains cholesterol. LDL is considered the "bad cholesterol" because it bonds with triglycerides, another lipid, and stores it within the tissues. This is the leading cause of plaque in the arteries and can lead to restricted blood flow and possible cardiac arrest. This process takes place over a number of years with continuous eating of saturated fats, smoking, diabetes, and high blood pressure.

HDL: The Good Cholesterol

HDL is produced when a person exercises, and it is considered the "good cholesterol." HDL also bonds with triglycerides, but it is then processed by the body, added to feces, and expelled through the colon. In other words, HDL helps the body to process excess triglycerides thus managing the amount of excess fat in the overall system. The best way to increase HDL in the body is to do weight-bearing exercises regularly. Example would be to put weights on ankles when exercising or carrying a pound of something in each hand (a lb. can, spaghetti package) when walking.

Video: LDL and HDL Cholesterol

Lipid Panel

A Lipid Panel is series of tests that measures the amount of cholesterol in the blood. A small sample of blood is drawn from the patient for this test. One number is for "total cholesterol." This number will show the total fats in the blood. The HDL will show the good fats; LDL will show the bad fats; Triglycerides will show good or bad fats depending on the number above or below 150.

Adult Blood Cholesterol and Triglyceride Target Numbers:

Total Cholesterol < 200 mg/dl

Total HDL > 35

Total LDL < 100

Total Triglycerides < 150

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Cholesterol is a type of lipid found in the blood and in the diet. It has many functions and is a structural part of all body cells. It is an essential component of brain and nerve tissue. Cholesterol is needed to form hormones, bile, and vitamin D.

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Leaflet by Heart UK about the risk factors for coronary heart disease

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Leaflet by Heart UK about the risk factors for coronary heart disease

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Includes modifiable and non-modifiable risk factors

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Paper about cardiovascular treatment adherence

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Paper about cardiovascular treatment adherence

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Abstract

Background

Treatment plan adherence is recognized as a worldwide health issue, particularly important in the management of cardiovascular patients. Healthcare professionals are the primary sources of information and support for people diagnosed with CVD and those who have experienced a cardiac event, yet we know little about how healthcare professionals contribute to the process of adherence to treatment plans that aim to prevent and/or reduce disease and adverse events. Qualitative evidence that explores factors that influence adherence to treatment plans is limited.

Objective

This systematic review identified and synthesised the best available evidence on factors that influence adherence to treatment plans amongst people living with cardiovascular disease.

Design

Systematic review and qualitative synthesis.

Methods

Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase- Non-Medline, Scopus, Cochrane Library, ProQuest Central (Grey Literature). Pre-defined keywords and MeSH terms were used to identify qualitative methods English-language studies published between 2001 and 2018. Quality appraisal of each paper was completed using the JBI Critical Appraisal Checklist and two reviewers extracted the data independently.

Results

Twenty-two articles were included. Eight key themes were identified that related to facilitators and barriers to adherence to treatment plans. Facilitators were identified as engaging in exercise, having support and mentorship, lifestyle modification, and the perceived value of taking medication. Barriers were identified as a perceived lack of support, concerns about taking medication, and lack of engagement in exercise and lifestyle changes.

Conclusions

The findings highlight the factors that support adherence and healthcare professionals can build on also the areas that can be targeted to support and improve adherence to treatment plans. Nurses can play an important role in enhancing the provision of information pre hospital discharge and support in the community on taking medication, the value of physical activity and dietary changes.

View Abstract

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Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: A review of published qualitative research studies

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Treatment plan adherence is recognized as a worldwide health issue, particularly important in the management of cardiovascular patients. Healthcare professionals are the primary sources of information and support for people diagnosed with CVD and those who have experienced a cardiac event, yet we know little about how healthcare professionals contribute to the process of adherence to treatment plans that aim to prevent and/or reduce disease and adverse events.

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https://www.nhlbi.nih.gov/health-topics/atherosclerosis

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4660641/

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https://www.mayoclinic.org/diseases-conditions/left-ventricular-hypertrophy/symptoms-causes/syc-20374314

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https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/symptoms-causes/syc-20350800#:~:text=Cholesterol%20is%20a%20waxy%20substance,deposits%20in%20your%20blood%20vessels.

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https://youtu.be/R6QTiBfzULE

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https://www.youtube.com/watch?v=1SsYduKxE0Q

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from

Principles of Anatomy and Physiology

Tortora, Gerard J.

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About PAD; a consequence of long term HTN 

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About PAD; a consequence of long term HTN 

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"Peripheral arterial disease (PAD) includes a range of arterial syndromes that are caused by atherosclerotic obstruction of the lower-extremity arteries."

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Dr Leila Mureebe would like to gratefully acknowledge Dr Ehrin Armstrong and Dr Kosmas I. Paraskevas, previous contributors to this topic. EA is an advisory board member for Abbott Vascular, Boston Scientific, Medtronic, and Philips. EA and KIP are both authors of references cited in this topic.

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Dr Leila Mureebe would like to gratefully acknowledge Dr Ehrin Armstrong and Dr Kosmas I. Paraskevas, previous contributors to this topic. EA is an advisory board member for Abbott Vascular, Boston Scientific, Medtronic, and Philips. EA and KIP are both authors of references cited in this topic.

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Essential hypertension is typically diagnosed by screening of an asymptomatic individual.

Treatment of uncontrolled hypertension reduces the risks of mortality and of cardiac, vascular, renal, and cerebrovascular complications.

Lifestyle changes are recommended for all patients: weight loss, exercise, decreased sodium intake, Dietary Approaches to Stop Hypertension (DASH) diet, and moderation of alcohol consumption.

Choice of drug therapy is often driven by considerations related to comorbid disease, but achievement of blood pressure goal may be accomplished with a variety of therapeutic agent(s).

Essential hypertension is defined as blood pressure (BP) ≥140/90 mmHg, with no secondary cause identified.[1]National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Aug 2004 [internet publication]. https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity.[4] Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998 Jun 13;351(9118):1755-62. http://www.ncbi.nlm.nih.gov/pubmed/9635947?tool=bestpractice.com

The Eighth Joint National Committee (JNC 8) guideline recommends starting pharmacological treatment in patients with chronic kidney disease and diabetes if BP ≥140/90 mmHg. In the general population aged ≥60 years, treatment to lower blood pressure should begin when BP ≥150/90 mmHg. The latter recommendation was not agreed upon by all panel members because of the risk of cardiovascular events associated with BP ≥140/90 mmHg.

In the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines, hypertension is defined as office systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, which is equivalent to a 24-hour ambulatory blood pressure measurement average of ≥130/80 mmHg, or a home blood pressure measurement average of ≥135/85 mmHg.

Blood pressure goals and recommendations continue to evolve in line with new evidence.

The 2017 American College of Cardiology/American Heart Association guideline defines hypertension as any systolic blood pressure measurement of ≥130 mmHg or any diastolic BP measurement of ≥80 mmHg. This definition differs from the JNC 8, ESC, and ESH guidelines.

The SPRINT trial (Systolic Blood Pressure Intervention Trial) found that a lower systolic target of 120 mmHg (as measured by automated office blood pressure) reduced cardiovascular complications and deaths in people aged over 50 years with high blood pressure and at least one additional risk factor for heart disease.[6] The SPRINT Study Research Group. Systolic Blood Pressure Intervention Trial. 2016 [internet publication]. https://www.sprinttrial.org/public/dspHome.cfm Patients with diabetes or stroke were excluded from the trial.

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Essential hypertension is typically diagnosed by screening of an asymptomatic individual. Treatment of uncontrolled hypertension reduces the risks of mortality and of cardiac, vascular, renal, and cerebrovascular complications. Lifestyle changes are recommended for all patients: weight loss, exercise, decreased sodium intake, Dietary Approaches to Stop Hypertension (DASH) diet, and moderation of alcohol consumption.

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Overview of risk factors in non-medical language

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Overview of risk factors in non-medical language

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how to phrase information about heart disease risks for patients

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More information

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We know it can be overwhelming if you're diagnosed with a heart or circulatory condition, but we're here to help. Read on to find out what support we can offer.
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We fund research into risk factors because if we can reduce or prevent them, fewer people may be affected by heart and circulatory diseases.
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Order or download our series of leaflets about the main risk factors of heart and circulatory diseases. Get leaflets We know it can be overwhelming if you're diagnosed with a heart or circulatory condition, but we're here to help. Read on to find out what support we can offer.

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https://www.amazon.co.uk/Medical-Students-Olivia-Antoinette-Smith/dp/1482250314/ref=sr_1_1?crid=35FYLITYMKVPX&dchild=1&keywords=mind+maps+for+medical+students&qid=1615801960&sprefix=mind+maps%2Caps%2C157&sr=8-1

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https://en.wikipedia.org/wiki/Myogenic_mechanism

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https://www.cvphysiology.com/Intro

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DD-CX-NS

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Blood vessels are the channels or conduits through which blood is distributed to body tissues. The vessels make up two closed systems of tubes that begin and end at the heart. One system, the pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium. The other system, the systemic vessels, carries blood from the left ventricle to the tissues in all parts of the body and then returns the blood to the right atrium. Based on their structure and function, blood vessels are classified as either arteries, capillaries, or veins.

Arteries

Arteries carry blood away from the heart. Pulmonary arteries transport blood that has a low oxygen content from the right ventricle to the lungs. Systemic arteries transport oxygenated blood from the left ventricle to the body tissues. Blood is pumped from the ventricles into large elastic arteries that branch repeatedly into smaller and smaller arteries until the branching results in microscopic arteries called arterioles. The arterioles play a key role in regulating blood flow into the tissue capillaries. About 10 percent of the total blood volume is in the systemic arterial system at any given time.

The wall of an artery consists of three layers. The innermost layer, the tunica intima (also called tunica interna), is simple squamous epithelium surrounded by a connective tissue basement membrane with elastic fibers. The middle layer, the tunica media, is primarily smooth muscle and is usually the thickest layer. It not only provides support for the vessel but also changes vessel diameter to regulate blood flow and blood pressure. The outermost layer, which attaches the vessel to the surrounding tissue, is the tunica externa or tunica adventitia. This layer is connective tissue with varying amounts of elastic and collagenous fibers. The connective tissue in this layer is quite dense where it is adjacent to the tunic media, but it changes to loose connective tissue near the periphery of the vessel.

Capillaries

Capillaries, the smallest and most numerous of the blood vessels, form the connection between the vessels that carry blood away from the heart (arteries) and the vessels that return blood to the heart (veins). The primary function of capillaries is the exchange of materials between the blood and tissue cells.

Capillary distribution varies with the metabolic activity of body tissues. Tissues such as skeletal muscle, liver, and kidney have extensive capillary networks because they are metabolically active and require an abundant supply of oxygen and nutrients. Other tissues, such as connective tissue, have a less abundant supply of capillaries. The epidermis of the skin and the lens and cornea of the eye completely lack a capillary network. About 5 percent of the total blood volume is in the systemic capillaries at any given time. Another 10 percent is in the lungs.

Smooth muscle cells in the arterioles where they branch to form capillaries regulate blood flow from the arterioles into the capillaries.

Veins

Veins carry blood toward the heart. After blood passes through the capillaries, it enters the smallest veins, called venules. From the venules, it flows into progressively larger and larger veins until it reaches the heart. In the pulmonary circuit, the pulmonary veins transport blood from the lungs to the left atrium of the heart. This blood has a high oxygen content because it has just been oxygenated in the lungs. Systemic veins transport blood from the body tissue to the right atrium of the heart. This blood has a reduced oxygen content because the oxygen has been used for metabolic activities in the tissue cells.

The walls of veins have the same three layers as the arteries. Although all the layers are present, there is less smooth muscle and connective tissue. This makes the walls of veins thinner than those of arteries, which is related to the fact that blood in the veins has less pressure than in the arteries. Because the walls of the veins are thinner and less rigid than arteries, veins can hold more blood. Almost 70 percent of the total blood volume is in the veins at any given time. Medium and large veins have venous valves, similar to the semilunar valves associated with the heart, that help keep the blood flowing toward the heart. Venous valves are especially important in the arms and legs, where they prevent the backflow of blood in response to the pull of gravity.

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Classification & Structure of Blood Vessels

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Blood vessels are the channels or conduits through which blood is distributed to body tissues. The vessels make up two closed systems of tubes that begin and end at the heart. One system, the pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium.