A.

SCENARIO
A 68 years old woman was taken to the health center by her family.
According to her family, the patient suddenly crashed slipped close to her bed
this morning because of treading her own urine.
The last few days, the patient intermittently to the toilet to urinate.
Patients experienced coughing and shortness of breath, and her appetite is
greatly reduced, but no fever since last week. Patients had been suffering from
diabetes and high blood pressure. Patients receive treatment from a doctor for
the disease. Patients experienced a stroke attack one year ago.
B. DIFFICULT WORDS CLARIFICATION
C. KEYWORDS
1. Woman, 68 years old
2. Suddenly falling down because slipped by her urine
3. Patient intermittent need to go toilet to urinate
4. Coughing and shortness of breath
5. Less of appetite
6. No fever since last week
7. Suffering of DM and high blood pressure
8. Receive treatment form doctor about her DM and hypertension
9. Stroke attack one year ago
D. PROBLEMS IDENTIFICATION
1 What the etiology and risk factor of urin incontinence?
2 What relation between other complain with urin incontinence?
3 What relation between previous desease with urin incontinence?
4 Is there any relation between stroke attack with urine incontinence problem of
5
6
7
8
9
10

patient?
What the impact of drug history?
How to assess the patient on scenario?
How to manage the patient based in this scenario?
What the impact that we can suspect from urine incontinence?
How to prevent the patient?
Explain Islam point of view according to scenario!

E. PROBLEMS ANALYSIS

1. What the etiology and risk factor of urine incontinence?

Etiologi
Acute Urine Incontinence:
To make it easier to remember sorts of acute urinary incontinence and usually
reversible, between Iain can utilize drip acronym, which stands for: (Kane et al.)

D: Delirium
R: restriction of mobility, retention
I: infection, inflammation, impaction tests
P: Pharmacy (drugs), poliuri

The use of the word DIAPPERS can also help remember most of the causes of this
incontinence.

Delirium: awareness decreased urination effect on excitatory responses, as well

as knowing where to urinate. Delirium is a major cause of incontinence for those

who are hospitalized, when delirium improved, incontinence recovering well.

Infection: Urinary tract infections frequently result in incontinence; not so with

asymptomatic bacteriuria.
Atrophic vaginitis and atrophic urethritis: atropic generally will be accompanied
atrophic vaginitis and urethritis these circumstances cause incontinence in
women. Usually there is a good response with oral estrogen preparations after a

few months of usage. Topical use less convenient and more expensive.
Pharmaceuticals: medicines is one of the main causes of incontinence are
temporary, such as diuretics, antikotinergik, psychotropic, analgesic opioids,

alpha blockers in women, alpha agonists in men, and a calcium inhibitor.

Psychologic factors; severe depression with psychomotor retardation can reduce

the ability or incentive to reach a place to urinate.

Excess urine output: excessive urine output may exceed the ability of the elderly
to the restroom. In addition to diuretic medications, which often causes Iain eg
treatment heart failure, metabolic disorders such as hyperglycemia, or too much

to drink.
Restricted mobility: mobility constraints to achieve a micturition. If mobility can

not be improved, providing urinals or dragons, can improve incontinence.

Stool impaction: faecal impaction is also a frequent cause of incontinence in
those treated or immobilized. When obstipasi solved, will restore kontinens
again.

Both needed to urinate with a good level of awareness, motivation, mobility and
skills so that problems outside of bladder incontinence often results in geriatric. The
causes of this often causes incontinence temporary (transient acute), even if not
recognized and treated can be sustained incontinence (persistent).
Persistentent/Chronic Urine Incontinence:
Causes of persistent incontinence should be sought, after the cause of incontinence that
while it has been treated and removed. In general cause persistent incontinence is due
to:
1. Excessive activity of detrusor (Over Active Bladder, urgency incontinence type):
Excessive activity of the detrusor muscle causing uncontrollable contraction of
the bladder and result in loss of urine. This situation is a major cause of urinary
incontinence in the elderly, reaching its 2/3.
2. Decreased of detrusor activity (overflow type of incontinence): Incontinence is
most rare. Can be idiopathic, or due to interference sacrum nerve (neurogenic
bladder). When the result in incontinence, characterized by frequent urination, at
night more often, with the amount of urine a little / small. Residual residual
urine after urination (usually around 450 cc) distinguish the type of incontinence
urgency and the type of stress.
3. Failure of the urethra (the type of stress incontinence): The main cause number
two after excessive detrusor activity, especially in elderly women. Incontinence
is characterized by leakage of urine during activities. Urine may come out while
laughing, sneezing, coughing or lifting heavy objects. Urine is more striking
during the day, unless there is jointly urge incontinence that often exist
simultaneously.
4. Obstruction of the urethra. Enlargement of the prostate gland, stricture urethra,
prostate cancer is the usual cause is obtained from incontinence in elderly men.
Can seem urine dripping after urination.
5. Functional Type
A simple way to find the cause of incontinence in the elderly is to consider three
things urinate normally:
a. know where the place to urinate
b. be able to reach the site
c. can withstand not to urinate before getting on place
Urinary incontinence is characterized by functional types of urine at an early
stage, due to the inability to reach a place to urinate because of physical or

cognitive disorders and the various barriers situation / environment to another

before it is ready to urinate. Psichology factors such as anger, depression can
also cause functional incontinence types.(1)
Risk Factor

Female
Old age/elderly
High parity
Menopause
Ever had hysterectomy
Using a seat type of toilet
Neurological disorders
Trauma to the pelvic
Radiation
Deficit of nutrients
Obesity
Smoker, alcoholism
Excessive fluid intake or lack of activity.(2)

2. What relation between other complain with urine incontinence?

At the time cough increased intra- abdominal pressure, which involved
contracting the abdominal muscles that will suppress the organs contained in the
cavity vesica urinary andominal one of them, so there will be a reflex
contraction of the bladder wall, where the people who experience stress
inkontinencia impaired in function spinchter urethra which resulted in the
internal spinchter relaxation, followed by a relaxation of the external spinchter ,
and finally emptying the bladder occur spontaneously . as well as in the event of
shortness of breath, someone who is experiencing shortness of breath due to lack
of PO2 in the body, so it will be in excess of compensation with the inspiration
to improve the PO2 in the body , while the intra- abdominal pressure increases
during inspiration ( contraction of the diaphragm ) and decreased during
expiration ( relaxation of the diaphragm ) .(3)
3. What relation between previous disease with urine incontinence?
Diabetes mellitus history:
a. Kidneys:
In patients with diabetes have a tendency to seventeen times more easily
impaired renal function caused by repeated infection factors that arise in the DM
and the narrowing of blood vessels called capillaries diabetic microangiopathy

b. Bladder
In patients with diabetes often experience urinary tract infection (UTI) is
repeated, except that the nerves that nourish bladder is often broken so that the
walls of the bladder become weak. The nature of the control nerve disrupted
causing sufferers often wet or urine out themselves unwittingly called urinary
incontinence.
One cause of incontinence is polyuria. Polyuria in patients with DM is
the result glucosuria resulting due to osmotic diuresis which increased spending
urine (polyuria), which will also lead to thirst (polidipsi) and hunger
(polyphagia). Lost with urinary glucose consumption resulting in a negative
calorie balance and reduced weight.

Diabetes mellitus

Hyperglycemia

Blood glucose exceed the renal threshold

Glucosuria

Osmotic diuresis

Polyuria

Inkontinence
In such a scenario it is said that patients already taking drugs melitis
diabetes, so the chances of patients already have vascular complications of

chronic (long-term) both microangiopathy and makroangiopati. Diabetic

microangiopathy is a specific lesion that attack capillaries and arterioles of the
retina (diabetic retinopathy), kidney glomerulus (diabetic nephropathy), muscles
and skin.
Neuropathic diabetic vascular complications of peripheral nerves in the
cord. Neuropathy arises due to interference polyol pathway (glucose-fructosesosbitol) due to decreased insulin. There is accumulation of sorbitol in the lens,
causing cataracts, while the nerve tissue accumulation of sorbitol and fructose
and decreased levels of mioinositol that cause neuropathy. Biochemical changes
in the neural network will interfere with the metabolic activity of Schwann cells
and lead to loss of axons. Motor conduction velocity will be reduced at an early
stage neuropathy trip. Neuropathy can affect peripheral nerves (mononeuropathy
and polyneuropathy), cranial nerves or the autonomic nervous system.
Diabetic neuropathy can cause negative effects on the genitourinary tract,
intestinal tract, and cerebrovascular. Especially urinary tract effects of diabetic
neuropathy is loss of sensation in the bladder that will lower the action /
contraction of the muscular dertrusor causing difficulty emptying the bladder
(neurogenic bladder) due to loss of tone due to disturbances in peripheral nerves,
which causes overflow incontinence.
Hypertension history
As for some of the aspects that can be analyzed from a history of
hypertension

in

patients

taking

the

drug

in this

scenario

include:

Antihypertensive Drugs have the effect of urinary incontinence according to the

workings of each.
1. Diuretics can cause polyuria, frequency, and urgency.
2. Ca Channel Blocker decrease smooth muscle tone and decrease muscle
contraction detrussor that would cause retention of urine, causing overflow
incontinence
3. ACE inhibitors may precipitate a cough which resulted in stress inkotinence
Chronic hypertension can lead to stroke. Stroke in the blood vessels in the brain can
cause ischemic brain. This will give effect to the decline in the functions of
coordination, in this scenario affect the coordination function of the urethral sphincter.
Thus hypertension can cause urinary incontinence indirectly.(4)(5)

4. Is there any relation between stroke attack with urine incontinence problem
of patient?
Normal Micronutrition
The process of normal micturition namely lower urinary tract (bladder
and urethra) got the parasympathetic innervation of nerve fibers, sympathetic,
and somatic. Corda parasympathetic fibers originating from the spinal segments
S2 - 4 (brought by neruusrelvicus on urinarin and neruuspudendal bladder to the
urethra).The parasympathetic system M.detrusor role in the contraction and
relaxation of the internal urethral sphincter.Corda sympathetic fibers derived
from the spinal segments T10 - L2 (brought on by nervous hypogastric). The
sympathetic system plays a role in the relaxation and contraction of the urethral
sphincter M.detrusorinterna. While the somatic fibers derived from the anterior
horn of the spinal corda S2 - 4 (taken by N.pudendus). then taken to corteks
cerebral impulses that will lead to relaxation of the external urethral sphincter
(realized because it consists of skeletal muscle) at the time of micturition.
At the time of micturition, occur stimulation and inhibition of the
sympathetic and parasympathetic also intravesikal pressure exceeds intraurethral
pressure.
Effective urination has several requirements, namely:
1. The function of lower urinary tract effective
- Charging vesica urinary
ovesica urinary Accommodation in increasing urine volume with low pressure.
o The internal urethral sphincter that closes well.
o optimal sensation when vesica urinary full.
o The absence of muscle contraction disorders detrussor.
- Discharging vesica urinary
o The ability of muscles to contract detrussor.
o The absence of anatomical obstruction.
o Good coordination between muscle contraction detrussor with urethral
sphincter relaxation.
2. Ability to walk to the toilet.
3. Cognitive function is good to recognize the body's need to urinate.
4. Motivation for effective micturition.
5. There is no interference from environmental factors and iatrogenic
Neuroanatomy
Brain
The brain is the master control of the entire urinary system.
The micturition control center is located in the frontal lobe of the brain.
The primary activity of this area is to send tonically inhibitory signals to the

detrusor muscle to prevent the bladder from emptying (contracting) until a

socially acceptable time and place to urinate is available.
Certain lesions or diseases of the brain, including stroke, cancer, or
dementia, result in loss of voluntary control of the normal micturition reflex.
The signal transmitted by the brain is routed through 2 intermediate stops
(the brainstem and the sacral spinal cord) prior to reaching the bladder.
Brainstem
The brainstem is located at the base of the skull. Within the brainstem is
a specialized area known as the pons, a major relay center between the brain and
the bladder. The pons is responsible for coordinating the activities of the urinary
sphincters and the bladder so that they work in synergy. The mechanical process
of urination is coordinated by the pons in the area known as the pontine
micturition center (PMC). The PMC coordinates the urethral sphincter relaxation
and detrusor contraction to facilitate urination.
The conscious sensations associated with bladder activity are transmitted
to the pons from the cerebral cortex. The interaction of a variety of excitatory
and inhibitory neuronal systems is the function of the PMC, which is
characterized by its inborn excitatory nature. The PMC functions as a relay
switch in the voiding pathway. Stimulation of the PMC causes the urethral
sphincters to open while facilitating the detrusor to contract and expel the urine.
The PMC is affected by emotions, which is why some people may
experience incontinence when they are excited or scared. The ability of the brain
to control the PMC is part of the social training that children experience during
growth and development. Usually the brain takes over the control of the pons at
age 3-4 years, which is why most children undergo toilet training at this age.
When the bladder becomes full, the stretch receptors of the detrusor
muscle send a signal to the pons, which in turn notifies the brain. People
perceive this signal (bladder fullness) as a sudden desire to go to the bathroom.
Under normal situations, the brain sends an inhibitory signal to the pons to
inhibit the bladder from contracting until a bathroom is found.
When the PMC is deactivated, the urge to urinate disappears, allowing
the patient to delay urination until finding a socially acceptable time and place.
When urination is appropriate, the brain sends excitatory signals to the pons,
allowing the urinary sphincters to open and the detrusor to empty.
Incontinence problem after Stroke

Lesions of the brain above the pons destroy the master control center,
causing a complete loss of voiding control. The voiding reflexes of the lower
urinary tractthe primitive voiding reflexremain intact. Affected individuals
show signs of urge incontinence, or spastic bladder (medically termed detrusor
hyperreflexia or overactivity). The bladder empties too quickly and too often,
with relatively low quantities, and storing urine in the bladder is difficult.
Usually, people with this problem rush to the bathroom and even leak urine
before reaching their destination. They may wake up frequently at night to void.
Besides that, stroke attack can lead difficulty walking or moving around
and the patient may not always be able to getthere in time(hemiparesis or
impaired mobility). The same may be true if patient have communication
difficulties and cannot make him/her understood in time.Any extra exertion
involved in moving mayitself make it more difficult to maintaincontrol. It cause
functional incontinence.
Stress incontinence is the complaint of involuntary leakage on effort,
sneezing, or coughing. Stress incontinence often precedes strokeonset but is
typically exacerbated after stroke by repeatedcoughing associated with
dysphagia and aspiration.
Moreover, some types of incontinence that can occur as a result of stroke
are reflex incontinence and overflow incontinence. Reflex incontinence is
passing urine without realising it. This happens when a stroke has affected the
part of the brain that senses and controls bladder movement. Then overflow
incontinence is where the bladderleaks due to being too full. This can be due toa
loss of feeling in your bladder, or difficultyin emptying your bladder effectively
(urineretention).(6)(7)(8)
5. What the impact of drug history?
Relationship hypertension therapy given

with

complaints

of

urinary

incontinence
a. Alpa blockers would inhibit alpha 1 receptors in the muscles of the internal
urethra spincther so sympathetic stimulation did not affect the result of the
internal fixed urethra muscle relaxation spincther so that incontinence type
overflow occurs

b. Diuretics, for example furosamid hamper co transport of Na, K, Cl, so that

will draw water consequently the amount of fluid in the exhaust increase occur
incontinence.
c. ACE inhibitors have side-effects for example catopril cough so elevating
intra-abdominal pressure pressing vesica urinary incontinence that can
precipitate. (9)
6. How to assess the patient on scenario?
History taking
History focuses on duration and patterns of voiding, bowel function, drug use,
and obstetric and pelvic surgical history. A voiding diary can provide clues to causes.
Over 48 to 72 h, the patient or caregiver records volume and time of each void and each
incontinent episode in relation to associated activities (especially eating, drinking, and
drug use) and during sleep. The amount of urine leakage can be estimated as drops,
small, medium, or soaking; or by pad tests (measuring the weight of urine absorbed by
feminine pads or incontinence pads during a 24-h period). If the volume of most nightly
voids is much smaller than functional bladder capacity (defined as the largest single
voided volume recorded in the diary), the cause is a sleep-related problem (patients void
because they are awake anyway) or a bladder abnormality (patients without bladder
dysfunction or a sleep-related problem awaken to void only when the bladder is full).
Of men with obstructive symptoms (hesitancy, weak urinary stream,
intermittency, feeling of incomplete bladder emptying), about one third have detrusor
overactivity without obstruction. Storage symptoms include urinary frequency, urgency
(compelling need to void that cannot be deferred), urgency incontinence, and voiding at
night (nocturia). Voiding symptoms include urinary hesitancy (difficulty initiating the
stream), straining to void, weak or intermittent stream (starts and stops), and incomplete
bladder emptying, also pain while urinating. These storage and voiding symptoms are
evaluated using the International Prostate Symptom Score (IPSS) questionnaire. The
International Prostate Symptom Score (IPSS) is an 8 question (7 symptom questions + 1
quality of life question) written screening tool used to screen for, rapidly diagnose, track
the symptoms of, and suggest management of the symptoms of the disease benign
prostatic hyperplasia (BPH). The 7 symptoms questions include feeling of incomplete
bladder emptying, frequency, intermittency, urgency, weak stream, straining and

nocturia, each referring to during the last month, and each involving assignment of a
score from 1 to 5 for a total of maximum 35 points. The 8th question of quality of life is
assigned a score of 1 to 6.
0-7

= Mildly symptomatic

8-19

= Moderately symptomatic

20-35 = Severely symptomatic

The IPSS was designed to be self-administered by the patient, with speed and
ease in mind. Hence, it can be used in both urology clinics as well as the clinics of
primary care physicians (i.e. by general practitioners) for the diagnosis of BPH.
Additionally, the IPSS can be performed multiple times to compare the progression of
symptoms and their severity over months and years. In addition to diagnosis and
charting disease progression, the IPSS is effective in helping to determine treatment for
patients.
The history may also include previous episodes of catheterization. The physician
should inquire about precipitating factors, including alcohol consumption, recent
surgery, UTI, genitourinary instrumentation, constipation, large fluid intake, cold
exposure, and prolonged travel. A detailed medication history should be obtained for
prescribed and over-the-counter medications, with special attention to those that are
known to cause urinary retention such as anticholinergics, antidepressants, COX-2
inhibitors, amphetamines, and opioids.
Assuming the patients walking problems do arise from the joint(s), the aims of
the history will be to differentiate between inflammatory and degenerative/mechanical
problems, to identify patterns that may help with the diagnosis, and to assess the impact
of the problem upon the patient. There are four important areas which need to be
covered when taking a musculoskeletal history:

a. Current symptoms
The main symptoms of musculoskeletal conditions are pain, stiffness and joint
swelling affecting one or more joints. Assessment of the patients current symptoms
may allow differentiation to be made between inflammatory and non-inflammatory
conditions. Inflammatory joint conditions are frequently associated with prolonged

early morning stiffness that eases with activity, whilst non-inflammatory conditions
are associated with pain more than stiffness, and the symptoms are usually exacerbated
by activity.

Pain
Stiffness
Joint swelling
Pattern of joint involvement

b. Evolution of the problem: is it acute or chronic?

The examiner should listen to the patients history to find out:

When did the symptoms start and how have they evolved? Was the onset sudden

or gradual?
Was the onset associated with a particular event, e.g. trauma or infection?
Which treatments has the condition responded to?
The way in which symptoms evolve and respond to treatment can be an

important guide in making a diagnosis. Gout, for example, is characterized by acute

attacks these often start in the middle of the night, become excruciatingly painful
within a few hours, and respond well to non-steroidal anti-inflammatory drugs
(NSAIDs).
Musculoskeletal symptoms lasting more than 6 weeks are generally described as
chronic. Chronic diseases may start insidiously and may have a variable course with
remissions and exacerbations influenced by therapy and other factors. It may be
helpful to represent the chronology of a condition graphically
To asses the dementia, the doctor should ask questions during a medical history
to assess a person's past and current overall health and to find out how well the person
functions. This process may be complicated if the patient isn't able to remember
important parts of his medical history or isn't aware of the memory loss. A family
member can be very helpful in providing information about the person's symptoms,
such as when the symptoms were first noticed, how quickly they developed, and
whether they have continued to get worse.
Other important information in a medical history includes:
a. Other medical problems the person has or has had, such as a stroke, Parkinson's
disease, HIV infection, depression, a head injury, heart disease, or lipid disorders

(problems with cholesterol levels). In some cases, illnesses can cause confusion
or other signs of dementia.
b. Whether there is a history of Alzheimer's disease or dementia in the family.
c. The person's family, social, cultural, and educational background, as well as any
recent unusual events in the person's life. These things can influence how a
person performs on a mental status test. And some experts believe that they may
affect the risk of dementia.
d. What medicines the person is taking. Some medicines can contribute to memory
loss or mental impairment. This side effect of certain drugs is an easy problem to
correct but is often overlooked as the cause of symptoms.
e. History of alcohol or drug abuse.
f. Mood changes, hallucinations, or unusual behavior (such as lack of inhibition).
g. Recent problems with forgetfulness.
Again, the previous diseases should be examined and the progress should be
questioned, are they get better or worse. Also, the medication history should be paid
ateention to, too.
Physical Examination
The first thing to do for the patient is to check vital signs. The scenario has
shown that the patient has taken medications for hypertension and heart disease, also he
had history of stroke, therefore the examiner should check the blood pressure and pulse.
Dont forget to check respiratory rate and temperature because geriatric patients are at
risk of pulmonary oedem and respiratory infection such as pneumonia .
A brief screening examination, which takes 12 minutes, has been devised for
use in routine clinical assessment. This has been shown to be highly sensitive in
detecting significant abnormalities of the musculoskeletal system. It involves inspecting
carefully for joint swelling and abnormal posture, as well as assessing the joints for
normal movement. This screening examination is known by the acronym GALS,
which stands for Gait, Arms, Legs and Spine.
a. Gait
Ask the patient to walk a few steps, turn and walk back. Observe the patients

gait for symmetry, smoothness and the ability to turn quickly.

With the patient standing in the anatomical position, observe from behind, from
the side, and from in front for:
o bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles
o limb alignment
o alignment of the spine

o
o
o
o

equal level of the iliac crests

ability to fully extend the elbows and knees
popliteal swelling
abnormalities in the feet such as an excessively high or low arch profile,
clawing/retraction of the toes and/or presence of hallux valgus.

b. Arms
Ask the patient to put their hands behind their head. Assess shoulder abduction
and external rotation, and elbow flexion (these are often the first movements to

be affected by shoulder problems).

With the patients hands held out, palms down, fingers outstretched, observe the

backs of the hands for joint swelling and deformity.

Ask the patient to turn their hands over. Look at the palms for muscle bulk and

for any visual signs of abnormality.

Ask the patient to make a fist. Visually assess power grip, hand and wrist

function, and range of movement in the fingers.

Ask the patient to squeeze your fingers. Assess grip strength.
Ask the patient to bring each finger in turn to meet the thumb. Assess fine

precision pinch (this is important functionally).

Gently squeeze across the metacarpophalangeal (MCP) joints to check for
tenderness suggesting inflammatory joint disease. (Be sure to watch the patients
face for non-verbal signs of discomfort.)

c. Legs
With the patient lying on the couch, assess full flexion and extension of both

knees, feeling for crepitus.

With the hip and knee flexed to 90, holding the knee and ankle to guide the
movement, assess internal rotation of each hip in flexion (this is often the first

movement affected by hip problems).

Perform a patellar tap to check for a knee effusion. Slide your hand down the
thigh, pushing down over the suprapatellar pouch so that any effusion is forced
behind the patella. When you reach the upper pole of the patella, keep your hand
there and maintain pressure. Use two or three fingers of the other hand to push

the patella down gently (see Figure 7). Does it bounce and tap? This indicates
the presence of an effusion.
From the end of the couch, inspect the feet for swelling, deformity, and
callosities on the soles.

Squeeze across the metatarsophalangeal (MTP) joints to check for tenderness

suggesting inflammatory joint disease. (Be sure to watch the patients face for

signs of discomfort.)
d. Spine
With the patient standing, inspect the spine from behind for evidence of

scoliosis, and from the side for abnormal lordosis or kyphosis.

Ask the patient to tilt their head to each side, bringing the ear towards the
shoulder. Assess lateral flexion of the neck (this is sensitive in the detection of

early neck problems).

Ask the patient to bend to touch their toes. This movement is important
functionally (for dressing) but can be achieved relying on good hip flexion, so it
is important to palpate for normal movement of the vertebrae. Assess lumbar
spine flexion by placing two or three fingers on the lumbar vertebrae. Your
fingers should move apart on flexion and back together on extension
It is important to assess the patient at rest for any involuntary movements,

including chorea, tremor, dystonia, and myoclonus (which may be spontaneous or

stimulus sensitive). The muscles should be observed for fasciculations. The presence or
absence of primitive reflexes (frontal release signs) should be determined. An ocular
examination should involve careful assessment of visual acuity, pupillary responses, eye
movements, optic discs, and visual fields. Assessment of speech and swallowing may
reveal the presence of bulbar features. Examination for pyramidal or extrapyramidal
signs is important and gait should be assessed wherever possible. Ataxia is unusual in
AD, dementia with Lewy bodies, and frontotemporal dementia; its presence should raise
the possibility of a different cause. The presence or absence of apraxia should be
assessed by asking the patient to perform alternating hand movements or copy gestures.
A peripheral neuropathy may be present and when cooperation allows signs of this
should be sought.
Neurologic, pelvic, and rectal examinations are the focus. Neurologic
examination involves assessing mental status, gait, and lower extremity function and
checking for signs of peripheral or autonomic neuropathy, including orthostatic
hypotension. Neck and upper extremities should be checked for signs of cervical
spondylosis or stenosis. The spinal column should be checked for evidence of prior
surgeries and for deformities, dimples, or hair tufts suggesting neural tube defects.

Innervation of the external urethral sphincter, which shares the same sacral roots
as the anal sphincter, can be tested by assessing:

Perineal sensation
Volitional anal sphincter contraction (S2 to S4)
The anal wink reflex (S4 to S5), which is anal sphincter contraction triggered by

lightly stroking perianal skin

The bulbocavernosus reflex (S2 to S4), which is anal sphincter contraction
triggered by pressure on the glans penis or clitoris
However, the absence of these reflexes is not necessarily pathologic. A rectal

examination should be performed to estimate prostate size and to check for prostate
nodules and fecal impaction. Rectal examination can identify fecal impaction, rectal
masses, and, in men, prostate nodules or masses. Prostate size should be noted but
correlates poorly with outlet obstruction. Suprapubic palpation and percussion to detect
bladder distention are usually of little value except in extreme acute cases of urinary
retention. A bladder should be percussible if it contains at least 150 mL of urine; it may
be palpable with more than 200 mL.
The doctor should perform physical examination and look for signs of damage
to the nerves that affect the bladder and rectum. Tests are often needed. These may
include:

Bladder stress test. The doctor checks to see if the patient lose urine when

coughing.
Q-tip test. The doctor inserts a cotton swab into the urethra while the patient
cough and strain. Excessive movement of the swab could mean weakening of

the tissues that support the bladder.

Catheterization. The doctor inserts a catheter to see if more urine comes out. A
bladder that doesn't empty completely could indicate overflow incontinence.
An EKG may be part of a routine physical exam or it may be used as a test for

heart disease. An EKG can be used to further investigate symptoms related to heart
problems. EKGs are quick, safe, painless, and inexpensive tests that are routinely
performed if a heart condition is suspected.EKG can be used for assessing heart rhythm,
diagnose poor blood flow to the heart muscle (ischemia), diagnose a heart attack,
evaluate certain abnormalities of the heart, such as an enlarged heart. An
echocardiogram is a test that uses ultrasound to evaluate heart muscle and heart valves.

Supporting examination
Laboratory
Urinalysis, urine culture, and measurement of BUN and serum creatinine are
required. A urine culture (an attempt to grow and identify bacteria in a laboratory dish)
is performed when a urinary tract infection is suspected. In the presence of severe or
chronic symptoms of BPH, blood tests to detect abnormalities in creatinine, blood urea
nitrogen, and hemoglobin are used to rule out the presence of kidney damage or anemia.
Other tests may include serum glucose and Ca (with albumin for estimation of proteinfree Ca levels) if the voiding diary suggests polyuria, electrolytes if patients are
confused, and vitamin B 12 levels if clinical findings suggest a neuropathy. Routine
tests such as complete blood counts, urinalysis, sedimentation rate (ESR),
biochemistries, and specialized tests such as rheumatoid factor and antinuclear antibody
(ANA) are useful simply to rule out other diseases that cause joint pain.
However, it should be remembered that as we age, a low level positive test for
rheumatoid arthritis (rheumatoid factor) or ANA, and elevations of sedimentation rate
(ESR) can sometimes develop without the presence of the illness. Although these
findings can sometimes be confusing to a patient, they need not be. The clinical picture
makes the diagnosis; lab tests are used only to confirm the clinical picture. Laboratory
tests should never be used alone to diagnose arthritis.
Traditional diagnostic tools include fasting plasma glucose (FPG) measurement
and oral glucose tolerance tests (OGTT) could be examined. Although these tests are
sensitive, they measure glucose levels only in the short term, require fasting or glucose
loading, and give variable results during stress and illness.2,3 Standardized hemoglobin
A1c (HbA1c) assays reliably estimate average glucose levels over a longer term (2-3
months), do not require fasting or glucose loading, have less variability during stress
and illness, and are more specific for identifying individuals at increased risk for
diabetes.3 Therefore, the American Diabetes Association (ADA) recommends HbA1c as
an additional alternative for diagnosing diabetes and increased diabetes risk.
A prostate-specific antigen (PSA) test is generally recommended. PSA values
alone are not helpful in determining whether symptoms are due to BPH or prostate
cancer because both conditions can cause elevated levels. However, knowing a man's

PSA level may help predict how rapidly his prostate will increase in size over time and
whether problems such as urinary retention are likely to occur.
Postvoid residual volume should be determined by catheterization or
ultrasonography. Postvoid residual volume plus voided volume estimates total bladder
capacity and helps assess bladder proprioception. A volume < 50 mL is normal; < 100
mL is usually acceptable in patients > 65 but abnormal in younger patients; and > 100
mL may suggest detrusor underactivity or outlet obstruction.
Urodynamic testing is indicated when clinical evaluation combined with the
appropriate tests is not diagnostic or when abnormalities must be precisely characterized
before surgery.
Cystometry may help diagnose urge incontinence, but sensitivity and specificity
are unknown. Sterile water is introduced into the bladder in 50-mL increments using a
50-mL syringe and a 12- to 14-F urethral catheter until the patient experiences urgency
or bladder contractions, detected by changes in fluid level in the syringe. If < 300 mL
causes urgency or contractions, detrusor overactivity and urge incontinence are likely.
Peak urinary flow rate testing with a flow meter is used to confirm or exclude
outlet obstruction in men. Results depend on initial bladder volume, but a peak flow rate
of < 12 mL/sec with a urinary volume of 200 mL and prolonged voiding suggest
outlet obstruction or detrusor underactivity. A rate of 12 mL/sec excludes obstruction
and may suggest detrusor overactivity. During testing, patients are instructed to place
their hand on their abdomen to check for straining during urination, especially if stress
incontinence is suspected and surgery is contemplated. Straining suggests detrusor
weakness that may predispose patients to postoperative retention.
Prostate-specific antigen (PSA) blood test: Elevated levels of PSA in the blood
may sometimes be an indicator of prostate cancer.
Synovial fluid is the liquid that is normally found within the joints. It helps
nourish and lubricate the joints. It is usually present in only very small amounts.
However when arthritis is present, it changes in character and amount. Withdrawing the
fluid can reduce swelling and pain. It can also help to confirm the diagnosis. When
synovial fluid is removed, it should be sent for culture, well as tested for cell count. In
osteoarthritis, the white cell count (pus cells) is usually low and the fluid is clear (like
water); higher counts should suggest inflammatory arthritis or infection.

The fluid may also be examined for the presence of uric acid crystals (seen in
gout) or calcium pyrophosphate crystals (seen in pseudogout or chondrocalcinosis). The
measurement of other biological markers is still experimental.
A lumbar puncture may also be used to check the protein levels in the brain. This
procedure involves taking a sample of spinal fluid from the lower back for testing signs
of Alzheimers disease.
Imaging and Radiology

Ultrasonography is the imaging study used most often in men with lower urinary
tract symptoms. The test involves pressing a microphone-sized device
(transducer) onto the skin of the lower abdomen. As the device is passed over
the area, it emits sound waves that reflect off the internal organs. The pattern of
the reflected sound waves is used to create an image of each organ.
Ultrasonography can be used to detect structural abnormalities in the kidneys or
bladder, determine the amount of residual urine in the bladder, detect the

presence of bladder stones, and estimate the size of the prostate.

Urodynamic testing. A doctor or nurse inserts a catheter into urethra and bladder
to fill the bladder with water. Meanwhile, a pressure monitor measures and
records the pressure within bladder. This test helps measure bladder strength and
urinary sphincter health, and it's an important tool for distinguishing the type of

incontinence the patient have.

Cystoscopy. A thin tube with a tiny lens is inserted into urethra. This procedure
allows the doctor to check, and possibly remove, abnormalities in the urinary

tract.
A chest X-ray (also called chest film) uses a very small amount of radiation to
produce an image of the heart, lungs, and chest bones on film. Chest X-ray can
be used for a glimpse of the structures of the chest (bones, heart, lungs), evaluate
placement of devices (pacemakers, defibrillators) or tubes placed during
hospitalization for treatment and monitoring (catheters, chest tubes), and to

diagnose lung and cardiac diseases.

Cystogram. The doctor inserts a catheter into urethra and bladder and injects a
special dye. As the patient urinate and expel this fluid, X-ray images of the
patient bladder help reveal problems with urinary tract.

IVP, a procedure in which a special solution is injected into a vein in the arm and

an X-ray is taken of the patient kidneys, ureters and bladder.

Spiral (helical) computed tomography (CT) scan uses X-rays to make detailed
pictures of structures inside the body. These scanners can check for an enlarged
prostate gland, blockage, and urine flow from the kidneys. CT examinations also
are excellent for demonstrating the degree of osteophyte (bone spur) formation
and its relationship to the adjacent soft tissues. CT examinations are also useful
in providing guidance for therapeutic and diagnostic procedures. CT scan alson
can be used to check heart problems.

Non-contrast CT of the brain remains the mainstay of imaging in the setting on

an acute stroke. It is fast, inexpensive and readily available. Its main limitation
however is the limited sensitivity in the acute setting. Detection depends on the
territory, the experience of the interpreting radiologist and of course the time of
the scan from onset of symptoms. Whether tissue is supplied by end arteries (e.g.
lenticulostriate arteries) or has collateral supply (much of the cerebral cortex)
will influence how quickly cytotoxic oedema develops

CT perfusion has emerged as a critical tool in selecting patients for reperfusion

therapy as well as increasing the accurate diagnosis of ischaemic stroke among
non-expert readers four fold compared to routine non-contrast CT

CT angiography may identify thrombus within an intracranial vessel, and may

guide intra-arterial thrombolysis or clot retrieval. This procedure also help
evaluation of the carotid and vertebral arteries in the neck
o establishing stroke aetiology (eg. atherosclerosis, dissection)
o access limitation for endovascular treatment (e.g. tortuosity, stenosis)

Magnetic resonance imaging (MRI): MRI provides views of the entire prostate
with excellent soft tissue contrast. MRI (magnetic resonance imaging) is also
very sensitive to bony and soft tissue changes when dedicated protocols for the
musculoskeletal system are used. MRI can demonstrate reactive bone edema or
soft tissue swelling as well as small cartilage or bone fragments in the joint
therefore can help to determine what type of arthritis the patient suffers from.
MRI also can evaluate the anatomy and function of the structures of the chest,
including the heart, lungs, major vessels, and pericardium (the outside lining of

the heart). It is also used to determine the presence of diseases such as coronary
artery disease, pericardial disease, cardiac tumors, heart valve disease, heart
muscle disease (cardiomyopathy), and congenital heart disease. In identifying
stroke, MRI is more time consuming and less available than CT, but has
significantly higher sensitivity and specificity in the diagnosis of acute
ischaemic infarction in the first few hours after onset. An MRI scan can provide
detailed information about the blood vessel damage that occurs in vascular
dementia, plus any shrinking of the brain (atrophy). In Alzheimer's disease, the
whole brain is susceptible to shrinking, whereas in frontotemporal dementia the
frontal and temporal lobes are mainly affected by shrinking.

Other types of scan, such as a single photon-emission computed tomography

(SPECT) scan or a positron emission tomography (PET) scan, may be
recommended if the result of your CT or MRI scan is uncertain. These scans
look at how the brain functions and can pick up abnormalities with the blood
flow in the brain.

In some cases, an electroencephalogram (EEG) may be taken to record the

brain's electrical signals (brain activity).

Psychology
a. Formal cognitive assessment
A more detailed assessment of memory is necessary and performed by using several
specific bedside cognitive tests. The role and method of using such tests has been
covered in a previous supplement. During a thorough cognitive assessment it is useful
to examine the following:

Orientationin time and place

Attentionfor example, serial sevens, months of the year or WORLD

backwards
Memoryfor example, address recall, name of prime minister, etc
Languagefor example, naming of items, reading, writing, comprehension,

repetition
Executive functionfor example, letter and category fluency
Praxisfor example, alternating hand movements, imitation of gestures
Visuospatial functionfor example, drawing a clock face, overlapping
pentagons.

b. Rating scales
The Mini Mental State Examination (MMSE) is the most commonly used test for
complaints of problems with memory or other mental abilities. It can be used by
clinicians to help diagnose dementia and to help assess its progression and severity. It
consists of a series of questions and tests, each of which scores points if answered
correctly. The MMSE tests a number of different mental abilities, including a person's
memory, attention and language. MMSE is only one part of assessment for dementia.
Clinicians will consider a person's MMSE score alongside their history, symptoms, a
physical exam and the results of other tests, possibly including brain scans.
The MMSE can also be used to assess changes in a person who has already been
diagnosed with dementia. It can help to give an indication of how severe a person's
symptoms are and how quickly their dementia is progressing. Again, results should be
considered alongside other measures of how the person is coping together with clinical
judgement.
The widely used mini mental state examination (MMSE) provides useful
information in grading established dementia but does have limitations, particularly in
detecting early disease. It contains a crude test of delayed recall, with only three items
being employed and not enough time allowed between registration and recall. It lacks a
timed test to detect problems with verbal fluency. The language items are also very easy,
with all but significantly aphasic patients tending to perform at ceiling on these items.
The Addenbrookes cognitive assessment (ACE) has been developed to address the
deficiencies of the MMSE. Addenbrooke's cognitive examination (ACE) is a brief
neuropsychological assessment of cognitive functions and a development on the Mini
mental state examination, which it incorporates. The test is widely used for determining
mild cognitive impairment and dementia. The test includes measures of language,
memory, visuospatial skills, and orientation. The test does not adequately test for
apraxia. It also has the advantage of being brief enough to allow a clinician to use it
within the time constraints of a new patient appointment. It should be noted that even
the ACE is no match for formal neuropsychology assessment. Such services, are,
however, patchy, and in some services are non-existent, so the clinician must remain
competent at assessing cognition. (10)(11)(12)(13)(14)

7. How to manage the patient based in this scenario?

To manage the problem in this scenario, we shoul make priority scale from the
problem list.
A. Incontinentia(15)
There are 3 incontinentia urine medication method :
1) Behavioral training
Learn and practice steps to control the bladder and
spinchter muscle with bladder training and pelvic floor excercise.
2) Medication
Incontinence
type
Urgency
or
stress
with
instabilization
detrusor

Drugs Type

Mecanism

Anticholinergic
and
antispasmodic

Increase bladder
capasity
and
decrease
of
bladder
involunter

Adrenergic

Increase smooth
muscle
contraction

Stress type and

sphincter
weakness

Estrogen agonist

Increasi blood
flow in urethra

Stress type and

urgencythat has
relation with
vaginitis atropi

Cholinergic
agonist

Bladder
contraction
stimulation

For overflow
type with atonik
urinary

agonis

3) Surgery
Sphincterectomi

Drugs name and

dossage
Dry mounth, Oksibutinin :
Increasing of
2,5-5 mg tid
intraocular Telterodine
:
pressure,
2mg bid
constipation, Propantheline :
delirium
15-3- mg tid
Dyciclomine :
10-20 mg
Imipramine 1050 mg tid
Headache,
Pseudofedri
tacicardi,
n : 15-30 mg
increasing
tid
blood
Phenylpropa
pressure
nolamine :
75 mg bid
Imipramine
10-50 mg
tid
Endometrriu Oral : 0,625
m cancer,
mg/hr
Topical : 0,5-1
Increase
mg/application
blood
pressure,
renal stone
Bradichardi
Bethanechol :
10-30 mg tid
Side Effect

4) Chateterization
In this sscenario there are 2 typeof chateterization in urin
incontinence
a. Intermitten chateter
2-4x/day
b. Indwelling chateter
B. Infection (suspect pneumonia)(17)
Sefalosporin sefadroxil 500-1000 mg
C. Fall down(15)
Treat the complication
Perform surgery if theres fracture
D. Anoreksia
Nutritional treatment
E. Hipertention(18)
- Diuresis
- Blocker system adrenergik
- Vasodilator
- RRA system blocker
- Antagonis Cadecrease urine secretoric
F. Diabetes Mellitus(17)(18)
- Control the complication
- Hipertention control
G. Stroke(18)
- Hipertention control
- Stop smooking and not to drink alcohol
- Life style modification (Physical activity management)
8. What the impact that we can suspect from urine incontinence?
Complications can accompany urinary incontinence just as urinary tract
infections, skin disorders, sleep disorders, psychosocial problems such as
depression, easy to get angry, and seemed to feel isolated from the environment
indirectly. In these problems can also lead to dehydration because patients
generally will reduce thedrink for fearbedwetting. Decubitus, recurrent
infections, falls, and no less important is the high maintenance costs for the
purchase of diapers. (19)
9. How to prevent the patient?

From several references, it is not always possible to prevent urinary

incontinence, but a healthy lifestyle may reduce the chances of the condition
developing.
Healthy weight
Being obese can increase your risk of developing urinary incontinence.
Obesity with BMI 30 kg/m2 or more will lead the constant retraction on bladder
and muscles around. It may therefore be able to lower your risk by maintaining a
healthy weight through regular exercise and healthy eating.
Drinking habits
It depending on particular bladder problem. If someone had urinary
incontinence, cut down on alcohol and drinks containing caffeine (such as tea,
coffee and cola), it will increase the risk of incontinence because the diuretic
effect of these drinks will fulfill the bladder faster and stimulate the sensation of
taking pee.
If someone had to urinate frequently during the night (nocturia), try
drinking less in the hours before sleep. However, make sure you still drink
enough fluids during the day.
Pelvic floor exercises
Being pregnant and giving birth can weaken the muscles that control the
flow of urine from the bladder. The pelvic floor muscles are located between the
legs, and run from the pubic bone at the front of the base and spine at the back.
As people get older, the pelvic floor muscles get weaker.
To strengthen the pelvic floor muscles, sit comfortably and squeeze the muscle
10 - 15 times in a row. Do not hold the breath or tighten the stomach, buttock or
thigh muscle at the same time.
Avoid smoking
Smoking will increase the risk of urinary incontinence, it will make the
bladder become more active because the effect of nicotine on wall bladder. (20)
10. Explain Islam point of view according to scenario!

And your Lord has decreed that you not worship except Him, and let the
mother and your father do well with the best. If one of the two or both until the
age further in the maintenance of you, then occasionally do not say to both the
word "ah" and do not yell at them and say to them a noble word. " (Al
Isra( chapter 17): verse 23)(21)
Atsar from Ibnu Abbas radhiyallahu anhuma:

"" It is not a Muslim who had both parents were Muslims who he is on
every day to do good to both of them, but God will open the door for him 2
(heaven). If the old man lived alone, then the first door that God opened. If he
makes angry / furious one of them, then God is not going up to the pleasure of
his good pleasure. "Someone said," If both parents dzalim? "Ibn 'Abbas said,"
Although parents dzalim!"(22)

F. Leaning Objective:
NORMAL BLADDER AND EFFECT AGING BLADER IN ELDERLY
Detrusor muscle of the bladder is contractile muscles and webbing each
others. Detrussor muscles are regulated by the nerve around pelvic bone, spinal
core, and centers in the brain. If the bladder is fully occupied by urine, nerve
sensation will be continued through the pelvical nerve and spinal core to the subcortical and cortex of the brain. Sub-Cortical centers will allow bladder to relax
and the filling process continue without any sensation of micturition. If the
filling process continue, distended bladder will trigger the sensation to reach
awareness centers in the brain. Thus, any disorder which caused by any disease

or drugs in sub-cortical or cortex of the brain will lead to inability to delay

micturition. If there is a willing of micturition, nerves impulse from cortex
continued through spinal core and pelvical nerves to the detrusor muscles by the
working of cholinergic substances. Beside cholinergic, detrusor muscles also has
receptors for prostaglandin, thus every drugs that inhibit prostaglandin can also
inhibit detrussors work. Bladder contraction is also depend on the work of
calcium ions. Activity of alfa adrenergic cause the contraction of urethral
sfingter. When micturition happening, stimulation of symphatic nerves decrease
and directly increasing of parasymphatic cause the bladder contract.
Generally, along the increasing of ages, bladders capacity will decrease.
Urine residue in bladder, after micturition, tend to increase and involunter
bladder muscles contraction is more often. This found in 40-75% of elderly who
got incontinence. In woman, being an elderly also cause reduction of urethral
and bladder orifice resistance. This associated with the reduction of estrogen
level and the weakness of pelvic muscles after labor, all the more with extra
action during labor.
Reduction of estrogen influence on elderly, also can cause atrophy
vaginitis and urethritis that will lead to incontinence. In male, hyperplasia of
prostat gland on eldery seems to have risk do develop incontinence. (23)

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22. Al-Hadits
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