Gastrointestinal and Genitourinary Disorders
PTA 103 Introduction to Clinical Practice 2

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment. Contact howardc@lanecc.edu for permissions.

Lesson Objectives

1. Describe the pathophysiology, risk factors, and classifications of common disorders of selected gastrointestinal (GI), genitourinary (GU), and metabolic/endocrine disorders encountered across the lifespan, including obesity
2. Identify medical treatment interventions for GI and GU conditions, including obesity
3. Discuss socioeconomic factors for obesity that influence effective treatment outcomes
4. Respond appropriately to signs and symptoms blood glucose disregulation before and during therapeutic interventions
5. Educate a patient on the influences of obesity on blood glucose regulation for a given case scenario
6. Recognize how race, ethnicity, and socioeconomic factors influence diabetes prevalence and access to effective care
7. Respond appropriately to signs and symptoms of a neurogenic bladder
8. Recognize the psychosocial impact of GI and GU dysfunction on patients quality of life
9. Demonstrate strong awareness of the role of the PTA in communication, interventions and patient education for selected GI, GU, and metabolic disorder management

Gastrointestinal (GI) Disorders

Common Causes

• Infections
• Autoimmune/immuno suppressives
• Genetic pre-disposition
• Lifestyle related: smoking, alcohol consumption (EtOH use), diet, stress
• Cancer
• Trauma
• Abdominal surgery: acute or history

Common Signs and Symptoms

• Nausea
• Vomiting (emesis)
• Anorexia
• Diarrhea
• Constipation
• Fluid and electrolyte imbalances
• Pain - abdominal and pain referred to abdominal region from another primary source
• Malnutrition

 Common Treatments for GI Disorders

• Dietary modifications: reduction of nicotine, caffeine, alcohol
• Stress reduction
• Drugs
• Laxative
• Anti-diarrhea
• Antacids
• Analgesics
• Anti-emetic
• Surgical
• Gastric bypass
• Gland removal
• Bowel resection for bowel obstruction
• Hernia repair

Patient support equipment

Intravenous (IV) lines

• IV fluids administration
• Total Parental Nutrition (TPN - IV delivery of food and nutrients)
• Red blood cell infusions

Nutritional support

• Percutaneous endoscopic gastrostomy (PEG) tube
• Nasogastric (N-G) tube
• Red blood cell infusions

Fluid drains

Active drains use suction to remove fluids

• Jackson-Pratt drains (JP) – closed drain (has a collector) that aids in removing fluid from abdominal wounds.

https://upload.wikimedia.org/wikipedia/commons/1/10/Post-operative_Jackson-Pratt_Drains.JPG

• Sump drains – open drain that also removes fluid by suction

Passive drains use pressure differentials and/or gravity to remove fluid

• Foley catheter - indwelling tube that collects urine

• Colostomy bag - external bag that collects fecal waste

https://commons.wikimedia.org/wiki/File:Ileostomy_with_bag.jpg

 Common Classification of GI Dysfunction

Obesity

Classified by Body Mass Index of >+30kg/m²

• Large population based studies show that for every additional 5 BMI points (from between 20-25kg/m2), there is a 39% increase in risk of death due to weight contributors
• Premature risk of death rates are higher in younger people and men with obesity
• Death from stroke, respiratory disease, and heart disease increases in people with BMI over 25kg/m2

Do you know your Body Mass Index? Calculate it here

• second most preventable cause of death (smoking is first)
• metabolic syndrome starts in utero before a child is born
• consumption of sugar by parent/mom due to:
• ready access to inexpensive and portable foods
• poverty and resultant lack of access to healthy food.
• children who experience food insecurity are more likely to develop obesity (Kaur, Lamb, & Ogden, 2015)
• education in healthy eating, calorie consumption, and its resultant effects can have a significant influence in obesity rates in children and parents

Disease risk factor increases related to obesity

(Lustig, Brindis, & Schmidt, 2012)

• – Type II diabetes
• – hypertension
• – coronary artery disease
• – cerebral vascular accident
• – osteoarthritis
• – asthma
• – obstructive sleep apnea
• - Erectile dysfunction (males)

 People with obesity are more likely to have malignancies in the GI tract as associated with the cause of death (Saab & Salvatore, 2015)

Psychosocial Obesity Affects

• decline in function due to restricted activity

• musculoskeletal pain (bone and joint)

• negative health perception

• anxiety and depression - including in children and adolescents

• increased personal health care costs

• increased incidence of disability

• increased discrimination and abuse

• increased risk for negative or biased health care decisions from health care providers (Casazza, et al., 2013).

• decreased access to treatment spaces and medical equipment during encounters with providers (e.g., BP cuffs, gowns, exam tables, scales)

Weight Loss Effects

• 5-10% reduction can produce measurable health benefits

• Decreased absenteeism from work reported from surgical and non-surgical weight loss programs

• Patients who are morbidly obese (BMI > 40 kg/m², or 100 pounds over ideal weight) may qualify for bariatric surgery (gastric bypass) for weight control

Physical Therapy Role

PT Examination and Evaluation

The physical therapist prioritizes interventions within the physical therapy plan of care by integrating knowledge of body structure and function, participation restrictions, and contextual factors that inform prognosis and physical therapy diagnosis. Patient education in lifestyle factors that influence GI system disease should be integrated into a plan of care, with collaborative coordination with the medical and behavioral healthcare team as indicated. Patients with GI dysfunction may often present with comorbitites in the integument, cardiopulmonary, and musculoskeletal systems. Physical therapy providers should self-assess and seek opportunities for professional development specific to metabolic and GI dysfunction in order to minimize bias and reduce negative perceptions of patients in this population.

PT/PTA Relationship

• Maintain positive, open, timely, patient-centered communication

• Delegate and accept responsibilities for treatment based on the skill level of the PTA

• POC

– PT: Modify and update POC based on progress reported or reassessment

– PTA: Document patient status (progress/barriers) and request clarification or input as needed depending patient response and skill set

Role of the PTA

Tests and Measures

Aerobic Capacity and Endurance

• VS pre- post- activity, Borg RPE, O2 sats, observation for s/sx of cardiopulmonary response

Anthropometric Characteristics

• Height, weight, BMI, edema measures

Arousal, attention, cognition

• A&O, memory and recall

Pain

• VAS, faces scale, location, referral patterns

Joint Integrity and Mobility

• Range of motion(PROM/AROM) extremities and trunk

Neuromuscular tests

• Sensation and reflexes
• Strength
• Coordination

Functional Activity Performance

• FIM, Oswestry Disability Index
• Gait and locomotion
• Bending, lifting, carrying, reaching

Interventions for decreased endurance/aerobic capacity

1. Log rolling/bracing with pillow

2. Transfer training

3. Endurance training (gait, exercise)

4. Postural training

Interventions for impaired ventilation/respiration

1. breathing exercises

2. incentive spirometry

3. huffing/directed cough

4. chest percussion and vibration

Interventions for Impaired integument integrity

1. Wound care for incisions

2. Skin/wound care for ostomies

3. Generalized skin care and education skin inspection for at-risk areas

Interventions for Decreased ADLs and Self-Care

1. Training in adaptive devices and equipment

2. Environmental assessment and modifications

 Interventions for Disability Prevention and Wellness

Education in

1. Lifestyle modification/decreasing risk of recurrence

2. Energy conservation (pacing and prioritizing)

3. Ostomy care

Genitourinary Diseases and Disorders

Urinary System

https://commons.wikimedia.org/wiki/File:Illu_urinary_system.jpg

Anatomy

 https://upload.wikimedia.org/wikipedia/commons/thumb/8/87/2610_The_Kidney.jpg/320px-2610_The_Kidney.jpg

• Primary components
• Kidneys
• Ureter
• Bladder
• Urethra
• Secondary Components
• Prostate
• Pelvic Floor Muscles
• Genitals

Physiology

Fluids are filtered through the kidneys and the filtrate is converted to urine. Urine is mostly water and urea, which is a metabolic by-product of protein metabolism, and electrolytes

Urination is mediated by voluntary and involuntary nervous system actions:

• L1-L3 forms the sympathetic branch
• S2-S4 forms the parasympathetic branch - visceral and afferent pathways

 

Selected GU Medical Terminology

• Dysuria = abnormal urine/urination. Incontinence is a form of dysuria
• Incontinence = involuntary loss of urine. Incontinence can be
• urge - sensation of needing to urinate - overactive
• stress - muscular insufficiency
• overflow - insufficient bladder emptying or urethra blockage
• functional - unable to find/get to the toilet in time
• Enuresis= involuntary voiding during sleep

• Voiding =emptying urine from bladder

• Micturition = urination (Link to animation of the micturition reflex)

• Hematuria = blood in urine

• Pyuria = presence of pus/bacterial infection in urine

• Urgency = sensation of need to urinate, may be neurological or due to a spasm of smooth muscle in the bladder

Pathology Overview

• Urinary Tract Infection UTI = bacterial infection
• Urethritis=inflammation of the urethra
• Cystitis= inflammation of the bladder
• Pyelonephritis = bacterial infection of the kidneys
• Nephrolithiasis= kidney stones composed of minerals and salts
• Cystocele= fallen bladder
• Neurogenic bladder = dysfunctional autonomic control of the micturition
• Benign prostate hypertrophy or dysplasia BPH= enlargement of the prostate gland

Urinary Tract Infection (UTI)

Overview

• Increased risk with catheterization
• Increased risk with hospitalization
• Higher risk if a medical history of UTI's is present
• Higher incidence with individuals with diabetes and women.
• women have a shorter urinary tract which increases the risk (NYT, 2013)
• Most common cause is E Coli bacterial infection
• If untreated can lead to kidney infection and sepsis/septic shock

Signs and Symptoms

• Frequency of urination/urinary urgency
• Painful urination
• More common in men with UTI's than women with UTI's which is one of the reasons why UTI's are under diagnosed in women
• Burning feeling in the bladder
• Confusion
• Milky or cloudy urine
• Blood in urine
• Fever
• LBP

Urethritis and Cystitis

• Associated with sexually transmitted disease (STD)
• Signs and symptoms include increased frequency and urinary urgency
• Suprapubic pain, foul smelling urine, pyuria
• Asymptomatic bacteriuria, fatigue, anorexia, cognitive changes
• Results in pain, swelling of involved structure
• Treated with antibiotics and education/nursing care

Pyelonephritis

https://commons.wikimedia.org/wiki/File:Douleur_fosse_lombaire_py%C3%A9lon%C3%A9phrite_-_Pyelonephritis.jpg

• Acute or chronic inflammation of renal pelvis, or parenchyma of kidney
• Infection ascends from lower urinary tract.
• Often pre-existing factor = hx of UTI's and or Diabetes Mellitus (DM)
• Signs and symptoms: mild sluggishness, s/sx cystitis, fever, chills, vomiting, malaise, severe flank pain, costovertebral tenderness on affected side
• Bacteriemia, septic shock
• Chronic pyelonephritis starts in medulla of kidney spreads to cortex.

Nephrolithiasis

• Problem primarily associated with the kidneys
• Kidney stones: crystallization of calcium, uric acid, magnesium-ammonium acetate
• Stones may form anywhere along the urinary tract
• Stone formation is associated with decreased fluid intake, low urine volume, genetic factors, bed rest and sedentary lifestyle
• Higher risk in areas of hot temperatures and high humidity
• S/sx similar to pyelonephritis marked increase in flank pain and urination pain

https://commons.wikimedia.org/wiki/File:Blausen_0595_KidneyStones.png

Renal Trauma

• Blunt trauma: car, bicycle accidents, sports injuries, falls with injury to flank, abdomen or back
• Penetrating gun shot and/or stab wounds
• Renal trauma is diagnosed using ultrasound, CT scan, MRI, recent history, hematuria, intravenous pyelogram/IVP.

Psychosocial affects of Urinary Incontinence

• contributes to avoiding social activities, travel
• contributes to avoiding sexual encounters

Patient Support Equipment for Medical Management of Incontinence

• Urethral catheters - tube placed in bladder via urethra

• Ureteral catheters - tube between kidney and urethra
• Suprapubic catheters -tube placed directly into superior aspect of bladder
• 

• Nephrostomy tubes
• 
• https://en.wikipedia.org/wiki/Nephrostomy
• Intermittent catheterization

Incontinence pads - these products are progressively improving to help support dignity and function

 Neurogenic Bladder

• Bladder dysfunction from CNS neurologic disorder or trauma to CNS
• Tumors, SCI, TBI, ALS, CVA, MS, diabetic neuropathy, chronic UTI's
• Failure to store, empty or both.
• Lack of impulse coordination in the nervous system.
• Dysfunction of bladder or urethra

Causes of Urinary Retention

• Antihypertensives - Aldomet, Apresoline
• Anti-Parkinsonian drugs - Leva dopa
• Antihistamines
• Anticolinergics- Atropine
• Antispasmodics
• Sedatives and spinal anesthesia
• Anesthesia
• Urethral obstruction
• Psychological

• Symptoms = urination on exertion, urination without sensation, chronic UTI's, inability to actively control bladder and urination.
• Medical treatment may include hormone replacement therapy and medications

PT Treatment for Neurogenic Bladder

• Pelvic floor mm strengthening exercises
• Kegel is the most commonly known exercise and is most effective in stress incontinence
• E-stim
• Used to stimulate or decrease over activation of pelvic floor and sphincter mm: electrodes are placed internally
• Biofeedback
• Timed voiding: coordinated with E-stim and biofeedback to retrain recognition and coordination of neurological components.
• "Pelvic PT" and "Womens' Health" are often terms used in PT to treat disorders associated with the pelvic floor
• PT for treating conditions of the pelvic floor is an area of specialization for female and male physical therapy providers

Cystocele

• Fallen bladder - prolapsed
• Etiology: related to heavy lifting, straining during bowel movements, decreased estrogen concentrations, child-birth
• Grades are based on severity of prolapse
• Grade One: bladder drops into vagina
• Grade Two: bladder has sunk into opening of vagina
• Grade Three: bladder protrudes into vaginal opening
• May require surgical re-positioning (bladder sling) for stabilization

Benign Prostate Hypertrophy/Hyperplasis (BPH)

https://commons.wikimedia.org/wiki/File:Benign_Prostatic_Hyperplasia_(BPH).png

• Prostate enlarges at age 40
• Affects 90% of men over 70
• Enlargement results in urethral compression with reflexive bladder contraction regardless of urine volume: frequency and urgency of micturition increases.
• Bladder can become thickened and distended
• Symptoms include hesitancy to urinate or thin/weak stream of urine flow, urgency to urinate, leaking or dribbling of urine, nocturnal frequency

 Medical interventions for BPH

• TUMT: Transurethral microwave thermotherapy: heats and destroys excessive prostate tissue.
• TUNA: Transurethral needle ablation: radio frequencies burn prostate tissue
• TURP: Transurethral resection of the prostate: surgical intervention to resect prostate tissue

This link provides a refresher of the GU A&P and then goes into BPH and TURP descriptions

Role of PTA in Treating Conditions associated with GU Disorders

• Patients may often confide GU complaints, and signs and symptoms of GU dysfunction to PT/PTA
• The patient's medical care providers may be unaware of patient GU complaints
• The PTA needs to
• Document patient complaints and communicate patient complaints to PT
• Maintain neutral communication and take care to engender trust and open communication
• Patient. may need support and education in the use of equipment and supplies to prevent social isolation and disability
• Patient may need education in the role of incontinence in contributing to their own decline in function and mobility
• Be aware of new or progressive complaints of acute flank pain (posterior trunk) or low back pain of non medical origin
• Consult with primary PT and refer back to primary care provider (PCP) as indicated
• Monitor BP due to additional stress on kidney function with urinary disorders
• Assist in positioning pt. out of supine to decrease stress on kidneys.
• Assist healthcare team with fluid input and output monitoring during patient encounters. May include assisting with urine collections "hat" and catheters before disposing/flushing of toilet. Communicate with CNA/RN regarding pt fluid intake and output.

• Monitor catheter position at bedside and during PT to prevent reflux into bladder: maintain gravity assisted positioning.
• Instruct pt's in airway clearance and mobility post-op GU surgery
• Modify activities according to pt response with ambulation following surgery such as prostate resection.
• No abdominal crunches or high impact exercises post op
• No abdominal crunches or high impact exercises in women with GU dysfunction
• Instruct in kegel exercises
• Instruct in abdominal and dynamic pelvic floor exercises with hip external rotation and abduction as prescribed by PT
• Instruct in body mechanics, pacing and prioritizing for proper lifting when cleared by physician.
• Modalities with advanced training outside of our PTA program for pelvic floor muscle re-education, biofeedback, autonomic nervous system self-monitoring
• Maintain neutral presence with pt disclosure of sexual abuse/dysfunction, maintain pt confidentiality and dignity.
• Communicate with PT when above conversation(s) disclosures about sexual abuse occur during treatment.
• Avoid assumptions about sexual activity or sexual orientation during patient education; use culturally neutral language when discussing patient-led concerns about sexual dysfunction as it relates to PT plan of care.

Considerations for Billing

• Document minutes spent providing direct patient care (can include set up and patient communication/family training if patient is present)

• Consider the impairment you are treating when selecting an appropriate billing code

– Endurance (therex – 97110 or ther act – 97530)

– Joint mobility (therex – 97110)

– Functional mobility (ther act -97530)

– Breathing exercises ( therex – 97110)

– Energy conservation techniques ( ther act – 97530)

– Chest PT (manual therapy – 97140)

-- Gait Training (97116)

References

Elsevier. 2016. Innervation of Urinary Bladder and Lower Ureter. Available at: file:///C:/Users/Marc/PTAEthics/PTA103wk8GIDisorders/index.html

Health Grades. (2015). Benign Prostatic Hypertrophy. Retrieved from http://www.rightdiagnosis.com/animations/benign-prostatic-hyperplasia-bph.htm

Casazza, K., Fontaine, K. R., Astrup, A., Birch, L. L., Brown, A. W., Bohan Brown, M. M., ... & McIver, K. (2013). Myths, presumptions, and facts about obesity. New England Journal of Medicine, 368(5), 446-454.

International Foundation for Functional Intestinal Disorders. (2017). Lower GI disorders. Retreived from https://www.iffgd.org/lower-gi-disorders.html

International Foundation for Functional Intestinal Disorders. (2017). Upper GI disorders. Retreived from https://www.iffgd.org/upper-gi-disorders.html

Kaur, J., Lamb, M. M., & Ogden, C. L. (2015). The association between food insecurity and obesity in children—The National Health and Nutrition Examination Survey. Journal of the Academy of Nutrition and Dietetics, 115(5), 751-758.

Lustig, R. H., Schmidt, L. A., & Brindis, C. D. (2012). Public health: The toxic truth about sugar. Nature, 482(7383), 27-29.

Mayo Clinic. (2016). Cystitis. Retrieved from http://www.mayoclinic.org/diseases-conditions/cystitis/basics/definition/con-20024076

Mayo Clinic. (2017). Pancreatitis. Retrieved from http://www.mayoclinic.org/diseases-conditions/pancreatitis/home/ovc-20252596

McGraw Hill. (2017). Animation Micturition Reflex. Retrieved from http://highered.mheducation.com/sites/0072495855/student_view0/chapter27/animation__micturition_reflex.html

Pizzi, M. A., & Vroman, K. (2013). Childhood obesity: effects on children's participation, mental health, and psychosocial development. Occupational therapy in health care, 27(2), 99-112.

New York Times. (2013). Urinary Incontinence. Retrieved from http://www.nytimes.com/health/guides/symptoms/urinary-incontinence/risk-factors.html

Saab., J & Salvatore, S.P. (2015). Evaluating the cause of death in obese individuals: A ten-year medical autopsy study. Journal of Obesity, p. 1-7. Retrieved from https://www.hindawi.com/journals/jobe/2015/695374/cta/.

UCTV. (2014, May 14). The skinning on obesity: Generation XL [Video file]. Retrieved from http://www.uctv.tv/shows/The-Skinny-on-Obesity-Ep-5-Generation-XL-23719

UCTV. (2014, March 11). The skinny on obesity: An epidemic for every body [Video file]. Retrieved from http://www.uctv.tv/shows/The-Skinny-on-Obesity-Ep-1-An-Epidemic-for-Every-Body-23305

University of Maryland Medical Center. (2016). Urinary Tract Infections in Women. Retrieved from http://umm.edu/health/medical/altmed/condition/urinary-tract-infection-in-women