Transcript Urinary Incontinence

Urinary Incontinence
Ahmad Ali Akbari Kamrani M D
Iranian Research Center on Ageing
University of Social Welfare &
Rehabilitation Sciences
Definition
Patient-centered :
 An uncontrollable loss of urine at
inappropriate or unwanted times.
Prevalence studies :
 Difficulty holding urine until you get to a toilet
 Unexpected or uncontrolled loss of urine
 Loss of control of urine
 Wet underpants
Definition
Severity definitions :
 Once or more
 Twice or more
 Three times or more
 Bad enough to cause social or hygienic problems
Frequency definitions :
 Ewer
 Past year
 Past month
 Past week
 Per day
Prevalence
Urinary incontinence can occur at any
age.
 It is normal among newborns,
 As enuresis among young children ,
 As a stress incontinence among women
of childbearing age
 As a geriatric syndrome among older
persons
Prevalence
Older persons who are
Homebound- long-term care facilities :
 50%
Community-dwelling older women :
 Any frequency of incontinence,
35%
 Daily incontinence,
14%
Community-dwelling older men :
 Any frequency of incontinence, 22%
 Daily incontinence, 4%
Unrecognized Incontinence
Physician : (do not routinely ask )
 11% of physicians & nurse practitioners &

33% of physician assistants ask patients
Patients : (do not seek care )

30% of OP with incontinence have ever sought care for the
problem.

Avoid discussing the problem because of :
Embarrassment ,
They believe it is a normal aspect of ageing for which no treatment
is available ,
They believe surgery is the only available treatment and do not
want to undergo surgery ,
Micturation mechanism
When the bladder fills :
 Stretch receptors in the bladder wall transmit neural
signals ,
 Through the sacral plexus & spinal cord
 To micturation center in the brain stem
 Then transmits back through the spinal cord & sacral
plexus to the detrusor muscle and this reflex loop
produces detrusor muscle contractions & voiding.
 Stimulation of detrusor contractions is inhibited by
neural centers in the frontal cortex, basal ganglia,&
cerebellum.
 Inhibitory activity keeps the bladder relaxed and
allows voluntarily urination .
Principal diagnosis
It is useful to consider,
three basic pathophysiologic mechanism :



Overactivity of the bladder detrusor muscle
(urge incontinence ).
Malfunction of the urinary sphincters
( stress incontinence ) .
Overflow bladder
(urinary retention )
Mixed Incontinence : multiple causes ,
Principal diagnosis
Each of the three mechanism ,


Transient : (medications, infection, ….)
Irreversible : ( degenerative neurologic
disorders, …. )
Detrusor overactivity
( Urge Incontinence )


Lack the ability to control or inhibit
contractions of the bladder detrusor
muscle
Detrusor muscle is overactive in relation
to the ability of the inhibitory centers
Detrusor overactivity
( Urge Incontinence
Transient causes :
1/3 of U.I.
-Drugs : most common cause
(diuretics, sedatives, alcohol, … )
-Metabolic & neurologic :
(hypoxemia, delirium, hyperglycemia,
hypercalcemia, excess fluid consumption)
-Inflamation :
( acute UTI , atrophic vaginitis, ..)

Detrusor overactivity
( Urge Incontinence
Irreversible causes :
 degenerative neurologic disorders
( detrusor hyperreflexia &instability )
-The most common :
( Dementia, Parkinson, Stroke,)

-Any neurodegenerative conditions :
(Normal-pressure hydrocephalus,
Cerebral neoplasm )
Spinal cord injury
( automatic bladder, or neurogenic )
lose all cerebral inhibitory input to the detrusor
Sphincter Malfunction
( stress incontinence )
Normal urinary sphincter function :
 Normal function of the sacral nerves that innervate the
sphincter muscle ,

Normal function of Sphincter muscles :
voluntary : periurethral skeletal muscles
( pelvic floor )
Involuntary : urethral smooth muscles
α – adrenergic ( constriction )
β – adrenergic ( relax )

Normal urethral positioning
closure of the urethral walls against themselves
exposed to the intraabdominal pressure (cough,)
and thereby prevents a pressure gradient between
the bladder & the urethral
Sphincter Malfunction
( stress incontinence )

Transient :
- medications :
α-adrenergic blocking , ( prazosin )
β- adrenergic agonist , (salbutamol )

Irreversible :
-Urethral prolapse (classic stress incontinence )
-Intrinsic urethral deficiency (denervation after
prostatectomy, trauma, radiation therapy,
malignancy, sacral spinal cord lesions, )
Overflow bladder
(urinary retention )
Two general mechanism cause :


Obstruction of urinary outflow
Failure of the detrusor to contract
effectively
Overflow bladder
(urinary retention )

Transient :
Medications :
anticholinergics
calcium channel blockers
NSAIDs (blocked prostagladin receptors in bllader )
α-adrenergic agonist
β-adrenergic antagonist
CNS depressant (narcotics, sedatives,)
Overflow bladder
(urinary retention )

Irreversible :
prostate enlargement (men )
strictures from previous surgery (women)
injury of cholinergic pelvic nerve
(neuropathic, neoplastic, traumatic,….)
Diabetes, MS, amyloidosis, syphilis,
heavy metal poisening
Symptoms suggesting the
Special evaluation

History of anti-incontinence surgery & radical pelvic
surgery – (urogynecologist )

Urge incontinence >2 - ( cystoscopy &… )

Hematuria & recurrent UTI – ( imaging studies & … )
physical findings suggesting
the Special evaluation

Prostate with a nodule or asymmetry
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Pelvic prolaps
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Neurologic disorder & spinal cord lesion
Physical Findings suggesting
the nature of Incontinence

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Parkinson & degenerative neurologic dis.
( uninhibited detrusor contractions )
Pelvic prolaps : cystocele , rectocele
( stress incontinence )
Palpation of distended bladder
(overflow : prostate, neuropathic dis. )
Physical Findings suggesting
transient Incontinence

Fecal impaction
(transient overflow)

Atrophic vaginitis
(transient detrusor overactivity )
(atrophic trigonitis & inflamation)
Ancillary Tests

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Routine evaluation :
U/A – PVR (post void residual)– NL<50 ml
Simple bladder function tests :
simple cystometry :(urgency<300 ml = detrusor overactivity )
stress testing: for women
(pad test with full bladder, supine & standing
Marshal test for surgery response :
finger elevate the urethra & cough forcibly )
urine flowmetry : for men
( normal aged men >20 ml / s )
Ancillary Tests

Selected patients ;
- RFT
- cystoscopy
- urine cytology
- imaging tests
- formal cystometrography :
(multilumen urethral catheter & rectal probe )
bladder pressure, intraabdominal pressure, urethral
pressure, leak-point pressure, urethral flow rate,
pelvic muscle electromyographic findings , …)
Algorithm
Treatment

Self-treatment
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Transient causes treatment

Irreversible causes treatment

Collect urine & maintain hygiene
Self-Treatment

Changing pattern of fluid intake
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Identifying the location of the toilet
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Absorbent pads
Herbal medication
Management of Transient
causes

Urge-type :
Acute UTI atrophic vaginitis delirium-hypoxia excessive fluid glycosuria hypercalciuria impaired mobility medication effects -
antibiotic
estrogen
underlying dis.
reduction
control diabetes
treat.hypercalcemia
therapy
D/C or change
Management of Transient
causes

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Sphincter malfunction :
medication effects -
D/C or change
Overflow bladder :
drug side effects -
D/C or change
fecal impact -
disimpaction &
stool softness
Management of Non-Transient
causes of urge incontinence
Behavioral therapy – medication - surgery
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Behavioral therapy :
bladder training (interval, 2 h-..longer)
pelvic muscle exercises (Kegels)
(for frail & cognitive impair. Less effective)
Management of Non-Transient
causes of urge incontinence

Medication :
oxybutinine – tolterodine
propantheline – imipramine
dicyclomine – calcium blocker
NSAIDs

Surgery :
1- augmentation cystoplasty (& a patch of intestine )
2- urinary diversion (ileal urostomy )
3- bladder denervation (subtrigonal phenol injections)
sacral rhizotomy
transvaginal denervation
sacral dorsal root gaglionectomy
Management of Non-Transient
causes of stress incontinence
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Women :
surgery – behavioral therapy
medication - devices
Men :
behavioral therapy – medication
surgery -
Management of Non-Transient
causes of stress incontinence
Women :
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surgery:(6000 pt.-75-79% completely cure)
(retropubic suspension procedure)
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behavioral : pelvic muscle exercises
biofeedback techniques:
(pressure gauges in the vagina provide
auditory or visual display )
vaginal weights:
(20-100 gr-placed in the vagina)
( for up to 15 min. using pelvic
muscle contractions ).
Medications : α-adrenergic agonist , estrogen
Management of Non-Transient
causes of stress incontinence
Women :

devices :
pessaries
occlusive devices
Management of Non-Transient
causes of stress incontinence
Men :
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
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behavioral therapy
medications- (α-adrenergic agonist )
Surgery :
periurethral bulking injection ( first choice)
placement of an artificial sphincter
most often: ISD (intrinsic sphincter deficiency)
after surgical trauma- radiation-urethra or nerve damage
surgical interventions
after prostatectomy/
waiting at least 6 month
Management of Non-Transient
causes of overflow incontinence
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
Objectives :
bladder drainage to prevent hydronephrosis
Prostate enlargement :
surgery : ( TUR ) – appropriate therapy
drugs : delayed action & unsuitable
New technologies : has not been defined
(balloon dilatation - laser- coils-stents thermal therapy-)

Exceptional circumstances ( neoplasia ) :
ileourostomy
Management of Non-Transient causes of
overflow incontinence
catheterization :
three options
- intermittent :(standard for inadequate detrusor contractions)
( 3 times/day or every 3-6 h. )( sterile or clean catheter- without antibiotic prophylactic )
( rate of infection : 1-4 episodes / 100 days )
- indwelling :
- suprapubic:
( foley- changed once a month )
( when obstruction prevents
passage of a catheter )
Management of Intractable
incontinence
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Can not be controlled other than catheterization
Environmental modifications :
physical access facilities
improvements in lighting
avoiding tea, coffee, ….
Devices & Collection systems
absorbent pads & garments
male candom catheters
female paush devices
penile clamps
urethral catheters ( 14 f, 16f, 18f, )
Complications : infection, encrustation, dermatitis,
Controversies
The current recommendations :


Expert opinion / evidence from
research
Different specialties / different approach
The end