Transcript Urinary Incontinence

Urinary Incontinence
Abdallah Rimawi, MD
Geriatrics Fellow
SVCMC
Definition
Involuntary loss of urine in a sufficient
amount or frequency to be a
social/health problem.
Epidemiology
UI has a prevalence
15-30% in community-residing elderly patients
50-84% among older adults in long-term care institutions
33% in older persons in acute care settings.
UI
affects more than 17 million Americans, 85% of whom are women.
Estimated
cost to society of $16 to 26 billion.
Race:
No clear evidence of racial differences in prevalence of UI has
been found.
UI
is approximately twice as prevalent in older women as in older men,
with 20% being women older than 45 years. In some women, stress
incontinence and urge incontinence, the two most common forms of UI,
may coexist.
Epidimiology
Urge incontinence constitutes over 50% of overall
incontinence in men, 10-15% in younger women,
and 30-40% in older women. Stress incontinence
tends to be more common in women younger than
65 years.
Stress vs Urge
Distribution of different types of incontinence in the general
population. Diagnoses other than stress, urge, and mixed are
excluded.
Dr. Hogne Sandvik: 1996 nobel award in biology
Prevalence of Stress vs Urge
Age
(years)
Numbers
evaluated
Stress
(%)
Urge
(%)
Mixed
(%)
>18
1 000
50
19
31
>18
851
52
25
23
42 - 50
541
50
12
38
30 - 59
2 631
48
7
45
>60
1 955
29
10
61
Prevalence in Females
Normal micturition
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The normal function of the urinary
bladder is to store and expel urine in a
coordinated, controlled fashion. This
coordinated activity is regulated by the
central and peripheral nervous systems
Normal Urination
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The process of urination involves two phases:
1) The filling and storage phase
2) The emptying phase
Filling Phase
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Filling/ storage phase: Under Sympathetic control
the bladder begins to fill with urine from the kidneys. The bladder stretches
to accommodate the increasing amounts of urine. No increase in pressure
Sympathetic system relaxes Detrusor muscle
Sympathetic system closes bladder neck by constricting internal urethral
sphincter
The first sensation of the urge to urinate occurs when approximately 200 ml
(just under 1 cup) of urine is stored. A healthy nervous system will respond to
this stretching sensation by alerting you to the urge to urinate, while also
allowing the bladder to continue to fill.
The average person can hold approximately 350 to 550 ml of urine. The
ability to fill and store urine properly requires a functional sphincter (the
circular muscles around the opening of the bladder) and a stable, expandable
bladder wall muscle (detrusor).
The filling of the urinary bladder depends on the intrinsic viscoelastic properties of the
bladder and the inhibition of the parasympathetic nerves. Thus, bladder filling primarily is a
passive event.
Sympathetic nerves also facilitate urine storage in the following ways:
Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder
contractions.
Emptying Phase
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Emptying phase: requires the ability of the detrusor
muscle to appropriately contract to force urine out of the
bladder. At the same time, your body must be able to relax
the sphincter to allow the urine to pass out of the body.
Normal micturition cycle
Central Control
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Brain
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The brain is the master control of the entire urinary system.
The micturition control center is located in the frontal lobe.
Sends inhibitory signals to the detrusor muscle Via the Pons
and spine 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 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.
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Brain  Pons
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PONS
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Pons: a major relay center between the brain and the bladder.
Contains the pontine micturition center (PMC) which coordinates the urethral sphincter
relaxation and detrusor contraction to facilitate urination.
The PMC is Exitatory in nature and causes urination unless inhibited by the brain.
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.
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.
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Sequence of normal events
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When Bladder becomes full, the stretch receptors of the detrusor
muscle send a signal to the pons (via the spinal cord), which in
turn notifies the brain. Patients 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 locating a suitable
bathroom. When urination is appropriate, the brain sends
excitatory signals to the pons, allowing the urinary sphincters to
open and the detrusor to empty.
Brain  Pons Spinal cord
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Spinal cord
The spinal cord connects the brainstem and the lumbosacral
spine.
The spinal cord functions as a long communication pathway
between the brainstem and the sacral spinal cord. When the
sacral cord receives the sensory information from the bladder,
this signal travels up the spinal cord to the pons and then
ultimately to the brain. The brain interprets this signal and
sends a reply via the pons that travels down the spinal cord to
the sacral cord where the bladder receives it.
Spinal cord Trauma
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An intact spinal cord is critical for normal micturition. If the spinal
cord is severely injured or severed, the affected individual will
exhibit constant urinary leakage because of uncontrollable
bladder spasms, a condition called detrusor hyperreflexia.
If complete spinal cord transection has occurred, the patient will
demonstrate symptoms of urinary frequency, urgency, and urge
incontinence but will be unable to empty his or her bladder
completely. This occurs because the urinary bladder and the
sphincter are both overactive, a condition termed detrusor
sphincter dyssynergia with detrusor hyperreflexia
Sacral spinal cord
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The sacral spinal cord is the terminal portion of the spinal cord
at the lower back in the lumbar area. This is a specialized area
of the spinal cord known as the sacral reflex center. It is
responsible for bladder contractions. The sacral reflex center is
the primitive voiding center.
If the sacral cord becomes severely injured (eg, spinal tumor,
herniated disc), the bladder may not function. Affected patients
may develop urinary retention, termed detrusor areflexia. The
detrusor will be unable to contract, so the patient will not be
able to urinate and urinary retention will occur.
Physiology PNS
Sympathetic system (Epinepherine & Norepinepherine):
Normally controls the bladder and internal urethral sphincter
Accommodation: an increase the bladder capacity without raising bladder pressure
Keeps the internal urinary sphincter tightly closed.
relaxes bladder dome
inhibits parasympathetic system
The sympathetic activity also inhibits the micturition reflex is inhibited.
Parasympathetic
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The parasympathetic nervous system functions in a manner
opposite to that of the sympathetic nervous system
stimulates the detrusor muscle to contract the bladder
Causes internal and external urethral sphincter relaxation and
opening
Inhibits the pudendal nerve which opens the external sphincter
Causes initiation of micturition and emptying of the urinary
bladder
Somatic
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Regulates action of voluntary muscles
Contraction of external urethral sphincter
The somatic nervous system regulates the actions of the
muscles under voluntary control. Such as muscles of the
external urinary sphincter and the pelvic diaphragm. .
suprasacral-infrapontine spinal cord trauma can cause
overstimulation of the pudendal nerve that results in urinary
retention.
Urinary Incontinence
Requirements for storage
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Accomodation – increase in volume with
decrease in pressure
Closed outlet
Appropriate sensation of fullness
Absence of involuntary bladder contractions
Requirements for emptying
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Good contractility
Lack of anatomic obstruction
Coordination of bladder and outlet
Requirements for continence
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Mobility
Manual dexterity
Cognitive ability to recognize and react to
bladder filling
The motivation to stay dry
Sudden/Temporary incontinence etiology
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Urinary tract infection or prostate infection/inflammation
Stool impaction causing pressure on the bladder
Side effects of medications (such as diuretics, tranquilizers, some
cough and cold remedies, certain antihistamines for allergies, and
antidepressants)
Polyurea due to poorly controlled diabetes
Pregnancy
Short-term bedrest -- for example, when recovering from surgery
Mental confusion
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Usually reversable once treated or removed
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Long term incontinence:
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Spinal injuries
Urinary tract anatomical abnormalities
Neurological conditions like multiple sclerosis or stroke
Weakness of the sphincter, the circular muscles of the bladder responsible for opening and
closing it; this can happen following prostate surgery in men, or vaginal surgery in women
Pelvic prolapse in women -- falling or sliding of the bladder, urethra, or rectum into the
vaginal space, often related to having had multiple pregnancies and deliveries
Large prostate in men
Depression or Alzheimer’s disease
Nerve or muscle damage after pelvic radiation
Bladder cancer
Bladder spasms
Types of Urinary Incontinence
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Stress incontinence - loss of urine with increased
intraabdominal pressure without detrusor contraction.
Most common form of UI in women
Urge incontinence - (true, detrusor overactivity, or
reflex) is precipitous loss of urine, preceded by a
strong urge to void, with increased intravesical
pressure and detrusor contraction.
Continuous incontinence - is involuntary loss of
urine at all times and in all positions.
Overflow incontinence - results from detrusor
underactivity, bladder outlet obstruction, or both.
Leakage is small in volume but continual. In men, it
can be the result of an enlarged prostate.
Stress incontinence
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Stress incontinence is an involuntary loss of urine that occurs during
physical activity, such as coughing, sneezing, laughing, or exercise.
Stress incontinence is a bladder storage problem in which the strength
of the urethral sphincter is diminished, and the sphincter is not able to
prevent urine flow when there is increased pressure from the abdomen.
Stress incontinence may occur as a result of weakened pelvic muscles
that support the bladder and urethra, or because of malfunction of the
urethral sphincter. Prior trauma to the urethral area, neurological injury,
and some medications may weaken the urethra. Stress incontinence
can worsen during the week before your menstrual period. At that time,
lowered estrogen levels might lead to lower muscular pressure around
the urethra, increasing chances of leakage. The incidence of stress
incontinence increases following menopause.
Stress incontinence
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Sphincter weakness may occur in men following prostate surgery or
in women after pelvic surgery. Stress incontinence is often seen in
women who have had multiple pregnancies and vaginal childbirths,
or who have pelvic prolapse (protrusion of the bladder, urethra, or
rectal wall into the vaginal space), with cystocele, cystourethrocele,
or rectocele.
Studies have documented that about 50% of all women have
occasional urinary incontinence, and as many as 10% have frequent
incontinence. Nearly 20% of women over age 75 experience daily
urinary incontinence.
Stress urinary incontinence is the most common type of urinary
incontinence in women. Risk factors for stress incontinence include
female sex, advancing age, childbirth, smoking, and obesity.
Conditions that cause chronic coughing, such as chronic bronchitis
and asthma, may also increase the risk of stress incontinence.
Stress incontinence treatment
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Goal of nonsurgical treatment is to increase internal sphincter tone.
Mild to moderate stress incontinence may be effectively treated with
exercise therapy, medications, or both.
The most common cause of stress incontinence in older women is
urethral hypermobility: In up to 60% of women with stress
incontinence, pelvic floor (Kegel) exercises can result in better control
of the bladder when coughing, laughing, sneezing, or exercising.1
These exercises should be performed 10-20 times, 3 times a day
Medication may be used to tighten the bladder and prevent urine
leakage, but its effectiveness varies.
Electrical stimulation can be used to reduce both stress incontinence
and urge incontinence
Treatment stress incontinence
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Surgical intervention
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Surgery elevates the bladder neck and brings the proximal urethra back
into the abdomen; the 1-year success rate is 80-95%. Surgery to add
support for the bladder neck is usually needed for severe stress
incontinence that does not respond to medication or exercise.
Treatment stress incontinence
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Medications:
Alpha-adrenergic agonists (pseudoephedrine) are used
especially for women on estrogen; they increase the internal
sphincter tone and bladder outflow resistance. Use with caution
in patients with hypertension or arrhythmia.
Estrogen cream to the vagina or oral estrogen tablets :
may be helpful in improving periurethral and vaginal tissue
thickness and quality.
Treat precipitating conditions (atrophic vaginitis, cough).
Incontinence pads may be used to absorb the small
amount of urine that usually leaks during stress.
Urge incontinence
Alternate Names : Detrusor Hyperreflexia, Detrusor Instability, Overactive
Bladder, Spasmodic Bladder, Unstable Bladder
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Bladder muscle contracts inappropriately, regardless of the amount of urine
that is in the bladder.
Population: May occur in anyone at any age, but it is more common in women and
elderly. Second only to stress incontinence as the most common cause of
urinary incontinence (involuntary loss of urine). Approximately 1% to 2% of
adult females are affected by urge incontinence.
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In men, urge incontinence may be due to secondary bladder injuries caused
by benign prostatic
Mechanism
PVC: "Premature Vesicular Contraction"
Overly sensitive bladder Urge to void is perceived
Inhibition of detrussor contraction is ineffective
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Etiology urge incontinence
Etiologies: Urge incontinence may result from neurological injuries (such as spinal
cord injury or stroke), neurological diseases (such as multiple sclerosis),
infection, bladder cancer, bladder stones, bladder inflammation, or bladder
outlet obstruction.
The majority of cases are classified as idiopathic -- a specific cause cannot be
identified
Signs and Symptoms
Irresistable urge to void
Urge preceeded by various stimulation : Posture change, Hear or feel water
,Laugh or cough
Urine volume lost :Few drops to entire bladder contents
Urine loss timing:Begins seconds after trigger
Urge incontinence
Diagnostics
Rule out neurological or infectious etiology
Sterile in-out catheterization or
Ultrasound measurement of post-void residual
Urge incontinence treatment
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Treat symptomatically if no known cause
Pelvic Muscle Rehabilitation : improves muscle tone and prevent urine leakage.
Daily Kegel exercises (contracting and relaxing the pelvic floor muscles)
Biofeedback
Vaginal weight training: Small weights are held within the vagina by tightening the vaginal
muscles.
Pelvic floor or nerve electrical stimulation. Mild, painless electrical impulses are used to
stimulate the pelvic muscles and/or nerves to help relieve the symptoms of overactive
bladder and urge incontinence.
Behavioral Therapies
Bladder training teaches people how to resist the urge to urinate.
Toileting assistance uses routine or scheduled toileting and prompted voiding to empty the
bladder regularly to prevent leaking.
Surgery
Surgical procedures of the bladder may be performed for people who do not respond to
any other treatment
Treatment urge incontinence
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Medication :aimed at relaxing the involuntary contraction of the bladder and improving
bladder function
anticholinergic agents (propantheline)
antispasmodic medications (oxybutynin, tolterodine, flavoxate)
tricyclic antidepressants (imipramine, doxepin)
calcium channel blockers (tolterodine)
beta agonist (terbutaline)
Oxybutynin (Ditropan) and tolterodine (Detrol) :antispasmodic medications that relax the
smooth muscle of the bladder. These are the most commonly used medications for urge
incontinence
Side effects of oxybutynin and tolterodine are minimal, with the most common being dry
mouth and constipation. However, these medications cannot be used by patients with
narrow angle glaucoma.
Anticholinergic medications block inappropriate contractions of the bladder. They were
widely used in the past to treat urge incontinence because they are relatively inexpensive
yet effective. Oxybutynin and tolterodine have virtually replaced the use of these
medications because they have fewer side effects.
Tricyclic antidepressants have also been used to treat urge incontinence because of their
ability to inhibit or "paralyze" the bladder smooth muscle. Possible side effects include
fatigue, dry mouth, dizziness, blurred vision, nausea and insomnia
Overflow incontinence
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Overflow Incontinence Overflow incontinence is the uncontrollable
leakage of small amounts of urine, usually caused by some type of
blockage or by weak contractions of the bladder muscles. When urine
flow is blocked or the bladder muscles can no longer contract, the
bladder becomes overfilled and enlarged. Pressure in the bladder
increases until small amounts of urine dribble out.
In men, an enlarged prostate can block the opening into the urethra from
the bladder. Less commonly, blockage is caused by narrowing of the
bladder neck or the urethra (urethral stricture), which may occur after
prostate surgery. In men and women, constipation can cause overflow
incontinence if stool fills the rectum to the point of putting pressure on
the bladder neck and urethra. A number of drugs that affect the brain or
spinal cord or that interfere with nerve messages, such as anticholinergic
drugs and opioids, may impair bladder contractions and cause overflow
incontinence. Nerve damage that paralyzes the bladder (neurogenic
bladder) can also cause overflow incontinence. Diabetes mellitus can
also cause a form of neurogenic bladder and overflow incontinence.
Overflow S/S
Signs and Symptoms
Palpable distended bladder post voiding
Post-void residual >200 cc
Have patient void
Insert Urinary Catheter and record urine volume
Normally less than 50 cc
Overflow Diagnosis and management
Diagnosis :Ultrasound assess bladder volume
Uroflowmetry (urodynamics)
Management: General
A.
B.
C.
D.
Correct underlying outflow obstruction
Intermittent Self Catheterization
Double Voiding
Crede's Maneuver
Overflow medications
Medical Management:
1) Betanachol (Urecholine)
Mechanism :
Cholinergic agonist with Parasympathetic stimulation contracts
detrussor
Indications: Non-obstructive bladder atony
Contraindications : Hyperthyroidism , Peptic Ulcer Disease , Asthma
2) Alpha-Adrenergic blockade
Prazosin (Minipress) ,Terazosin (Hytrin)
Mechanism
Decreases bladder neck and urethral tone
Indications :Benign Prostatic Hypertrophy ,Sphincter Hyperspasticity
Overflow Outlet obstruction
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These patients have difficulty emptying their bladders;
therefore, the goal is to improve bladder drainage. Follow
conservative management by modifying fluid excretion
and prompted voiding.
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Do a renal sono to find cause and proceed
Medications include alpha-adrenergic antagonists; prazosin
decreases internal sphincter tone and can improve the flow of
urine. Use antiandrogens and luteinizing hormone-releasing
hormone (LHRH) analog if atonic bladder-cholinergics (eg,
bethanechol) are ineffective in treating UI.
Self-catheterization or a Foley catheter is used, especially in
cases of neurogenic bladder.
Urethral strictures may require dilation or surgery, especially if
the prostate is enlarged.
Overflow Underactive detrusor
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Initial goals are to reduce residual volume,
eliminate hydronephrosis, and prevent
urosepsis. Insert an indwelling or
intermittent catheter to decompress the
bladder (for 2 wk).
Identify and reverse potential causes of
impaired detrusor function (eg, fecal
impaction, medications).
Female Pelvic muscles
Types of UI
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Intense urge to void:
Detrusor
overactivity/Urge
incontinence
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Loss with
cough/laugh/bending:
stress incontinence
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Continuous leakage:
Detrusor
underactivity/overflo
w incontinence
History
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Obtaining a thorough history is the most important step in the
evaluation of UI.
Onset
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Frequency/severity/amount
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During pregnancy
Postpartum
Surgery or trauma
Number of pads
Voiding diary
A small amount of urine usually is seen in overflow incontinence or outlet
incompetence, and moderate flow in detrusor overactivity.
Patterns (eg, nocturnal versus diurnal)
Precipitants
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Medications
Cough
Position changes
History cont…
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Associated symptoms
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Medical conditions
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Straining
Incomplete emptying
Dysuria
Cancer
Diabetes
Neurologic disease
Surgeries
Radiation
Benign prostatic hyperplasia
UTI
Prolonged labor
Trauma
Hypertension
Congestive heart failure (CHF)
Medications (eg, anticholinergics, calcium channel blockers, diuretics, sedatives, alpha-agonists,
alpha-antagonists, alcohol)
Living conditions
Physical
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Carry out a thorough examination, including a brief psychiatric and neurologic
evaluation. Eliminate any serious disease that may be the underlying cause of
incontinence and any transient cause or functional impairment.
Assess the abdomen, looking at flanks; check for masses, distended bladder after
voiding, and signs of fluid overload.
Neurologic
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Check for perineal sensation and fecal impaction. Check bulbocavernous reflex, anal
sphincter tone, and prostate.
Absence of an anal wink is not necessarily pathologic in elderly patients.
Pelvic
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A pelvic examination is necessary for women; the examination should be made with
the patient's bladder empty to check organs and with the bladder full to check for
prolapse, cystocele, rectocele, or incontinence.
Rotate the speculum to evaluate the anterior and posterior vaginal walls.
Look for atrophic vaginitis, masses, muscle laxity, and cystocele.
Internal sphincter weakness can be assessed by asking the patient to cough while
supine; leakage of urine is suggestive of outlet incompetence.
Physical cont…
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Q-Tip test
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This is used to evaluate urethral mobility; hypermobility can lead to stress
incontinence.
Perform this test by inserting a cotton swab through the urethra into the
bladder and note any changes in the angle of the swab with the patient
straining.
A change of 30-40° suggests excessive urethral movement.
The Q-Tip test has been found to have a high false-negative rate in elderly
women.
Stress testing
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Stress testing assesses for stress-induced leakage when the bladder is full.
Stress testing is performed by having the patient relax and asking the patient
to cough or strain once vigorously; instantaneous leakage is typical of stress
urinary incontinence, delayed leakage is typical of stress-induced detrusor
overactivity.
This test, if performed correctly, is greater than 90% sensitive and specific.
Diagnosis
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UA, urine culture to look for infection, and serum electrolytes,
including calcium
Blood glucose
PSA
Postvoid residual urine volume
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Postvoid residual (PVR) urine volume is assessed by catheterizing and
measuring residual urine within 5 minutes after voiding.
PVR greater than 50 mL may indicate obstruction of hypotonic bladder.
PVR greater than 400 mL is likely overflow incontinence.
Renal Sono
Urodynamic studies
Cystometry
Treatment
References
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http://www.nlm.nih.gov/medlineplus/ency/article/003142.
htm
http://www.emedicine.com/emerg/topic791.htm
http://www.americangeriatrics.org/products/ui/incon5.m.h
tm
http://www.familydoctor.co.uk/htdocs/FEMALEURINE/F
EMALEURINE_specimen.html
http://www.netterimages.com/womenshealth/image8.htm
http://www.medscape.com/viewprogram/2666_pnt
http://www.irishhealth.com/?level=4&id=117
http://jaapa.com/issues/j20051001/articles/urinary1005.ht
m
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