Transcript Urinary Incontinence in Women

Urine and Fecal Incontinence in
Women
Raissa Liem
Rebecca Ayesha
Rinda Martanti
Roshni Manwani
Urinary Incontinence in Women
Definition
• The International Continence Society, an organization charged with
defining the various disorders of pelvic floor dysfunction, recently
defined incontinence as “the complaint of any involuntary leakage
of urine”
Anatomy of Urinary bladder
Epidemiology of urinary incontinence
• Urinary incontinence affects 10 million people in the United States
and 200 million people worldwide.
• Urinary incontinence affects
– 15-30% of the general geriatric population
– 50-84% of the elderly persons in long-term care facilities.
– up to 7% of children older than 5 years.
• Incidence is 1.4% of adults aged 15-24 years and 2.9% of those aged
55-64 years.
• Prevalence of female incontinence is reported at 38%, increasing
with age from 20–30% during young adult life to almost 50% in
elderly women.
Anatomy of Incontinence
Types of Urinary Incontinence
Stress Urinary Incontinence
Stress urinary incontinence occurs during periods of increased
intra–abdominal pressure when the intravesical pressure rises
higher than the pressure that the urethral closure mechanism can
withstand
 (e.g., sneezing, coughing, or exercise)
The most common form of urinary incontinence in women and is
particularly common in younger women.
Active women are more likely to notice symptoms of stress urinary
incontinence.
In a survey of 144 collegiate female varsity athletes, 27% reported
stress incontinence while participating in their sport . The activities
most likely to produce urinary loss were jumping, high–impact
landings, and running.
Urge Urinary Incontinence
• It is the involuntary leakage of urine accompanied by or
immediately preceded by urgency.
– This is a symptom–based diagnosis and may or may not be caused by
detrusor overactivity, which is a urodynamic observation characterized by
involuntary detrusor contractions during the filling phase.
• More commonly found in older women
• Women may also have related problems such as urgency, nocturia,
and increased daytime frequency.
• Increased daytime frequency occurs when the patient considers
that she voids too often. (Note that the term pollakisuria is used to
describe this condition in many countries.)
Overflow Urinary Incontinence
• Major contributing factor to overflow incontinence is incomplete
bladder emptying secondary to impaired detrusor contractility or
bladder outlet obstruction.
• Symptoms of overflow incontinence include
–
–
–
–
dribbling,
urgency
hesitancy,
straining, a weak urine stream or low urine production even though
your bladder feels full.
• It’s more common in men, but overflow incontinence occurs in a
significant number of women as well.
Functional urinary incontinence
• Functional incontinence is more common is elderly women and
refers to incontinence that occurs because of factors unrelated to
the physiologic voiding mechanism.
• A woman who can't get to the bathroom quickly may often become
incontinent.
• Functional incontinence can be related to such factors as
– decreased mobility,
– musculoskeletal pain
– poor vision
Risk Factors of Urinary Incontinence
• There is some evidence that age, pregnancy, childbirth, obesity,
functional impairment, and cognitive impairment are associated
with increased rates of incontinence or incontinence severity
–
–
Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence. In: Abrams P,
Cardozo L, Khoury S, et al., eds. Incontinence.Plymouth, UK: Plymbridge Distributors Ltd, 2002:165–201.
Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence in women. Urology
2003;62:16–23.
• Pregnancy and delivery predispose women to stress urinary
incontinence, at least during their younger years.
• Of women who have not borne children, those who are pregnant
leak more often than their nonpregnant counterparts; about half of
women report symptoms of stress urinary incontinence during
pregnancy, but in most, the symptom resolves after delivery.
–
Berek nNovak’s
DIAGNOSIS OF URINARY
INCONTINENCE
Anamnesis
Does the patient:
- urinate during coughing, sneezing, walking, or
jumping?  stress incontinence
- History of previous UTI
- History of painful during urination
- Does the urine contain/mix of blood?
UTI
- Often feel the urge to urinate and has
urinated before came to the toilet?
How is the frequency:
- urination in a day
- to wake up for urinating at night
Does the urine come out:
- at sleep?
- When the stress arises?
- During sexual intercourse?
- Does the patient need to use
tampon to prevent the urine come out?
disease
severity
- Does the flow very slow?
• Does the patient do contraction
to urinate?
urinary
difficulty
• Does the patient realise when the urine come
out?  overflow incontinesia
• Does the patient still feel the urge to urinate after
urination (anyang-anyangan)?  vesicovaginal
fistule
• History:
- Obstetric and gynecology
- Other diseases: DM, stroke, chronic constipation
- Previous operation
- Medications related to urinary disorders 
diuresis, anticholinergic, alpha adrenergic blocker
- Behaviour/habits  daily urination, alcohol
consumption
From Anamnesis
• Discover:
- Type of incontinensia ( stress, urge, mixed,
overflow, continue)
- Severity (I,II,III), amont of tampon use in a day,
episode in a day
- Related to other diseases/infection
- Related to life style/habits
- Related to other medications
Normal range
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•
•
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Diuresis: 1000-1800 cc/hour
Frequency : < 8x/hour
Nocturia < 2x at night/morning
Average urine volume 200-400 cc (max 400600 cc)
Physical Examination
General status
Risk factors:
- cardiovascular insufficiency
- pulmonary disease (asthma)
- occult neurologic processes (e.g., multiple sclerosis,
stroke, Parkinson's disease, and anomalies of the
spine and lower back), abdominal masses, and
mobility
Voiding Diary
Residual urine <50 mL
• First desire to void occurs between
Cystometric capacity
150 and 250 mL infused
• Strong desire to void does not
occur until after 250 mL
• Cystometric capacity between 400
and 600 mL
• Bladder compliance between 20
and 100 mL/cm H2O measured
60 sec after reaching
during filling, despite provocation
• No stress or urge incontinence
demonstrated, despite provocation
• Voiding occurs as a result of a
voluntarily initiated and sustained
detrusor contraction
• Flow rate during voiding is >15 mL/sec
with a detrusor pressure of <50 cm
H2O
• No uninhibited detrusor contractions
Neurologic
• Mental status
• Perineal sensation
• Perineal reflexes
• Patellar reflexes
Abdominal examination
• Masses
Cardiovascular
• Congestive heart failure
• Lower extremity edema
Mobility
• Gait assessment
Pelvic examination
• Prolapse
• Atrophy
• Levator muscle
palpation (symmetry,
ability to squeeze)
• Anal sphincter function
• Test of urethral mobility
(e.g., Q–tip test)
Urethral Function tests
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•
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Urinalysis
Postvoid residual voulme
Voiding cystometography
Imaging test: USG, fluoroscopy, MRI
Neurophysiologic test
Electromyography
Other examinations
• Cough stress test
• Pad test
• Advance:
- Urodynamics
- uroflowmetry
- Filling cystometry
MANAGEMENT AND TREATMENT
Non-surgical treatment
• Lifestyle changes: obesity, postural changes,
decreases caffeine intake
• Physical therapy: Kegel exercise, pelvic floor
muscle training
• Behavioral therapy and bladder training
• Vaginal and urethral devices
include a
- single–use triangularly
shaped foam device with
an adhesive hydrogel that
adheres to
the perimeatal area to
keep urine from exiting
the urethral meatus
- a hat–shaped silicone
patch that adheres by
applying an adhesive gel
to the edge of the device,
squeezing the
central dome, and
creating a vacuum
- The patch can be
reapplied after voids and
reused for up to
1 week.
Medications
Stress incontinence (The tone of the urethra and
bladder neck is maintained in large part by α–
adrenergic activity from the sympathetic
nervous system)
• imipramine (has a concomitant relaxing effect
on the detrusor)
• ephedrine, pseudoephedrine,
phenylpropanolamine, and norepinephrine
Urge incontinence and overactive bladder
• anticholinergic agents  effects on the
bladder by blocking the activity of
acetylcholine at muscarinic receptor sites
Nocturia and nocturnal Enuresis
• tricyclic antidepressants, particularly
imipramine  altering sleep mechanism, by
providing anticholinergic or antidepressant
effects, or by affecting antidiuretic hormone
excretion
Surgical treatment for stress
Incontinence
Retropubic Urethropexy
(Colposuspension)
Traditional Pubovaginal Sling
Surgical treatment for Detrusor
Overactivity
• Neuromodulation: sacral nerve stimulation
therapy
• Botox injections
• Augmentation cytoplasty and Urinary
Diversion
Surgical treatment of Fistule:
Cytoscopy
Fecal Incontinence
Definition
• Fecal incontinence is failure of control of the anal sphincters, with
involuntary passage of faeces and flatus; it may be either
psychogenic or organic in origin. Also called as encopresis and anal,
bowel, or rectal incontinence.
• (Dorland’s Illustrated Medical Dictionary 31st edition)
• Fecal incontinence could cause psychologically and socially
debilitating conditions. It can lead to social isolation, loss of selfesteem and self-confidence, and depression.
Epidemiology
The United States, it is reported that the
prevalence of fecal incontinence in the general
population is approximately 2-3% and vary
greatly among the study population. In
women, at 3-6 months after vaginal or
cesarean delivery, there was 13-25%. Women
almost twice the men.
Anatomy
External anal sphincter :
• A subcutaneous portion
• a superficial portion,
• a deep portion exist.  receives innervation
from the pudendal nerve.
Internal anal sphincter:
• continuation of the inner circular smooth
muscle of the bowel wall.
• thickens over the last 2.5-4 cm of the rectum.
• lies deep to the external anal sphincter,
• its distal extent is just proximal to the
subcutaneous portion of the external
sphincter.
• The internal anal sphincter is supplied by the
autonomic nervous system.
The levator complex is composed of :
• the pubococcygeus,
• the iliococcygeus,
• the coccygeus muscles.
The most medial fibers of the pubococcygeus make up the
puborectalis. These fibers loop around the posterior aspect of
the rectum and create an anterior displacement of the rectum
known as the anorectal angle.
The pelvic surface of the levator complex is innervated by sacral
efferents from S2 through S4. The inferior surface is supplied
by the perineal and inferior rectal branches of the pudendal
nerve. Consequently, pudendal block does not abolish
voluntary contraction of the pelvic floor but completely
abolishes external anal sphincter function.
Normal Physiology and Anatomy of
anorectal region:
Bowel function is controlled by:
• anal sphincter pressure,
• anorectal sensation,
• rectal compliance,
• colonic transit time,
• stool volume and consistency.
• adequate cognitive function with appropriate ability
to access bathroom facilities are necessary for
continence.
If any of these factors are compromised, incontinence
can occur.
Continence requires the complex integration of:
• signals among the smooth muscle of the colon
and rectum,
• the puborectalis muscle,
• the anal sphincters, which is comprised of 2
components:
– the internal anal sphincter (IAS)  0.3-0.5 cm
expansion of the circular smooth muscle layer of
the rectum
– the external anal sphincter (EAS)  0.6-1.0 cm
expansion of the levator ani muscles.
• The IAS  maintain continence at rest and
contributes approximately 70-80% of the
resting sphincter tone.
• This is reinforced during voluntary squeeze by
the EAS, the anal mucosal folds, and the anal
endovascular cushions, which are further
augmented by the puborectalis muscle, which
forms a sling around the rectum and creates a
forward pull to reinforce the anorectal angle.
• The anorectal angle, which is approximately
90 degrees at rest, is created as the rectum
perforates the levator complex.
• Innervation of the EAS is from the pudendal
nerve, a mixed motor and sensory nerve that
arises from the second, third, and fourth
sacral nerves (S2, S3, and S4). Innervation of
the puborectalis arises more directly from
these sacral nerves.
Continence Process
• Colonic contents @ rectum  rectum
distends sensation distension to S2, S3, and
S4 parasympathetic nerves  relaxation IAS
(rectoanal inhibitory reflex) and EAS contract
(rectoanal contractile reflex) contact of
rectal contents with sensitive epithelial lining
of the upper anal canal (rich sensory nerve
endings, especially anal valves)  contents
are sampled as to their nature (ie, gas, liquid,
or solid)  equalization of the rectal and
upper anal canal pressures.
Defecation process
• Anorectal angle straightens (due to squatting
or sitting) + increased abdominal pressure by
straining descent the pelvic floor,
contraction of the rectum, inhibition of the
external anal sphincter, and subsequent
evacuation of the rectal contents.
• If evacuation is not wanted, sympathetically
mediated inhibition of the smooth muscle of
the rectum and voluntary contraction of EAS
and puborectalis musculature occur  The
anorectal angle becomes more acute and
prevents the bolus of stool from descending
further  The contents of the rectum are
forced back into the compliant rectal reservoir
above the levators, which allows the IAS to
recover and contract again.
Causes of fecal incontinence include:
Is multifactorial
• Psychogenic
• Organic :
– constipation,
– diarrhea,
– muscle or nerve damage.
 weakened anal sphincter associated with aging
or to damage to the nerves and muscles of the
rectum and anus from giving birth.
Organic Causes
• Congenital abnormalities (such as spina bifida
and myelomeningocele)
• Medical conditions that may result in fecal
incontinence include:
– diabetes mellitus,
– stroke,
– spinal cord trauma,
– degenerative disorders of the nervous system.
Anal sphincter weakness
• Obstetrical rupture of anal sphincter (chronic
third- or fourth-degree perineal tears)
• Injury related to surgical procedures
– Internal sphincterotomy
– Fistulotomy
– Low anterior colorectal resection
– Hemorrhoidectomy
Neuropathy stretch
injury
Anatomic disturbances
of the pelvic floor
• Obstetric trauma
• Chronic straining
• Fecal impaction
• Fistula
• Rectal prolapse
• Descending perineum
syndrome
Inflammatory conditions
Neurologic conditions
• Inflammatory bowel
disease
• Radiation enteritis
• Infectious enteritis
•
•
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•
•
•
•
•
•
Congenital anomalies
Multiple sclerosis
Parkinson disease
Systemic sclerosis
Spinal cord injury
Stroke
Dementia
Diabetic neuropathy
Diarrheal states
Predisposing factors:
Vaginal delivery as the most common
predisposing factor to fecal incontinence
• Vaginal delivery may result in :
– internal or external anal sphincter disruption,
Factors that are significantly associated with an
increased risk of third-degree obstetric sphincter tears
are :
• primiparity, occiput posterior presentation, use of forceps,
fetal weight greater than 4000 g, perineal tears, episiotomy,
prolonged second stage of labor.
• Damage to the pudendal nerve through
overstretching and/or prolonged compression and
ischemia.
The pudendal nerve innervates the external
anal sphincter muscle, anal canal skin, and
coordinates reflex pathways.
– anorectal function was unaltered in women
undergoing cesarean delivery early in labor.
– In women with advanced cervical dilation (>8 cm)
at the time of cesarean delivery, they found
delayed pudendal nerve terminal motor latency
(PNTML) and reduced anal squeeze pressures.
– In vaginal delivery  decreased anal resting tone
and squeeze pressures, EMG  nerve damage.
• This disruption of anal function sometimes is
just due to defect in structural component,
without any nervous damage. Not only among
those who have prominent vaginal laceration.
• In vaginal delivery using forceps increased
latency of pudendal nerve (PNTML)
sometimes the damage is permanent
• However, some studies found that mostly anal
incontinence that happen post partum, cease
within 1 year after delivery.
Age
• Aging resulted in lower rectal volumes needed to
inhibit anal sphincter tone, slowed pudendal
nerve conduction, perineal descent at rest, and
decreased anorectal sensory function.
• in women older than 50 years  anal canal
squeeze pressure was significantly lower
compared with that found in younger women.
• Prevalence rate  <30 years was 12.3%,
compared with 19.4% in those older than 70
years.
• Anal has many estrogen receptor menopausal
women with HRT have better anal sensory and
pressure function
DIAGNOSIS
Anamnesis
• usually have extreme embarrassment over
their condition  Care should be given
• type and duration of fecal incontinence,
frequency of incontinent episodes, type of
stool lost, impact of the disorder on the
patient's life, history of associated trauma or
surgery
• True incontinence must be differentiated from
pseudoincontinence, and patients may
perceive drainage of mucous, pus, or blood
from the perianal region as incontinence.
•
•
•
•
•
Medications and dietary habits
systemic medical conditions that contribute
An obstetric history
Habits of straining, constipation
Sexual abuse, regular anal intercourse
Physical Examination
• inspection of the perineal body and anus.
• Speculum  vaginal area
• anal  skin tags, hemorrhoids, anal fissures, scars, or
chemical dermatitis, Rectal prolapse or fistulae
• assessment of sensation of the perianal region
• Digital examination  to detect obvious anal
pathology and provide an initial assessment of the anal
resting tone
• A bimanual digital rectal examination  1 digit in the
rectum and 1 digit in the vagina
Supporting examination
Ultrasonography
• transanal or endoanal ultrasonography  allows
the provider to perform a real-time, 360-degree
evaluation of both the internal and external anal
sphincters.
• Sensitivity and specificity of ultrasonography
findings are 98-100% for the external anal
sphincter and 95.5% for the internal anal
sphincter.
• Could evaluate the rectum
Anal manometry
• to evaluate both the resting and squeeze
pressures of the rectum.
• to evaluate the rectoanal inhibitory reflex, rectal
capacity, and rectal compliance.
• Low manometric pressures are not predictive of
anal sphincter defects. Women with known
sphincter defects tend to have lower mean
resting pressures; however, mean squeeze
pressures may be unaffected.
• Squeeze pressures are not significantly related to
the presence of an external anal sphincter defect.
Pudendal nerve terminal motor latency
• helps evaluate the length of time required for
a fixed electrical stimulus to travel along the
pudendal nerve from the ischial spine to the
anal verge.
• Findings reflect the myelin function of the
peripheral nerve, and the test allows for the
evaluation of pelvic floor neuromuscular
integrity.
Electromyelogram
• EMG helps evaluate the electrical activity
generated by muscle fibers
Defecography
• Evacuation proctography (defecography) involves
imaging the rectum with contrast material and
observation of the process, rate, and
completeness of rectal evacuation using
fluoroscopic techniques.
• Defecography helps to assess qualitatively the
function of the anorectum and the adequacy of
rectal emptying; static images measure the length
of the anal sphincter, the anorectal angle, and
perineal descent.
Treatment
Medical Therapy
Conservative treatment  bulking agents and
biofeedback.
The goal of medical therapy  to reduce stool
frequency and improve stool consistency.
• A regular bowel regimen including daily laxatives
should be established.
• restricting fluid with intake  in the patient who
has incontinence of soft stool or liquid stool.
• In patients with diarrhea due to noninfectious
etiologies  Loperamide . Other: atropine
sulphate
• Biofeedback is a safe, minimally invasive
behavioral technique that uses auditory or
visual feedback to reeducate the pelvic floor
musculature.
• The most commonly used techniques are
rectal sensitivity training and anal sphincter
strength training.
• injectable materials may provide
improvement in anal sphincter function. (e.g:
silicone)
Surgical Therapy
Goal  restoration of normal anatomy.
• the anterior overlapping sphincteroplasty 
consists of dissecting out the external anal
sphincter, dividing the scar tissue in the midline,
and then overlapping the scar so that muscle is
approximated to muscle as closely as possible.
• the internal anal sphincter repair  dissection
along the intersphincteric plane and identification
of the internal anal sphincter. The sphincter is
then dissected free from the rectal mucosa and
mobilized. The surgical technique varies
depending on the bulk of scar tissue. The scar
tissue is either divided or left intact as the
sphincter is plicated.
• Post anal technique
• Muscle-wrap techniques have been developed
in which striated muscles from the gracilis or
gluteus muscles are transposed and wrapped
around the anal canal to increase tone.
• The artificial bowel sphincter (Acticon
Neosphincter) was designed to act as a
patient's own anal sphincter in cases of severe
fecal incontinence.
• Colostomy may be considered when all
strategy are failed
Outcome and prognosis
• Initial outcome after sphincteroplasty is 64–
90% with short-term follow-up.The success
rate starts to fall after the first few years and
continues to fall with longer follow-up. Two
long-term studies demonstrate that only half
of the patients have satisfactory continence at
69-80 months postoperatively.
References
• Berek and Novak’s Gynecological 14th edition.
• Altman D, Ekström Å, Forsgren C, et al. Symptoms of anal and
urinary incontinence following cesarean section or spontaneous
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icle.htm
• www.mayoclinic.com
• http://emedicine.medscape.com/article/268674-media
• Lewicky-Gaupp Christina, et al. Urinary and Anal Incontinence in
African American Teenaged Gravidas during Pregnancy and the
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• Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural
history of urinary incontinence. In: Abrams P, Cardozo L, Khoury S,
et al., eds. Incontinence.Plymouth, UK: Plymbridge Distributors Ltd,
2002:165–201.
• Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural
history of urinary incontinence in women. Urology 2003;62:16–23.