Transcript Urinary Incontinence

Urinary Incontinence
Girija Charugundla
Definition
• UI is the involuntary loss of Urine
that leads to a hygiene or social
problem
Prevalence
1.Increases with age (not a part of normal
aging)
2. 25 – 30% community dwelling women, 10 –
15% community dwelling men
3.About 1/3 of patients in acute care setting
4.Greater than 50% of residents in nursing
homes associated with dementia, immobility
and Fecal Incontinence
Anatomy of lower Urinary
Tract
1.Muscular storage and contractile organ
called detrusor (smooth muscle)
2.Smooth muscle sphincter located in Proximal
urethra (internal sphincter)
3.Distal peri-urethral striated muscle
(external sphincter)
Physiology of Micturation
1. Autonomic (sympathetic and Para-sympathetic) and
somatic (voluntary) nervous systems coordinate
micturation
2.Normal bladder fills passively with little change in
intravesicle pressure (facilitated by CNS inhibition of
Para-sympathetic activity) and the sphincters remain
closed (facilitated by reflex increase in alfaadrenergic and somatic tone)
3.For voiding para-sympathetic mediated bladder
contraction coincides with coordinated sphincter
relaxation
Urinary Changes With
Normal Aging
1.Increase in post void residual volume (PVR),
Involuntary bladder contraction (urgency)
nocturia 1-2 times at night
2.Decrease in bladder capacity and force of
contraction, ability to postpone voiding
(frequency), urethral compliance and
strength of pelvic floor muscle
Potentially reversible causes of
Incontinence (Transient Incontinence)
Delirium
Infection, urinary (symptomatic)
Atrophic urethritis- vaginitis
Pharmaceuticals
Psychological disorders
Endocrine disorders/ excessive urine
production
- Restricted mobility
- Stool impaction
-
Lower Urinary Tract
Dysfunction
Failure to Store
- Hyperactive or
Overactive Bladder
- Incompetent
Sphincter
Failure to Empty
- Under-active
Bladder
- Obstruction
Types of Urinary
Incontinence
•
•
•
•
Stress
Urge
Overflow
Functional
Urge Incontinence
1.Most common cause of UI over age 75years
2.Abrupt desire to Void (Urgency that can not
be suppressed)
3.Usually idiopathic
4.Other causes- bacterial cystitis bladder
tumor, bladder stones, atrophic vaginitis/
urethritis, stroke, Parkinson’s disease,
dementia
Stress Incontinence
1.Most common in women especially less than
75 years
2.Hyper mobility of bladder neck and urethra,
aging, hormonal, multiple child birth,
hysterectomy, pelvic surgery
3.Intrinsic sphincter deficiency, previous
pelvic or anti-incontinence surgery, pelvic
radiation, trauma, neurogenic disorders
Overflow Incontinence
1.Over distension of the bladder causing
constant or frequent dribbling
2.Bladder outlet/ stricture obstruction
cystocele, BPH, Fecal impaction
3.Acontractile bladder (AKA: Detrusor hypo
mobility, atonic bladder, Diabetes, MS,
Lumber spinalstenosis, spinal cord injury, and
medications
Functional Incontinence
1.Does not involve lower urinary tract
2.Result of Physical and /or cognitive
impairment (arthritis, stroke, dementia)
Mixed Incontinence
1.When a combination of the above types
exists
2.Most common combination is Detrusor
overactivity (urge incontinence) and outlet
incompetence (stress incontinence)
Office Work Up
1.Ask the question “in the past year have you
ever lost urine or gotten wet?” if “yes” “have
you lost urine on at least 6 separate days?”
2.Duration, severity, symptoms, previous
treatment, medication, previous antiincontinence surgery
3.Bladder record, frequency, type, and number
of incontinent episodes
Physical Examination
1. Assess mental status
2.Assess mobility
3.Look for peripheral edema or evidence of CHF
4.Abdominal exam
5.Neurologic- evaluation of lumbosacral nerves, focal
findings, peripheral neuropathy
6.Pelvic exam- atrophic vaginitis, cystocele, uterine
prolapse, rectocele, para vaginal muscle tone, mass
7.Rectal- sphincter tone (active of resting), to asses
integrity of sacral flexes (S2-S4), fecal impaction
Pad test/cough stress test
1.Perform with a full bladder, patient standing
2.Instantaneous leakage with cough- stress
3.Specificity greater than 90%
4.Leakage delayed or persists after coughsuspect urge UI
Post-voidal residual volume
(PVR)
1.Perform within 5min of voiding
2.
Catheterization or bladder ultrasound
- PVR less than 50cc adequate bladder emptying
- PVR less than 100cc adequate bladder emptying
greater than 65 years
- PVR more than 200cc refer to specialist
Basic lab evaluation for UI
1.Calcium, glucose
2.BUN/ Cr- if PVR is greater than 200cc
3.UA and culture
Simple Cystometry
1.Useful when unsure of type of UI
2.Office based procedure 15-20min
3.3 determines bladder capacity and stability
4.Correlates with multichannel
systometrogram
Management of UI
1. Behavior therapy
2.Pharmacological therapy
3.Surgery
4.Pessaries
5.Peri-urethral bulking agents
6.Occlusive devices
7.Garments and pads
8.Catheters
Behavioral intervention
1.Reduce amount and timing of fluid intake
2.Avoid bladder stimulant such as caffeine,
ETOH
3.Use diuretics judiciously
4.Make toilet easier to get to by Suggesting
bed side commode
Patient dependent
behavioral intervention
1.Bladder retraining
2.Pelvic muscle (kegel) exercises
Caregiver dependent
behavioral intervention
1.Scheduled toileting
2.Habit training
3.Prompted voiding
Current therapy for UI
1.Oral medications
2.Trandermal oxybutynine
3.Intravesicle therapy
4.Botulinum toxins
5.Interstim system
Treatment for stress
incontinence
1.Meds
2.Surgical techniques
3.Pessary
4.Peri-urethral bulking agents
Therapy for overflow
incontinence
1.Meds to relieve obstruction
2.Surgery to relieve obstruction
3. Intermittent catheterization