Transcript Urinary Incontinence - Josh Karram PGY1

Urinary
Incontinence
JOSH KARRAM PGY1 RIVERSIDE
JUNE 2016
Overview
 Why
it matters?
 Normal
physiology
 Identify
historical & physical traits to aid in
diagnosis and classification of urinary
incontinence
 Identify
reversible causes of urinary incontinence
 Approach
to treatment
Why it matters?

Prevalence is high

Affects quality of life

More likely to:

Have depression

Limited social & sexual function

Have increased dependence on caregivers
Normal Physiology

Bladder fills  stretch receptors activated 
signal sent via S2-S4  spinal cord  sensory
cortex where need to void is perceived

Threshold volume is reached (unique to the
person) triggers awareness of need to void

External urinary sphincter at bladder outlet
stays contracted until ready to void; micturition
inhibitory centre in frontal lobe also helps inhibit

Decision made to void  signal to micturition
centre  simultaneously contracts detrusor
smooth muscle (via parasympathetic
cholinergic nerve fibres) and relaxes internal
sphincter (alpha sympathetic nerve fibres),
striated muscles and pelvic floor
Normal Physiology
CNS
MSK/Anatomy
How do we classify
incontinence?

Typically broken down into 5 different categories
Stress
Urge
Overflow
Mixed
Functional
Case 1

52 yo F G4P4 – all SVDs no
complications/instrumentation

BMI 30

Going through menopause

Recently on health kick – wants to lose weight

Certain exercises at gym causing her to leak urine

Also noticed with coughing or laughing

No urgency, frequency, dysuria, or nocturia

Self-conscious

Otherwise healthy; no medications
Stress
Pathophysiology:

Loss of urethral “support”
(sphincter and/or pelvic
floor weakness) allows for
hypermobility and/or
intrinsic sphincter
deficiency

Increased abdominal
pressure leads to opening
of urethra and leakage
Stress
Risk factors

Vaginal delivery

Obesity

Vaginal delivery

Poor tissue

Vaginal delivery

Instrumental vaginal
delivery

Connective tissue
disease, radiation,
smoking, lack of
estrogen, surgery

Chronic cough

Prostate surgery
Stress
History

Leaks during physical activity or
increased intra-abdominal pressure:

Usually starts as small
volumes and can often
predict when it will happen

No nocturia

Coughing

Laughing

Sneezing

Jumping

Lifting

Normal urge to void

Exercise

Normal voiding stream

Walking

Rising from chair
Stress
Physical Exam

Pelvic exam

Estrogen deficiency?



atrophy
Cough stress test

Good sensitivity and specificity

Full bladder (but comfortable)

Separate labia, patient to forcibly cough once

Supine +/- standing

+ve if urine leaks with onset and cessation of cough
Levator ani muscle strength – normally 5-10s
Stress
Treatment

Weight loss

Fluid optimization

Constipation management

Smoking cessation
Stress
Treatment

Proper absorbent pads

Pelvic floor muscle training

Kegels

Isolate muscles that stop urine flow

3 sets; 8-12 contractions; 8-10s each; 3x/day

Vaginal weights

Biofeedback

Supervised pelvic floor physiotherapy
Stress
Treatment con’t

Continence pessary

Surgery

Midurethral sling – gold
standard


Tension free vaginal tape (TVT)
or trans obturator tape (TOT)
May also consider:

Bladder neck sling

Periurethral bulking

Radiofrequency denaturation
Stress
Medications

Vaginal estrogen ring

Vaginal estrogen cream

Alpha adrenergic agonists (pseudoephedrine,
phenylephrine)


Increase resting urethral tone

Weak evidence
Duloxetine (Cymbalta)

Incontinence reduction

Not a good stand alone option but for depressed patient
with concurrent stress incontinence, may be helpful
Case 2

41 yo G2P2 – SVDs no instrumentation

Frequency & urgency – sometimes makes it;
sometimes doesn’t

Having to get up in the night 2-3x

No dysuria

Otherwise healthy

Admits that she loves her coffee and wonders if that
could be contributing
Urge
Pathophysiology:

Involuntary detrusor
contractions during the filling
of the bladder

+/- full bladder

2 subtypes

Sensory – result of local
irritation, inflammation or
infection

Neurologic – most often
caused by loss of cerebral
inhibition of detrusor
contractions
Urge

Risk factors

Irritation


cystitis, prostatitis, atrophic
vaginitis, prior pelvic
radiation therapy
Loss of neurologic control

Stroke, dementia, spinal
cord injury, Parkinson’s
Urge
History

Urgency, frequency,
nocturia

Small or large volumes

May be stimulated by
change in body position or
with sensory stimulation

If they make it to the toilet –
overactive bladder; if they
don’t - urge incontinence
Examination

Usually normal

May consider urodynamic
testing

Cystoscopy if smokers or
hematuria
Urge
Treatment

Lifestyle changes

Caffeine elimination

Weight loss

Optimize fluid intake

Smoking cessation

Constipation management

Review medications

Pelvic floor strengthening –
can be more effective than
medications

Bladder training

Distraction

Sacral nerve modulation
Urge

Medical therapy


Anticholinergic medications – antagonize M2/M3
muscarinic receptors of bladder; selective/long-acting
agents preferred

Selective - darifenacin & solifenacin; non-selective - oxybutynin
and tolterodine

Increases storage, decreases urgency

Side effects: dry eyes, dry mouth, constipation

CI – narrow angle glaucoma, urinary retention, myasthenia
gravis, dementia, GI obstruction/retention
Beta-adrenergic agonists – mirabegron


Relax detrusor; SE N/D, HA, dizziness, constipation, HTN
Bladder Botox – lasts 3-6 months
Urge
Surgery

Implanted devices

Stimulate sacral, paraurethral and pudental nerves

Refractory to all other treatment

Costly and risk of surgical complications
Mixed
Stress
Mixed
Urge
Overflow
Pathophysiology

Urine loss associated with overdistension of bladder

Typically by an underactive bladder and/or outlet
obstruction

Common example is benign prostatic hyperplasia
Overflow

Risk factors

Presentation

DM

Constant wetness/dribbling

Spinal cord injury

+/- urge

MS


Bladder distension injuries
+/- sensation of incomplete
emptying

Obstruction – prolapse

BPH

Anticholinergic medications

Physical examination

Wet vulva

Palpable bladder

High PVR – U/S scan vs I/O
catheter
Overflow

Treatment

Remove obstruction

Clean intermittent
catheterization

Sacral nerve modulation

MRI if suspicious of MS

One of the earlier
complaints for first
presentation of MS
Functional

Secondary to impairment

May be physical or cognitive

Unable to make it to the toilet

May also be in combination with previously
mentioned etiologies

Risk factors

Dementia

Physical frailty

Inability to ambulate

Mental health disorder
Putting it all together
History



HPI

Urgency, frequency, nocturia

Leakage with cough, sneeze, laugh, increased intra-abdominal pressure

Constantly wet, dribble, incomplete void

Dysuria
PMHx

Bowel, back, gynecologic or bladder surgery; pelvic radiotherapy

CHF, COPD, neurological & MSK conditions,

Prostate pathology

Cognitive changes/functional abilities

Constipation
Gyne/ObHx

Estrogen status, deliveries and type, time in between
Putting it all together

Free tools available

3 incontinence questions –
popular tool

Categorizes urinary
incontinence in middle-aged
to older women

Stress


Sensitivity 0.86

Specificity 0.6
Urge

Sensitivity 0.75

Specificity 0.77
Putting it all together
Still not sure?

Can also consider use of a
voiding diary

Short term may be as
helpful as longer term –
easier on you and the
patient

Help clarify situations,
frequency, volume
Functional Inquiry


Effects on:

Work

ADLs

Sleep

Sexual Activity

Social interactions

Interpersonal relationships

General perception of health

Quality of life
Identify the most bothersome symptom – this will help direct
management
Putting it all together

MEDICATIONS!

Recent changes?

Some contribute by
increasing urine
production or
impairing neuro
functioning rather
than having direct
effect on urinary
tract
Putting it all together
Physical Exam

CVS – arteriovascular disease; volume status

RESP – chronic cough?

GI – evidence of constipation, masses

GU – bladder distension, vaginitis and atrophy, cough
test

NEURO – signs of stroke, impaired mental state, spinal
stenosis, peripheral neuropathy; lumbosacral nerve root
testing

MSK – mobility

DERM – irritation from incontinence
Transient Causes of Urinary
Incontinence (DIAPPERS)

Delirium

Infection (acute UTI)

Atrophic vaginitis

Pharmaceuticals

Psychological disorder, especially depression

Excessive urine output

Reduced mobility (e.g. functional) or reversible
urinary retention (e.g. drug-induced)

Stool impaction
Putting it all together
Investigations

Creatinine

Urinalysis

Urine culture

MoCA

Post void residual

Recommended to diagnose overflow

<50ml negative; 100-200ml indeterminate; >200ml positive

U/S or I/O catheter
Diagnostic Approach
Indications for Referral

Associated recurrent symptomatic UTIs

Associated new-onset neurologic symptoms, muscle
weakness, or both

Marked prostate enlargement

Pelvic organ prolapsed past the introitus

Pelvic pain associated with incontinence

Persistent hematuria

Persistent proteinuria

Post void residual >200ml - obstruction

Previous pelvic surgery or radiation

Uncertain diagnosis
SAMP

List 3 indications for referral of urinary incontinence
Indications for Referral

Associated recurrent symptomatic UTIs

Associated new-onset neurologic symptoms, muscle
weakness, or both

Marked prostate enlargement

Pelvic organ prolapsed past the introitus

Pelvic pain associated with incontinence

Persistent hematuria

Persistent proteinuria

Post void residual >200ml - obstruction

Previous pelvic surgery or radiation

Uncertain diagnosis
SAMP

List 3 causes of reversible urinary incontinence
Transient Causes of Urinary
Incontinence (DIAPPERS)

Delirium

Infection (acute UTI)

Atrophic vaginitis

Pharmaceuticals

Psychological disorder, especially depression

Excessive urine output

Reduced mobility (e.g. functional) or reversible
urinary retention (e.g. drug-induced)

Stool impaction
SAMP

What non-pharmacologic treatment can be used
for both urge and stress incontinence?
References

Culligan, P. J., & Heit, M. (2000). Urinary
incontinence in women: evaluation and
management. American family physician, 62(11),
2433-44.

Hersh, L., & Salzman, B. (2013). Clinical management
of urinary incontinence in women. American family
physician, 87

Khandelwal, C., & Kistler, C. (2013). Diagnosis of
urinary incontinence. American Family
Physician, 87(8), 543-50.(9), 634-640.