Transcript Stress urinary incontinence

Dr mansooreh yaraghi
Fellowship of pelvic floor
INTRODUCTION:
• Prevalence
In older women:17 to 55 %
Younger and middle-aged women: 12 to 42%
• Universal screening in women:
Difficult topic for patients
Screening:
Women who
• Have had Children
• Comorbid conditions associated with increased risk
for urinary incontinence (diabetes, obesity,
neurologic disease)
• Over 65 years of age
Should specifically be asked about symptoms of
urinary incontinence
INTRODUCTION:
• Should not be dismissed simply as an age-related
inconvenience:
Herald a serious underlying condition (neurologic
disease or malignancy)
• Specialized testing and referral to a specialist are
required in only a minority of cases.
CLASSIFICATION:
• Urge urinary incontinence(UUI):
Typically have symptoms of involuntary leakage of urine
accompanied by urgency
 The amount of leakage:
• From a few drops to completely soaked undergarments.
Common triggers:
• Running water, hand washing, and cold weather exposure.
Urgency incontinence is believed to be partly caused by
detrusor overactivity
CLASSIFICATION:
• Stress urinary incontinence(SUI):
Involuntary leakage with effort, exertion, sneezing ,
coughing, laughing
 Anytime an increase in intra abdominal pressure
exceeds urethral sphincter closure
Provoked by minimal or no activity when there is severe
sphincter dysfunction
CLASSIFICATION:
• Stress urinary incontinence:
Most common type in younger women
Incidence is highest in women between 45 and 49 years
old
• Mixed incontinence
 In middle-aged and older women, it often coexists with
urgency incontinence
CLASSIFICATION:
• Overflow incontinence:
 Involuntary, continuous, urinary leakage or dribbling
and incomplete bladder emptying
• Impaired detrusor contractility
• Bladder outlet obstruction
Rare in women
Scarring from prior surgery for incontinence
Significant pelvic organ prolapse
CLASSIFICATION:
• Overflow incontinence:
Other associated symptoms :
• weak or intermittent urinary stream, hesitancy, frequency, and
nocturia
• When the bladder is very full: stress leakage can occur
Can point to an underlying cause
CLASSIFICATION:
• Uncategorized incontinence:
Cannot be classified into one of the above categories on the
basis of signs and symptoms
 Certain clinical features, with some overlap
 Many women have features of more than one type of
incontinence
 The type of incontinence does not correspond precisely
to a specific underlying pathophysiology
Causes:
• Genitourinary system causes
Intra urethral incontinence
Extra urethral Incontinence
• Systemic conditions
• Functional and Transient Incontinence(DIAPPERS)
• Medications
Causes:
• Intra urethral incontinence
Older women : several physiologic changes in the lower
urinary tract :
• Involuntary detrusor contractions or overactivity
• Decreased detrusor contractility
• Low estrogen levels
• Changes in fluid excretion patterns
• Decrease in urethral closure pressure
Causes:
• Intra urethral incontinence:
Interstitial cystitis (painful bladder syndrome):
• Younger women
• Urgency incontinence :can be an atypical manifestation of
interstitial cystitis
Characterized by urgency and frequent voiding of small amounts of
urine, often accompanied by dysuria
Pelvic organ prolapse ( cystocele )
Causes:
 Extra urethral Incontinence:
• Observation of urine leakage through channels other than the
urethra
• Stress or continuous leakage
• Congenital:
Bladder exstrophy
Ectopic ureter
• Traumatic:
Vesicovaginal (developing nations)
Ureterovaginal
Vesicouterine
CAUSES:
• Systemic conditions:
Congestive heart failure : Nocturia
Neurologic disorders:
• stroke, multiple sclerosis, Parkinson disease, disc herniation ,
spinal cord injury, normal pressure hydrocephalus, or subacute
combined degeneration
Diabetes mellitus:
• Increased urine volume and frequency :in uncontrolled
hyperglycemia
• Overflow incontinence and poor urinary stream :in diabetic
autonomic neuropathy.
CAUSES:
• Systemic conditions :
Diabetes insipidus :
• Polyuria , which must be differentiated from urinary frequency
or nocturia
Cancers:
• Urinary frequency :urethral cancers
• Hematuria should raise concern for bladder cancer.
Sleep disorders:
Depression:
Obesity:
nocturia
CAUSES:
Functional and Transient Incontinence:(DIAPPERS)
CAUSES:
Medications:
• Diuretics:
Polyuria, frequency, urgency
• Caffeine:
 Frequency, urgency
• Alcohol
 Sedation , impaired mobility , diuresis
• Narcotic analgesics:
 Urinary retention, fecal impaction , sedation, delirium
• Anticholinergic agents:
 Urinary retention, voiding difficulty
CAUSES:
Medications:
• Antihistamines:
Anticholinergic actions, sedation
• Psychotropic agents
• Antidepressants:
Anticholinergic actions, sedation
• Antipsychotics:
Anticholinergic actions, sedation
• Sedatives/hypnotics:
Sedation, muscle relaxation , confusion
CAUSES:
Medications:
• Alpha-adrenergic blockers:
 Stress incontinence
• Alpha-adrenergic agonists:
Urinary retention, voiding difficulty
• Calcium-channel blockers:
Urinary retention, voiding difficulty
CAUSES:
Medications:
• Angiotensin - converting enzyme inhibitors:
cough worsens stress and possibly urge leakage in
persons with impaired sphincter function
• Estrogen:
Worsens stress and mixed leakage in women
• GABAnergic agents(gabapentin , pregablin):
Pedal edema : nocturia and nighttime incontinence
• NSAID:
Pedal edema:nocturnal polyuria
CAUSES:
Medications:
• Oral contraceptives:
 Stress, urge, and mixed incontinence
• Cholinesterase inhibitors
Alone may increase incontinence
Increased functional impairment when combined with
anti incontinence antimuscarinic agents
• Beta blockers:
Urge incontinence
• Lithium:
 Polyuria
Warrant Consultation:
• Uncertain diagnosis and inability to develop a
reasonable treatment plan based on the basic
diagnostic evaluation
• Lack of correlation between symptoms and clinical
findings
Warrant Consultation:
• Failure to respond to the patient’s satisfaction to an
adequate therapeutic trial, and the patient is
interested in pursuing further therapy.
• Consideration of surgical intervention, particularly if
previous surgery failed or the patient has a high
surgical risk.
Warrant Consultation:
• The presence of other comorbid conditions:
Incontinence associated with recurrent symptomatic
urinary tract infection
Persistent symptoms of difficult bladder emptying
History of previous anti incontinence surgery, radical
pelvic surgery, or pelvic radiation therapy
Warrant Consultation:
• The presence of other comorbid conditions:
Symptomatic pelvic prolapse, especially if beyond
hymen
Abnormal postvoid residual urine
Neurologic condition such as multiple sclerosis or spinal
cord lesions or injury
Warrant Consultation:
• Fistula or suburethral diverticulum
• Hematuria without infection
EVALUATION:
• Characterizing and classifying the type of
incontinence
• identifying reversible or serious underlying
History
Physical examination
Urinalysis
EVALUATION:
• Additional evaluation :
in the presence of complex medical conditions or
worrisome findings on history and physical examination
• specific clinical tests:
Bladder stress test
Postvoid residual
Additional laboratory tests
Radiographic imaging
Referral to a specialist
History:
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Urinary symptoms
Frequency
Volume
onset of incontinence
Timing
Severity
Duration
Hesitancy
precipitating triggers
Nocturia
History:
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Intermittent or slow stream
Incomplete emptying
Continuous urine Leakage
Straining to void
Degree of bother and effect on quality of life (QOL)
Underlying causes
Living environment:
Access to toilets or toilet substitutes
Social factors such as living arrangements, social
contacts, and caregiver involvement
Questions:
• Do you ever leak urine/water when you don’t want
to?
 1.Do you leak urine when you cough, sneeze, laugh or
exercise ? (stress incontinence)
 2. Do you ever have such an uncomfortably strong
need to urinate that if you don’t reach the toilet you
will leak? (sense of urgency)
 3.If “yes” to question 2, do you ever leak before you
reach the toilet? (urge incontinence)
Questions:
 4.How many times during the day do you urinate?
(Frequency)
 5.How many times do you void during the night after
going to bed? (Frequency)
 6. Have you wet the bed in the past year? (bedwetting)
 7. Do you develop an urgent need to urinate when you
are nervous, under stress, or in a hurry or on the way to
the bathroom ? (sense of urgency)
Questions:
8. Do you ever leak during or after sexual intercourse?
(leaking with intercourse)
9. How often do you leak? (severity)
Questions 2 through 9:
symptoms associated with detrusor overactivity
10. Do you find it necessary to wear a pad ,
tissue or cloth in your underwear to catch urine
because of your leaking? (severity)
Questions:
11. Have you had bladder, urine, or kidney infections?
(urinary tract infection and neoplasia)
12. Are you troubled by pain or discomfort when you
urinate? (urinary tract infection and neoplasia)
13. Have you had blood in your urine? ( urinary tract
infection and neoplasia)
Questions:
14. Do you find it hard to begin urinating? (voiding
Dysfunction)
15. Do you have a slow urinary stream or have to strain
to pass your urine? (voiding Dysfunction)
16. After you urinate, do you have dribbling or a feeling
that your bladder is still full? (voiding Dysfunction)
Voiding (bladder) diaries
• histories of frequency and severity:often inaccurate
and misleading
• more reliable
• incontinence frequency
• Severity
• associated events or symptoms such as coughing,
urgency, and pad use
• volume of urine loss during incontinent episodes
• Bedwetting
• The maximum voided volume
Voiding (bladder) diaries
• can be helpful:
Nocturia
High urinary frequency or incontinence frequency
Unclear history
• mixed incontinence: the predominant, more
bothersome component for the individual
• Neither sensitive nor specific for determining the
urodynamic cause of incontinence
• excessive frequency and volume of fluid intake:
restriction of excessive oral fluid intake
combined with scheduled voiding
improve symptoms of stress and urge incontinence
Voiding (bladder) diaries
• at least 2 days.(1-7days:3days)
• 4 things every time you pass or leak urine:
– The time
– The amount of urine that pass
– leaked any urine (were "wet") or not (were "dry")
– Whether anything special may have caused you to go
(for instance, "just had coffee," "coughed," "was running
to the bathroom," "just took my water pill")
• Start the record in the morning the first time you go
to the bathroom after you get up.
Voiding (bladder) diaries:
• the time you got up and the time you went to bed.
• a special receptacle (called a "hat"). Place the hat
in the toilet to catch the urine every time you go.
Look at how high the urine fills the hat, and write
down the amount from the numbers on the inside
of the hat. Remember to empty the hat after each
time you go.
• If you leak urine and cannot measure the amount
that came out, write down your best guess.
Quality of life:
• Depression
• Anxiety
• Work
• Relationships
• Social life
• Sexual function
 validated instruments (ICIQ, Kings Health Questionnaire)
used to assess treatment efficacy for women with urinary
incontinence.
Systemic symptoms:
• Onset of incontinence
• Abdominal or pelvic pain
• Hematuria
• Lower extremity weakness
• Changes in gait
• Cardiopulmonary
• Neurologic symptoms
Systemic symptoms:
• Weight changes
• Mental status changes
• Functional status
• Mobility
• Cognitive status
• Changes in bowel function
• Detailed medication history
• Alcohol and caffeine intake
Past medical &surgical history:
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Gynecologic
Neurologic
Obstetric histories
Diabetes, stroke, and lumbar disk disease
Chronic pulmonary disease:
strong coughing worsen symptoms of stress incontinence.
• Chronic severe constipation:
Voiding difficulties, urgency, stress incontinence,increased bladder
capacity, and POP
• prior surgical trauma to the lower urinary tract
Hysterectomy
Vaginal repair
 Pelvic cancer
 Pelvic radiotherapy
Surgery for incontinence
Drugs:
• Altering drug dosage
• Changing to a drug with similar therapeutic
effectiveness but with fewer lower urinary tract side
effects
• Will often improve or “cure” the offending urinary
tract symptom
Physical examination:
• The cardiovascular examination:
volume overload (rales, pedal edema)
• The abdominal examination:
masses or tenderness.
abdominal examination is not sensitive for detecting
bladder distension
Physical examination:
• The extremities:
joint mobility, function, and muscular atrophy or
wasting.
• The neck examination:
with osteoarthritis:
• neck movement and evaluate for interosseous muscle wasting
of the hands.
• These changes, especially if a Babinski reflex is also
present:cervical spondylosis or stenosis causing detrusor
overactivity
Physical examination:
• Detailed pelvic examination:
Inspect the vaginal mucosa :
• atrophy (thinning, pallor, loss of rugae)
• narrowing of the introitus
• vault stenosis
• inflammation (erythema, petechiae, telangiectasia, friability)
• Vaginal discharge
Palpate bimanually :
• masses or tenderness.
Palpation of the anterior vaginal wall and urethra :
• urethral discharge or tenderness : urethral diverticulum, carcinoma, or
inflammatory condition of the urethra
Physical examination:
• Detailed pelvic examination:
Assess the adequacy of pelvic support, and assess for
pelvic organ prolapse, by a split-speculum
• Cough once: looking for urethral leakage
• urethra remains firmly fixed or swings quickly forward (urethral
hypermobility),
• anterior wall support defect
• posterior wall support defect
• Pelvic organ prolapse often coexists with urinary incontinence
Rectal exam
Q-Tip Test:
• measurement of the axis change with straining
sterile, lubricated cotton-tipped applicator
transurethrally into the bladder, withdrawn slowly until
definite resistance is felt (at the bladder neck)
supine lithotomy
• The resting angle in relation to the horizontal
With goniometer or protractor
• Maximum straining angle from the horizontal at cough
and Valsalva maneuver
• Not affected by the amount of urine in the bladder
• Maximum straining angle >30° :abnormal
Q-Tip Test:
• Urethral mobility in continent women:
Age
Parity
support defects of the anterior vaginal wall
• urethral hypermobility” is common in
asymptomatic women.
• wide overlap in measurements between the
continent and incontinent women
• no longer considered useful in helping with
diagnosis or treatment of incontinence
Physical examination:
• Detailed neurologic examination must be
performed in :
Sudden onset of incontinence (especially urge)
Known neurologic disease
New onset of neurologic symptoms
Physical examination:
• Screening neurologic examination:
Mental status
 Sensory
Motor function of both lower extremities
Lumbosacral neurologic examination:
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Pelvic floor muscle strength
Anal sphincter resting tone
Voluntary anal contraction
Perineal sensation
Physical examination:
• Mental status:
 Level of consciousness
 Orientation
 Memory
 Speech
 Comprehension.
• Disorders with mental status aberrations&changes in bowel
or bladder function:
 Senile and presenile dementia
 Brain tumors
 Stroke,
 Parkinson’s disease
 Normal pressure hydrocephalus.
Physical examination:
• Perineal sensation:
Light touch
Pinprick
Temperature
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Peripheral sensation
Resting and volitional tone of the anal sphincter
Anal wink
Vibration
Physical examination:
• Babinski reflex
• Patellar, ankle reflex
• Two reflexes of sacral reflex:
Anal reflex
• stroking the skin adjacent to the anus causes reflex contraction
of the external anal sphincter muscle.
 The bulbocavernosus reflex:
• Contraction of the bulbocavernosus and ischiocavernosus
muscles in response to tapping or squeezing of the clitoris
These reflexes can be difficult to evaluate clinically
Not always present, even in neurologically intact women
Bladder stress test:
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Full bladder
Stand
Relax
Single vigorous cough
Clinician observes directly
Negative test is less useful
Positive bladder stress test :Does not require
treatment unless the patient reports significant
bother related to the incontinence.