Transcript Urinary Incontinence (Student Lecture).

Urinary Incontinence
in Women
Dr. Hazem Al-Mandeel
Associate Professor
Department of Obstetrics and Gynecology
College of Medicine, King Saud University
Prevalence of
Urinary Incontinence (UI)
• Prevalence of UI in Europe for women was
35% - 40.%
• Prevalence of UI in Canada was 50%
• Prevalence of UI in Far Asia was 22% - 50%
• Prevalence of UI in Saudi was 29% - 41%
• Prevalence of UI in Qatar was 20.6%
Implications of Incontinence
o Medical:
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o
o
o
Skin ulcers
Skin rashes
UTI
Falls
o Social:
o Loss of self-esteem
o Social restriction
o Depression
o Economic:
o Personal costs
Quality of Life Impact
 Impact on lifestyle and avoidance of
activities
 Fear of losing bladder control
 Embarrassment
 Impact on relationships
 Increased dependence on caregivers
 Discomfort and skin irritation
Differential Dx of Urinary Incontinence
in Women
Genitourinary
o Stress incontinence
o Detrusor overactivity
o Mixed incontinence
o Urogenital Fistula
o Urethral diverticulum
Non-genitourinary
• Functional
(Neurogenic,
cognitive,
psychological,
physical
impairment)
• Environmental
• Pharmacologic
• Metabolic
Reversible causes of incontinence
(DIAPPERS)
Delirium
Urinary Tract Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Endocrine (D.M)
Restricted mobility
Stool impaction
Common Types of
Urinary Incontinence
 Stress incontinence
 Urge incontinence
 Mixed
 Overflow incontinence
 Functional incontinence
Stress Incontinence:
 Involuntary loss of urine on effort or with physical
exertion (causing increases in intra-abdominal
pressure)
 Caused by pelvic floor damage/weakness or weak
sphincter(s)
 Symptoms include loss of urine with cough,
laugh, sneeze, running, lifting, walking
 Most common type in younger women (< 65 yrs.)
Risk factors for SUI
Age
Childbearing
Obesity
Increased intra-abdominal pressure
Estrogen depletion (Menopause)
Urge Incontinence:
 Involuntary loss of urine associated with
urgency (due to an involuntary detrusor
contractions)
 Complaints of urgency, frequency, inability
to reach the toilet in time, up a lot at night
to use the toilet
 Multiple triggers
Causes of Urge Incontinence
Neurogenic:
CVAs
Cerebral Tumors
Cerebral Aneurysm
Cerebral Hemorrhage
Multiple Sclerosis
Parkinson's Disease
Spinal cord injury
Idiopathic
Other conditions
UTI
Atrophic Urethritis
Urogenital Prolapse
Fecal Impaction
Bladder tumor
Bladder stone
Mixed Incontinence:
 Combination of stress and urge
incontinence
 Common presentation of mixed
symptoms
 Urodynamics necessary to confirm
Stress : 49%
Urge : 22%
Mixed : 29%
Overflow Incontinence
Large bladder volumes result in an intravesical pressure greater than the urethral
closure pressure
Causes:
oAtonic Bladder
oOutlet Obstruction
Chronic Urinary Retention:
 Outlet obstruction or bladder underactivity
 May be related to previous surgery, aging,
development of bad bladder habits, or
neurologic disorders
 Medication, such as antidepressants
 May present with symptoms of stress or
urge incontinence, continuous leakage, or
urinary tract infection
Functional and Transient
Incontinence:
 Mostly in the elderly
 Urinary tract infection
 Restricted mobility
 Severe constipation
 Medication - diuretics, antipsychotics
 Psychological/cognitive deficiency
Diagnosis of
Urinary Incontinence
History
Physical
Voiding Diary
PVR
Urinalysis
Urodynamics
Patient History:
 Focus on medical, neurologic,
genitourinary history
 Review voiding patterns/fluid intake
 Voiding diary
 Review medications
 Explore symptoms (duration, most
bothersome, frequency, precipitants)
 Assess mental status and mobility
Symptoms:
 Frequency
 Nocturia
 Dysuria
 Incomplete emptying
 Incontinence
 Urgency
 Recurrent infections
 Dyspareunia
 Prolapse
Physical Examination:
 General examination
 Edema, neurologic abnormalities, mobility,
cognition, dexterity
 Abdominal examination
 Pelvic and rectal exam - women
 Examination of back and lower limbs
 Observe urine loss with cough
Urinalysis:
 Conditions associated with overactive
bladder
 Hematuria
 Pyuria
 Bacteriuria
 Glucosuria
 Proteinuria
 Urine culture
Postvoid Residual Volume (PVR):
 If clinically indicated accurate PVR can be done by
 Catheterization
 Ultrasound
 PVR of <50 ml is considered adequate, repetitive
PVR >200 ml is considered inadequate
 Use clinical judgment when interpreting PVR
results in the intermediate range (50-199 ml)
Treatment : Stress Incontinence
Nonsurgical
Pelvic floor muscle training (Kegel)
Biofeedback
Electrical stimulation
Pessaries
Medications
Surgical : recreating urethral support
Abdominal
Vaginal
Kegel Exercise
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10 – 20 repetitions three times per day
Hold contraction for 5 to 10 seconds
A set can be done to suppress urgency
Results take 6 – 8 weeks to manifest
NOT to be done while voiding
Improvement & cure rates as high as 60%
Treatment : Electrical Stimulation
Treatment : Pessary
Treatments : Surgical
Abdominal approaches
Open retropubic colposuspension (Burch)
Pubo-vaginal sling
Midurethral tape procedure (e.g. TVT,
TOT,TVTO, Mini Slings)
Periurethral Bulking Agents
Treatment Modalities for OAB
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Behavioural Modification
Drug Treatment
Neuromodulation (for refractory cases)
Surgical Treatment (for refractory cases)
Behavioral Modification
Bladder
retraining
Education
Pelvic Floor
muscle exercises
Behavioral
Modification
Lifestyle changes
Toileting
programs
Bladder Retraining
• Bladder Drill:
– Increase intervals between voids
– Aim for q2-3h
• Timed Voids (spinal cord)
– Voiding times pre-selected e.g.. q2h
– Interval based on avoiding leakage
• Prompted Voids
– Fixed time interval between voids
– Third party prompt
– Interval based on avoiding leakage
Lifestyle Interventions
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Elimination of bladder irritants
Manage fluid intake
Cessation of smoking
Weight reduction
Bowel regulations
Use diuretics judiciously (not before bed)
Reduce physical barriers to toilet (use bedside
commode)
Drug Treatment of OAB
Drug
Level of evidence
Antimuscarinics
Tolterodine
Trospium
Darifenacin
Solifenacin
Propantheline
1A
1A
1A
1A
2B
Drugs with mixed actions
Oxybutynin
Propiverine
Flavoxate
Dicyclomine
1A
1A
2D
3C
Antidepressants
Imipramine
3C
Vasopressin analogues
Desmopressin
1A
International Consultation on Incontinence, 2004
Treatment: Overflow Incontinence
Self Intermittent Catheterization
?Alpha Blockers
? Cholinergic Agents
Treatment: Mixed Incontinence
Treat the component which is most
troubling to the patient