urinary incontinence
DESCRIPTION
Urinary Incontinence. Dr. Eyad Z. AL-Aqqad Special Urologist. Definition. INCONTINENCE: - PowerPoint PPT PresentationTRANSCRIPT
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Urinary Incontinence
Dr. Eyad Z. AL-AqqadSpecial Urologist
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Definition
INCONTINENCE:
Involuntary loss of urine or stool in sufficent amount or frequency to constitute a social and/or health problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence with concomatant fecal incontinence
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How Common is Incontinence?
• Prevalence increases with age (but it is not a part of normal aging)
• 25-30% of community dwelling older women• 10-15% of community dwelling older men• 50% of nursing home residents; often associated with
dementia, fecal incontinence, inability to walk and transfer independently
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Urinary Incontinence is Often Under-Diagnoses and Under-Treated
• Only 32% of primary care physicians routinely ask about incontinence
• 50-75% of patients never describe symptoms to physicians
• 80% of urinary incontinence can be cured or improved
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Why is Incontinence Important?
• Social stigmata - leads to restricted activities and depression
• Medical complications - skin breakdown, increased urinary tract infections
• Institutionalization - UI is the second leading cause of nursing home placement
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Anatomy of Micturition• Detrusor muscle• External and Internal sphincter• Normal capacity 300-600cc• First urge to void 150-300cc• CNS control
– Pons - facilitates– Cerebral cortex - inhibits
• Harmonal effects - estrogen
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Peripheral Nerves in Micturition
• Parasympathetic (cholinergic) - Bladder contraction• Sympathetic - Bladder Relaxation• Sympathetic - Bladder Relaxation (β adrenergic)• Sympathetic - Bladder neck and urethral contraction (α
adrenergic)• Somatic (Pudendal nerve) - contraction pelvic floor
musculature
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Peripheral Nerves in Micturition
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Taking the History
• Duration, severity, symptoms, previous treatment, medications, GU surgery
• 3 P’s– Position of leakage (supine, sitting, standing)– Protection (pads per day, wetness of pads)– Problem (quality of life)
• Bladder record or diary
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Potentially Reversible CausesD - DeliriumI - InfectionA - Atrophic vaginitis or urethritisP - PharmaceuticalsP - Psychological disordersE - Endocrine disordersR - Restricted mobilityS - Stool impaction 2
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Medications That May Cause Incontinence
• Diuretics• Anticholinergics - antihistamines, antipsychotics,
antidepressants• Seditives/hypnotics• Alcohol• Narcotics• α-adrenergic agonists/antagnists• Calcium channel blockers
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Categories of Incontinence
• Urge incontinence• Stress incontinence• Overflow incontinence• Functional incontinence
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Urge Incontinence
• Most common cause of UI >75 years of age• Abrupt desire to void cannot be suppressed• Usually idiopathic• Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s Disease, dementia
Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder
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Stress Incontinence• Most common type in women < 75 years old• Occurs with increase in abdomenal pressure;
cough, sneeze, etc.• Hypermotility of bladder neck and urethra; associated
with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases)
• Intrinsic sphinctor problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)
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Overflow Incontinence
• Over distention of bladder• Bladder outlet obstruction; stricture, BPH, cystocele,
fecal impaction
• Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury, medications
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Functional Incontinence
• Does not involve lower urinary tract• Result of psychological, cognitive or physical
impairment
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Physical Examination
• Mental status• Mobility• Fluid overload• Abdominal exam• Neurologic exam• Pelvic• Rectal
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Diagnostic Tests
• Stress test (diagnostic for stress incontinence; specificity >90%)
• Post-void residual• Blood Tests (calcium, glucose, BUN, Cr)
• Urine Culture• Simple (bedside) Cystometrics
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Bladder Pressure-Volume Relationship
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Interpretation of Post-Void Residual
PVR < 50cc - Adequate bladder emptyingPVR > 150cc - Avoid bladder relaxing drugsPVR > 200cc - Refer to UrologyPVR > 400cc - Overflow UI likely
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Treatment Options
• Reduce amount and timing of fluid intake• Avoid bladder stimulants (caffeine)• Use diuretics judiciously (not before bed)• Reduce physical barriers to toilet (use bedside
commode)
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Treatment Options• Bladder training
– Patient education– Scheduled voiding– Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)• Biofeedback• Caregiver interventions
– Scheduled toileting– Habit training– Prompted voiding
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Pharmacological Interventions• Urge Incontinence
– Oxybutynin (Ditropan)– Propantheline (Pro-Banthine)– Imipramine (Tofranil)
• Stress Incontinence– Phenylpropanolamine (Ornade)– Pseudo-Ephedrine (Sudafed)– Estrogen (orally, transdermally or transvaginally)
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Surgical Interventions
• Urethral Hypermotility– Marshall-Marchetti-Kantz
procedure– Needle neck suspension
• Intrinsic sphincter deficiency– Sling procedure
Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years.
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Other Interventions
• Pessaries• Periurethral bulking agents (periurethral injection
of collagen, fat or silicone)• Diapers or pads• Chronic catheterization
– Periurethral or suprapubic– Indwelling or intermittant
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Pessaries
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Indwelling Catheter
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