Transcript Urinary Incontinence: Diagnosis and Treatment

Urinary Incontinence:
Diagnosis and Management
2015-07-18
Jae S. Choi
Fairleigh Dickinson University
Upon completion of this program
the participant will:
1. Define the pathophysiology of
normal and abnormal micturition
process
2. Review the current research data
supporting the management of urinary
incontinence
3. Understand how to identify,
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evaluate, and treat urinary incontinence
4. Identify future research directives
concerning urinary incontinence
Urinary Incontinence:
Scope of the Problem
>Affects approximately 17 million men and
women in US
>Costs an estimated $26 billion a year to manage
in US
>One half of the homebound and
institutionalized elderly are incontinent
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>Second-most common
reason for the institution
of the elderly
(Walsh, 2002)
Urinary Incontinence:
Scope of the Problem
Prevalence of UI (1995)
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Urinary Incontinence
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The uncontrollable
loss of urine
Incontinence Concerns
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Finance
Isolation
Occupation
Odor
Skin problems
Depression
Embarrassment
Anatomy: Female Genitalia (Swartz,2002)
Anatomy: Male Genitalia (Swartz,2002)
Mechanism of Continence
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Active mechanism
of continence
Anatomic
mechanism of
continence
Mucosal seal
mechanism
Active Mechanism of Continence
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Supply by the active contraction of the muscle in
the urethra, sphincter, and bladder neck
Active contraction of these muscles provides a
force that closes the bladder outlet
Traumatic deliveries or other precipitators of
incontinence may damage the nerves to the
muscles or the muscles themselves by replacement
with scar tissue
Anatomic Mechanism of Continence
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Proper rigidity of the ligament and
fascia supporting the urethra and
bladder neck
An anatomically well supported
bladder neck
Ligaments that are lax and
stretched allow the bladder neck to
descend
Most surgical treatments for
incontinence attempt to restore this
anatomic mechanism
Mucosal Seal Mechanism
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Leak-proof mucosal seal provided by the supple
urothelium and the vascularity of the submucosal
vessels of the urethra and bladder neck
Loss of suppleness and adequate blood supply
can be caused by prior surgery, radiation, or loss
of estrogen
Types of incontinence
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Stress
Urge
Mixed
Overflow
Functional
Stress Incontinence
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The involuntary loss of
urine during coughing,
laughing, sneezing, or
other activities that
increase intra-abdominal
pressure
Genuine Stress Incontinence (GSI)
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The involuntary loss of urine
occurring when, in the
absence of bladder muscle
contraction, the pressure
inside the bladder is greater
than the pressure generated
by the urethral sphincter. The
pressure differential results in
the leakage of urine.
Factors Contributing to Stress UI
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Age, Parity, Pregnancy (Thorp, et al, 1999)
Previous Gynecologic Surgery
Increased Body Mass Index
Family History (Bergman,2002)
Constipation as a young adult
Smoking
Sports
Race (Graham, 2001)
Urge Incontinence
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The involuntary
loss of urine
associated with an
abrupt and strong
desire to urinate
Urge UI is also known as:
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Overactive bladder
Detrusor hyperactivity
Detrusor instability
Neurogenic bladder
Detrusor hyperreflexia
Evaluation of Urge UI
Need to distinguish between:
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Neurogenic
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Non-neurogenic
Neurogenic Urge Incontinence
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Stroke
Spinal cord injury
Multiple Sclerosis
Synonymous with Detrusor
hyperreflexia and
neurogenic bladder
Diabetes
Pontine Micturition Center
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Lesions above the pons:
CVA, TBI, MS,
Hydrocephalus, CP,
Alzheimer’s, tumor
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Lesions below the pons:
Spinal cord injury (C2-T12),
MS, Spinomuscular disease,
Disc problem
Sacral Segments Involved Incontinence
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Sacral segment S2, S3, and
S4 provide afferent and
enervation to two final
peripheral nerves: pelvic
nerve to bladder, pudendal
nerve to striate sphincter of
the urogenital diaphragm
and levator ani muscles
Non-neurogenic Urge Incontinence
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Sensory urge incontinence
Motor urge incontinence
Most likely combination of both
Often idiopathic
Synonymous with detrusor
instability, detrusor
hypersensitivity/hyperactivity
overactive bladder (OAB).
Sensory Urge Incontinence
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Acute or chronic cystitis
Interstitial cystitis
Bladder stones
Bladder cancer
Bladder irritants
Unknown
Motor Urge Incontinence
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Symptomatic presentation is similar to sensory urge
incontinence
Diagnosis is usually supported by urodynamic findings
of detrusor constrictions
Can be associated with bladder outlet obstruction in
men from (BPH) or anatomic stress incontinence in
women
Can be idiopathic
Also referred to as Detrusor instability
Overactive Bladder (OAB)
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New definition for urinary
urgency and urge incontinence
More descriptive; takes into
consideration all other previous
definitions
Phrase coined by industry for
marketing purposes
Overactive Bladder (OAB):
Cluster of Symptoms
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Diurnal frequency; >8
micturitions a day
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Nocturia: >2 micturition a night
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Urgency and/or urge Urinary
Incontinence
Mixed Urinary Incontinence
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Usually stress and urge
Can include other
combinations
Most common in the older
patient
Treatment plan is more
complex
Overflow Incontinence
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Incontinence occurs because the bladder does
not empty properly related decreased sensation,
urine leaks, or dribbles out
Causes: 1. Obstruction: prostate, stool
impaction, cystocele. 2. Neurogenic: diabetic
neuropathy, stroke, multiple sclerosis, other
neurologic disease, spinal cord injury, vitamin
B12 deficiency
Functional Incontinence
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Occurs when a person
cannot make it to the
bathroom related to
impairment of the mind or
body (Alzheimer’s patients,
wheel chair bound)
Common in institutionalized
patients or those with
disabilities
Urinary system is normal
Transient Causes of Incontinence
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D
I
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P
P
E
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S
Delirium/confusion states
Infection-urinary (Symptomatic)
Atrophic urethritis/vaginitis
Pharmaceuticals
Psychologic, especially depression
Endocrine (hyperglycemia, hypercalcemia)
Restricted mobility
Stool impaction
Evaluation of Incontinence
Components include:
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History
Physical examination
with additional tests
(PVR, provocative
stress testing)
Urinalysis
History
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Focused medical history
Neurologic history
Genitourinary history
Surgical history
Traumatic history
Medication review including
nonprescription medication
Herbal medication and other
supplements
History: A Detailed Exploration of the
Symptoms of UI
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Duration and characteristics of UI
Frequency, timing, and amount of continent and
incontinent voids
Precipitants of UI (cough, laughing, stress, constipation)
Other lower urinary tract symptoms
Fluid intake pattern, including caffeine containing or
other diuretic fluids
Alteration in bowel habit or sexual function
Previous treatment and effects on UI
Use of pads, briefs, or protective devices
Physical Examination
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Abdominal examination: detect masses or suprapubic
fullness or tenderness
Pelvic examination: assess genital atrophy, pelvic prolapse,
urethral prolapse, cystocele, rectocele, enterocele, pelvic
mass, perivaginal muscle tone, urethral diverticulum, and
urethra and bladder neck hypermobility
Rectal examination: assess perineal sensation, sphincter
tone, bulbocavernous reflex, fecal impaction, rectal mass
General: edema, sleep pattern, mobility,
cognition,environmental and social factors
Tests
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Estimation of PVR volume: bladder scanning,
catheterization
Provocative stress testing
Urinalysis: basic test for UI work-up to assess hematuria,
leukocytes, nitrates, bacteriuria, glycosuria, proteinuria
Use of a voiding record
Urine cytology
Blood tests: BUN, creatinine, glucose
Urodynamics: EMG/CMG,Uroflow studies: flow rate
Treatment for Stress Urinary Incontinence:
Medical Therapy
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Estrogen therapy: estrogen
cream,Vegifem, Estring
No need to oppose vaginal
ertrogen
Systemic HRT still requires
local therapy
Treatment for Stress Urinary Incontinence:
Behavioral Therapy
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Behavioral
modification
PME: pelvic Muscle
exercises: Vaginal
cones, biofeedback
Physical therapy
Electrical Stimulation
Treatment for Stress Urinary Incontinence:
Surgical Therapy
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Periurethral injections:
collagen, durasphere
Various types of surgical
procedures: pubovaginal
slings, bladder neck
suspension, artificial
urinary sphincter
Treatment for Stress Urinary Incontinence:
Surgical Therapy
Treatment for Stress Urinary Incontinence:
Non-Surgical Therapy: Pessary
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Various shapes and sizes
depending types of
problems
Modern Pessaries made of
silicone
Need to be removed every
3 months for maintenance
Need to assess for irritation
or erosion
Treatment for UUI/OAB:
Behavioral Therapy
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Fluid/dietary techniques:
Obtain adequate fluid intake: 15ml/lb/day
reduce or avoid bladder irritants: caffeine, alcohol
Aggressively manage constipation
Behavioral modification: scheduled voiding, urge
suppression, Pelvic muscle exercise, electrical
stimulation
Treatment for UUI/OAB:
Medical Therapy
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Usually anticholinergics:
Ditropan 2.5-10mg tid, Ditropan XL 5-15mg qd
Detrol 2mg bid, Detrol LA 4mg qd
Side effects of anticholinergics:dry mouth, dry
eyes, constipation, confusion in the elderly more
common with Ditropan because it crosses the BBB
Intravesical agents: Ditropan more for neurogenic
dysfunction
Treatment for UUI/OAB:
Surgical Therapy
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Surgical treatment :
Sacral
neuromodulation
Bladder
augmentation
Treatment for Neurogenic Bladder
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If neurogenic
bladder is suspected
refer to a
neurologist,
urologist, or
neurourologist.
Summary of the Presentation
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The tremendous number of patients with urinary
incontinence is becoming recognized, and the economic
impact is staggering.
Because the prevalence of the urinary incontinence
increases with age, a working knowledge of the diagnosis
and treatment of the various types of urinary incontinence
is fundamental.
By obtaining a careful medical history and performing a
comprehensive physical examination, the primary care
providers can initiate successful treatment for the majority
of patients without the need for invasive testing.
Future Research and Study
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There is a need for prospective studies of age and ethnically
diverse individuals to provide data that permit more accurate
problem identification in these populations.
Quality of life is significant. Quality of life should be
incorporated as an outcome in clinical trials evaluating
causes and therapy.
Study is needed to understand the people who have
emotional and social isolation with urinary incontinence.
Study is needed to determine the efficacy of behavioral and
physical therapy for urinary incontinence.
References
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Culligan, P. J.(2000), Urinary incontinence in women: evaluation and management, American Family Physician, 66(11), 243344,2447,2452.
Elia, G., Bergman, J., and Dye, T.D., (2002), Familial incidence of urinary incontinence, American Journal of Obstetrics and
Gynecology,187 (1), 53-55.
Graham, C.A. and Mallett, V.T., Race as a predictor of urinary incontinence and pelvic organ prolapse, American Journal of
Obstetrics and Gynecology, 185(1),116-120.
Roberts,R. O., et al., (1999), Prevalence of combined fecal and urinary incontinence: a community-based study, Journal of
American Geriatrics Society, 47(7), 837-841.
Swartz, M., (2002), Textbook of Physical Diagnosis, 4th ed., Philadelphia: W.B. Saunders Company.
Tierney, L. M., et al, (2002), Current Medical Diagnosis and Treatment, 41st ed., New York: Lange Medical Books/McGrawHill..
Thorp,J.M.,et al,(1999), Urinary incontinence in pregnancy and the puerperium: a prospective study, American Journal of
Obstetrics and Gynecology, 181(2), 266-273.
Walsh, (2002), Campbell’s Urology, 8th ed., Elsevier Science.
www.chs.stste.ky.us
www.drylife.org
www.incontinence-foundation.org
www.jhbnc.jhu.edu
www.merck.com
www.university obgyn.com
*Pictures: Georgia O’Keeffe