Transcript Urinary Incontinence

Urinary Incontinence
A Practical Approach
What is urinary incontinence?
Involuntary loss of urine
Epidemiology
• Prevalence
• 10-30% in females age <64
• 15-30% in individuals in community
• >50% in long-term care
• Cost
• >$20 billions a year
• Mainly protective garment
Morbidity and mortality
• Psychological effects
• Depression
• Social withdrawal
• Skin infection
• Sleep deprivation
Pathophysiology
Bladder hyper or
hypoactivity
Outlet obstruction or
insufficiency
Start the work-up?
• History…history…history…
• Ask since patients are frequently
embarrassed to discuss about
urinary incontinence
What to ask?
Think through the possible causes of
urinary incontinence
Classifications?
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Urge
Stress
Overflow
Mixed
Functional
Most common type?
Urge incontinence
What is urge incontinence?
Overactive bladder
Causes of urge incontinence?
• Idiopathic
• Upper motor neuron problem
• Lack of CNS inhibition
• Stroke, cervical stenosis, multiple
sclerosis
• Age-related
• Bladder irritation: UTI, tumor, and
stones
Clinical presentation of urge
incontinence?
• Urge sensation to void, a delay,
then void
• Leak a large amount of urine from
bladder contraction
What is stress incontinence?
Leak of urine with increased abdominal
pressure but without bladder contraction
Causes of stress incontinence?
• Insufficient urethral support from
pelvic muscles and fascia
• Urethral sphincter insufficiency
• From operative trauma and scarring and
mucosal atrophy due to menopause
• Leak urine without stress maneuver
• Urethral instability
• Controversial
• Urethral spontaneously relaxes
Clinical presentations of stress
incontinence?
• Associated with increased
intraabdominal pressure, such as
coughing, laughing, sneezing
• Small amount of urine leakage
occurs instantly after the stress
maneuver
What is overflow incontinence?
Urinary retention leading to leakage of urine
when the intravesicular pressure exceeds that
of urethral sphincter
Causes of overflow incontinence?
• Obstructive process
• BPH – commonly present with urinary
retention rather than overflow incontinence
• Surgical correction for urinary incontinence
• Large cystocele that kinks the urethra
• Detrusor underactivity
• Peripheral neuropathy: diabetes mellitus,
syphilis, vitamin B12 defiency
• Damage to spinal detrusor afferents: tumor,
disc herniation
• Detrusor fibrosis from chronic obstruction
Clinical presentations of overflow
incontinence?
• Obstructive symptoms: hesitancy,
frequency, urgency, post-void dribbling
• Leaking urine continually
• Neurological problems
Mixed incontinence
• Stress and urge
• Detrusor hyperactivity with impaired
contractility (DHIC): precipitant urgency
and elevated postvoid residual without
outlet obstruction
Functional
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Impaired mental status
Impaired mobility
Urinary tract infection
Fecal impaction
Functional
• Medications
• Anticholinergic agents – retention, fecal
impaction
• Diuretics – not thiazide
• Calcium blockers
• Alpha-blocker – relax urethral sphincter
• Narcotics – fecal impaction, sedation
• Alcohol – sedation
History?
• Usual: duration, frequency,
aggravating, alleviating factors,
associated symptoms
• Diary: time, leak?, amount, associated
symptoms
• Neurologic symptoms
Physical exam?
• Mental status
• Mobility
• Pelvic exam
• Cystocele
• Anal wink
• Bulbocavernosus reflex
• Spinal
• Cervical stenosis
• Occult spina bifida
Tests?
• Postvoid residual
• Normal: 50-150 mL
• Abnormal: >200 mL
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Urinalysis
Q-tip
Bedside cystometry
Urodynamic tests – mainly for
surgery and uncertain diagnosis
Treatment for urge incontinence?
• Bladder training: timed voiding &
suppressing the urgency through
relaxation technique
• Biofeedback
• Medications
• Oxybutynin – ER and patch have less
side-effects
• Tolterodine – less side-effect than
oxybutynin
• Estrogen but not estrogen/progesterone
Treatments for stress incontinence?
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Pelvic muscle exercise
Biofeedback: weighed vaginal cone
Pessary
Medications
• Imipramine – alpha-agonist and anticholinergic
effect may be used in mixed urge and stress
incontinence
• Topical estrogen – treat mucosa atrophy and
increase the number and sensitivity of alpha
receptors
• Surgery
• Most effective treatment
• Burch retropubic urethropexy
Treatments for overflow incontinence?
• Relieve the obstruction
• Catherization
• Improve bladder emptying with
Valsalva maneuver, Crede maneuver,
“double” voiding