Urinary Incontinence

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Urinary Incontinence

• Abdallah Rimawi, MD
• Geriatrics Fellow
• SVCMC

2
Definition

• Involuntary loss of urine in a sufficient amount
  or frequency to be a social/health problem.

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Epidemiology

• UI has a prevalence
• 15-30 in community-residing elderly patients
• 50-84 among older adults in long-term care
  institutions
• 33 in older persons in acute care settings.
• UI affects more than 17 million Americans, 85 of
  whom are women.
• Estimated cost to society of 16 to 26 billion.
• Race No clear evidence of racial differences in
  prevalence of UI has been found.
• UI is approximately twice as prevalent in older
  women as in older men, with 20 being women older
  than 45 years. In some women, stress incontinence
  and urge incontinence, the two most common forms
  of UI, may coexist.

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Epidimiology

• Urge incontinence constitutes over 50 of
  overall incontinence in men, 10-15 in younger
  women, and 30-40 in older women. Stress
  incontinence tends to be more common in women
  younger than 65 years.

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Stress vs Urge

• Distribution of different types of incontinence
  in the general population. Diagnoses other than
  stress, urge, and mixed are excluded.
• Dr. Hogne Sandvik 1996 nobel award in biology

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Prevalence of Stress vs Urge
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Prevalence in Females
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Normal micturition

• The normal function of the urinary bladder is to
  store and expel urine in a coordinated,
  controlled fashion. This coordinated activity is
  regulated by the central and peripheral nervous
  systems

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Normal Urination

• The process of urination involves two phases
• 1) The filling and storage phase
• 2) The emptying phase

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Filling Phase

• Filling/ storage phase Under Sympathetic
  control
• the bladder begins to fill with urine from the
  kidneys. The bladder stretches to accommodate the
  increasing amounts of urine. No increase in
  pressure Sympathetic system relaxes Detrusor
  muscle
• Sympathetic system closes bladder neck by
  constricting internal urethral sphincter
• The first sensation of the urge to urinate occurs
  when approximately 200 ml (just under 1 cup) of
  urine is stored. A healthy nervous system will
  respond to this stretching sensation by alerting
  you to the urge to urinate, while also allowing
  the bladder to continue to fill.
• The average person can hold approximately 350 to
  550 ml of urine. The ability to fill and store
  urine properly requires a functional sphincter
  (the circular muscles around the opening of the
  bladder) and a stable, expandable bladder wall
  muscle (detrusor).
• The filling of the urinary bladder depends on the
  intrinsic viscoelastic properties of the bladder
  and the inhibition of the parasympathetic nerves.
  Thus, bladder filling primarily is a passive
  event.
• Sympathetic nerves also facilitate urine storage
  in the following ways
• Sympathetic nerves inhibit the parasympathetic
  nerves from triggering bladder contractions.
• Sympathetic nerves directly cause relaxation and
  expansion of the detrusor muscle.
• Sympathetic nerves close the bladder neck by
  constricting the internal urethral sphincter.
  This sympathetic input to the lower urinary tract
  is constantly active during bladder filling.
• As the bladder fills, the pudendal nerve becomes
  excited. Stimulation of the pudendal nerve
  results in contraction of the external urethral
  sphincter. Contraction of the external sphincter,
  coupled with that of the internal sphincter,
  maintains urethral pressure (resistance) higher
  than normal bladder pressure. The combination of
  both urinary sphincters is known as the
  continence mechanism.
• The pressure gradients within the bladder and
  urethra play an important functional role in
  normal micturition. As long as the urethral
  pressure is higher than that of the bladder,
  patients will remain continent. If the urethral
  pressure is abnormally low or if the intravesical
  pressure is abnormally high, urinary incontinence
  will result.
• As the bladder initially fills, a small rise in
  pressure occurs within the bladder (intravesical
  pressure). When the urethral sphincter is closed,
  the pressure inside the urethra (intraurethral
  pressure) is higher than the pressure within the
  bladder. While the intraurethral pressure is
  higher than the intravesical pressure, urinary
  continence is maintained.
• During some physical activities and with
  coughing, sneezing, or laughing, the pressure
  within the abdomen rises sharply. This rise is
  transmitted to both the bladder and urethra. As
  long as the pressure is evenly transmitted to
  both the bladder and urethra, urine will not
  leak. When the pressure transmitted to the
  bladder is greater than urethra, urine will leak
  out, resulting in stress incontinence.

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Emptying Phase

• Emptying phase requires the ability of the
  detrusor muscle to appropriately contract to
  force urine out of the bladder. At the same time,
  your body must be able to relax the sphincter to
  allow the urine to pass out of the body.

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Normal micturition cycle
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Central Control

• Brain
• The brain is the master control of the entire
  urinary system.
• The micturition control center is located in the
  frontal lobe.
• Sends inhibitory signals to the detrusor muscle
  Via the Pons and spine to prevent the bladder
  from emptying (contracting) until a socially
  acceptable time and place to urinate is
  available.
• Certain lesions or diseases of the brain,
  including stroke, cancer, or dementia, result in
  loss of control of the normal micturition reflex.
  
• The signal transmitted by the brain is routed
  through 2 intermediate stops (the brainstem and
  the sacral spinal cord) prior to reaching the
  bladder.

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Brain ? Pons

• PONS
• Pons a major relay center between the brain and
  the bladder.
• Contains the pontine micturition center (PMC)
  which coordinates the urethral sphincter
  relaxation and detrusor contraction to facilitate
  urination.
• The PMC is Exitatory in nature and causes
  urination unless inhibited by the brain.
• The PMC functions as a relay switch in
  the voiding pathway. Stimulation of the PMC
  causes the urethral sphincters to open while
  facilitating the detrusor to contract and expel
  the urine.
• Usually the brain takes over the control of the
  pons at age 3-4 years, which is why most children
  undergo toilet training at this age.

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Sequence of normal events

• When Bladder becomes full, the stretch
  receptors of the detrusor muscle send a signal to
  the pons (via the spinal cord), which in turn
  notifies the brain. Patients perceive this signal
  (bladder fullness) as a sudden desire to go to
  the bathroom. Under normal situations, the brain
  sends an inhibitory signal to the pons to inhibit
  the bladder from contracting until a bathroom is
  found.
• When the PMC is deactivated, the urge to urinate
  disappears, allowing the patient to delay
  urination until locating a suitable bathroom.
  When urination is appropriate, the brain sends
  excitatory signals to the pons, allowing the
  urinary sphincters to open and the detrusor to
  empty.

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Brain ? Pons ?Spinal cord

• Spinal cord
• The spinal cord connects the brainstem and the
  lumbosacral spine.
• The spinal cord functions as a long communication
  pathway between the brainstem and the sacral
  spinal cord. When the sacral cord receives the
  sensory information from the bladder, this signal
  travels up the spinal cord to the pons and then
  ultimately to the brain. The brain interprets
  this signal and sends a reply via the pons that
  travels down the spinal cord to the sacral cord
  where the bladder receives it.

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Spinal cord Trauma

• An intact spinal cord is critical for normal
  micturition. If the spinal cord is severely
  injured or severed, the affected individual will
  exhibit constant urinary leakage because of
  uncontrollable bladder spasms, a condition called
  detrusor hyperreflexia.
• If complete spinal cord transection has occurred,
  the patient will demonstrate symptoms of urinary
  frequency, urgency, and urge incontinence but
  will be unable to empty his or her bladder
  completely. This occurs because the urinary
  bladder and the sphincter are both overactive, a
  condition termed detrusor sphincter dyssynergia
  with detrusor hyperreflexia

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Sacral spinal cord

• The sacral spinal cord is the terminal portion of
  the spinal cord at the lower back in the lumbar
  area. This is a specialized area of the spinal
  cord known as the sacral reflex center. It is
  responsible for bladder contractions. The sacral
  reflex center is the primitive voiding center.
• If the sacral cord becomes severely injured (eg,
  spinal tumor, herniated disc), the bladder may
  not function. Affected patients may develop
  urinary retention, termed detrusor areflexia. The
  detrusor will be unable to contract, so the
  patient will not be able to urinate and urinary
  retention will occur.

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Physiology PNS

• Sympathetic system (Epinepherine
  Norepinepherine)
• Normally controls the bladder and internal
  urethral sphincter
• Accommodation an increase the bladder
  capacity without raising bladder pressure
• Keeps the internal urinary sphincter
  tightly closed.
• relaxes bladder dome
• inhibits parasympathetic system
• The sympathetic activity also inhibits the
  micturition reflex is inhibited.

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Parasympathetic

• The parasympathetic nervous system functions in
  a manner opposite to that of the sympathetic
  nervous system
• stimulates the detrusor muscle to contract the
  bladder
• Causes internal and external urethral sphincter
  relaxation and opening
• Inhibits the pudendal nerve which opens the
  external sphincter
• Causes initiation of micturition and emptying of
  the urinary bladder

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Somatic

• Regulates action of voluntary muscles
• Contraction of external urethral sphincter

The somatic nervous system regulates the
actions of the muscles under voluntary control.
Such as muscles of the external urinary sphincter
and the pelvic diaphragm. .
suprasacral-infrapontine spinal cord trauma can
cause overstimulation of the pudendal nerve that
results in urinary retention.
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Urinary Incontinence
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Requirements for storage

• Accomodation increase in volume with decrease
  in pressure
• Closed outlet
• Appropriate sensation of fullness
• Absence of involuntary bladder contractions

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Requirements for emptying

• Good contractility
• Lack of anatomic obstruction
• Coordination of bladder and outlet

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Requirements for continence

• Mobility
• Manual dexterity
• Cognitive ability to recognize and react to
  bladder filling
• The motivation to stay dry

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Sudden/Temporary incontinence etiology

• Urinary tract infection or prostate
  infection/inflammation
• Stool impaction causing pressure on the bladder
• Side effects of medications (such as diuretics,
  tranquilizers, some cough and cold remedies,
  certain antihistamines for allergies, and
  antidepressants)
• Polyurea due to poorly controlled diabetes
• Pregnancy
• Short-term bedrest -- for example, when
  recovering from surgery
• Mental confusion
• Usually reversable once treated or removed

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Long term incontinence

• Spinal injuries
• Urinary tract anatomical abnormalities
• Neurological conditions like multiple sclerosis
  or stroke
• Weakness of the sphincter, the circular muscles
  of the bladder responsible for opening and
  closing it this can happen following prostate
  surgery in men, or vaginal surgery in women
• Pelvic prolapse in women -- falling or sliding of
  the bladder, urethra, or rectum into the vaginal
  space, often related to having had multiple
  pregnancies and deliveries
• Large prostate in men
• Depression or Alzheimers disease
• Nerve or muscle damage after pelvic radiation
• Bladder cancer
• Bladder spasms

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Types of Urinary Incontinence

• Stress incontinence - loss of urine with
  increased intraabdominal pressure without
  detrusor contraction. Most common form of UI in
  women
• Urge incontinence - (true, detrusor overactivity,
  or reflex) is precipitous loss of urine, preceded
  by a strong urge to void, with increased
  intravesical pressure and detrusor contraction.
• Continuous incontinence - is involuntary loss of
  urine at all times and in all positions.
• Overflow incontinence - results from detrusor
  underactivity, bladder outlet obstruction, or
  both. Leakage is small in volume but continual.
  In men, it can be the result of an enlarged
  prostate.

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Stress incontinence

• Stress incontinence is an involuntary loss of
  urine that occurs during physical activity, such
  as coughing, sneezing, laughing, or exercise.
• Stress incontinence is a bladder storage problem
  in which the strength of the urethral sphincter
  is diminished, and the sphincter is not able to
  prevent urine flow when there is increased
  pressure from the abdomen.
• Stress incontinence may occur as a result of
  weakened pelvic muscles that support the bladder
  and urethra, or because of malfunction of the
  urethral sphincter. Prior trauma to the urethral
  area, neurological injury, and some medications
  may weaken the urethra. Stress incontinence can
  worsen during the week before your menstrual
  period. At that time, lowered estrogen levels
  might lead to lower muscular pressure around the
  urethra, increasing chances of leakage. The
  incidence of stress incontinence increases
  following menopause.

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Stress incontinence

• Sphincter weakness may occur in men following
  prostate surgery or in women after pelvic
  surgery. Stress incontinence is often seen in
  women who have had multiple pregnancies and
  vaginal childbirths, or who have pelvic prolapse
  (protrusion of the bladder, urethra, or rectal
  wall into the vaginal space), with cystocele,
  cystourethrocele, or rectocele.
• Studies have documented that about 50 of all
  women have occasional urinary incontinence, and
  as many as 10 have frequent incontinence. Nearly
  20 of women over age 75 experience daily urinary
  incontinence.
• Stress urinary incontinence is the most common
  type of urinary incontinence in women. Risk
  factors for stress incontinence include female
  sex, advancing age, childbirth, smoking, and
  obesity. Conditions that cause chronic coughing,
  such as chronic bronchitis and asthma, may also
  increase the risk of stress incontinence.

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Stress incontinence treatment

• Goal of nonsurgical treatment is to increase
  internal sphincter tone. Mild to moderate stress
  incontinence may be effectively treated with
  exercise therapy, medications, or both.
• The most common cause of stress incontinence in
  older women is urethral hypermobility In up to
  60 of women with stress incontinence, pelvic
  floor (Kegel) exercises can result in better
  control of the bladder when coughing, laughing,
  sneezing, or exercising.1 These exercises should
  be performed 10-20 times, 3 times a day
• Medication may be used to tighten the bladder and
  prevent urine leakage, but its effectiveness
  varies.
• Electrical stimulation can be used to reduce both
  stress incontinence and urge incontinence

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Treatment stress incontinence

• Surgical intervention
• Surgery elevates the bladder neck and brings the
  proximal urethra back into the abdomen the
  1-year success rate is 80-95. Surgery to add
  support for the bladder neck is usually needed
  for severe stress incontinence that does not
  respond to medication or exercise.

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Treatment stress incontinence

• Medications
• Alpha-adrenergic agonists (pseudoephedrine) are
  used especially for women on estrogen they
  increase the internal sphincter tone and bladder
  outflow resistance. Use with caution in patients
  with hypertension or arrhythmia.
• Estrogen cream to the vagina or oral estrogen
  tablets may be helpful in improving
  periurethral and vaginal tissue thickness and
  quality.
• Treat precipitating conditions (atrophic
  vaginitis, cough).
• Incontinence pads may be used to absorb the small
  amount of urine that usually leaks during stress.

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Urge incontinence

• Alternate Names Detrusor Hyperreflexia,
  Detrusor Instability, Overactive Bladder,
  Spasmodic Bladder, Unstable Bladder
• Bladder muscle contracts inappropriately,
  regardless of the amount of urine that is in the
  bladder.
• Population May occur in anyone at any age, but
  it is more common in women and elderly. Second
  only to stress incontinence as the most common
  cause of urinary incontinence (involuntary loss
  of urine). Approximately 1 to 2 of adult
  females are affected by urge incontinence.
• In men, urge incontinence may be due to secondary
  bladder injuries caused by benign prostatic
• Mechanism
• PVC "Premature Vesicular Contraction"
• Overly sensitive bladder Urge to void is
  perceived
• Inhibition of detrussor contraction is
  ineffective

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Etiology urge incontinence

• Etiologies Urge incontinence may result from
  neurological injuries (such as spinal cord injury
  or stroke), neurological diseases (such as
  multiple sclerosis), infection, bladder cancer,
  bladder stones, bladder inflammation, or bladder
  outlet obstruction.
• The majority of cases are classified as
  idiopathic -- a specific cause cannot be
  identified
• Signs and Symptoms
• Irresistable urge to void
• Urge preceeded by various stimulation
  Posture change, Hear or feel water ,Laugh or
  cough
• Urine volume lost Few drops to entire
  bladder contents
• Urine loss timingBegins seconds after
  trigger

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Urge incontinence

• Diagnostics
• Rule out neurological or infectious etiology
• Sterile in-out catheterization or
• Ultrasound measurement of post-void residual

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Urge incontinence treatment

• Treat symptomatically if no known cause
• Pelvic Muscle Rehabilitation improves muscle
  tone and prevent urine leakage.
• Daily Kegel exercises (contracting and relaxing
  the pelvic floor muscles)
• Biofeedback
• Vaginal weight training Small weights are held
  within the vagina by tightening the vaginal
  muscles.
• Pelvic floor or nerve electrical stimulation.
  Mild, painless electrical impulses are used to
  stimulate the pelvic muscles and/or nerves to
  help relieve the symptoms of overactive bladder
  and urge incontinence.
• Behavioral Therapies
• Bladder training teaches people how to resist the
  urge to urinate.
• Toileting assistance uses routine or scheduled
  toileting and prompted voiding to empty the
  bladder regularly to prevent leaking.
• Surgery
• Surgical procedures of the bladder may be
  performed for people who do not respond to any
  other treatment

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Treatment urge incontinence

• Medication aimed at relaxing the involuntary
  contraction of the bladder and improving bladder
  function
• anticholinergic agents (propantheline)
• antispasmodic medications (oxybutynin,
  tolterodine, flavoxate)
• tricyclic antidepressants (imipramine, doxepin)
• calcium channel blockers (tolterodine)
• beta agonist (terbutaline)
• Oxybutynin (Ditropan) and tolterodine (Detrol)
  antispasmodic medications that relax the smooth
  muscle of the bladder. These are the most
  commonly used medications for urge incontinence
• Side effects of oxybutynin and tolterodine are
  minimal, with the most common being dry mouth and
  constipation. However, these medications cannot
  be used by patients with narrow angle glaucoma.
• Anticholinergic medications block inappropriate
  contractions of the bladder. They were widely
  used in the past to treat urge incontinence
  because they are relatively inexpensive yet
  effective. Oxybutynin and tolterodine have
  virtually replaced the use of these medications
  because they have fewer side effects.
• Tricyclic antidepressants have also been used to
  treat urge incontinence because of their ability
  to inhibit or "paralyze" the bladder smooth
  muscle. Possible side effects include fatigue,
  dry mouth, dizziness, blurred vision, nausea and
  insomnia

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Overflow incontinence

• Overflow Incontinence Overflow incontinence is
  the uncontrollable leakage of small amounts of
  urine, usually caused by some type of blockage or
  by weak contractions of the bladder muscles. When
  urine flow is blocked or the bladder muscles can
  no longer contract, the bladder becomes
  overfilled and enlarged. Pressure in the bladder
  increases until small amounts of urine dribble
  out.
• In men, an enlarged prostate can block the
  opening into the urethra from the bladder. Less
  commonly, blockage is caused by narrowing of the
  bladder neck or the urethra (urethral stricture),
  which may occur after prostate surgery. In men
  and women, constipation can cause overflow
  incontinence if stool fills the rectum to the
  point of putting pressure on the bladder neck and
  urethra. A number of drugs that affect the brain
  or spinal cord or that interfere with nerve
  messages, such as anticholinergic drugs and
  opioids, may impair bladder contractions and
  cause overflow incontinence. Nerve damage that
  paralyzes the bladder (neurogenic bladder) can
  also cause overflow incontinence. Diabetes
  mellitus can also cause a form of neurogenic
  bladder and overflow incontinence.

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Overflow S/S

• Signs and Symptoms
• Palpable distended bladder post voiding
• Post-void residual gt200 cc
• Have patient void
• Insert Urinary Catheter and record urine volume
• Normally less than 50 cc

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Overflow Diagnosis and management

• Diagnosis Ultrasound assess bladder volume
• Uroflowmetry (urodynamics)
• Management General
• Correct underlying outflow obstruction
• Intermittent Self Catheterization
• Double Voiding
• Crede's Maneuver

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Overflow medications

• Medical Management
• 1) Betanachol (Urecholine)
• Mechanism
• Cholinergic agonist with Parasympathetic
  stimulation contracts detrussor
• Indications Non-obstructive bladder
  atony
• Contraindications Hyperthyroidism ,
  Peptic Ulcer Disease , Asthma
• 2) Alpha-Adrenergic blockade
• Prazosin (Minipress) ,Terazosin (Hytrin)
• Mechanism
• Decreases bladder neck and urethral tone
• Indications Benign Prostatic
  Hypertrophy ,Sphincter Hyperspasticity

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Overflow Outlet obstruction

• These patients have difficulty emptying their
  bladders therefore, the goal is to improve
  bladder drainage. Follow conservative management
  by modifying fluid excretion and prompted
  voiding.
• Do a renal sono to find cause and proceed
• Medications include alpha-adrenergic antagonists
  prazosin decreases internal sphincter tone and
  can improve the flow of urine. Use antiandrogens
  and luteinizing hormone-releasing hormone (LHRH)
  analog if atonic bladder-cholinergics (eg,
  bethanechol) are ineffective in treating UI.
• Self-catheterization or a Foley catheter is used,
  especially in cases of neurogenic bladder.
• Urethral strictures may require dilation or
  surgery, especially if the prostate is enlarged.

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Overflow Underactive detrusor

• Initial goals are to reduce residual volume,
  eliminate hydronephrosis, and prevent urosepsis.
  Insert an indwelling or intermittent catheter to
  decompress the bladder (for 2 wk).
• Identify and reverse potential causes of impaired
  detrusor function (eg, fecal impaction,
  medications).

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Female Pelvic muscles
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Types of UI

• Intense urge to void Detrusor overactivity/Urge
  incontinence
• Loss with cough/laugh/bending stress
  incontinence
• Continuous leakage Detrusor underactivity/overflo
  w incontinence

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History

• Obtaining a thorough history is the most
  important step in the evaluation of UI.
• Onset
• During pregnancy
• Postpartum
• Surgery or trauma
• Frequency/severity/amount
• Number of pads
• Voiding diary
• A small amount of urine usually is seen in
  overflow incontinence or outlet incompetence, and
  moderate flow in detrusor overactivity.
• Patterns (eg, nocturnal versus diurnal)
• Precipitants
• Medications
• Cough
• Position changes

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History cont

• Associated symptoms
• Straining
• Incomplete emptying
• Dysuria
• Medical conditions
• Cancer
• Diabetes
• Neurologic disease
• Surgeries
• Radiation
• Benign prostatic hyperplasia
• UTI
• Prolonged labor
• Trauma
• Hypertension
• Congestive heart failure (CHF)
• Medications (eg, anticholinergics, calcium
  channel blockers, diuretics, sedatives,
  alpha-agonists, alpha-antagonists, alcohol)
• Living conditions

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Physical

• Carry out a thorough examination, including a
  brief psychiatric and neurologic evaluation.
  Eliminate any serious disease that may be the
  underlying cause of incontinence and any
  transient cause or functional impairment.
• Assess the abdomen, looking at flanks check for
  masses, distended bladder after voiding, and
  signs of fluid overload.
• Neurologic
• Check for perineal sensation and fecal impaction.
  Check bulbocavernous reflex, anal sphincter tone,
  and prostate.
• Absence of an anal wink is not necessarily
  pathologic in elderly patients.
• Pelvic
• A pelvic examination is necessary for women the
  examination should be made with the patient's
  bladder empty to check organs and with the
  bladder full to check for prolapse, cystocele,
  rectocele, or incontinence.
• Rotate the speculum to evaluate the anterior and
  posterior vaginal walls.
• Look for atrophic vaginitis, masses, muscle
  laxity, and cystocele.
• Internal sphincter weakness can be assessed by
  asking the patient to cough while supine leakage
  of urine is suggestive of outlet incompetence.

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Physical cont

• Q-Tip test
• This is used to evaluate urethral mobility
  hypermobility can lead to stress incontinence.
• Perform this test by inserting a cotton swab
  through the urethra into the bladder and note any
  changes in the angle of the swab with the patient
  straining.
• A change of 30-40 suggests excessive urethral
  movement.
• The Q-Tip test has been found to have a high
  false-negative rate in elderly women.
• Stress testing
• Stress testing assesses for stress-induced
  leakage when the bladder is full.
• Stress testing is performed by having the patient
  relax and asking the patient to cough or strain
  once vigorously instantaneous leakage is typical
  of stress urinary incontinence, delayed leakage
  is typical of stress-induced detrusor
  overactivity.
• This test, if performed correctly, is greater
  than 90 sensitive and specific.

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Diagnosis

• UA, urine culture to look for infection, and
  serum electrolytes, including calcium
• Blood glucose
• PSA
• Postvoid residual urine volume
• Postvoid residual (PVR) urine volume is assessed
  by catheterizing and measuring residual urine
  within 5 minutes after voiding.
• PVR greater than 50 mL may indicate obstruction
  of hypotonic bladder.
• PVR greater than 400 mL is likely overflow
  incontinence.
• Renal Sono
• Urodynamic studies
• Cystometry

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Treatment
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References

• http//www.nlm.nih.gov/medlineplus/ency/article/00
  3142.htm
• http//www.emedicine.com/emerg/topic791.htm
• http//www.americangeriatrics.org/products/ui/inco
  n5.m.htm
• http//www.familydoctor.co.uk/htdocs/FEMALEURINE/F
  EMALEURINE_specimen.html
• http//www.netterimages.com/womenshealth/image8.ht
  m
• http//www.medscape.com/viewprogram/2666_pnt
• http//www.irishhealth.com/?level4id117
• http//jaapa.com/issues/j20051001/articles/urinary
  1005.htm

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Thank You