Urinary Incontinence: Diagnosis and Management

1
Urinary IncontinenceDiagnosis and Management

• Jae S. Choi
• Fairleigh Dickinson University

2
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, evaluate, and
  treat urinary incontinence
• 4. Identify future research directives concerning
  urinary incontinence

3
Urinary IncontinenceScope of the Problem

• gtAffects approximately 17 million men and women
  in US
• gtCosts an estimated 26 billion a year to manage
  in US
• gtOne half of the homebound and
  institutionalized elderly are incontinent
• gtSecond-most common reason for the institution of
  the elderly
• (Walsh, 2002)

4
Urinary IncontinenceScope of the Problem

• Prevalence of UI (1995)

5
Urinary Incontinence

• The uncontrollable loss of urine

6
Incontinence Concerns

• Finance
• Isolation
• Occupation
• Odor
• Skin problems
• Depression
• Embarrassment

7
Anatomy Female Genitalia (Swartz,2002)
8
Anatomy Male Genitalia (Swartz,2002)
9
Mechanism of Continence

• Active mechanism of continence
• Anatomic mechanism of continence
• Mucosal seal mechanism

10
Active Mechanism of Continence

• 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

11
Anatomic Mechanism of Continence

• 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

12
Mucosal Seal Mechanism

• 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

13
Types of incontinence

• Stress
• Urge
• Mixed
• Overflow
• Functional

14
Stress Incontinence

• The involuntary loss of urine during coughing,
  laughing, sneezing, or other activities that
  increase intra-abdominal pressure

15
Genuine Stress Incontinence (GSI)

• 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.

16
Factors Contributing to Stress UI

• 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)

17
Urge Incontinence

• The involuntary loss of urine associated with an
  abrupt and strong desire to urinate

18
Urge UI is also known as

• Overactive bladder
• Detrusor hyperactivity
• Detrusor instability
• Neurogenic bladder
• Detrusor hyperreflexia

19
Evaluation of Urge UINeed to distinguish between

• Neurogenic
• Non-neurogenic

20
Neurogenic Urge Incontinence

• Stroke
• Spinal cord injury
• Multiple Sclerosis
• Synonymous with Detrusor hyperreflexia and
  neurogenic bladder
• Diabetes

21
Pontine Micturition Center

• Lesions above the pons CVA, TBI, MS,
  Hydrocephalus, CP, Alzheimers, tumor
• Lesions below the pons Spinal cord injury
  (C2-T12), MS, Spinomuscular disease, Disc problem

22
Sacral Segments Involved Incontinence

• 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
  
  

23
Non-neurogenic Urge Incontinence

• Sensory urge incontinence
• Motor urge incontinence
• Most likely combination of both
• Often idiopathic
• Synonymous with detrusor instability, detrusor
  hypersensitivity/hyperactivity overactive bladder
  (OAB).
  

24
Sensory Urge Incontinence

• Acute or chronic cystitis
• Interstitial cystitis
• Bladder stones
• Bladder cancer
• Bladder irritants
• Unknown
  

25
Motor Urge Incontinence

• 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
  
  

26
Overactive Bladder (OAB)

• New definition for urinary urgency and urge
  incontinence
• More descriptive takes into consideration all
  other previous definitions
• Phrase coined by industry for marketing purposes
  
  

27
Overactive Bladder (OAB)Cluster of Symptoms

• Diurnal frequency gt8 micturitions a day
• Nocturia gt2 micturition a night
• Urgency and/or urge Urinary Incontinence
  
  

28
Mixed Urinary Incontinence

• Usually stress and urge
• Can include other combinations
• Most common in the older patient
• Treatment plan is more complex
  
  

29
Overflow Incontinence

• 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
  

30
Functional Incontinence

• Occurs when a person cannot make it to the
  bathroom related to impairment of the mind or
  body (Alzheimers patients, wheel chair bound)
• Common in institutionalized patients or those
  with disabilities
• Urinary system is normal
  
  

31
Transient Causes of Incontinence

• D Delirium/confusion states
• I Infection-urinary (Symptomatic)
• A Atrophic urethritis/vaginitis
• P Pharmaceuticals
• P Psychologic, especially depression
• E Endocrine (hyperglycemia, hypercalcemia)
• R Restricted mobility
• S Stool impaction
  

32
Evaluation of IncontinenceComponents include

• History
• Physical examination with additional tests (PVR,
  provocative stress testing)
• Urinalysis

33
History

• Focused medical history
• Neurologic history
• Genitourinary history
• Surgical history
• Traumatic history
• Medication review including nonprescription
  medication
• Herbal medication and other supplements

34
History A Detailed Exploration of the Symptoms
of UI

• 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

35
Physical Examination

• 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

36
Tests

• 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

37
Treatment for Stress Urinary IncontinenceMedical
Therapy

• Estrogen therapy estrogen cream,Vegifem, Estring
• No need to oppose vaginal ertrogen
• Systemic HRT still requires local therapy

38
Treatment for Stress Urinary IncontinenceBehavio
ral Therapy

• Behavioral modification
• PME pelvic Muscle exercises Vaginal cones,
  biofeedback
• Physical therapy
• Electrical Stimulation

39
Treatment for Stress Urinary IncontinenceSurgica
l Therapy

• Periurethral injections collagen, durasphere
• Various types of surgical procedures pubovaginal
  slings, bladder neck suspension, artificial
  urinary sphincter

40
Treatment for Stress Urinary IncontinenceSurgica
l Therapy
41
Treatment for Stress Urinary IncontinenceNon-Sur
gical Therapy Pessary

• 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

42
Treatment for UUI/OABBehavioral Therapy

• 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

43
Treatment for UUI/OABMedical Therapy

• Usually anticholinergics
• Ditropan 2.5-10mg tid, Ditropan XL 5-15mg qd
• Detrol 2mg bid, Detrol LA 4mg qd
• Side effects of anticholinergicsdry mouth, dry
  eyes, constipation, confusion in the elderly more
  common with Ditropan because it crosses the BBB
• Intravesical agents Ditropan more for neurogenic
  dysfunction

44
Treatment for UUI/OABSurgical Therapy

• Surgical treatment
• Sacral neuromodulation
• Bladder augmentation

45
Treatment for Neurogenic Bladder

• If neurogenic bladder is suspected refer to a
  neurologist, urologist, or neurourologist.

46
Summary of the Presentation

• 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.

47
Future Research and Study

• 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.

48
References

• Culligan, P. J.(2000), Urinary incontinence in
  women evaluation and management, American Family
  Physician, 66(11), 2433-44,2447,2452.
• 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/McGraw-Hill..
• 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), Campbells 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 OKeeffe