Urinary Incontinence

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Urinary Incontinence

• Ahmad Ali Akbari Kamrani M D
• Iranian Research Center on Ageing
• University of Social Welfare Rehabilitation
  Sciences

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Definition

• Patient-centered
• An uncontrollable loss of urine at inappropriate
  or unwanted times.
• Prevalence studies
• Difficulty holding urine until you get to a
  toilet
• Unexpected or uncontrolled loss of urine
• Loss of control of urine
• Wet underpants

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Definition

• Severity definitions
• Once or more
• Twice or more
• Three times or more
• Bad enough to cause social or hygienic problems
• Frequency definitions
• Ewer
• Past year
• Past month
• Past week
• Per day

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Prevalence

• Urinary incontinence can occur at any age.
• It is normal among newborns,
• As enuresis among young children ,
• As a stress incontinence among women of
  childbearing age
• As a geriatric syndrome among older persons

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Prevalence

• Older persons who are
• Homebound- long-term care facilities
• 50
• Community-dwelling older women
• Any frequency of incontinence, 35
• Daily incontinence, 14
• Community-dwelling older men
• Any frequency of incontinence, 22
• Daily incontinence, 4

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Unrecognized Incontinence

• Physician (do not routinely ask )
• 11 of physicians nurse practitioners
• 33 of physician assistants ask patients
• Patients (do not seek care )
• 30 of OP with incontinence have ever sought care
  for the problem.
• Avoid discussing the problem because of
• Embarrassment ,
• They believe it is a normal aspect of ageing for
  which no treatment is available ,
• They believe surgery is the only available
  treatment and do not want to undergo surgery ,

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Micturation mechanism

• When the bladder fills
• Stretch receptors in the bladder wall transmit
  neural signals ,
• Through the sacral plexus spinal cord
• To micturation center in the brain stem
• Then transmits back through the spinal cord
  sacral plexus to the detrusor muscle and this
  reflex loop produces detrusor muscle contractions
  voiding.
• Stimulation of detrusor contractions is inhibited
  by neural centers in the frontal cortex, basal
  ganglia, cerebellum.
• Inhibitory activity keeps the bladder relaxed and
  allows voluntarily urination .

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Principal diagnosis

• It is useful to consider,
• three basic pathophysiologic mechanism
• Overactivity of the bladder detrusor muscle
  (urge
  incontinence ).
• Malfunction of the urinary sphincters
• ( stress incontinence ) .
• Overflow bladder
• (urinary retention )
• Mixed Incontinence multiple causes ,

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Principal diagnosis

• Each of the three mechanism ,
• Transient (medications, infection, .)
• Irreversible ( degenerative neurologic
  disorders, . )

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Detrusor overactivity ( Urge Incontinence )

• Lack the ability to control or inhibit
  contractions of the bladder detrusor muscle
• Detrusor muscle is overactive in relation to the
  ability of the inhibitory centers

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Detrusor overactivity ( Urge Incontinence

• Transient causes 1/3 of U.I.
• -Drugs most common cause
• (diuretics, sedatives, alcohol, )
• -Metabolic neurologic
• (hypoxemia, delirium, hyperglycemia,
• hypercalcemia, excess fluid consumption)
  
• -Inflamation
• ( acute UTI , atrophic vaginitis, ..)

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Detrusor overactivity ( Urge Incontinence

• Irreversible causes
• degenerative neurologic disorders
• ( detrusor hyperreflexia
  instability )
• -The most common
• ( Dementia, Parkinson, Stroke,)
• -Any neurodegenerative conditions
• (Normal-pressure hydrocephalus,
  
• Cerebral
  neoplasm )
• Spinal cord injury
• ( automatic bladder, or
  neurogenic )
• lose all cerebral inhibitory input
  to the detrusor

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Sphincter Malfunction ( stress incontinence )

• Normal urinary sphincter function
• Normal function of the sacral nerves that
  innervate the sphincter muscle ,
• Normal function of Sphincter muscles
• voluntary periurethral
  skeletal muscles
• 
  ( pelvic floor )
• Involuntary urethral smooth
  muscles
• a
  adrenergic ( constriction )
• ß
  adrenergic ( relax )
• Normal urethral positioning
• closure of the urethral walls
  against themselves
• exposed to the intraabdominal
  pressure (cough,)
• and thereby prevents a pressure
  gradient between
• the bladder the urethral

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Sphincter Malfunction ( stress incontinence )

• Transient
• - medications
• a-adrenergic
  blocking , ( prazosin )
• ß- adrenergic
  agonist , (salbutamol )
• Irreversible
• -Urethral prolapse (classic
  stress incontinence )
• -Intrinsic urethral
  deficiency (denervation after
• prostatectomy, trauma,
  radiation therapy,
• malignancy,
  sacral spinal cord lesions, )

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Overflow bladder (urinary retention )

• Two general mechanism cause
• Obstruction of urinary outflow
• Failure of the detrusor to contract effectively

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Overflow bladder (urinary retention )

• Transient
• Medications
• anticholinergics
• calcium channel blockers
• NSAIDs (blocked prostagladin
  receptors in bllader )
• a-adrenergic agonist
• ß-adrenergic antagonist
• CNS depressant (narcotics,
  sedatives,)

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Overflow bladder (urinary retention )

• Irreversible
• prostate enlargement (men )
• strictures from previous surgery
  (women)
• injury of cholinergic pelvic nerve
• (neuropathic, neoplastic,
  traumatic,.)
• Diabetes, MS, amyloidosis,
  syphilis,
• heavy metal poisening

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Symptoms suggesting the Special evaluation

• History of anti-incontinence surgery radical
  pelvic surgery (urogynecologist )
• Urge incontinence gt2 - ( cystoscopy )
• Hematuria recurrent UTI ( imaging studies
  )

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physical findings suggesting the Special
evaluation

• Prostate with a nodule or asymmetry
• Pelvic prolaps
• Neurologic disorder spinal cord lesion

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Physical Findings suggesting the nature of
Incontinence

• Parkinson degenerative neurologic dis.
• ( uninhibited detrusor contractions )
• Pelvic prolaps cystocele , rectocele
• ( stress incontinence )
• Palpation of distended bladder
• (overflow prostate, neuropathic dis. )

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Physical Findings suggesting transient
Incontinence

• Fecal impaction
• (transient overflow)
• Atrophic vaginitis
• (transient detrusor overactivity )
• (atrophic trigonitis inflamation)

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Ancillary Tests

• Routine evaluation
• U/A PVR (post void residual) NLlt50 ml
• Simple bladder function tests
• simple cystometry (urgencylt300
  ml detrusor overactivity )
• stress testing for women
• (pad
  test with full bladder, supine standing
• Marshal
  test for surgery response
• finger
  elevate the urethra cough forcibly )
• urine flowmetry for men
• (
  normal aged men gt20 ml / s )

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Ancillary Tests

• Selected patients
• - RFT
• - cystoscopy
• - urine cytology
• - imaging tests
• - formal cystometrography
• (multilumen urethral catheter
  rectal probe )
• bladder pressure,
  intraabdominal pressure, urethral
• pressure, leak-point
  pressure, urethral flow rate,
• pelvic muscle
  electromyographic findings , )

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Algorithm
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Treatment

• Self-treatment
• Transient causes treatment
• Irreversible causes treatment
• Collect urine maintain hygiene

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Self-Treatment

• Changing pattern of fluid intake
• Identifying the location of the toilet
• Absorbent pads
• Herbal medication

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Management of Transient causes

• Urge-type
• Acute UTI - antibiotic
• atrophic vaginitis - estrogen
• delirium-hypoxia - underlying dis.
• excessive fluid - reduction
• glycosuria - control
  diabetes
• hypercalciuria -
  treat.hypercalcemia
• impaired mobility - therapy
• medication effects - D/C or change
  

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Management of Transient causes

• Sphincter malfunction
• medication effects - D/C
  or change
• Overflow bladder
• drug side effects - D/C
  or change
• fecal impact -
  disimpaction
• 
  stool softness

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Management of Non-Transient causes of urge
incontinence

• Behavioral therapy medication - surgery
• Behavioral therapy
• bladder training (interval, 2
  h-..longer)
• pelvic muscle exercises (Kegels)
• (for frail cognitive impair. Less
  effective)

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Management of Non-Transient causes of urge
incontinence

• Medication
• oxybutinine tolterodine
• propantheline imipramine
• dicyclomine calcium blocker
• NSAIDs
• Surgery
• 1- augmentation cystoplasty ( a patch
  of intestine )
• 2- urinary diversion (ileal urostomy )
  
• 3- bladder denervation (subtrigonal
  phenol injections)
• 
  sacral rhizotomy
• 
  transvaginal denervation
• 
  sacral dorsal root gaglionectomy

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Management of Non-Transient causes of stress
incontinence

• Women
• surgery behavioral therapy
• medication - devices
• Men
• behavioral therapy medication
• surgery -

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Management of Non-Transient causes of stress
incontinence

• Women
• surgery(6000 pt.-75-79 completely cure)
• (retropubic suspension procedure)
  
• behavioral pelvic muscle exercises
• biofeedback
  techniques
• (pressure
  gauges in the vagina provide
• 
  auditory or visual display )
• vaginal weights
• 
  (20-100 gr-placed in the vagina)
• (
  for up to 15 min. using pelvic
• 
  muscle contractions ).
• Medications a-adrenergic agonist , estrogen

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Management of Non-Transient causes of stress
incontinence

• Women
• devices
• pessaries
• occlusive devices

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Management of Non-Transient causes of stress
incontinence

• Men
• behavioral therapy
• medications- (a-adrenergic agonist )
• Surgery
• periurethral bulking
  injection ( first choice)
• placement of an artificial
  sphincter
• most often ISD (intrinsic sphincter deficiency)
• after surgical trauma- radiation-urethra or nerve
  damage
• 
  surgical interventions
• after prostatectomy/ waiting at
  least 6 month

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Management of Non-Transient causes of overflow
incontinence

• Objectives bladder drainage to prevent
  hydronephrosis
• Prostate enlargement
• surgery ( TUR )
  appropriate therapy
• drugs delayed
  action unsuitable
• New technologies
  has not been defined
• (balloon dilatation - laser-
  coils-stents thermal therapy-)
• Exceptional circumstances ( neoplasia )
  ileourostomy

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Management of Non-Transient causes of overflow
incontinence

• catheterization three options
• - intermittent (standard for
  inadequate detrusor contractions)
• ( 3 times/day or every 3-6
  h. )-
• ( sterile or clean catheter-
  without antibiotic prophylactic )
  
  
• ( rate of infection
  1-4 episodes / 100 days )
• - indwelling ( foley- changed
  once a month )
• - suprapubic ( when obstruction
  prevents
• 
  passage of a catheter )

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Management of Intractable incontinence

• Can not be controlled other than catheterization
• Environmental modifications
• physical access
  facilities
• improvements in
  lighting
• avoiding tea, coffee,
  .
• Devices Collection systems
• absorbent pads garments
  
• male candom catheters
• female paush devices
• penile clamps
• urethral catheters ( 14
  f, 16f, 18f, )
• Complications infection, encrustation,
  dermatitis,

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Controversies

• The current recommendations
• Expert opinion / evidence from research
• Different specialties / different approach

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The end