Urinary Incontinence - Presentation PDF

Urinary incontinence Dr. Iman Y. Abdulmalek  INTRODUCTION Urinary incontinence (UI) is defined as the involuntary loss, it affects well over 13 million people in USA, that is objectively demonstrable and is a social or hygienic problem. It is increasingly prevalent as...

Urinary incontinence Dr. Iman Y. Abdulmalek  INTRODUCTION Urinary incontinence (UI) is defined as the involuntary loss, it affects well over 13 million people in USA, that is objectively demonstrable and is a social or hygienic problem. It is increasingly prevalent as the ageing population expands. It affects an individual's physical, psychological & social well- being & is associated with a significant reduction in quality of life. The Prevalence: Approximately 5% of women between 15- 44 years of age being affected, rising to 10% of those between 45-64, & 20% of those older than 65 years. It is  The lower urinary tract can be divided ANATOMY into three parts: Bladder —Hollow muscular organ lined with transitional epithelium designed for urine storage. -- consists of three layers of smooth muscle, which are densely intertwined and constitute the detrusor muscle -- stays relaxed to facilitate urine storage and contracts periodically to completely evacuate its contents when appropriate and acceptable --Trigone at the bladder base --Vesical neck and urethra 3-4 cm --composition and support of the urethra and bladder neck play key roles in the function and maintenance The normal physiological filling to go to urinate is when in the urine bladder is about 250 ml of urine.  URINARY INCONTINENCE Types and Definition Evaluation Treatment  Types and Definition Stress urinary incontinence (SUI) Urge incontinence (overactive bladder) Mixed incontinence Overflow incontinence Functional incontinence Reflex incontinence. Extraurethral sources of urine  Types and Definition SUI (Stress UI) Loss of urine that occurs with increased abdominal pressure, such as coughing or straining Result of loss of anatomic support of the urethrovesical junction or urethra It most commonly occurs following pelvic floor muscle and nerve damage that resulted from childbearing  Types and Definition Urge incontinence ( over active Bladder) is defined by the symptom of urine loss that occurs when the patient experiences urgency, or a strong desire to void, it is caused by minor condition such as infection, or a more severe condition such as a neurological disorder or diabetes. – is often accompanied by symptoms of urinary frequency, urgency, and nocturia  Types and Definition Mixed incontinence (stress & Urge) Occurs when both stress and detrusor instability occur simultaneously Patients may present with symptoms of both types of incontinence  Reflex incontinence is the unexpected loss of urine due to a spasm of the bladder's detrusor muscle. Individuals generally do not feel an urge to urinate, without being able to stop it. This type of urinary incontinence is related to neurological factors that affect messaging from the brain to the bladder. It is categorized as being spinal or supraspinal reflex incontinence. Multiple Sclerosis, a host of different dementias, stroke, Alzheimer’s disease and Parkinson’s disease.  Types and Definition Functional incontinence For this type functional incontinence, the problem lies in getting to and using the toilet when the need arises. Diagnosis and Treatment of Functional Incontinence requires treating the medical conditions that cause or contribute to the problem. For example, appropriate treatment for arthritis may make it easier to get to the bathroom quickly. Alzheimer's disease or other forms of dementia also lead to this problem, in addition to severe depression.  Types and Definition Overflow incontinence Occurs because of underactivity of the detrusor muscle Be associated with retention of urine The bladder does not empty completely, and “dribbling” of urine occurs  Types and Definition Extraurethral sources of urine Include genitourinary fistulas Be congenital or follow: *pelvic surgery (direct injury), *obstetrical causes (obstructed labour) due to pressure of presenting part on bladder, *infection like TB or *radiation. These typically cause continuous leaking of urine. Treatment by Surgery to correct it.  Evaluation History Physical examination Diagnostic tests Cystoscopy  Risk factors Gender. Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. Age. older, the muscles in bladder and urethra lose some of their strength. Changes with age reduce how much bladder can hold and increase the chances of involuntary urine release. Being overweight. Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze. Smoking. Tobacco may increase risk of urinary incontinence. Family history. If a close family member has urinary incontinence, especially urge incontinence, a risk is higher. Some diseases. Neurological disease or diabetes may increase your risk of incontinence.  Evaluation A detailed history is essential and should include: a. Urinary symptoms, including the presence of voiding frequency, nocturia, urgency, precipitating events, and frequency of loss. A voiding diary allows the patient to document voiding frequency and incontinence episodes during a specific period b. Previous urologic surgery C history, including parity, birth weights, and mode of delivery d. CNS or spinal cord disorders e. Use of medications, including diuretics, antihypertensives, caffeine, alcohol, anticholinergics, decongestants, nicotine, and psychotropics f. Presence of other medical disorders (e.g., hypertension or hematuria)  Evaluation Physical examination may detect: a. Exacerbating conditions, such as chronic obstructive pulmonary disease, obesity, or intra-abdominal mass b. Hypermobility of the urethra c. Pelvic organ prolape (POP) d. Neurologic disorder  Evaluation Diagnostic tests a. A midstream urine specimen b. Postvoid residual urine volume c. The Q-tip test d. Urodynamic testing  Evaluation Diagnostic tests -- midstream urine specimen Be collected for urinalysis or culture and sensitivity Infection may aggravate urinary incontinence  Evaluation Diagnostic tests -- Postvoid residual urine volume should be measured (by ultrasound or catheterization) after the patient has voided Typically, the postvoid residual urine volume is less than 50 ml  Evaluation Diagnostic tests -- The Q-tip test is an indirect measure of the urethral axis A Q-tip is inserted into the urethra with the patient in the lithotomy position If the Q-tip moves more than 30 degrees from the horizontal with straining, urethra hypermobility is present Q-TIP TEST At rest the Q-tip is in a horizontal position, but with straining & coughing it shows a positive deflection owing to inadequate support at the urethrovesical junction. Bladder at rest Bladder with straining Q-TIP TEST At rest the Q-tip is in a horizontal position, but with straining & coughing it shows a positive deflection owing to inadequate support at the urethrovesical junction. Bladder at rest Bladder with straining  Evaluation Diagnostic tests -- Urodynamic testing including a cystometrogram and voiding studies, may be useful for demonstrating the type of incontinence present These tests measure pressures within the bladder and abdomen during bladder filling and emptying Urodynamic testing is indicated for complex cases of urinary incontinence such as mixed incontinence or in patients with incontinence and retention of urine  Evaluation Cystoscopy is performed in some patients to examine the bladder and urethral mucosa for abnormalities such as diverticula or neoplasms Cystoscopy What can irritate bladder? Urinalysis: WBC, RBC, Bacteria Culture: Positive  Typical case 51 years old woman complaining urine loss almost all time on daytime, especially after micturition TOT for her ,but she cannot pass the urine Open the urethra with pressure, she can pass the urine with frequency, urgency Postvoid residual urine volume—450ml  Treatment Therapy depends on the underlying diagnosis. Treatment of exacerbating factors Pelvic muscle rehabilitation Pessaries are useful conservative therapies for SUI Drug therapy Surgery  Treatment Treatment of exacerbating factors may improve SUI excess weight chronic cough constipation  Treatment Pelvic muscle rehabilitation -- be helpful for both SUI and Detrosur overactivity(DO) a. Kegel exercises b. Vaginal cones c. Biofeedback d. Electrical stimulation  Treatment Drug therapy is the mainstay of treatment for DO but is of limited value in treating SUI. a. Antispasmodic agents (Tolterodine) are highly effective and are the most commonly prescribed treatments for DO. b. α-Adrenergic stimulating agents increase smooth muscle contraction in the urethral sphincter and may decrease SUI symptoms c. Estrogens improve irritative bladder symptoms such as urgency and dysuria in postmenopausal women but do not significantly improve urinary leakage. HRT does not reduce the incidence of urinary symptoms in postmenopausal women  Treatment Surgery is extremely effective in the treatment of SUI. It is rarely helpful for DO a. Injection of bulking agents around the urethra b. Retropubic urethropexy c. Transvaginal needle procedures d. Suburethral sling procedures  Treatment Surgery --Injection of bulking agents around the urethra is a minimally invasive procedure to treat SUI resulting from intrinsic urethral sphincteric deficiency Collagen, the bulking agent currently used most commonly, provides a temporary (3 to 12 months) cure or improvement rates ranging from 50% to 70% They are generally indicated for patients unable to tolerate major surgery  Treatment Surgery --Retropubic urethropexy elevates the urethra and bladder neck by fixing the paraurethral connective tissues to the pubis The most common type is the Burch procedure, which suspends the vaginal fascia lateral to the iliopectineal line (Cooper ligament) Burch procedure are most successful in patients who have SUI with urethral hypermobility, resulting in long-term cure rates of 75% to 90% Postoperative complications are uncommon but may include urinary retention and new DO  Elevation of Urethrovesicle Junction Burch procedure/ MMK Brubaker, p.167, Fig 19-1  Treatment Surgery -- Suburethral sling procedures place biologic and synthetic materials under the urethra appear to affect treatment by partially obstructing the urethra during times of increased intra-abdominal pressure differ according to the type of material and the sling fixation points used; however, they all have high cure rates (80% to 90%) are more effective than retropubic operations in patients with intrinsic urethral sphincteric deficiency Complications may include infection, ulceration and urinary retention Tension-free Vaginal Tape Procedure THANK YOU FOR YOUR ATTENTION