BEDAH Inkontinensia

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Urology Division, Surgery DepartmentMedical Faculty, University of Sumatera Utara References

Definition

ICS 2009 The complaint of any involuntary leakage of urine That is social or hygienic problem

EPIDEMIOLOGY Twice as common in women as in men. Prevalence estimates :- Female : 5% - 69% - Male : 1 % - 39 % Incidence of Urinary Incontinence increased with age

Estimated number of individuals with UI 2008, 2013 and 2018

Estimated Number of Individuals withIncontinenceRegion200820132018World346 383420Africa33 3843North America323447South america202224Asia206 231256Europe545657Estimated Worldwide Number of Individuals with Incontinence by Region (In Millions)

Predisposing Factors

FEMALEMALE 1. AGE2. PREGNANCY, PARITY AND PARTURITION3. OBESITY AND BODY MASS4. HORMONES (MENOPAUSE )5. HYSTERECTOMY6. DIABETES7. GENETICSAGELUTS AND INFECTIONSFUNCTIONAL AND COGNITIVE IMPAIRMENTNEUROLOGICAL DISORDERS (mengingo-myelocele and spinal injuries, Parkinsons disease and multiple sclerosis.)5. PROSTATECTOMY

CLASSIFICATION 1. Stress Urinary Incontinence (SUI) 2. Urgency Urinary Incontinence (UUI) 3. Mixed Urinary Incontinence (MUI) 4. Post-micturition dribble and Continuous Urinary Incontinence 5. Nocturnal Enuresis

Co Morbid conditions D elirium I nfection A trophic vaginitis P harmaceutical P sychological disorderE ndocrine disorderR estricted mobilityS tool impaction

1. STRESS URINARY INCONTINENCE (SUI) The complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Leakage with increase in intra abdominal pressure Urethral sphincter malfunction (intrinsic weakness), bladder neck hypermobility Associated with weakning pelvic floor muscle Loss small or to moderate amount of urine No evidence of urgency or nocturia

2. URGENCY URINARY INCONTINENCE (UUI) The complaint of involuntary leakage accompanied by or immediately preceded by urgency Detrusor overactivity Frequency Night time voiding Most common in older women

3. MIXED URINARY INCONTINENCE (MUI) The complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

The complaint of continuous leakage ectopic ureteral insertion vagino vesical fistula post radical prostatectomy

4. CONTINUOUS URINARY INCONTINENCE

5. Nocturnal Enuresis

Any involuntary loss of urine occurring during sleep

Initial Assessment of UrinaryIncontinence History Physical Examination Laboratory Basic office testing

GENERAL MEDICAL HISTORY1. Urinary symptoms Description of precipitating and aggravating factors of urinary loss. Time of onset Duration of symptoms Micturition pattern Voiding difficulties Degree of bother

2. Obstetric/Gynaecology History Number of pregnancies Childrens birth weights Type of deliveries Menstrual statusMedications

4. Medical History

5. Surgical History6. Bowel Habits Sexual History (Dyspareunia,vaginal dryness and coital incontinence)8. Prolapse symptoms The feeling of a lump (something coming down)

Physical Examination

a. General examination: Bladder, bowel, or sexual, function ,height and weight and body mass index Neurological examination sacral pathways Rectal examinationb. Abdominal examination Scars from previous surgery Palpate the kidneys and bladderc. Vaginal examination

d. Perineal/genital inspection

Presence of any abnormal anatomical Atrophy or excoriation, and erythema due to incontinence Wearing of pads.

e) Urethro-vesical junction (bladder neck) mobility Visual inspection (lithotomy position) Q-tip test (Urethrovesical junction hypermobility is defined by a axis exceeding +30 degrees from the horizontal

Laboratory and Basic office test

Urinalisis and urine cytology Post-void residual urine Uroflowmetry Urodynamic Pad weighing test to assess degree of incontinence Collect mid-stream urine for culture and microscopy Cough stress test Creatinine PSA ( male )

Upper TractUltrasonography ( USG )Intravenous Urography ( IVU )Computerize Tomography ( CT )Magnetic Resonance Imaging ( MRI )

Imaging

Lower TractVoiding cystourethrogram (VCUG)

ICS 2009 / EAU Guideline 2010

ICS 2009 / EAU Guideline 2010

MANAGEMENTCONSERVATIVE MANAGEMENTGenuine Stress Incontinence Conservative therapy is indicated :The patient refuses or is undecided about surgeryThe patient is mentally or physically unfit Childbearing continuesThere is uncontrolled detrusor instability or voiding difficulty.

CONSERVATIVE THERAPY Lifestyle interventions : reduce body weight, stop caffein Pharmacoherapy Pelvic floor muscle training Vaginal cones Electrical stimulationDrugs used in the treatment of stress urinary incontinenceDrugLEGR.Duloxetine Imipramine Clenbuterol Methoxamine Midodrine Ephedrine Norephedrine (phenylpropanolamine) Oestrogen

NR: Not Recommended 1332233

2BNRCNRCNRNR

NR

URGENCY URINARY INCONTINENCE (UUI) Conservative therapy :Bladder TrainingPharmocotherapy :* Antimuscarinic Drugs* Antidiurectics * Oestrogen Replacement

SURGICAL TREATMENTGenuine Stress Incontinence- Bulking Agents urethra and bladder neck injection : * Teflon * Collagen * Silica- Needle Suspension- Colposuspension * The Burch Colposuspension * Marshall-Marchetti-Krantz Procedure- Sling Operation * Tension-free vaginal tape procedure (TVT) * Stamey bladder neck suspension- Artificial Urinary Sphincter (AU

Continuous Urinary Incontinence

* ureterovaginal fistel * vesico-vaginal fistel Repair Fistel * urethrovaginal fistel

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