URINARY INCONTINENCE

IS IT A PROBLEM IN FAMILY

DOCTORS` PRACTICES?

Maria Magdalena Bujnowska - Fedak

Department of Family Medicine,

Wrocław Medical Academy, Poland

Urinary incontinence is the

involuntary loss of urine

from the bladder.

URINARY INCONTINENCE DEFINITION

The International Continence Society (ICS) defines incontinence as ‘a condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable’ ( weak for epidemiological purposes).

Other definitions: ‘any uncontrolled urine loss in the previous 12 months without regard to severity’, more than two episodes in a month’

URINARY INCONTINENCE DEFINITION

URINARY INCONTINENCE PREVALANCE

UI prevalance in women varies between 14-40,5%;

UI prevalance in men varies between 1,6-24%; according to the definition applied, the country of survey and the method of survey.

UI IS THE SOCIAL DISEASE.

It is supposed that about 4-6 millions people in Poland suffers from urinary incontinence (UI).

Bladder control problem concerns especially women.

URINARY INCONTINENCE

13 million Americans are incontinent; 11 million are women (85%)

1 in 4 women ages 30-59 have experienced an episode of UI.

50% or more of the elderly persons living at home or in long-term care facilities are incontinent.

AMERICAN FACTS ABOUT URINARY INCONTINENCE

$16.4 billion is spent every year on

incontinence-related care: $11.2 billion

for community-based programs and at

home, and $5.2 billion in long-term

care facilities.

$1.1 billion is spent every year on

disposable products for adults.

AMERICAN FACTS ABOUT URINARY INCONTINENCE

Stress incontinence happens when

the bladder can't handle the increased

intra abdominal pressure during

exercise, coughing, laughing or

sneezing.

This kind of incontinence happens

mostly to women under 60 and in men

who have had prostate surgery.

TYPES OF URINARY INCONTINENCE

Urge incontinence is caused by a

sudden, involuntary bladder

contraction (abnormal detrusor

muscle contraction, ‘overactive

bladder’).

It is characterised by an abrupt and

strong desire to void, urgency,

nocturia. It is more common in older

adults.

TYPES OF URINARY INCONTINENCE

STRESS AND URGE INCONTINENCE

COMPARISON OF SYMPTOMS

SYMPTOMS STRESS INCONTINENCE

URGE INCONTINENCE

RELEASINGFACTOR

coughing, laughing, physical activity, lifting, changingposition

sudden stimulus, changing position

URINE FLOW immediate delayed

URINE VOLUME small ---> big small

URGENCY sometimes YES

NOCTURIA rarely YES

SPONTANEOUS RECOVERY

NO occasionaly

Mixed incontinence is a combination of both stress and urge incontinence, and is most common in older women.

Overflow incontinence, in which thebladder becomes too full (over-distention of the bladder) because itcan't be fully emptied, is rarer and isthe result of bladder obstruction orinjury. In men, it can be the result ofan enlarged prostate.

TYPES OF URINARY INCONTINENCE

Total incontinence: continuous loss

of urine with minimal activity, usually

seen in women with severe stress UI.

Functional incontinence: urine loss

due to acute or chronic impairment of

both physical or cognitive function.

TYPES OF URINARY INCONTINENCE

RISK FACTORS ARE JUDGED TO BE:

Constitutional

Urogynaecological

Neurogenic

Behavioural

RISK FACTORS FOR URINARY INCONTINENCE

Constitutional:

Age (elderly)

Sex (women)

Obesity

Race ( eg. Caucasian race)

RISK FACTORS FOR URINARY INCONTINENCE

Urogynaecological:

Minor pelvic surgery (e.g.

hysterectomy)

Uterine prolapse, cystocoele

Oestrogen deficiency (

menopause)

Childbirth, pregnancy

RISK FACTORS FOR URINARY INCONTINENCE

Neurological risk factors relate

rather to overactive bladder and

detrusor hyperreflexia than to

stress incontinence ( e.g. Parkinson`s

desease, Alzheimer`s disease, SM,

dementia, depression, brain tumors,

stroke, brain and spinal cord injuries,

congenital defects, polineuropathy).

RISK FACTORS FOR URINARY INCONTINENCE

Behavioural:

Diet: caffeine, alcohol and tobacco

consumption

Constipations

Drugs

Low physical activity ( physical

disability)

Psychosocial disorders, toilet habits

RISK FACTORS FOR URINARY INCONTINENCE

Others:

URINARY TRACT INFECTIONS!

Chronic diseases: diabetes,

hipercalcemia

RISK FACTORS FOR URINARY INCONTINENCE

Near 2/3 cases of UI remains undiagnosed!

Patients do not often reveal the problem: shame, lack of confidence to the doctor, lack of information about the illness, UI as ‘a natural consequence of aging’ etc.

Doctors haven’t sufficient knowledge and skills in diagnosing and treating UI.

URINARY INCONTINENCE

Review medical and social history Question the patient about possible

urinary incontinence including time

of onset, frequency and severity.

Inquire about symptoms such as

urgency, nocturia, hematuria,

dribbling and hesitancy.

EVALUATION FOR UI

Perform physical examination,

especially abdominal, genital, rectal,

and skin examination,Valsalva

maneuver for women.

Determine presence/absence of

indwelling catheter. If present,

determine whether use is indicated.

Complete functional, environmental,

and mental status assessment.

EVALUATION FOR UI

Perform diagnostic test results:

urinalysis and urine cultures.

• Perform bladder ultrasonography or

catheter insertion to evaluate post-

void residual urine.

• Perform basic analytic and

biochemical blood tests: glucose,

creatinine, electrolytes etc.

• Perform urodynamic tests (optional).

Complete bladder diary or voiding

record.

EVALUATION FOR UI

Treatment for UI depends on

the type of incontinence, its

causes, and the capabilities

of the patient.

URINARY INCONTINENCE TREATMENT

Pelvic Muscle Rehabilitation— toimprove pelvic muscle tone andprevent leakage.

Kegel exercises. Regular, daily

exercising of pelvic muscles can improve,and even prevent, urinary incontinence.This is particularly helpful for youngerwomen. Should be performed 30-80 timesdaily for at least 8 weeks.

Biofeedback. Used in conjunction with

Kegel exercises, biofeedback helps peoplegain awareness and control of their pelvicmuscles.

UI TREATMENT

Pelvic Muscle Rehabilitation— to improvepelvic muscle tone and preventleakage.

Vaginal weight training. Small weights

are held within the vagina by tightening the vaginal muscles. Should be performed for 15 minutes, twice daily, for 4 to 6 weeks.

Pelvic floor electrical stimulation. Mild

electrical pulses stimulate muscle contractions. Should be performed in conjunction with Kegel exercises.

Magnetic therapy (ExMI).New method in testing

UI TREATMENT

Behavioral Therapies —to help people regain control of their bladder.

Bladder training teaches people to resist the urge to void and gradually expand the intervals between voiding.

Toileting assistance uses routine or scheduled toileting, habit training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.

UI TREATMENT

Pharmacologic Therapies —to improve incontinence medically.

Anticholinergic drugs – first-line pharmacotherapy (oxybutynin, tolterodine, darifenacin, solifenacine) prevents urge incontinence by relaxing sphincter muscles.

Bladder relaxants ( e.g.imipramine), for urge incontinence.

Mirabegron – strong and selective agonist of β3-adrenergic receptors (OAB).

UI TREATMENT

Pharmacologic Therapies —to improve incontinence medically.

Alpha-adrenergic antagonists ( e.g. pseudoephidrine), for stress incontinence.

Duloxetine (SNRI), for stress incontinence.

Estrogen replacement therapy, mostly vaginal, may be helpful in conjunction with other treatments for postmenopausal women with UI.

UI TREATMENT

Surgical Therapies —to treat specific anatomical problems.

Sling procedures (TVT Tension Free

vaginal Tape surgery), bulking injections (such as collagen), artificial sphincter and other surgical procedures support or move the bladder to improve continence.

UI TREATMENT

Other supporting methods (to keep people dry):

Indwelling urethral catheters

Pelvic organ support devices (

e.g. pessaries, vaginal rings,

vaginal balls)

Disposable absorbent products

UI TREATMENT

Patients and professionals should learn about the different treatment options for incontinence.

Patients and their families should

know that incontinence is not

inevitable or shameful but is treatable

or at least manageable.

All management alternatives should

be explained.

UI EDUCATION

Patients and professionals should learn about the different treatment options for incontinence.

Professional education about UI

evaluation and treatment should be

included in the basic curricula of

undergraduate and graduate training

programs of all health care providers,

as well as continuing education

programs.

UI EDUCATION

URINARY

INCONTINENCE

I KNOW…