Urinary Incontinence

Ahmad Ali Akbari Kamrani M DIranian Research Center on Ageing

University of Social Welfare & Rehabilitation Sciences

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

Definition

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

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

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%

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 ,

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 .

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 ,

Principal diagnosis

Each of the three mechanism , Transient : (medications, infection,

….)

Irreversible : ( degenerative neurologic disorders, …. )

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

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, ..)

Detrusor overactivity ( Urge IncontinenceIrreversible 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

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 α – adrenergic ( constriction ) β – 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

Sphincter Malfunction ( stress incontinence ) Transient : - medications : α-adrenergic blocking , ( prazosin ) β- adrenergic agonist , (salbutamol )

Irreversible : -Urethral prolapse (classic stress incontinence )

-Intrinsic urethral deficiency (denervation after prostatectomy, trauma, radiation therapy, malignancy, sacral spinal cord lesions, )

Overflow bladder (urinary retention )

Two general mechanism cause :

Obstruction of urinary outflow

Failure of the detrusor to contract effectively

Overflow bladder (urinary retention )

Transient : Medications : anticholinergics calcium channel blockers NSAIDs (blocked prostagladin receptors in

bllader )

α-adrenergic agonist β-adrenergic antagonist CNS depressant (narcotics, sedatives,)

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

Symptoms suggesting the Special evaluation

History of anti-incontinence surgery & radical pelvic surgery – (urogynecologist )

Urge incontinence >2 - ( cystoscopy &… )

Hematuria & recurrent UTI – ( imaging studies & … )

physical findings suggesting the Special evaluation Prostate with a nodule or

asymmetry

Pelvic prolaps

Neurologic disorder & spinal cord lesion

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. )

Physical Findings suggesting transient Incontinence

Fecal impaction (transient overflow)

Atrophic vaginitis (transient detrusor overactivity ) (atrophic trigonitis &

inflamation)

Ancillary Tests

Routine evaluation : U/A – PVR (post void residual)– NL<50 ml

Simple bladder function tests : simple cystometry :(urgency<300 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 >20 ml / s )

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 , …)

Algorithm

Treatment

Self-treatment

Transient causes treatment Irreversible causes treatment

Collect urine & maintain hygiene

Self-Treatment

Changing pattern of fluid intake

Identifying the location of the toilet

Absorbent pads

Herbal medication

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

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

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)

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

Management of Non-Transient causes of stress incontinence Women : surgery – behavioral therapy medication - devices

Men : behavioral therapy – medication surgery -

Management of Non-Transient causes of stress incontinenceWomen : 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 : α-adrenergic agonist , estrogen

Management of Non-Transient causes of stress incontinence

Women : devices :

pessaries

occlusive devices

Management of Non-Transient causes of stress incontinenceMen : behavioral therapy medications- (α-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

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

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 )

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,

Controversies

The current recommendations :

Expert opinion / evidence from research

Different specialties / different approach

The end