Priya vasudevan md pgy 2
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PRIYA VASUDEVAN MD PGY 2. URINARY INCONTINENCE. OBJECTIVES. Identify the various forms of Urinary Incontinence (UI) To become knowledgeable about the treatment interventions available To understand the impact of Urinary Incontinence. DEFINITION.

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Priya vasudevan md pgy 2

PRIYA VASUDEVAN MD

PGY 2

URINARY INCONTINENCE


Objectives

OBJECTIVES

  • Identify the various forms of Urinary Incontinence (UI)

  • To become knowledgeable about the treatment interventions available

  • To understand the impact of Urinary Incontinence


Definition

DEFINITION

  • Incontinence: “Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence…”


Urinary incontinence is often under diagnosed and under treated

Urinary Incontinence is Often Under-Diagnosed and Under-Treated

  • Only 32% of primary care physicians routinely ask about incontinence.

  • Often not mentioned to physicians

  • 50-75% of patients never describe symptoms to physicians

  • 80% of urinary incontinence can be cured or improved.


Prevalence of urinary incontinence

Prevalence of Urinary Incontinence

  • Affects 13 million Americans

  • 33% of women >65 have some degree of UI

  • 26% of women>18 experience various degree of SI

  • 15% to 30% of noninstitutionalized older adults (19% men; 39% women)

  • Prevalence increases with age (not normal aging)

  • 50% of those in nursing facilities


Economic costs

Economic Costs

  • 10 billion $ in 1987

  • Costs of UI in 1995 is 24.3 billion or $ 3,561 per incontinence person.

  • 32.1 billion $ in 2000 for UI and OAB

  • Cost: physical, psychological and social impact


Anatomy of micturition

Anatomy of Micturition

  • Detrusor Muscle

  • External and Internal sphincter

  • Normal capacity 300- 600 cc

  • First urge to void150-300 cc

    • Parasympathetic-Bladder contracts

  • Sympathetic- Bladder relaxes and Bladder neck and urethral contraction.

  • Somatic- Pudendal nerve –contraction of pelvic floor muscle


Nerves and micturition

Nerves and Micturition


Risk and contributing factors

Risk and Contributing Factors

  • Age

  • Parity

  • Obesity

  • Vaginal delivery

  • Episiotomy

  • Diabetes

  • Stroke

  • Estrogen depletion

  • Genitourinary surgery and radiation


Types of urinary incontinence

TYPES OF URINARY INCONTINENCE

  • Urge Incontinence – Strong urge to void immediately( with or without increased frequency)

  • Stress incontinence – Increased intra-abdominal pressure that leads to incontinence

  • Overflow Incontinence – Over distended bladder leading to UI/dribbling

  • Functional Incontinence – Physical/Psychological impairment due to inability to get to BR

  • Mixed Incontinence – Combination of 2 or more types


Stress incontinence

STRESS INCONTINENCE

  • Most common type in women in < 75 years old

  • Occurs with increase in abdominal pressure- cough, laugh, sneeze, etc

  • Hyper motility of bladder neck and urethra associated with aging, child birth, hormonal changes

  • Intrinsic sphincter problems( pelvic irradiation, surgery, trauma, incontinence surgery)

  • No urgency or nocturia


Stress incontinence1

STRESS INCONTINENCE


Urge incontinence

URGE INCONTINENCE

  • OAB, Detrusor instability, irritable bladder, detrusor hyperactivity.

  • Most common UI > 75 years of age

  • Abrupt desire to void urine cannot be suppressed

  • Associated with frequency / nocturia.

  • Causes- infection, vaginitis, tumor, stones, MS, idiopathic


Urge incontinence1

URGE INCONTINENCE


Gotta go gotta go

GOTTA GO, GOTTA GO!!!!!!!!


Overflow incontinence

OVERFLOW INCONTINENCE

  • Over Distension of Bladder

  • Bladder outlet obstruction- Stricture, BPH, Cystocele, fecal impaction

  • Non contractile bladder- Diabetes, MS, Spinal injury.

  • Filling occurs to the stretch limit of the bladder

  • Large PVR >400cc

  • Dribbling, frequency

  • High rates of infections


Functional incontinence

FUNCTIONAL INCONTINENCE

Does not involve lower urinary tract

Result of psychological, cognitive or physical impairment


Mixed incontinence

MIXED INCONTINENCE


Reversible causes

REVERSIBLE CAUSES

  • D- Delirium

  • I - Infection

  • A-Atrophic Vaginitis

  • P- Pharmaceuticals/ Psychological

  • E- Endocrine

  • R- Restricted mobility

  • S- Stool impaction


Evaluation of incontinence

EVALUATION OF INCONTINENCE

  • History

  • Physical exam ( including Neuro and abdominal , pelvic and rectal examination)

  • Clinical testing- Stress test, PVR by catheterization or ultrasound.

  • Laboratory testing- UA, Urine culture, Blood test.

  • URODYNAMIC TESTING


Taking the history

TAKING THE HISTORY

  • Duration, Symptoms, Severity, nocturnal symptoms, no . Of pads per day.

  • Medical and surgical history

  • Medications

  • Social history

  • Bladder diary

  • Record the time and volume

  • Number of voiding

  • Number of pads

  • Incontinence episode

  • Severity of the problem

  • Time of the day with increased frequency.


Key questions

KEY QUESTIONS

  • Are you leaking urine ?

  • Do you have trouble making it to the bathroom?

  • Do you go to the BR frequently?

  • Do you leak urine when coughing, laughing or sneezing

  • Do you wear pads for urine leakage?

  • How many times do you wake up at night?


Bladder diary

BLADDER DIARY


Clinical tests

CLINICAL TESTS

  • Stress test

  • Post void residual volume


Laboratory tests

LABORATORY TESTS

  • UA

  • Urine culture if infection is suspected.

  • Urine Cytology if hematuria +, pelvic pain

  • Kidney function tests

  • Calcium and glucose testing.

  • Vitamin B12

  • PSA

  • REFERRAL for URODYNAMIC STUDY in refractory cases.


Treatment of ui

TREATMENT OF UI

  • Lifestyle Modifications including weight loss, dietary changes.

  • Behavioral therapy are effective in urge, stress and mixed incontinence and should be the initial treatment.

  • Medications

  • Devices

  • REFERRAL for further investigation and Surgery


Life style modification

LIFE STYLE MODIFICATION

  • Weight loss

  • Dietary Changes

    • alcoholic beverages

    • carbonated beverages

    • coffee or tea(with or without caffeine)

    • citrus juice, tomatoes, chocolate, spicy foods, artificial sweetener.


Behavioral treatment

BEHAVIORAL TREATMENT

  • STRESS INCONTINENCE

  • Patient education

  • Pelvic muscle exercises

  • Diet modification

  • Weighted vaginal cones

  • Pessary

  • Pelvic floor electrical stimulation

  • Weight reductions

  • URGE INCONTINENCE

  • Patient education

  • Timed voiding

  • Habit training

  • urge inhibition

  • bladder training

  • Pelvic muscle exercises

  • Diet modification


Behavioral treatment1

BEHAVIORAL TREATMENT

  • MIXED INCONTINENCE

  • Patient education

  • Treat the predominant type

  • Kegel exercises-81% reduction in urinary leakage

  • Diet modification

  • Bladder training

  • OVERFLOW INCONTINENCE

  • Patient education

  • “Double voiding technique”

  • Diet modification

  • Avoid caffeine/alcohol

  • Barrier product to prevent skin breakdown


Behavioral treatment2

BEHAVIORAL TREATMENT

  • FUNCTIONAL INCONTINENCE

  • Patient education

  • Environment alterations

  • Grab bars/raised seats

  • Caregiver assistance/education

  • Screen for depression/cognitive impairment

  • Occupational /Physical therapy


Pelvic muscle exercises

PELVIC MUSCLE EXERCISES

  • Kegel exercises are used for Urge, stress and mixed incontinence

  • Recommended regimen is 3 sets of 8 to 12 slow velocity Ctxs sustained for 6 to 8 secs each performed 3-4 times a week and continued for at least 15-20 weeks.


Pharmacotherapy

PHARMACOTHERAPY

  • Anticholinergics=detrusor underactivity, may cause retention

  • Cholinergics=detrusor overactivity, may

    cause frequency

  • Alpha agonists=outlet overactivity, may cause retention

  • Alpha blockers=outlet underactivity, may cause stress incontinence


Anticholinergics

ANTICHOLINERGICS

  • Darifenacin (Enablex)

  • Oxybutynin (Ditropan, DitropanXL,Oxytrol)

  • Solifenacin (Vesicare)

  • Tolterodine (Detrol, Detrol LA)

  • Trospium (Sanctura)

  • Flavoxate (Urispas)


Other medications in urge incontinence

OTHER MEDICATIONS IN URGE INCONTINENCE

  • Bethanechol (Urecholine)( used to treat underactive detrusor function with elevated PVR)

  • Dicyclomine an antispasmodic.

  • TCA- Imipramine in mixed incontinence.

  • Duloxetine ( approved by the EU for treatment of SI.

  • Estrogen- No clear role for topical estrogen

  • Oral estrogen should not be prescribed for urinary incontinence in post menopausal woman.

  • Botox Not yet approved fby FDA, off label use for refractory urge incontinence.


Alpha agonists

ALPHA AGONISTS

  • Stimulates urethral smooth muscle contraction and have been used in the Rx for stress incontinence.

  • Phenylpropanolamine hydrochloride-no longer marketed in U.S. (Intracerebral hemorrhage)

  • Pseudoephedrine (Sudafed)

  • Midodrine (Proamatine


Alpha blockers 5 alpha reductase inhibitors

ALPHA BLOCKERS & 5 ALPHA REDUCTASE INHIBITORS

  • Are effective in men with OAB symptoms associated with BPH.

  • Alfuzosin (Uroxatral)

  • Doxazosin (Cardura)

  • Tamsulosin (Flomax)

  • Terazosin (Hytrin

  • Finasteride(Proscar)


Key recommendations

KEY RECOMMENDATIONS


Referral

REFERRAL

  • Failure to respond to treatment

  • Appearance of new symptoms

  • Microscopic hematuria in the absence of infection

  • Severe prolapse

  • Neurological symptoms


Other treatment options

OTHER TREATMENT OPTIONS

  • Electrical stimulation therapies for UI

    • Small removable device placed in either the vagina or anus

    • SNS is used for refractory urge UI, refractory urgency-frequency and idiopathic non- obstructive urinary retention

    • Intravesical stimulation

    • PC stimulation of tibial nerve.


Surgical treatment

SURGICAL TREATMENT

  • Indications:

    • Failed nonsurgical management

    • Unable to tolerate side effects of medications

    • More definitive therapy


Surgery contd

SURGERY Contd

  • Surgery offers the highest cure rates for stress UI

  • Burch colposuspension

  • Sling procedures

  • Periurethral bulking injection with collagen


Adjunctive measures

ADJUNCTIVE MEASURES

  • Pads and protective garments

  • Continence pessaries

  • Catheter (indwelling or intermittent )


References

References

  • Wilson L obstetrics and gynec 2001

  • Wagner, Urology 1998; 51:355

  • 355-61.,2004

  • Resnick, JAMA 1998; 280:2034

  • 2034-5.

  • Hendrix, Disease

  • Disease-A-Month, 2002; 48:622 622-636.

  • Management recommendations, In: Abrams, P, cardozo, L Khoury, S Wein, A. Incontinence 4 th international consultation on incontinence

  • Wallace , SA Roe, b Williams,K, Palmer, M,cochrane database sys review 2004; CD001308.


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