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Urinary Incontinence: Diagnosis and Management

Urinary Incontinence: Diagnosis and Management. Jae S. Choi Fairleigh Dickinson University. Upon completion of this program the participant will:. 1. Define the pathophysiology of normal and abnormal micturition process

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Urinary Incontinence: Diagnosis and Management

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  1. Urinary Incontinence:Diagnosis and Management Jae S. Choi Fairleigh Dickinson University

  2. Upon completion of this program the participant will: 1. Define the pathophysiology of normal and abnormal micturition process 2. Review the current research data supporting the management of urinary incontinence 3. Understand how to identify, evaluate, and treat urinary incontinence 4. Identify future research directives concerning urinary incontinence

  3. Urinary Incontinence:Scope of the Problem >Affects approximately 17 million men and women in US >Costs an estimated $26 billion a year to manage in US >One half of the homebound and institutionalized elderly are incontinent >Second-most common reason for the institution of the elderly (Walsh, 2002)

  4. Urinary Incontinence:Scope of the Problem Prevalence of UI (1995)

  5. Urinary Incontinence • The uncontrollable loss of urine

  6. Incontinence Concerns • Finance • Isolation • Occupation • Odor • Skin problems • Depression • Embarrassment

  7. Anatomy: Female Genitalia (Swartz,2002)

  8. Anatomy: Male Genitalia (Swartz,2002)

  9. Mechanism of Continence • Active mechanism of continence • Anatomic mechanism of continence • Mucosal seal mechanism

  10. Active Mechanism of Continence • Supply by the active contraction of the muscle in the urethra, sphincter, and bladder neck • Active contraction of these muscles provides a force that closes the bladder outlet • Traumatic deliveries or other precipitators of incontinence may damage the nerves to the muscles or the muscles themselves by replacement with scar tissue

  11. Anatomic Mechanism of Continence • Proper rigidity of the ligament and fascia supporting the urethra and bladder neck • An anatomically well supported bladder neck • Ligaments that are lax and stretched allow the bladder neck to descend • Most surgical treatments for incontinence attempt to restore this anatomic mechanism

  12. Mucosal Seal Mechanism • Leak-proof mucosal seal provided by the supple urothelium and the vascularity of the submucosal vessels of the urethra and bladder neck • Loss of suppleness and adequate blood supply can be caused by prior surgery, radiation, or loss of estrogen

  13. Types of incontinence • Stress • Urge • Mixed • Overflow • Functional

  14. Stress Incontinence • The involuntary loss of urine during coughing, laughing, sneezing, or other activities that increase intra-abdominal pressure

  15. Genuine Stress Incontinence (GSI) • The involuntary loss of urine occurring when, in the absence of bladder muscle contraction, the pressure inside the bladder is greater than the pressure generated by the urethral sphincter. The pressure differential results in the leakage of urine.

  16. Factors Contributing to Stress UI • Age, Parity, Pregnancy (Thorp, et al, 1999) • Previous Gynecologic Surgery • Increased Body Mass Index • Family History (Bergman,2002) • Constipation as a young adult • Smoking • Sports • Race (Graham, 2001)

  17. Urge Incontinence • The involuntary loss of urine associated with an abrupt and strong desire to urinate

  18. Urge UI is also known as: • Overactive bladder • Detrusor hyperactivity • Detrusor instability • Neurogenic bladder • Detrusor hyperreflexia

  19. Evaluation of Urge UINeed to distinguish between: • Neurogenic • Non-neurogenic

  20. Neurogenic Urge Incontinence • Stroke • Spinal cord injury • Multiple Sclerosis • Synonymous with Detrusor hyperreflexia and neurogenic bladder • Diabetes

  21. Pontine Micturition Center • Lesions above the pons: CVA, TBI, MS, Hydrocephalus, CP, Alzheimer’s, tumor • Lesions below the pons: Spinal cord injury (C2-T12), MS, Spinomuscular disease, Disc problem

  22. Sacral Segments Involved Incontinence • Sacral segment S2, S3, and S4 provide afferent and enervation to two final peripheral nerves: pelvic nerve to bladder, pudendal nerve to striate sphincter of the urogenital diaphragm and levator ani muscles

  23. Non-neurogenic Urge Incontinence • Sensory urge incontinence • Motor urge incontinence • Most likely combination of both • Often idiopathic • Synonymous with detrusor instability, detrusor hypersensitivity/hyperactivity overactive bladder(OAB).

  24. Sensory Urge Incontinence • Acute or chronic cystitis • Interstitial cystitis • Bladder stones • Bladder cancer • Bladder irritants • Unknown

  25. Motor Urge Incontinence • Symptomatic presentation is similar to sensory urge incontinence • Diagnosis is usually supported by urodynamic findings of detrusor constrictions • Can be associated with bladder outlet obstruction in men from (BPH) or anatomic stress incontinence in women • Can be idiopathic • Also referred to as Detrusor instability

  26. Overactive Bladder (OAB) • New definition for urinary urgency and urge incontinence • More descriptive; takes into consideration all other previous definitions • Phrase coined by industry for marketing purposes

  27. Overactive Bladder (OAB):Cluster of Symptoms • Diurnal frequency; >8 micturitions a day • Nocturia: >2 micturition a night • Urgency and/or urge Urinary Incontinence

  28. Mixed Urinary Incontinence • Usually stress and urge • Can include other combinations • Most common in the older patient • Treatment plan is more complex

  29. Overflow Incontinence • Incontinence occurs because the bladder does not empty properly related decreased sensation, urine leaks, or dribbles out • Causes: 1. Obstruction: prostate, stool impaction, cystocele. 2. Neurogenic: diabetic neuropathy, stroke, multiple sclerosis, other neurologic disease, spinal cord injury, vitamin B12 deficiency

  30. Functional Incontinence • Occurs when a person cannot make it to the bathroom related to impairment of the mind or body (Alzheimer’s patients, wheel chair bound) • Common in institutionalized patients or those with disabilities • Urinary system is normal

  31. Transient Causes of Incontinence • D Delirium/confusion states • I Infection-urinary (Symptomatic) • A Atrophic urethritis/vaginitis • P Pharmaceuticals • P Psychologic, especially depression • E Endocrine (hyperglycemia, hypercalcemia) • R Restricted mobility • S Stool impaction

  32. Evaluation of IncontinenceComponents include: • History • Physical examination with additional tests (PVR, provocative stress testing) • Urinalysis

  33. History • Focused medical history • Neurologic history • Genitourinary history • Surgical history • Traumatic history • Medication review including nonprescription medication • Herbal medication and other supplements

  34. History: A Detailed Exploration of the Symptoms of UI • Duration and characteristics of UI • Frequency, timing, and amount of continent and incontinent voids • Precipitants of UI (cough, laughing, stress, constipation) • Other lower urinary tract symptoms • Fluid intake pattern, including caffeine containing or other diuretic fluids • Alteration in bowel habit or sexual function • Previous treatment and effects on UI • Use of pads, briefs, or protective devices

  35. Physical Examination • Abdominal examination: detect masses or suprapubic fullness or tenderness • Pelvic examination: assess genital atrophy, pelvic prolapse, urethral prolapse, cystocele, rectocele, enterocele, pelvic mass, perivaginal muscle tone, urethral diverticulum, and urethra and bladder neck hypermobility • Rectal examination: assess perineal sensation, sphincter tone, bulbocavernous reflex, fecal impaction, rectal mass • General: edema, sleep pattern, mobility, cognition,environmental and social factors

  36. Tests • Estimation of PVR volume: bladder scanning, catheterization • Provocative stress testing • Urinalysis: basic test for UI work-up to assess hematuria, leukocytes, nitrates, bacteriuria, glycosuria, proteinuria • Use of a voiding record • Urine cytology • Blood tests: BUN, creatinine, glucose • Urodynamics: EMG/CMG,Uroflow studies: flow rate

  37. Treatment for Stress Urinary Incontinence:Medical Therapy • Estrogen therapy: estrogen cream,Vegifem, Estring • No need to oppose vaginal ertrogen • Systemic HRT still requires local therapy

  38. Treatment for Stress Urinary Incontinence:Behavioral Therapy • Behavioral modification • PME: pelvic Muscle exercises: Vaginal cones, biofeedback • Physical therapy • Electrical Stimulation

  39. Treatment for Stress Urinary Incontinence:Surgical Therapy • Periurethral injections: collagen, durasphere • Various types of surgical procedures: pubovaginal slings, bladder neck suspension, artificial urinary sphincter

  40. Treatment for Stress Urinary Incontinence:Surgical Therapy

  41. Treatment for Stress Urinary Incontinence:Non-Surgical Therapy: Pessary • Various shapes and sizes depending types of problems • Modern Pessaries made of silicone • Need to be removed every 3 months for maintenance • Need to assess for irritation or erosion

  42. Treatment for UUI/OAB:Behavioral Therapy • Fluid/dietary techniques: • Obtain adequate fluid intake: 15ml/lb/day • reduce or avoid bladder irritants: caffeine, alcohol • Aggressively manage constipation • Behavioral modification: scheduled voiding, urge suppression, Pelvic muscle exercise, electrical stimulation

  43. Treatment for UUI/OAB:Medical Therapy • Usually anticholinergics: • Ditropan 2.5-10mg tid, Ditropan XL 5-15mg qd • Detrol 2mg bid, Detrol LA 4mg qd • Side effects of anticholinergics:dry mouth, dry eyes, constipation, confusion in the elderly more common with Ditropan because it crosses the BBB • Intravesical agents: Ditropan more for neurogenic dysfunction

  44. Treatment for UUI/OAB:Surgical Therapy • Surgical treatment : • Sacral neuromodulation • Bladder augmentation

  45. Treatment for Neurogenic Bladder • If neurogenic bladder is suspected refer to a neurologist, urologist, or neurourologist.

  46. Summary of the Presentation • The tremendous number of patients with urinary incontinence is becoming recognized, and the economic impact is staggering. • Because the prevalence of the urinary incontinence increases with age, a working knowledge of the diagnosis and treatment of the various types of urinary incontinence is fundamental. • By obtaining a careful medical history and performing a comprehensive physical examination, the primary care providers can initiate successful treatment for the majority of patients without the need for invasive testing.

  47. Future Research and Study • There is a need for prospective studies of age and ethnically diverse individuals to provide data that permit more accurate problem identification in these populations. • Quality of life is significant. Quality of life should be incorporated as an outcome in clinical trials evaluating causes and therapy. • Study is needed to understand the people who have emotional and social isolation with urinary incontinence. • Study is needed to determine the efficacy of behavioral and physical therapy for urinary incontinence.

  48. References • Culligan, P. J.(2000), Urinary incontinence in women: evaluation and management, American Family Physician, 66(11), 2433-44,2447,2452. • Elia, G., Bergman, J., and Dye, T.D., (2002), Familial incidence of urinary incontinence, American Journal of Obstetrics and Gynecology,187 (1), 53-55. • Graham, C.A. and Mallett, V.T., Race as a predictor of urinary incontinence and pelvic organ prolapse, American Journal of Obstetrics and Gynecology, 185(1),116-120. • Roberts,R. O., et al., (1999), Prevalence of combined fecal and urinary incontinence: a community-based study, Journal of American Geriatrics Society, 47(7), 837-841. • Swartz, M., (2002), Textbook of Physical Diagnosis, 4th ed., Philadelphia: W.B. Saunders Company. • Tierney, L. M., et al, (2002), Current Medical Diagnosis and Treatment, 41st ed., New York: Lange Medical Books/McGraw-Hill.. • Thorp,J.M.,et al,(1999), Urinary incontinence in pregnancy and the puerperium: a prospective study, American Journal of Obstetrics and Gynecology, 181(2), 266-273. • Walsh, (2002), Campbell’s Urology, 8th ed., Elsevier Science. • www.chs.stste.ky.us • www.drylife.org • www.incontinence-foundation.org • www.jhbnc.jhu.edu • www.merck.com • www.university obgyn.com *Pictures: Georgia O’Keeffe

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