Urinary Incontinence

Girija Charugundla

Definition

• UI is the involuntary loss of Urine that leads to a hygiene or social problem

Prevalence

1. Increases with age (not a part of normal aging)

2. 25 – 30% community dwelling women, 10 – 15% community dwelling men

3.About 1/3 of patients in acute care setting

4.Greater than 50% of residents in nursing homes associated with dementia, immobility and Fecal Incontinence

Anatomy of lower Urinary Tract

1. Muscular storage and contractile organ called detrusor (smooth muscle)

2.Smooth muscle sphincter located in Proximal urethra (internal sphincter)

3.Distal peri-urethral striated muscle (external sphincter)

Physiology of Micturation

1. Autonomic (sympathetic and Para-sympathetic) and somatic (voluntary) nervous systems coordinate micturation

2.Normal bladder fills passively with little change in intravesicle pressure (facilitated by CNS inhibition of Para-sympathetic activity) and the sphincters remain closed (facilitated by reflex increase in alfa-adrenergic and somatic tone)

3.For voiding para-sympathetic mediated bladder contraction coincides with coordinated sphincter relaxation

Urinary Changes With Normal Aging

1. Increase in post void residual volume (PVR), Involuntary bladder contraction (urgency) nocturia 1-2 times at night

2.Decrease in bladder capacity and force of contraction, ability to postpone voiding (frequency), urethral compliance and strength of pelvic floor muscle

- Delirium - Infection, urinary (symptomatic)- Atrophic urethritis- vaginitis - Pharmaceuticals - Psychological disorders- Endocrine disorders/ excessive urine

production- Restricted mobility - Stool impaction

Potentially reversible causes of Incontinence (Transient

Incontinence)

Lower Urinary Tract Dysfunction

Failure to Store- Hyperactive or

Overactive Bladder

- Incompetent Sphincter

Failure to Empty- Under-active

Bladder

- Obstruction

Types of Urinary Incontinence

• Stress• Urge• Overflow• Functional

Urge Incontinence

1. Most common cause of UI over age 75years

2.Abrupt desire to Void (Urgency that can not be suppressed)

3.Usually idiopathic 4.Other causes- bacterial cystitis bladder

tumor, bladder stones, atrophic vaginitis/ urethritis, stroke, Parkinson’s disease, dementia

Stress Incontinence

1. Most common in women especially less than 75 years

2.Hyper mobility of bladder neck and urethra, aging, hormonal, multiple child birth, hysterectomy, pelvic surgery

3.Intrinsic sphincter deficiency, previous pelvic or anti-incontinence surgery, pelvic radiation, trauma, neurogenic disorders

Overflow Incontinence

1. Over distension of the bladder causing constant or frequent dribbling

2.Bladder outlet/ stricture obstruction cystocele, BPH, Fecal impaction

3.Acontractile bladder (AKA: Detrusor hypo mobility, atonic bladder, Diabetes, MS, Lumber spinalstenosis, spinal cord injury, and medications

Functional Incontinence

1. Does not involve lower urinary tract

2.Result of Physical and /or cognitive impairment (arthritis, stroke, dementia)

Mixed Incontinence

1. When a combination of the above types exists

2.Most common combination is Detrusor overactivity (urge incontinence) and outlet incompetence (stress incontinence)

Office Work Up

1. Ask the question “in the past year have you ever lost urine or gotten wet?” if “yes” “have you lost urine on at least 6 separate days?”

2.Duration, severity, symptoms, previous treatment, medication, previous anti-incontinence surgery

3.Bladder record, frequency, type, and number of incontinent episodes

Physical Examination

1. Assess mental status2. Assess mobility3. Look for peripheral edema or evidence

of CHF4. Abdominal exam5. Neurologic- evaluation of lumbosacral

nerves, focal findings, peripheral neuropathy6. Pelvic exam- atrophic vaginitis,

cystocele, uterine prolapse, rectocele, para vaginal muscle tone, mass

7. Rectal- sphincter tone (active of resting), to asses integrity of sacral flexes (S2-S4), fecal impaction

Pad test/cough stress test

1. Perform with a full bladder, patient standing

2.Instantaneous leakage with cough- stress3.Specificity greater than 90% 4.Leakage delayed or persists after cough-

suspect urge UI

Post-voidal residual volume (PVR)

1. Perform within 5min of voiding

2. Catheterization or bladder ultrasound

- PVR less than 50cc adequate bladder emptying

- PVR less than 100cc adequate bladder emptying greater than 65 years

- PVR more than 200cc refer to specialist

Basic lab evaluation for UI

1. Calcium, glucose2.BUN/ Cr- if PVR is greater than 200cc3.UA and culture

Simple Cystometry

1. Useful when unsure of type of UI

2.Office based procedure 15-20min 3.3 determines bladder capacity and

stability 4.Correlates with multichannel

systometrogram

Management of UI

1. Behavior therapy2. Pharmacological therapy3. Surgery4. Pessaries5. Peri-urethral bulking agents 6. Occlusive devices 7. Garments and pads8. Catheters

Behavioral intervention

1. Reduce amount and timing of fluid intake

2.Avoid bladder stimulant such as caffeine, ETOH

3.Use diuretics judiciously 4.Make toilet easier to get to by

Suggesting bed side commode

1. Bladder retraining 2.Pelvic muscle (kegel) exercises

Patient dependent behavioral intervention

Caregiver dependent behavioral intervention

1. Scheduled toileting 2.Habit training3.Prompted voiding

Current therapy for UI

1. Oral medications2.Trandermal oxybutynine 3.Intravesicle therapy4.Botulinum toxins5.Interstim system

Treatment for stress incontinence

1. Meds2.Surgical techniques3.Pessary4.Peri-urethral bulking agents

Therapy for overflow incontinence

1. Meds to relieve obstruction2.Surgery to relieve obstruction3. Intermittent catheterization