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Urinary Incontinence
Ahmad Ali Akbari Kamrani M DIranian Research Center on Ageing
University of Social Welfare & Rehabilitation Sciences
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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
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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
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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
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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%
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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 ,
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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 .
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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 ,
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Principal diagnosis
Each of the three mechanism , Transient : (medications, infection,
….)
Irreversible : ( degenerative neurologic disorders, …. )
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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
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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, ..)
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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
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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
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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, )
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Overflow bladder (urinary retention )
Two general mechanism cause :
Obstruction of urinary outflow
Failure of the detrusor to contract effectively
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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,)
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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
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Symptoms suggesting the Special evaluation
History of anti-incontinence surgery & radical pelvic surgery – (urogynecologist )
Urge incontinence >2 - ( cystoscopy &… )
Hematuria & recurrent UTI – ( imaging studies & … )
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physical findings suggesting the Special evaluation Prostate with a nodule or
asymmetry
Pelvic prolaps
Neurologic disorder & spinal cord lesion
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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. )
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Physical Findings suggesting transient Incontinence
Fecal impaction (transient overflow)
Atrophic vaginitis (transient detrusor overactivity ) (atrophic trigonitis &
inflamation)
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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 )
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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 , …)
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Algorithm
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Treatment
Self-treatment
Transient causes treatment Irreversible causes treatment
Collect urine & maintain hygiene
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Self-Treatment
Changing pattern of fluid intake
Identifying the location of the toilet
Absorbent pads
Herbal medication
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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
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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
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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)
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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
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Management of Non-Transient causes of stress incontinence Women : surgery – behavioral therapy medication - devices
Men : behavioral therapy – medication surgery -
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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
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Management of Non-Transient causes of stress incontinence
Women : devices :
pessaries
occlusive devices
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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
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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
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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 )
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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,
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Controversies
The current recommendations :
Expert opinion / evidence from research
Different specialties / different approach
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The end