URINARY

INCONTINENCE

Urology Division, Surgery DepartmentMedical Faculty,

University of Sumatera Utara

Definition

� The involuntary loss of urine

� May denote a symptom, a sign or a condition

� Symptom � the patient’s complaint of involuntary urine lossinvoluntary urine loss

� Sign � objective demonstration of urine loss

� The condition � the underlying cause

� Prevalence 38%, increasing with age

Classification

� Anatomic or genuine urinary stress incontinence

� Urge incontinence

� Neuropathic incontinence� Neuropathic incontinence

� Congenital incontinence

� False (overflow) incontinence

� Posttraumatic or iatrogenic incontinence

� Fistulous incontinence

URINARY INCONTINENCEURINARY INCONTINENCEURINARY INCONTINENCEURINARY INCONTINENCE

BLADDER RELATED

• URGE INCONTINENCE

�Detrusor overactivity

�Hyperreflexia

�Instability

SPHINCTER RELATED

• STRESS INCONTINENCE

�Anatomic / urethral hypermobility

�Intrinsic Sphincter Deficiency (ISD)

SPHINCTER RELATED

• STRESS INCONTINENCE

�Anatomic / urethral hypermobility

�Intrinsic Sphincter Deficiency (ISD)

�Instability

�Poor / Low Compliance

�Small Capacity

• OVERFLOW INCONTINENCE /

NON CONTACTILE / AREFLEXIE

�BPH with chronic retention

�Diabetic bladder neuropathy

�Complete parasympathetic lessions

Deficiency (ISD)Deficiency (ISD)

Combined problem associated with incontinence

� Detrusor overactivity with outlet obstruction

� Detrusor overactivity with impaired bladder contractility

� Sphincteric incontinence with impaired bladder � Sphincteric incontinence with impaired bladder contractility

� Sphincteric incontinence with detrusor overactivity

URINARY STRESS INCONTINENCE

� Women after middle age (with repeated pregnancies)

� A result of weakness of the pelvic floor

Sign & symptom

� Symptom : complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

� Sign :

- can be observed as the involuntary leakage of- can be observed as the involuntary leakage of

urine from the urethra

- a cough stress test by asking the patient to

cough with a full bladder and the objectively

assess the leakage of urine

Main risk factors

� Predisposing factors :

- Familiar predisposition

- Gender � higher in women

- Anatomic, neurological and muscular- Anatomic, neurological and muscular

abnormalities

� Inciting factors :

- pregnancy/childbirth/parity

- side effect of pelvic surgery & radio therapy

� Promoting factors :

- obesity

- constipation

- lung disease &

� Decompensating factors :

- age

- dementia & debility- lung disease &

smoking

- UTI

- neurological disease

- menopause

- drugs / medication

- dementia & debility

- drugs / medication

� The most studied and proven risk factors are :

- age

- obesity

- parity- parity

Diagnosis

� Detailed history : degree of leakage, its relation to activity, position and state of bladder fullness, timing of its onset, course of its progressionprogression

� Past surgical and obstetric history, medication taken, dietary habits, systemic disease

Treatment

� Conservative treatment :

- lifestyle intervention (weight loss, stop

smoking)

- pelvic floor muscle training- pelvic floor muscle training

� Pharmacological treatment :

- α1-adrenoceptor agonists

- tricyclic antidepressants

- oestrogens

� Surgical treatment

URGE INCONTINENCE

� Involuntary loss of urine, accompanied or immediately preceded by urgency

� Basic feature : detrusor instability and the loss of urine while attempting to inhibit micturationof urine while attempting to inhibit micturation

� OAB (overactive bladder)� urgency, frequency, nocturia

� Etio : neuropathic injuries (spinal cord injury), obstruction, inflammation, diabetes, BPH, iatrogenic

Diagnosis

� Detailed history

� Physical examination

� Urinalysis

Identification of modifiable causes usch as � Identification of modifiable causes usch as impaired mobility

Normal Control of Voiding:

Overactive Bladder:

Treatment

� Lifestyle modification (fluid management)

� Behavioral techniques (bladder training)

� Anticholinergic therapy (tolteridine, oxybutynin, trospium)oxybutynin, trospium)

� Medical management is more efficacious

� Surgical procedures (bladder reconstruction or urinary diversion)

MIXED URINARY INCONTINENCE

� Occurrence of stress-related incontinence with symptomatic urinary urgency and UI

� Detrusor dysfunction and is associated with urethral sphincter underactivityurethral sphincter underactivity

� Incidence increases with advancing age , most commonly in women > 60 years old

Therapy

� Behavioral therapy

� Anticholinergic � 70% cases have symptomatic improvement

� Surgical� Surgical

OVERFLOW INCONTINENCE

� Involuntary loss of urine associated with bladder overdistention

� 2 primary process are involved :

- urinary retention caused by bladder outlet- urinary retention caused by bladder outlet

obstruction

- inadequate bladder contraction

Diagnosis

� Overflow bladder is detected by measuring post-void residual urine volume with USG or urethral catheterization immediately after urinatesurinates

� N < 50 mL, if > 200 mL � overflow bladder

Treatment

� Initial treatment � focus on reversible causes (cystocele, pelvic organ prolapse, etc)

� If precipitating element not be found �conservatively : adjustment fluid intake and conservatively : adjustment fluid intake and timed voiding

WR’08