URINARY INCONTINENCE

1. PRIYA VASUDEVAN MD PGY 2 URINARY INCONTINENCE

2. OBJECTIVES • Identify the various forms of Urinary Incontinence (UI) • To become knowledgeable about the treatment interventions available • To understand the impact of Urinary Incontinence

3. 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…”

4. 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.

5. 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

7. 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

8. 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

9. Nerves and Micturition

10. Risk and Contributing Factors • Age • Parity • Obesity • Vaginal delivery • Episiotomy • Diabetes • Stroke • Estrogen depletion • Genitourinary surgery and radiation

11. 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

13. 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

14. STRESS INCONTINENCE

15. 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

16. URGE INCONTINENCE

17. GOTTA GO, GOTTA GO!!!!!!!!

18. 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

19. FUNCTIONAL INCONTINENCE Does not involve lower urinary tract Result of psychological, cognitive or physical impairment

20. MIXED INCONTINENCE

21. REVERSIBLE CAUSES • D- Delirium • I - Infection • A-Atrophic Vaginitis • P- Pharmaceuticals/ Psychological • E- Endocrine • R- Restricted mobility • S- Stool impaction

23. 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

24. 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.

25. 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?

26. BLADDER DIARY

28. CLINICAL TESTS • Stress test • Post void residual volume

29. 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.

30. 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

31. 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.

32. 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

33. 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

34. BEHAVIORAL TREATMENT • FUNCTIONAL INCONTINENCE • Patient education • Environment alterations • Grab bars/raised seats • Caregiver assistance/education • Screen for depression/cognitive impairment • Occupational /Physical therapy

35. 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.

36. 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

37. ANTICHOLINERGICS • Darifenacin (Enablex) • Oxybutynin (Ditropan, DitropanXL,Oxytrol) • Solifenacin (Vesicare) • Tolterodine (Detrol, Detrol LA) • Trospium (Sanctura) • Flavoxate (Urispas)

38. 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.

39. 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

40. 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)

41. KEY RECOMMENDATIONS

42. REFERRAL • Failure to respond to treatment • Appearance of new symptoms • Microscopic hematuria in the absence of infection • Severe prolapse • Neurological symptoms

43. 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.

44. SURGICAL TREATMENT • Indications: • Failed nonsurgical management • Unable to tolerate side effects of medications • More definitive therapy

45. SURGERY Contd • Surgery offers the highest cure rates for stress UI • Burch colposuspension • Sling procedures • Periurethral bulking injection with collagen

46. ADJUNCTIVE MEASURES • Pads and protective garments • Continence pessaries • Catheter (indwelling or intermittent )

47. 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.