Urinary Incontinence

1. Urinary Incontinence Dr. Eyad Z. AL-Aqqad Special Urologist

3. Definition INCONTINENCE: Involuntary loss of urine or stool in sufficent 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 with concomatant fecal incontinence

4. How Common is Incontinence? • Prevalence increases with age (but it is not a part of normal aging) • 25-30% of community dwelling older women • 10-15% of community dwelling older men • 50% of nursing home residents; often associated with dementia, fecal incontinence, inability to walk and transfer independently

5. Urinary Incontinence is OftenUnder-Diagnoses and Under-Treated • Only 32% of primary care physicians routinely ask about incontinence • 50-75% of patients never describe symptoms to physicians • 80% of urinary incontinence can be cured or improved

6. Why is Incontinence Important? • Social stigmata - leads to restricted activities and depression • Medical complications - skin breakdown, increased urinary tract infections • Institutionalization - UI is the second leading cause of nursing home placement

7. Anatomy of Micturition • Detrusor muscle • External and Internal sphincter • Normal capacity 300-600cc • First urge to void 150-300cc • CNS control • Pons - facilitates • Cerebral cortex - inhibits • Harmonal effects - estrogen

8. Peripheral Nerves in Micturition • Parasympathetic (cholinergic) - Bladder contraction • Sympathetic - Bladder Relaxation • Sympathetic - Bladder Relaxation (β adrenergic) • Sympathetic - Bladder neck and urethral contraction (α adrenergic) • Somatic (Pudendal nerve) - contraction pelvic floor musculature

9. Peripheral Nerves in Micturition

10. Taking the History • Duration, severity, symptoms, previous treatment, medications, GU surgery • 3 P’s • Position of leakage (supine, sitting, standing) • Protection (pads per day, wetness of pads) • Problem (quality of life) • Bladder record or diary 1

11. Potentially Reversible Causes D - Delirium I - Infection A - Atrophic vaginitis or urethritis P - Pharmaceuticals P - Psychological disorders E - Endocrine disorders R - Restricted mobility S - Stool impaction 2

12. Medications That May Cause Incontinence • Diuretics • Anticholinergics - antihistamines, antipsychotics, antidepressants • Seditives/hypnotics • Alcohol • Narcotics • α-adrenergic agonists/antagnists • Calcium channel blockers

13. Categories of Incontinence • Urge incontinence • Stress incontinence • Overflow incontinence • Functional incontinence

14. Urge Incontinence Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder • Most common cause of UI >75 years of age • Abrupt desire to void cannot be suppressed • Usually idiopathic • Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

15. Stress Incontinence • Most common type in women < 75 years old • Occurs with increase in abdomenal pressure; cough, sneeze, etc. • Hypermotility of bladder neck and urethra; associated with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases) • Intrinsic sphinctor problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

16. Overflow Incontinence • Over distention of bladder • Bladder outlet obstruction; stricture, BPH, cystocele, fecal impaction • Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury, medications

17. Functional Incontinence • Does not involve lower urinary tract • Result of psychological, cognitive or physical impairment

18. Physical Examination • Mental status • Mobility • Fluid overload • Abdominal exam • Neurologic exam • Pelvic • Rectal

19. Diagnostic Tests • Stress test (diagnostic for stress incontinence; specificity >90%) • Post-void residual • Blood Tests (calcium, glucose, BUN, Cr) • Urine Culture • Simple (bedside) Cystometrics

20. Bladder Pressure-Volume Relationship

21. Interpretation of Post-Void Residual PVR < 50cc - Adequate bladder emptying PVR > 150cc - Avoid bladder relaxing drugs PVR > 200cc - Refer to Urology PVR > 400cc - Overflow UI likely

22. Treatment Options • Reduce amount and timing of fluid intake • Avoid bladder stimulants (caffeine) • Use diuretics judiciously (not before bed) • Reduce physical barriers to toilet (use bedside commode) 1

23. Treatment Options • Bladder training • Patient education • Scheduled voiding • Positive reinforcement • Pelvic floor exercises (Kegel Exercises) • Biofeedback • Caregiver interventions • Scheduled toileting • Habit training • Prompted voiding 2

24. Pharmacological Interventions • Urge Incontinence • Oxybutynin (Ditropan) • Propantheline (Pro-Banthine) • Imipramine (Tofranil) • Stress Incontinence • Phenylpropanolamine (Ornade) • Pseudo-Ephedrine (Sudafed) • Estrogen (orally, transdermally or transvaginally)

25. Surgical Interventions Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years. • Urethral Hypermotility • Marshall-Marchetti-Kantz procedure • Needle neck suspension • Intrinsic sphincter deficiency • Sling procedure

26. Other Interventions • Pessaries • Periurethral bulking agents (periurethral injection of collagen, fat or silicone) • Diapers or pads • Chronic catheterization • Periurethral or suprapubic • Indwelling or intermittant

27. Pessaries

28. Indwelling Catheter