Urine incontinence

2. Urine incontinence Maryam Hajhashemy

3. Urinary incontinence, the involuntary leakage of urine, is common particularly in pregnancy. 50 percent of adult women experience urinary incontinence. only 25 to 61 percent of symptomatic community-dwelling women seek care embarrassment lack of knowledge about treatment options and/or fear of surgery

7. Urinary incontinence is not associated with increased mortality However, incontinence can impact many other aspects of a patient's health

8. History Many patients are reluctant to initiate a discussion about their incontinence. Women who have comorbid conditions associated with increased risk (eg, prolapse, bowel leakage, diabetes, obesity, neurologic disease) and those who are over 65 years of age should specifically be asked about urinary incontinence

10. The initial evaluation of urinary incontinence includes characterizing and classifying underlying conditions (eg, neurologic disorder or malignancy) reversible causes of incontinence

11. Stress urinary incontinence is associated with urine loss with increases in intra abdominal pressure, such as occurs with laughing, coughing, or sneezing. Urine volume lost may be small or large. There is no urge to urinate prior to the leakage.Urgency incontinence/overactive bladderis associated with frequent, small volume voids that may keep the patient up at night or worsen after taking a diuretic. The patient has a strong urge to void with an inability to make it to the bathroom in time.Overflow incontinence due to detrusor muscle underactivity is characterized by loss of urine with no warning or triggers. The volume leaked may be small or large. Urine loss often occurs with a change in position. This may be associated with urinary hesitancy, slow flow, urinary frequency and nocturia.

13. Classifying incontinence

15. UTIunderlying conditionsSudden onset of incontinenceAssociated abdominal/pelvic pain or hematuria without urinary tract infectionChanges in gait or new lower-extremity weaknessCardiopulmonary Neurologic symptoms, mental status changes Recurrent documented UTIs (three or more per year), Advanced pelvic organ prolapse beyond the hymen Elevated post void residual (PVR; >1/3 total volume) Long-term urinary catheterization Difficulty passing a urinary catheter

16. Normal Bladder Function:Bladder Filling Sympathetic “On” Parasympathetic “Off” 2,3 2,3 NorE Ach Pelvic Nerve Detrusor Voluntary NorE 1 Hypogastric Nerve Bladder Neck Pudendal Nerve Striated Sphincter

17. Normal Bladder Function:Bladder Emptying Parasympathetic “On” Sympathetic “Off” Parasympathetic “On” Ach NorE 2,3 2,3 Pelvic Nerve Detrusor Voluntary Pelvic Nerve 2,3 2,3 Ach NorE Detrusor Hypogastric Nerve Hypogastric Nerve NorE 1 Bladder Neck NorE 1 Bladder Neck Pudendal Nerve Striated Sphincter

18. Pharmacologic Causes, Continued • alpha-agonists •  urethral sphincter tone  retention and Overflow • alpha-antagonists •  urethral sphincter tone  Stress

24. Transient Causes of UI • Drugs & Diet • Infection • Atrophic Urethritis • Psychological - Depression, Delirium • Endocrine - Diabetes, Hypercalcemia • Restricted Mobility • Stool Impaction

26. Voiding diaries Basic diary records of frequency and volume Helpful to determine if urinary incontinence is associated with high fluid intakeA measure of the severity of the problem that can be followed over timeIdentify the maximum bladder capacity Time interval that the woman can wait between voids(guide bladder training)Three-day voiding 24-hour diaryNormal voiding frequency is less than eight times a day andonce at night, with total volumes of less than 1800 mL per 24 hours

29. Explain that reducing or eliminating caffeinated beverages, a well as reducing total fluid intake, can really make a difference to her incontinence

30. Impact on quality of lifeClinicians should identify those symptoms that are most bothersometo the patient as this can help guide treatment.The impact of the patient's incontinence on her quality of life can be assessed informally by asking a few targeted questions or by using a validated instrument.

31. Physical examinationWomen with atypical symptoms, diagnostic uncertainty, or failure of initial treatment strategies should undergo pelvic examination with special attention to evaluate for pelvic floor muscle integrity, vaginal atrophy, pelvic masses, and advanced pelvic organ prolapse beyond the hymen.Concomitant fecal incontinence requires a rectal exam to check for impaction or poor sphincter tone.

33. In women, check PFM strength using a digital vaginal exam. Ask patients to squeeze your finger with their vagina, in order to assess whether: you can feel a strong contraction and the woman has a good technique prior to suggesting a regular PFM exercise routine. an advantage of testing their PFM strength in clinic is that patients understand that weakness will be a factor. When I tell them the muscles are weak, the patient can sense this (sometimes it is REALLY obvious because they cannot even identify and contract the muscles at all).

34. PFM exercises are always recommended as first line therapy These can be prescribed alone or under the supervision of a physiotherapist, and should only take 10-15 minutes per day. tell them that many old patients were cured of incontinence, just by doing PFM exercises and cutting out their tea. Also tell them that there are no medications that can strengthen muscles, only exercise. Then I see if they want to give it a try

35. If there is concern for neurologic disease (sudden onset of incontinence (especially urgency symptoms) or new onset of neurologic symptoms) we ought to perform a limited evaluation of lower-extremity strength, reflexes, and perineal sensation. As examples, weakness with hyper reflexia of the lower extremity may suggest an upper motor neuron lesionAbsent perineal sensation with decreased rectal tone is concerning for cauda equine syndrome.

36. prescribe an exercise program for patients with arthritis and mobility problems to increase gait speed to get to the bathroom on time.

37. check for pedal edema if the patient complains of night-time symptoms, as fluid redistribution may contribute to nocturia. recommend the use of compression stockings to control pedal edema or diuretics

38. Laboratory tests A urinalysis should be performed for all patients, and urine culture performed if a UTI or hematuria is suggested on screening.Do not routinely check renal function unless there is concern for severe urinary retention resulting in hydronephrosis

40. Clinical tests: Only a few clinical tests are necessary for the initial evaluation of a woman with urinary incontinence as conservative treatment can be initiated based on symptoms aloneDo not obtain radiographic imaging for the initial evaluation in patients without complex neurologic conditions or abnormal findings on physical examination.

42. Bladder stress testThis test is performed with the patient in the standing position with a comfortably full bladder. While the examiner visualizes the urethra by separating the labia, the patient is asked to Valsalva and/or cough vigorously. The clinician observes directly whether or not there is leakage from the urethra. This test may be difficult in women with mobility or cognitive impairments; these women may benefit from performing the test in the dorsal lithotomy position.

44. The positive predictive value of the bladder stress test is 78 to 97 percent.A pooled analysis of three studies demonstrated that a positive bladder stress test helps to confirm stress leakage in women with stress or mixed incontinence. A negative test is less useful because a false negative may result from a small urine volume in the bladder or from patient inhibition.

46. Post void residual Measuring the PVR can be helpful when: Diagnosis is uncertain Initial therapy is ineffective Concern for urinary retention and/or overflow incontinence Neurologic disease Recurrent urinary tract infections History concerning for detrusor underactivity or bladder outlet obstruction History of urinary retention Severe constipation Pelvic organ prolapse beyond the hymen New-onset or recurrent incontinence after surgery for incontinence Diabetes mellitus

47. PVRParameters for interpreting the results of PVR testing are neither standardized nor well evaluated.In general, a PVR of less than one-third of total voided volume is considered adequate emptying.We use a PVR of >150 mL or >1/3 total volume as a cut point for further evaluation of voiding dysfunction. Additional suggested parameters include a PVR under 50 Ml as normal and a PVR greater than 200 mL as abnormal

49. Urodynamic testingDo not routinely refer for urodynamic testing in the initial evaluation of urinary incontinence in women whose symptoms are consistent with stress, urgency or mixed, incontinence

50. a Cochrane review concluded there were insufficient data from randomized studies to determine whether treatment of urinary incontinence according to a urodynamic-based diagnosis was more effective than treatment based upon history and examination alone