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Urinary Incontinence

This article provides a practical approach to understanding and managing urinary incontinence, including its epidemiology, pathophysiology, classifications, and treatment options.

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Urinary Incontinence

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  1. Urinary Incontinence A Practical Approach

  2. What is urinary incontinence? Involuntary loss of urine

  3. Epidemiology • Prevalence • 10-30% in females age <64 • 15-30% in individuals in community • >50% in long-term care • Cost • >$20 billions a year • Mainly protective garment

  4. Morbidity and mortality • Psychological effects • Depression • Social withdrawal • Skin infection • Sleep deprivation

  5. Pathophysiology Bladder hyper or hypoactivity Outlet obstruction or insufficiency

  6. Start the work-up? • History…history…history… • Ask since patients are frequently embarrassed to discuss about urinary incontinence

  7. What to ask? Think through the possible causes of urinary incontinence

  8. Classifications? • Urge • Stress • Overflow • Mixed • Functional

  9. Most common type? Urge incontinence

  10. What is urge incontinence? Overactive bladder

  11. Causes of urge incontinence? • Idiopathic • Upper motor neuron problem • Lack of CNS inhibition • Stroke, cervical stenosis, multiple sclerosis • Age-related • Bladder irritation: UTI, tumor, and stones

  12. Clinical presentation of urge incontinence? • Urge sensation to void, a delay, then void • Leak a large amount of urine from bladder contraction

  13. What is stress incontinence? Leak of urine with increased abdominal pressure but without bladder contraction

  14. Causes of stress incontinence? • Insufficient urethral support from pelvic muscles and fascia • Urethral sphincter insufficiency • From operative trauma and scarring and mucosal atrophy due to menopause • Leak urine without stress maneuver • Urethral instability • Controversial • Urethral spontaneously relaxes

  15. Clinical presentations of stress incontinence? • Associated with increased intraabdominal pressure, such as coughing, laughing, sneezing • Small amount of urine leakage occurs instantly after the stress maneuver

  16. What is overflow incontinence? Urinary retention leading to leakage of urine when the intravesicular pressure exceeds that of urethral sphincter

  17. Causes of overflow incontinence? • Obstructive process • BPH – commonly present with urinary retention rather than overflow incontinence • Surgical correction for urinary incontinence • Large cystocele that kinks the urethra • Detrusor underactivity • Peripheral neuropathy: diabetes mellitus, syphilis, vitamin B12 defiency • Damage to spinal detrusor afferents: tumor, disc herniation • Detrusor fibrosis from chronic obstruction

  18. Clinical presentations of overflow incontinence? • Obstructive symptoms: hesitancy, frequency, urgency, post-void dribbling • Leaking urine continually • Neurological problems

  19. Mixed incontinence • Stress and urge • Detrusor hyperactivity with impaired contractility (DHIC): precipitant urgency and elevated postvoid residual without outlet obstruction

  20. Functional • Impaired mental status • Impaired mobility • Urinary tract infection • Fecal impaction

  21. Functional • Medications • Anticholinergic agents – retention, fecal impaction • Diuretics – not thiazide • Calcium blockers • Alpha-blocker – relax urethral sphincter • Narcotics – fecal impaction, sedation • Alcohol – sedation

  22. History? • Usual: duration, frequency, aggravating, alleviating factors, associated symptoms • Diary: time, leak?, amount, associated symptoms • Neurologic symptoms

  23. Physical exam? • Mental status • Mobility • Pelvic exam • Cystocele • Anal wink • Bulbocavernosus reflex • Spinal • Cervical stenosis • Occult spina bifida

  24. Tests? • Postvoid residual • Normal: 50-150 mL • Abnormal: >200 mL • Urinalysis • Q-tip • Bedside cystometry • Urodynamic tests – mainly for surgery and uncertain diagnosis

  25. Treatment for urge incontinence? • Bladder training:timed voiding & suppressing the urgency through relaxation technique • Biofeedback • Medications • Oxybutynin – ER and patch have less side-effects • Tolterodine – less side-effect than oxybutynin • Estrogen but not estrogen/progesterone

  26. Treatments for stress incontinence? • Pelvic muscle exercise • Biofeedback: weighed vaginal cone • Pessary • Medications • Imipramine – alpha-agonist and anticholinergic effect may be used in mixed urge and stress incontinence • Topical estrogen – treat mucosa atrophy and increase the number and sensitivity of alpha receptors • Surgery • Most effective treatment • Burch retropubic urethropexy

  27. Treatments for overflow incontinence? • Relieve the obstruction • Catherization • Improve bladder emptying with Valsalva maneuver, Crede maneuver, “double” voiding

  28. The End

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