Urinary Incontinence

1. Urinary Incontinence Duke Family Medicine Joyce A Copeland, MD

2. Definition • Unintentional leakage of urine at inappropriate times

3. Epidemiology • 13,000,000 Americans • Before age 60 • 5:1 female • After age 50 • 2:1 female • 50% of homebound and institutionalized • Community • Men > 60: 10-15% • Women > 60: 20-35%

4. Under-reported • Identified <50% of the time • Considered normal part of aging • “untreatable” or only surgery works and not interested

5. Complications • Medical • Decubitus ulcers • UTIs • Sepsis • Renal failure • Increased mortality

6. Social • Loss of self-esteem • Restriction of social and sexual activities • Depression • Dependence • Nursing home placement • Economic • >$16,000,000,000

7. Mechanism of micturation • Multilayered contractile muscle of bladder • Components • Detrusor muscle • Pelvic nerves • Spinal nerves • Cerebral centers

8. Physiology • Bladder fills neural impulse Pelvic nerves spinal cord subcortical and cortical cerebral centers • Subcortical: basal ganglia and cerebellum subconscious relaxation of bladder to allow filling without urge to void • Filling continues bladder distention reaches conciousness cortical recognition in frontal lobe urge to void: volitional delay of urination

9. Desire to urinate neural impulse from cortex to spinal cord and pelvic nerves to detrusor muscle Cholinergic action Contract empty bladder • Other receptor chemicals • Also prostaglandin receptors • Calcium channel dependent

10. Sphincter mechanism • Alpha-adrenergic innervation: Contraction of urinary sphincter • Agonist strengthen contractions, eg. Pseudoephedrine • Blockade impair contraction, eg terazosin • -adrenergic innervation: Relaxation of sphincter • -Blocker impair relaxation unopposed alpha-adrenergic activity contraction of sphincter

11. Anatomy • Relationship of bladder to urethra and the abdominal cavity • Continence requires proper angulation • Effective transmission in intra-abdominal pressure • Prevent loss of urine with increase of intra-abdominal pressure

12. Categories • Urge incontinence • Increases frequency with age and decrease cognitive function • Stress incontinence • Most prevalent in elderly, predominant in women • Overflow bladder • Least common • Risks for hydronephrosis, renal damage • More common in men: BPH • Mixed: Urge and stress

13. Urge incontinence • Inability to delay voiding after sensation of fullness • Bladder contractions overwhelm cerebral center inhibition • Causes • Inflammation or irritation • Central impairment • High urine volume load • Impaired mobility prevents response: “functional” incontinence

14. Stress Incontinence • Malfunction of sphincter • Leak with increase in intra-abdominal pressure • Common causes • Pelvic prolapse • Urethral hypermobility • Displacement of urethra and bladder neck • Intrinsic sphincter deficiency

15. Overflow incontinence • Urinary retention with bladder distention • Leakage • Dribble • May mimic stress incontinence

16. Overflow: sources • Medication: Relaxation of detrusor • Neuropathy • Diabetes, MS, etc • Mechanical • BPH • Impaction • Stricture • Idiopathic

17. Mixed Incontinence • Stress + Overactive bladder • Identify most bothersome symptom

18. Functional Incontinence • Physical impairment • Cognitive impairment

20. DIAPPERS • Delirium, confusional state • Infections • Atrophic vaginitis or urethritis • Pharmaceuticals • Psychological conditions, especially depression • Endocrine/excessive urine production • Restricted mobility, urinary retention • Stool: impaction

21. Contributing factors • Pregnancy, childbirth, vaginal delivery • Estrogen depletion • Pelvic surgery • Immobility • Neurological disorders • Pelvic injury or radiation • Chronic disease

22. Symptoms • Problems holding or emptying bladder • Leak with cough, laugh, lift, sneeze • Leak on route to toilet • Frequency during day, nocturia • Urge awakens • Leak during physical activities • Use absorbent pads • Frequency of change • Urine staining

23. Symptoms present • Bowel and voiding habits • Other urinary sx • Nocturia, dysuria, hesitancy, change in stream, strain, hematuria, pain • Fluid intake • Caffeine • Change in bowel or bladder fct • Most bothersome sx

24. More questions • Precipitants • Surgery, injury, radiation, trauma, new onset dx, new medication • Treatment expectations • Environmental and functional assessment • Mental status prn

26. Voiding Diary • 24 hour voiding pattern • Times • Fluid intake • Urine volume estimate • Accidental leaks • Sensation/urge

27. Identify Reversible Causes

29. Exam • Cardiopulmonary • Signs of failure • Evidence of pulmonary disease • Cough • Medication

30. Exam • Endocrine • Diabetic Retinopathy • Adrenal • Thyroid • Obesity • Mobility

31. Neurological Neuropathy Cognition Cerebrovascular Affect and mood Spinal cord integrity LS nerve assessment DTRs Sensation Strength Perineal reflexes Exam

32. Regional reflexes

33. Abdomen Distention Hepatomegaly Pregnancy Musculature Masses Rectal Impaction Masses Sensation Prostate size, etc Exam

34. Genital Mass, foreskin, Glans, skin Pelvic Vaginal mucosa Friability Pelvic musculature Inflammation Discharge (pyridium test) Diverticula Bimanual Levator ani function 5-10 seconds Exam

35. Exam • Pelvic or rectal mass • Prolapse • Uterine, cystocele, cystourethrocele, rectocele, enterocele • Cough stress test • Supine • If positive with relatively empty bladder consider internal sphincter deficiency

36. Post-void residual volume • US: less risk but more cost • Post void volume • Within 10 minutes of voiding • Cath post voiding • 50-100 ml okay • > 200 ml definitely abnormal • Ultrasound

37. Lab • Urinalysis • Hematuria • Kidney stone • Malignancy • Cytology • Infection • Glycosuria • Bun, Cr with urinary retention • PSA

38. Special studies

39. Urge Incontinence • Urge • Loss of urine a/w strong desire to void • Frequency • Unable to get to toilet quickly enough after 1st urge • Sensation of incomplete emptying • No specific physical findings

40. Treatment: Urge • Behavioral therapy • Bladder training • Improves in 50% • More effective than oxybutynin • Pelvic floor exercises: Kegel • 81% reduction • vs. 69% with oxybutynin • Biofeedback • May help to learn Kegel • Does not decrease UI frequency vs. Kegel alone

41. Non-pharmacological • Bladder and pelvic floor training • Access to toilet • Reasonable fluid intake • 49-64 oz per day40-50 oz urine output • Avoid constipation: fiber • Limit caffeine and alcohol • Review medications and modify if possible

42. Bladder training • Advising the patient to control the urge to void • schedule urination at specific intervals • increase interval over time • teach methods to tighten pelvic muscles • goal 3-4 hours between voiding

43. Prompted voiding: cognitively impaired • Caretaker assists patient to toilet at scheduled intervals regardless of urge to void

44. Medication: Urge • Oxybutynin • Nonselective anticholinergic • Transdermal patches • Tolterodine • Selective anticholinergic • Less impact on salivary glands • Long acting formulations • More effective • Fewer anticholinergic effects • Patch • More effective than placebo • As effective as oral versions • More cutaneous side effects

45. Medication: Urge

46. Treatment: Urge • Electrical therapy • Severe refractory urge incontinence • Generator in s.c. tissue of lower back or buttocks • Lead placed through sacral foramen • Stimulate S3 sacral nerve • Decrease detrusor muscle contractions • $10,000 • Plus surgical costs for implantation • Medicare covers

47. Treat Stress Incontinence • Stress • Momentary leakage with sneezing, coughing, laughing, etc. • When bladder full or partially full • Stops with reduction of intra-abdominal pressure

48. Treatment: Stress

49. Intravaginal devices • Tampons, diaphragms • Pessaries • Hodge • Incontinence dish • Incontinence ring

50. Pessaries