Urinary Incontinence Dr Eyad Z ALAqqad Special Urologist

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

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

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

Urinary Incontinence is Often Under-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

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

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

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

Peripheral Nerves in Micturition

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

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

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

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

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

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)

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

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

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

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

Bladder Pressure-Volume Relationship

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

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

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

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

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

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

Pessaries

Indwelling Catheter