Urinary incontinence Dr Mohammad Hatef Khorrami Urologist Fellowship

Urinary incontinence Dr Mohammad Hatef Khorrami Urologist Fellowship of endourology isfahan university of medical science

Incontinence Stress Urge mixed Unconscious Continuous Nocturnal enuresis

Epidemiology n n In women %3 -%11 In men %2 - %6

Mechanism of continence n n Good compliance sphincter

Structure of the Bladder Ureter Detrusor smooth muscle External urethral sphincter Pelvic floor Prostate gland

Micturition Reflex Direction of nerve impulse Brain Spinal cord Bladder Pelvic floor

Bladder Filling & Emptying Cycle 1. Bladder fills Detrusor muscle relaxes Urethral sphincter contracts The cycle of bladder filling and emptying Detrusor muscle contracts Urination Urethral sphincter relaxes 3. Urination voluntarily inhibited until time and place are right 2. First desire to urinate (bladder half full)

Etiology n Bladder abnormality n Detrusor overactivity Decreased bladder compliance n Sphincter abnormality n

Causes of detrusor overactivity n n n Idiopathic Neurologic CVA, brain atrophy, brain tumor , MS, SCI Non neurogenic UTI, obsruction, pelvic organ prolaps, bladder tumor, bladder stone, age

Sphincteric abnormality n Men n Prostate surgery, trauma, neurologic n Women n Urethral hypermobility, intrinsic sphincteric insufficiency, neurogenic

Causes of transient incontinence n n n n Delirium Infection Athrophic vaginitis Psychologic Pharmacologic Excess urine production Restricted mobility Stool impaction

How to Recognize Patients with incontinence • • Symptom assessment Medical history Physical examination Urinalysis Bladder diary Pad test Referral for medical evaluation and treatment

Medical History Other questions that your doctor/nurse might ask: • History of previous surgery or radiotherapy involving the pelvic region • Medications currently taking • Main symptoms (complaints) • Duration of symptoms

Physical Examination • Abdomen exam • Rectal exam • Pelvic exam • Neurologic exam

Urinalysis To rule out urinary tract infection

Bladder Diary Helps patients record details of: • Bladder symptoms • Type/amount of drinks taken • Time/amount of urine passed

Pad Test A supplementary test used to confirm urine leakage and quantify the degree of urine loss.

Pad Test Method: • Drink 500 ml of fluid as quickly as possible

Pad Test Method (cont’d): • Perform a series of physical tasks in a 1 -hour period • Walking • Climbing stairs • Coughing vigorously • Running on the spot

Pad Test Method (cont’d): • The pad is re-weighed. • A weight gain of more than 1 g signifies that the patient is incontinent.

Referral for Further Evaluation and Treatment Urodynamic test Imaging Endoscopy

treatment n n Low bladder compliance Drug Enterocystoplasty Denervation

Treatment sphincteric dysfunction n n n Behavioral modification Drug Urethral bulking agent surgery Sling Artificial sphincter

Management of Overactive Bladder • Drug therapy • Bladder training • Incontinence pads and protective devices • Bladder self-catheterization • Pelvic floor exercises • Biofeedback • Review diet and food intake • Skin care and cleanliness • Surgery

Bladder Training A behavioural approach to the treatment of the overactive bladder, which is often used in combination with drug therapy.

Bladder Training Aims: • Increase the time intervals between bladder emptying. • Increase bladder capacity by teaching patients to resist and suppress the urge to pass urine.

Incontinence Pads and Protective Equipment All-in-one briefs Absorbent pads Dribble pouch Reusable underpants designed to carry disposable absorbent pads Chair and bed pads

Pelvic Floor Exercises Also known as Kegel exercises

Pelvic Floor Exercises Aim: To strengthen the pelvic floor muscle and increase overall muscle tone.

Biofeedback Aim: Helps patient identify the correct muscle for performing Kegel exercises

Biofeedback Source: Biofeedback Instrument Corporation

Review Diet and Fluid Intake Some patients will try to reduce the risk of leakage by restricting their fluid intake.

Review Diet and Fluid Intake However, drinking too little results in concentrated urine, which itself can irritate the bladder

Review Diet and Fluid Intake Therefore, it is important that patients are encouraged to drink appropriate amount of fluids.

Review Diet and Fluid Intake Reduce consumption of: • Caffeine (i. e. tea and coffee) • Carbonated soft drinks • Alcoholic drinks

Management of Overactive Bladder • Drug therapy • Bladder training • Incontinence pads and protective devices • Bladder self-catheterization • Pelvic floor exercises • Biofeedback • Review diet and food intake • Skin care and cleanliness • Surgery

Role of Nurses • Help to recognise patients who have problems maintaining continence • Offer help and advice to patients and relatives

Control Confidence Freedom