Urinary Incontinence Dr Nedaa Bahkali 2012 Definitions Urinary

Urinary Incontinence Dr. Nedaa Bahkali 2012

Definitions: �Urinary incontinence is defined as involuntary leakage of urine.

Definitions: � Stress urinary incontinence (SUI): • involuntary urine leakage on exertion or with sneezing or coughing. � Urge urinary incontinence: • women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay. • If urge urinary incontinence is objectively demonstrated by cystometric evaluation, the condition is known as detrusor overactivity (DO).

Definitions: �Mixed urinary incontinence : • When both stress and urge components are present, it is called.

Epidemiology: �Prevalence of 25 - 55 %. � Among women with urinary incontinence, • the most common condition is stress incontinence, which represents 29 to 75 %of cases. • Detrusor overactivity accounts for up to 33 % of incontinence cases. • whereas the remainder is attributable to mixed forms.

Anatomy and Physiology of Micturition

Anatomy and Physiology of Micturition �Detrusor muscle �External and Internal sphincter �Normal capacity 500 -600 cc �First urge to void 150 cc

Anatomy and Physiology of Micturition

Anatomy and Physiology of Micturition

Anatomy and Physiology of Micturition Storage Reflex

Anatomy and Physiology of Micturition Reflex

Risks for Urinary Incontinence: o o o o Age Pregnancy Childbirth Menopause Hysterectomy Obesity Chronically increased abdominal pressure • Chronic cough • Constipation • Occupational risk o Smoking

Continence Theories �Pressure Transmission �Urethral Support

Pressure Transmission � In an ideally supported urogenital tract, increases in intra-abdominal pressure are equally transmitted to the bladder, bladder base, and urethra. � In women who are continent, increases in downward-directed pressure from cough, laugh, sneeze, and Valsalva maneuver are countered by supportive tissue tone provided by the levator ani muscle and vaginal connective tissue.

Pressure Transmission �In those with a weakened supportive "backboard", however, downward forces are not countered. � This leads to funneling of the urethrovesical junction, a patent urethra, and in turn, urine leakage.

Pressure Transmission

Urethral Support � Urethral support is integral to continenc • (1) ligaments along the lateral aspects of the urethra, termed the pubourethral ligaments; • (2) the vagina and its lateral fascial condensation; • (3) the arcus tendinous fascia pelvic; • (4) levator ani muscles. � With loss of urethral support, the urethra's ability to close against a firm supportive backboard is diminished.

Urethral Support

Urethral Support

Urethral Support

Diagnosis �History : • Duration, severity, symptoms, previous treatment, (Urinary Frequency, Urinary Retention, volume of urine lost , Postvoid dribbling is classically associated with urethral diverticulum) • medications, Past medical hx, GU surgery, Ob hx �Voiding Diary

Symptom Comparison of Women with Stress or Urge Incontinence Symptom Stress Incontinence Urgency Yes Frequency with urgency Yes Urine leakage with increased intra-abdominal pressures No Amount of urinary leakage with each incontinence Large episode Urge Incontinence No No Yes small Ability to reach the toilet in time following an urge Often No to void Yes Waking to void at night Seldom Usually

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

Physical Examination �General Inspection and Neurologic Evaluation • evidence of atrophy. • neurologic evaluation of the perineum: �bulbocavernosus reflex �normal circumferential anal sphincter contraction, colloquially called an "anal wink",

Pelvic Support Assessment �Pelvic Organ Prolapse Evaluation

Pelvic Support Assessment �Q-Tip Test

Diagnostic Testing �Urinalysis and Culture �Postvoid Residual �Cystometrics �Uroflowmetry

Treatment, ,

Treatment Options �Conservative/Nonsurgical: • Pelvic Floor Strengthening Exercises • Pelvic Floor Muscle Training (PFMT)

�Electrical Stimulation �Biofeedback Therapy �Dietary �Scheduled Voiding �Estrogen Replacement

Treatment of Stress Urinary Incontinence

Treatment of Stress Urinary Incontinence �Medications: • Pharmaceutical treatment plays a minor role in the treatment of women with SUI. • imipramine is reasonable to aid urethral contraction and closure. • Recently, duloxetine a selective serotonin and norepinephrine reuptake inhibitor, has been evaluated for the treatment of SUI

Pessaries

Surgical Treatment of Intrinsic Sphincteric Deficiency �Periurethral Bulking Agents

Surgical Treatment of Anatomic Stress Incontinence �Retropubic Urethropexy �Pubovaginal Slings �Midurethral Slings

Treatment of Urge Urinary Incontinence

Treatment of Urge Incontinence �Antimuscarinics: tertiary amines that act to block the muscarinic receptors in response to acetocholine • First line �Oxybutinin (Ditropan) �Tolteridine (Detrol)