Urinry Incontinence

Urinary Incontinence

Contents • Definition • Epidemiology • Physiology of micturition • Causes of urinary incontinence

• • • • • •

Risk factors Types of UI Diagnostic test Prevention Conclusion References

Definition INCONTINENCE: Involuntary loss of urine or stool in sufficient 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 concomitant fecal incontinence

How Common is Incontinence? • • • • •

Prevalence of UI in a community is 30% Increases with age (but it is not a part of normal aging) 25-30% of community older women 10-15% of community older men 50% of hospital patients have urinary incontinence; often associated with dementia, fecal incontinence, inability to walk and transfer independently

Urinary Incontinence is Often

Under-Diagnosed 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 stigma- 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 Micturtion • • • • •

Normal capacity 300-600ml First urge to void 150-300ml Detrusor muscle External and Internal sphincter CNS control -Pons ,Cerebral cortex

• ANS • Somatic Nervous system • Hormonal effects - estrogen

Peripheral Nervous system • Parasympathetic (cholinergic) :- Bladder contraction • Sympathetic :β adrenergic - Bladder Relaxation α adrenergic -Bladder neck and urethral contraction • Somatic (Pudendal nerve) - contraction pelvic of floor musculature

Peripheral Nervous system Bladder Relaxation β adrenergic

Parasympathetic Bladder contraction

Bladder neck and urethral contraction α adrenergic

Contraction of pelvic floor musculature

PHYSIOLOGY OF MICTURITION

• Impulse travel from the bladder wall to the sacral region of the spinal cord

Parasympathetic neurons are activated and this will cause smooth muscle on bladder wall to contract

Sensory signals to the sacral region of the spinal cord also stimulate ascending pathway to the pons and cerebrum which results in conscious desire to urinate

If urination is not convenient at the time the brain sends impulses down the spinal cord to inhibit the micturtion reflex somatic nerve keep the urinary sphincter contracted

Causes of urinary incontinence • Temporary urinary incontinence -UTI -Alcohol -Constipation -Caffeine -Over-hydration -Dehydration -Bladder irritation -Medication

Persistent Urinary incontinence -Pregnancy and childbirth -Aging -Hysterectomy -Painful bladder syndrome -Enlarged prostate -Obstruction -Neurological disorder

Risk factors • • • • • • •

Sex Age Obesity Smoking Vascular disease High impact sports Other disease

Types of UI • Acute incontinence -sudden onset, transitory episode due to acute illness eg:- infection, delirium, epilepsy • Persistent incontinence -Urge incontinence -Stress incontinence -Overflow incontinence -Functional incontinence -Gross total incontinence

Urge Incontinence Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder, over active bladder

• Most common cause of UI >75 years of age • Sudden ,intense urge to urinate, followed by an involuntary loss of urine • Abrupt desire to void cannot be suppressed • Detrusor instability or detrusor hyperreflexia • Causes: infection, tumor, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

Stress Incontinence • Most common type in women < 75 years old • Loss of urine when exert pressure or stress to the bladder by coughing , sneezing, exercising,etc. • Due weakness of sphincter muscle • Causes:- aging, hormonal changes, trauma of

childbirth or pelvic surgery • In man stress incontinence is due to prostatectomy

Overflow Incontinence • Characterized by hesitancy, dribbling, poor urinary stream, leakage of small amount urine • Common in man with outflow tract obstruction due to prostatic hypertrophy • Non-contractile bladder (hypoactive detrusor or atonic bladder):- diabetes, spinal injury, medications • In women it associated with cystocoele

Functional Incontinence • Inability of an old person to reach toilet in time • Result of psychological, cognitive or physical impairment • Does not involve lower urinary tract • Disease associated with this:-Arthritis, AD, Dementia

Gross total incontinence • Continuous leakage of urine • Bladder has no storage capacity • Due anatomical defect, spinal cord injury, injury to urinary system • Fistula

Diagnostic approach 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

Diagnostic test • Urine microscopy • Routine blood test • Postvoid residual urine (PVR):-to measure how much urine remains in the bladder after urination • Urodynamic studies:-tests to measure pressure and urine flow • Multi-channel cystometric studies (inspect inside of the bladder) • Prostate specific antigen

Treatment • Noninvasive Treatments Behavioral Modifications Medications • Minimally Invasive Treatments Bulking agents Botulinum toxin Devices • Surgical Treatment Pubovaginal Fascial Slings Suburethral Slings Sacral Nerve Stimulation Enlarging the Bladder Laparoscopic Surgery

Behavioral Modifications • Pelvic floor muscle exercises (Kegel exercises) • Proper performance of Kegel exercises should be confirmed by digital vaginal examination or biofeedback. • Bladder training • Modifying the diet, fluid management , eliminating or adding medications, Avoiding Physical and Occupational Stress • Do not have side effects and are often very effective • Stress incontinence, detrusor instability, and urge incontinence

Medication • Drugs can change the autonomic function of the bladder by affecting the cholinergic and adrenergic nerves Anticholinergic drugs Propantheline bromide Emperonium bromide Musculotrophic drugs Oxybutinine Dicyclomine Flavoxate Tricyclic antidepressants Imipramine Doxypin

•

•

•

Beta (β) - adrenoceptor agonists Terbutaline Salbutamol Isoprenaline Alpha (α) - adrenoceptor antagonists Phenoxybenzamine Prazosine Prostaglandin synthetase inhibitors Flurbiprofen Indomethacin

Bulking agents • Treat stress incontinence in men and women • Bulking materials can be injected into the tissue around the urethra to add bulk and keep the sphincter muscles closed to stop urine from leaking • Collagen, Carbon particle beads Synthetic sugar

Botulinum Toxin • Is a neurotoxin protein produced by the bacterium C. botulinum • Injected into the muscles of the bladder to treat incontinence • Blocks the release of chemicals which cause muscle spasms • Is effective for nine months to a year

Devices

• Pessary- a special device inserted in the vagina to hold up the bladder and prevent leakage • Bladder neck support device -inserted in the vagina

to elevate the bladder neck and restore the normal anatomic relationship between the bladder and urethra

• Urethral insert- A small plug that is inserted into the

urethra, and removed for urination • Urine seal -a small disposable foam pad that is placed over the urethra opening • Artificial urinary sphincter -A tiny, doughnut-shaped device is inserted under the skin of the penis to close the urethra

Surgical Treatment Pubovaginal Fascial Slings • Attaches a piece of fascia around the bladder neck to keep urine in • Fascia taken from the patient's body • Success rate of over 90 percent Suburethral Slings • This is an outpatient, minimally invasive form of sling surgery with a high success rate • Suburethral slings are made of a synthetic mesh Sacral Nerve Stimulation • FDA-approved electronic stimulation therapy which can be effective in reducing urge incontinence • Small electrode tip is surgically placed near the sacral nerve act as a bladder pacemaker

Enlarging the Bladder Using a segment of intestine to enlarge the size of the bladder, this surgery can cure incontinence. However, in up to 30 percent of cases, patients may need a catheter.

Laparoscopic Surgery These procedures are used to surgically remove urinary tract obstructions, such as kidney stones and enlarged prostate glands

Prevention • • • • •

Maintain a healthy weight Don’t smoke Practice Kegel exercises Avoid bladder irritant Eat more fiber

Conclusion Management of UI needs very comprehensive planned approach after an accurate assessment and diagnostic evaluation. The majority of the patient are treatable, often curable. Appropriate treatment almost always resolves or improves the problem

References • Management of urinary incontinence ;P K Sarkar and A E S Ritch: Jr of Clin Pharm and Therap:(2000)25,251-263

• Pathophysiology of Overactive Bladder and Urge Urinary Incontinence; William D Steers, MD, FACS Rev Urol. 2002; 4 (Suppl 4): S7–S18

• The Pathophysiology of Stress Urinary Incontinence: A Historical Perspective; Geoffrey W Cundiff, MD Rev Urol. 2004; 6(Suppl 3): S10–S18. • Drug Therapy for Urinary Incontinence; D r V i k K h u l l a r Senior Lecturer and Consultant Urogynaecologist, Urogynaecology Unit,Department of Obstetrics and Gynaecology,