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Dr mansooreh yaraghi Fellowship of pelvic floor INTRODUCTION: • Prevalence In older women:17 to 55 % Younger and middle-aged women: 12 to 42% • Universal screening in women: Difficult topic for patients Screening: Women who • Have had Children • Comorbid conditions associated with increased risk for urinary incontinence (diabetes, obesity, neurologic disease) • Over 65 years of age Should specifically be asked about symptoms of urinary incontinence INTRODUCTION: • Should not be dismissed simply as an age-related inconvenience: Herald a serious underlying condition (neurologic disease or malignancy) • Specialized testing and referral to a specialist are required in only a minority of cases. CLASSIFICATION: • Urge urinary incontinence(UUI): Typically have symptoms of involuntary leakage of urine accompanied by urgency The amount of leakage: • From a few drops to completely soaked undergarments. Common triggers: • Running water, hand washing, and cold weather exposure. Urgency incontinence is believed to be partly caused by detrusor overactivity CLASSIFICATION: • Stress urinary incontinence(SUI): Involuntary leakage with effort, exertion, sneezing , coughing, laughing Anytime an increase in intra abdominal pressure exceeds urethral sphincter closure Provoked by minimal or no activity when there is severe sphincter dysfunction CLASSIFICATION: • Stress urinary incontinence: Most common type in younger women Incidence is highest in women between 45 and 49 years old • Mixed incontinence In middle-aged and older women, it often coexists with urgency incontinence CLASSIFICATION: • Overflow incontinence: Involuntary, continuous, urinary leakage or dribbling and incomplete bladder emptying • Impaired detrusor contractility • Bladder outlet obstruction Rare in women Scarring from prior surgery for incontinence Significant pelvic organ prolapse CLASSIFICATION: • Overflow incontinence: Other associated symptoms : • weak or intermittent urinary stream, hesitancy, frequency, and nocturia • When the bladder is very full: stress leakage can occur Can point to an underlying cause CLASSIFICATION: • Uncategorized incontinence: Cannot be classified into one of the above categories on the basis of signs and symptoms Certain clinical features, with some overlap Many women have features of more than one type of incontinence The type of incontinence does not correspond precisely to a specific underlying pathophysiology Causes: • Genitourinary system causes Intra urethral incontinence Extra urethral Incontinence • Systemic conditions • Functional and Transient Incontinence(DIAPPERS) • Medications Causes: • Intra urethral incontinence Older women : several physiologic changes in the lower urinary tract : • Involuntary detrusor contractions or overactivity • Decreased detrusor contractility • Low estrogen levels • Changes in fluid excretion patterns • Decrease in urethral closure pressure Causes: • Intra urethral incontinence: Interstitial cystitis (painful bladder syndrome): • Younger women • Urgency incontinence :can be an atypical manifestation of interstitial cystitis Characterized by urgency and frequent voiding of small amounts of urine, often accompanied by dysuria Pelvic organ prolapse ( cystocele ) Causes: Extra urethral Incontinence: • Observation of urine leakage through channels other than the urethra • Stress or continuous leakage • Congenital: Bladder exstrophy Ectopic ureter • Traumatic: Vesicovaginal (developing nations) Ureterovaginal Vesicouterine CAUSES: • Systemic conditions: Congestive heart failure : Nocturia Neurologic disorders: • stroke, multiple sclerosis, Parkinson disease, disc herniation , spinal cord injury, normal pressure hydrocephalus, or subacute combined degeneration Diabetes mellitus: • Increased urine volume and frequency :in uncontrolled hyperglycemia • Overflow incontinence and poor urinary stream :in diabetic autonomic neuropathy. CAUSES: • Systemic conditions : Diabetes insipidus : • Polyuria , which must be differentiated from urinary frequency or nocturia Cancers: • Urinary frequency :urethral cancers • Hematuria should raise concern for bladder cancer. Sleep disorders: Depression: Obesity: nocturia CAUSES: Functional and Transient Incontinence:(DIAPPERS) CAUSES: Medications: • Diuretics: Polyuria, frequency, urgency • Caffeine: Frequency, urgency • Alcohol Sedation , impaired mobility , diuresis • Narcotic analgesics: Urinary retention, fecal impaction , sedation, delirium • Anticholinergic agents: Urinary retention, voiding difficulty CAUSES: Medications: • Antihistamines: Anticholinergic actions, sedation • Psychotropic agents • Antidepressants: Anticholinergic actions, sedation • Antipsychotics: Anticholinergic actions, sedation • Sedatives/hypnotics: Sedation, muscle relaxation , confusion CAUSES: Medications: • Alpha-adrenergic blockers: Stress incontinence • Alpha-adrenergic agonists: Urinary retention, voiding difficulty • Calcium-channel blockers: Urinary retention, voiding difficulty CAUSES: Medications: • Angiotensin - converting enzyme inhibitors: cough worsens stress and possibly urge leakage in persons with impaired sphincter function • Estrogen: Worsens stress and mixed leakage in women • GABAnergic agents(gabapentin , pregablin): Pedal edema : nocturia and nighttime incontinence • NSAID: Pedal edema:nocturnal polyuria CAUSES: Medications: • Oral contraceptives: Stress, urge, and mixed incontinence • Cholinesterase inhibitors Alone may increase incontinence Increased functional impairment when combined with anti incontinence antimuscarinic agents • Beta blockers: Urge incontinence • Lithium: Polyuria Warrant Consultation: • Uncertain diagnosis and inability to develop a reasonable treatment plan based on the basic diagnostic evaluation • Lack of correlation between symptoms and clinical findings Warrant Consultation: • Failure to respond to the patient’s satisfaction to an adequate therapeutic trial, and the patient is interested in pursuing further therapy. • Consideration of surgical intervention, particularly if previous surgery failed or the patient has a high surgical risk. Warrant Consultation: • The presence of other comorbid conditions: Incontinence associated with recurrent symptomatic urinary tract infection Persistent symptoms of difficult bladder emptying History of previous anti incontinence surgery, radical pelvic surgery, or pelvic radiation therapy Warrant Consultation: • The presence of other comorbid conditions: Symptomatic pelvic prolapse, especially if beyond hymen Abnormal postvoid residual urine Neurologic condition such as multiple sclerosis or spinal cord lesions or injury Warrant Consultation: • Fistula or suburethral diverticulum • Hematuria without infection EVALUATION: • Characterizing and classifying the type of incontinence • identifying reversible or serious underlying History Physical examination Urinalysis EVALUATION: • Additional evaluation : in the presence of complex medical conditions or worrisome findings on history and physical examination • specific clinical tests: Bladder stress test Postvoid residual Additional laboratory tests Radiographic imaging Referral to a specialist History: • • • • • • • • • • Urinary symptoms Frequency Volume onset of incontinence Timing Severity Duration Hesitancy precipitating triggers Nocturia History: • • • • • • • Intermittent or slow stream Incomplete emptying Continuous urine Leakage Straining to void Degree of bother and effect on quality of life (QOL) Underlying causes Living environment: Access to toilets or toilet substitutes Social factors such as living arrangements, social contacts, and caregiver involvement Questions: • Do you ever leak urine/water when you don’t want to? 1.Do you leak urine when you cough, sneeze, laugh or exercise ? (stress incontinence) 2. Do you ever have such an uncomfortably strong need to urinate that if you don’t reach the toilet you will leak? (sense of urgency) 3.If “yes” to question 2, do you ever leak before you reach the toilet? (urge incontinence) Questions: 4.How many times during the day do you urinate? (Frequency) 5.How many times do you void during the night after going to bed? (Frequency) 6. Have you wet the bed in the past year? (bedwetting) 7. Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry or on the way to the bathroom ? (sense of urgency) Questions: 8. Do you ever leak during or after sexual intercourse? (leaking with intercourse) 9. How often do you leak? (severity) Questions 2 through 9: symptoms associated with detrusor overactivity 10. Do you find it necessary to wear a pad , tissue or cloth in your underwear to catch urine because of your leaking? (severity) Questions: 11. Have you had bladder, urine, or kidney infections? (urinary tract infection and neoplasia) 12. Are you troubled by pain or discomfort when you urinate? (urinary tract infection and neoplasia) 13. Have you had blood in your urine? ( urinary tract infection and neoplasia) Questions: 14. Do you find it hard to begin urinating? (voiding Dysfunction) 15. Do you have a slow urinary stream or have to strain to pass your urine? (voiding Dysfunction) 16. After you urinate, do you have dribbling or a feeling that your bladder is still full? (voiding Dysfunction) Voiding (bladder) diaries • histories of frequency and severity:often inaccurate and misleading • more reliable • incontinence frequency • Severity • associated events or symptoms such as coughing, urgency, and pad use • volume of urine loss during incontinent episodes • Bedwetting • The maximum voided volume Voiding (bladder) diaries • can be helpful: Nocturia High urinary frequency or incontinence frequency Unclear history • mixed incontinence: the predominant, more bothersome component for the individual • Neither sensitive nor specific for determining the urodynamic cause of incontinence • excessive frequency and volume of fluid intake: restriction of excessive oral fluid intake combined with scheduled voiding improve symptoms of stress and urge incontinence Voiding (bladder) diaries • at least 2 days.(1-7days:3days) • 4 things every time you pass or leak urine: – The time – The amount of urine that pass – leaked any urine (were "wet") or not (were "dry") – Whether anything special may have caused you to go (for instance, "just had coffee," "coughed," "was running to the bathroom," "just took my water pill") • Start the record in the morning the first time you go to the bathroom after you get up. Voiding (bladder) diaries: • the time you got up and the time you went to bed. • a special receptacle (called a "hat"). Place the hat in the toilet to catch the urine every time you go. Look at how high the urine fills the hat, and write down the amount from the numbers on the inside of the hat. Remember to empty the hat after each time you go. • If you leak urine and cannot measure the amount that came out, write down your best guess. Quality of life: • Depression • Anxiety • Work • Relationships • Social life • Sexual function validated instruments (ICIQ, Kings Health Questionnaire) used to assess treatment efficacy for women with urinary incontinence. Systemic symptoms: • Onset of incontinence • Abdominal or pelvic pain • Hematuria • Lower extremity weakness • Changes in gait • Cardiopulmonary • Neurologic symptoms Systemic symptoms: • Weight changes • Mental status changes • Functional status • Mobility • Cognitive status • Changes in bowel function • Detailed medication history • Alcohol and caffeine intake Past medical &surgical history: • • • • • Gynecologic Neurologic Obstetric histories Diabetes, stroke, and lumbar disk disease Chronic pulmonary disease: strong coughing worsen symptoms of stress incontinence. • Chronic severe constipation: Voiding difficulties, urgency, stress incontinence,increased bladder capacity, and POP • prior surgical trauma to the lower urinary tract Hysterectomy Vaginal repair Pelvic cancer Pelvic radiotherapy Surgery for incontinence Drugs: • Altering drug dosage • Changing to a drug with similar therapeutic effectiveness but with fewer lower urinary tract side effects • Will often improve or “cure” the offending urinary tract symptom Physical examination: • The cardiovascular examination: volume overload (rales, pedal edema) • The abdominal examination: masses or tenderness. abdominal examination is not sensitive for detecting bladder distension Physical examination: • The extremities: joint mobility, function, and muscular atrophy or wasting. • The neck examination: with osteoarthritis: • neck movement and evaluate for interosseous muscle wasting of the hands. • These changes, especially if a Babinski reflex is also present:cervical spondylosis or stenosis causing detrusor overactivity Physical examination: • Detailed pelvic examination: Inspect the vaginal mucosa : • atrophy (thinning, pallor, loss of rugae) • narrowing of the introitus • vault stenosis • inflammation (erythema, petechiae, telangiectasia, friability) • Vaginal discharge Palpate bimanually : • masses or tenderness. Palpation of the anterior vaginal wall and urethra : • urethral discharge or tenderness : urethral diverticulum, carcinoma, or inflammatory condition of the urethra Physical examination: • Detailed pelvic examination: Assess the adequacy of pelvic support, and assess for pelvic organ prolapse, by a split-speculum • Cough once: looking for urethral leakage • urethra remains firmly fixed or swings quickly forward (urethral hypermobility), • anterior wall support defect • posterior wall support defect • Pelvic organ prolapse often coexists with urinary incontinence Rectal exam Q-Tip Test: • measurement of the axis change with straining sterile, lubricated cotton-tipped applicator transurethrally into the bladder, withdrawn slowly until definite resistance is felt (at the bladder neck) supine lithotomy • The resting angle in relation to the horizontal With goniometer or protractor • Maximum straining angle from the horizontal at cough and Valsalva maneuver • Not affected by the amount of urine in the bladder • Maximum straining angle >30° :abnormal Q-Tip Test: • Urethral mobility in continent women: Age Parity support defects of the anterior vaginal wall • urethral hypermobility” is common in asymptomatic women. • wide overlap in measurements between the continent and incontinent women • no longer considered useful in helping with diagnosis or treatment of incontinence Physical examination: • Detailed neurologic examination must be performed in : Sudden onset of incontinence (especially urge) Known neurologic disease New onset of neurologic symptoms Physical examination: • Screening neurologic examination: Mental status Sensory Motor function of both lower extremities Lumbosacral neurologic examination: • • • • Pelvic floor muscle strength Anal sphincter resting tone Voluntary anal contraction Perineal sensation Physical examination: • Mental status: Level of consciousness Orientation Memory Speech Comprehension. • Disorders with mental status aberrations&changes in bowel or bladder function: Senile and presenile dementia Brain tumors Stroke, Parkinson’s disease Normal pressure hydrocephalus. Physical examination: • Perineal sensation: Light touch Pinprick Temperature • • • • Peripheral sensation Resting and volitional tone of the anal sphincter Anal wink Vibration Physical examination: • Babinski reflex • Patellar, ankle reflex • Two reflexes of sacral reflex: Anal reflex • stroking the skin adjacent to the anus causes reflex contraction of the external anal sphincter muscle. The bulbocavernosus reflex: • Contraction of the bulbocavernosus and ischiocavernosus muscles in response to tapping or squeezing of the clitoris These reflexes can be difficult to evaluate clinically Not always present, even in neurologically intact women Bladder stress test: • • • • • • • Full bladder Stand Relax Single vigorous cough Clinician observes directly Negative test is less useful Positive bladder stress test :Does not require treatment unless the patient reports significant bother related to the incontinence.