Download Mixed Urinary Incontinence

Urinary Incontinence
Donald R. Noll DO FACOI
Edited by Edward Warren, MD,
Chair Geriatrics
Carolinas Campus, March 2012
GOAL
To understand urinary incontinence, its
types, its evaluation, and its treatment.
Learning Objectives
1. Define urinary incontinence and how to uncover it.
(slides 5 - 7)
2. Discuss the neurology of urinary function. (slides 8 – 11)
3. List the types of urinary incontinence. (slide 12)
4. List causes of transient urinary incontinence. (slide 13)
5. Discuss urge incontinence. (slides 14 – 16)
6. Discuss stress incontinence. (slides 17 – 20)
7. Discuss overflow incontinence. (slides 21 – 23)
8. Discuss functional incontinence. (slides 24 – 25)
9. Describe mixed urinary incontinence. (slides 26 – 27)
Learning Objectives
10. Describe the elements of the H&PE related to urinary
incontinence evaluation. (slides 28 – 31)
11. Describe the use of a bladder diary. (slides 32 – 33)
12. Discuss the use of post voiding residual urine volume and urodynamic
testing. (slides 34 – 35)
13. Describe nonpharmacological treatment of urinary incontinence and
Kegel exercises. (slides 36 – 40)
14. List and explain the medications useful for urinary incontinence. (slides
41 – 43)
15. Discuss surgical treatment of urinary incontinence. (slide 44)
16. Explain the use of vaginal pessaries for urinary incontinence. (slide 45)
17. Discuss the use and risks of Foley catheters in urinary incontinence.
(slide 46)
Urinary Incontinence
• Involuntary leakage of urine
• Under diagnosed and under-treated
• Ask about it. Patients often don’t
mention it.
• ~ ⅓ community dwelling elders
• ~ ½ of hospitalized patients.
Risky Medications
• Loop diuretics – urgency
• Calcium channel blockers – detrusor
contractility impairment, nocturnal
diuresis
• NSAIDS – noctural diuresis
• Anticholinergics – bladder retention
Questions
• Do you ever leak urine when you don’t
want to?
• Do you ever leak urine when you cough,
laugh or exercise?
• Do you leak urine on the way to the
bathroom?
• Do you wear pads in your underwear to
catch urine?
Neurologic Input
Neurologic Input
Parasympathetic
Response
Sympathetic
Response
• Stimulates Detrusor
Contractions
• Relaxes the trigone
and urinary
sphincter
• Beta 2 - Relaxes
Detrusor
• Alpha 1 - Contracts
the trigone and
urinary sphincter
During Urine Storage
• Bladder distention stimulates:
– Sympathetic outflow to the bladder
– Pudendal outflow to the urinary sphincter
• The above two functions are spinal
reflexes.
• A region in the pons allows conscious
increase in urinary sphincter activity.
During Voiding
• The pontine micturition center is
stimulated.
• Parasympathetic outflow then leads to:
– Bladder contraction
– Sphincter relaxation
Types of Urinary Incontinence
Transient
Urge
Stress
Overflow
Functional
Mixed
Transient Incontinence
Mnemonic: DIAPPERS
•
•
•
•
•
•
•
•
D elirium
I nfection
A trophic urethritis / vaginitis
P harmaceuticals
P sychological (severe depression, psychosis)
E xcessive Fluid output (diuretics, caffeine)
R estrictive Mobility
S tool Impaction
Urge Incontinence
• Abrupt onset or overwhelming desire
to void.
• Can be precipitated by running water,
going out in the cold or even trying to
unlock the door to get into the house.
• Is characterized by leakage of moderate to
large amounts of urine leakage.
Urge Incontinence
• The etiology:
– Uninhibited bladder contractions or detrusor
overactivity
• Contributing factors or causes of this include:
– Age-related changes
– Disruption of CNS inhibitory pathways
– Bladder irritation by infection, inflammation,
stones
Urge Incontinence
• Urge incontinence is often due to a
combination of detrusor hyperactivity and
impaired contractility
• These patients have urgency as well as an
elevated post void residual volume.
Stress Incontinence
• Leakage of small amounts of urine when
there is increased intra-abdominal pressure.
• This pressure overcomes the sphincter tone.
• The leakage occurs immediately.
• If delayed, it might be stress-maneuverinduced urge incontinence.
Stress Incontinence
• Caused by impaired urethral support
from the pelvic musculature in women
• Worse in
–Multi-parous women
–Overweight women
Stress Incontinence
• Less commonly, can be due to sphincter
incompetence from:
– Trauma and scarring or
– Mucosal atrophy in post-menopausal women
• With sphincter incompetence, the leakage is
continuous and not solely with increased intraabdominal pressure.
Stress Incontinence
Stress incontinence does not
generally respond well to
drug treatment and is usually
treated with muscle training
or surgical approaches.
Overflow Incontinence
• This is continual leakage of urine or
dribbling associated with incomplete
bladder emptying.
• Due to
– Impaired detrusor contractility
– bladder outlet obstruction (BPH)
– Or both
Overflow Incontinence
• Post-void residuals (urine remaining in the
bladder following micturition) are elevated.
• There are often stress incontinence type of
symptoms when an intact sphincter is
overwhelmed by the large bladder volume.
Overflow Incontinence
• Detrusor underactivity is the most common
cause of overflow incontinence.
• Outlet obstruction from prostatic disease is the
second most common cause of overflow
incontinence in older men.
• Patient are in danger of renal failure due to back
pressure into the kidneys harming glomerular
function.
Functional Incontinence
• Due to functional or situational
issues and often involves both
urinary and fecal incontinence.
• Not an organic or anatomic cause
• Examples
– Limited mobility from arthritis
– Limited cognition from dementia
Functional Incontinence
Treatment is pragmatic.
• If the bathroom is too far away,
consider a bedside commode.
• Timed voidings, especially at night,
helps avoid urgent situations.
Mixed Urinary Incontinence
Often, an individual patient, especially
older patients, have multiple factors
contributing to their problem.
• An elderly man might have a functional
impairment from a previous CVA, outlet
obstruction from prostatic hypertrophy,
detrusor overactivity and be on a diuretic
which contributes to urinary urgency.
Mixed Urinary Incontinence
• Many patients have a MIXED
picture
• Examples:
–Stress + Urge in women
–Functional + Urge in Dementia
Approach to a Patient: History
Ask about volume and circumstances of urine loss.
• Does your entire bladder empty at once?
• Is your urine leaking continuously?
• Does your urine only leak when you cough or exercise?
• Do you feel as though you do not empty your bladder
completely or have to go to the bathroom a second time
to finish?
• Do you ever loose stool?
Approach to a Patient: History
History questions
• Do you have a history of Prostate problems?
• Are you post-menopausal?
• How many children have you had?
• How big was your largest baby delivered
vaginally?
• Did you tear or have to have an episiotomy with
your deliveries?
Approach to a Patient
Review Medical and Surgical History
• Have you ever had bladder or prostate
surgery?
• Have you ever had a significant injury to
your private area?
• Have you ever had low back problems or
spinal surgery?
• Have you ever had a stroke?
Approach to a Patient
•
•
•
•
Review drugs
Physical exam-includes pelvic in woman
A rectal in both men and woman
Lab work based on symptoms but nearly
also includes at least a urinalysis
• Bladder diary-helps to clarify details of the
incontinence if not clear.
Instructions on Keeping a Bladder
Diary
Things to record
• The time
• Amount of urine you pass
• Whether you leaked urine
• Any special circumstances that may have
made you leak
Example of a Bladder Diary
Approach to a Patient
Post void residual urine volume
• Very helpful test
• Can be done with a bladder scan
(ultrasound) in many places or with an in and
out catheterization.
• Less than 50 ml of urine is considered
normal but many feel the normal range for
older patients should be up to 200 ml.
Approach to a Patient
Urodynamic Testing
• Measure the volume and pressure in the bladder
during filling and voiding
• Done by a urologist in office or hospital outpatient setting
• Not needed for all, do in
– Men considering an prostatectomy
– Women considering surgery
– Failed empiric medical treatment
• Considered the gold standard - invasive and costly.
Treatment: General
• Avoid Ethanol
• Weight loss
• Limit fluid intake at bedtime or when
a bathroom will be inconvenient
• Control constipation
Treatment: Physical strengthening
•
•
•
•
Kegel’s exercises
Vaginal Weights
Biofeedback
Best in women with to strengthen pelvic
floor muscles. These are especially
beneficial in women with stress
incontinence.
KEGEL Exercises
FINDING THE RIGHT MUSCLES TO EXERCISE
• Squeeze muscles to try to stop the flow of urine when you are sitting on
the toilet. If you can do it, you are probably using the right muscles. This
is just a technique to FIND the muscles. Do not do your exercises
regularly while you are urinating.
• Squeeze the muscles you would use if you were trying to stop passing
gas. If you sense a "pulling" feeling, those are the right muscles for
pelvic exercises. Don't tighten your abdominal muscles, or push down.
Pretend you are sitting on a marble, and gently use your vaginal
muscles (or, if you are a man, use your bowel muscles) to "lift" that
marble up. It is more important to do the exercise correctly, than to use a
lot of force.
KEGEL Exercises
EXERCISES — After you have identified the
correct muscles to squeeze, you can begin
performing pelvic muscle exercises.
Squeeze the muscles and hold for a count of
3, then relax for a count of 3. Perform a set
of 10 to 15 repetitions each time you
exercise and do a set of exercises three
times each day.
Treatment: Behavioral therapy
• Toileting regimens for cognitively impaired
• Bladder training for cognitively intact: This involves
timed voiding while awake based upon smallest time
intervals in a bladder diary and relaxation techniques
to suppress urge in between times.
• Biofeedback may help with bladder training:
sometimes done by occupational therapists.
Drug Therapy
• Anticholinergics-inhibit action of acetylcholine
and reduce bladder spasms.
Oxybutynin (Ditropan)*
Trospium (Santura)
Darifencin (Enablex)
Tolterodine (Detrol)*
Solifenacin (Vesicare)
• Anticholinergics can lead to urinary retention and must
be used with care, especially if the patient also has
outlet obstruction.
• * These can lead to confusion in the elderly.
Drug Therapy
• Alpha 1 receptors in the trigone area promote
contraction.
• Imipramine has a dual alpha agonist and anticholinergic
properties and might be useful in some patients with
mixed incontinence (Urge, Stress).
• Alpha 1 blockers are often used with prostate disease
in an effort to help relax the urinary sphincter (Overflow)
-- tamsulosin
Drug Therapy
• Bethanechol stimulates cholinergic receptors
and increases detrusor tone. It is useful in
urinary retention.
• Oral Estrogen-increases the number and
responsiveness of alpha receptors: beneficial.
• Oral estrogen/progesterone regimens have been
shown to worsen incontinence.
• Intravaginal / Topical products are useful in some
studies, not in others.
Surgical Treatments
• Multiple surgical approaches are available
depending on the type of incontinence.
• Surgery works best for stress incontinence
or to repair outlet obstruction.
• Procedures range from peri-urethral
collagen injections to bladder suspension.
Other Treatments: Vaginal Pessaries
• Help in women with stress incontinence,
vaginal prolapse, weak pelvic floor.
• Patients must understand the need for
removal and cleaning of a pessary and
they need to be fitted by an experienced
health care provider.
• Fitted exactly like a diaphragm.
Other Treatments
• Indwelling catheters (Foleys): These carry a high risk
of infection and are best used for short term only.
• Intermittent catheterization is theoretically safer but
requires a motivated patient and caregivers.
• Men needing long term Foleys should have a
suprapubic cystostomy. Otherwise, the catheter will
eventually cut through the length of the penile shaft on
the dorsum.
References
Bladder Diary. National Kidney and Urologic
Disease Information Clearinghouse. 3
Information Way
Bethesda, MD 20892–3580.
Available at:
http://kidney.niddk.nih.gov/kudiseases/pubs/pdf
/diary.pdf