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Urinary Incontinence Ahmad Ali Akbari Kamrani M D Iranian Research Center on Ageing University of Social Welfare & Rehabilitation Sciences Definition Patient-centered : An uncontrollable loss of urine at inappropriate or unwanted times. Prevalence studies : Difficulty holding urine until you get to a toilet Unexpected or uncontrolled loss of urine Loss of control of urine Wet underpants Definition Severity definitions : Once or more Twice or more Three times or more Bad enough to cause social or hygienic problems Frequency definitions : Ewer Past year Past month Past week Per day Prevalence Urinary incontinence can occur at any age. It is normal among newborns, As enuresis among young children , As a stress incontinence among women of childbearing age As a geriatric syndrome among older persons Prevalence Older persons who are Homebound- long-term care facilities : 50% Community-dwelling older women : Any frequency of incontinence, 35% Daily incontinence, 14% Community-dwelling older men : Any frequency of incontinence, 22% Daily incontinence, 4% Unrecognized Incontinence Physician : (do not routinely ask ) 11% of physicians & nurse practitioners & 33% of physician assistants ask patients Patients : (do not seek care ) 30% of OP with incontinence have ever sought care for the problem. Avoid discussing the problem because of : Embarrassment , They believe it is a normal aspect of ageing for which no treatment is available , They believe surgery is the only available treatment and do not want to undergo surgery , Micturation mechanism When the bladder fills : Stretch receptors in the bladder wall transmit neural signals , Through the sacral plexus & spinal cord To micturation center in the brain stem Then transmits back through the spinal cord & sacral plexus to the detrusor muscle and this reflex loop produces detrusor muscle contractions & voiding. Stimulation of detrusor contractions is inhibited by neural centers in the frontal cortex, basal ganglia,& cerebellum. Inhibitory activity keeps the bladder relaxed and allows voluntarily urination . Principal diagnosis It is useful to consider, three basic pathophysiologic mechanism : Overactivity of the bladder detrusor muscle (urge incontinence ). Malfunction of the urinary sphincters ( stress incontinence ) . Overflow bladder (urinary retention ) Mixed Incontinence : multiple causes , Principal diagnosis Each of the three mechanism , Transient : (medications, infection, ….) Irreversible : ( degenerative neurologic disorders, …. ) Detrusor overactivity ( Urge Incontinence ) Lack the ability to control or inhibit contractions of the bladder detrusor muscle Detrusor muscle is overactive in relation to the ability of the inhibitory centers Detrusor overactivity ( Urge Incontinence Transient causes : 1/3 of U.I. -Drugs : most common cause (diuretics, sedatives, alcohol, … ) -Metabolic & neurologic : (hypoxemia, delirium, hyperglycemia, hypercalcemia, excess fluid consumption) -Inflamation : ( acute UTI , atrophic vaginitis, ..) Detrusor overactivity ( Urge Incontinence Irreversible causes : degenerative neurologic disorders ( detrusor hyperreflexia &instability ) -The most common : ( Dementia, Parkinson, Stroke,) -Any neurodegenerative conditions : (Normal-pressure hydrocephalus, Cerebral neoplasm ) Spinal cord injury ( automatic bladder, or neurogenic ) lose all cerebral inhibitory input to the detrusor Sphincter Malfunction ( stress incontinence ) Normal urinary sphincter function : Normal function of the sacral nerves that innervate the sphincter muscle , Normal function of Sphincter muscles : voluntary : periurethral skeletal muscles ( pelvic floor ) Involuntary : urethral smooth muscles α – adrenergic ( constriction ) β – adrenergic ( relax ) Normal urethral positioning closure of the urethral walls against themselves exposed to the intraabdominal pressure (cough,) and thereby prevents a pressure gradient between the bladder & the urethral Sphincter Malfunction ( stress incontinence ) Transient : - medications : α-adrenergic blocking , ( prazosin ) β- adrenergic agonist , (salbutamol ) Irreversible : -Urethral prolapse (classic stress incontinence ) -Intrinsic urethral deficiency (denervation after prostatectomy, trauma, radiation therapy, malignancy, sacral spinal cord lesions, ) Overflow bladder (urinary retention ) Two general mechanism cause : Obstruction of urinary outflow Failure of the detrusor to contract effectively Overflow bladder (urinary retention ) Transient : Medications : anticholinergics calcium channel blockers NSAIDs (blocked prostagladin receptors in bllader ) α-adrenergic agonist β-adrenergic antagonist CNS depressant (narcotics, sedatives,) Overflow bladder (urinary retention ) Irreversible : prostate enlargement (men ) strictures from previous surgery (women) injury of cholinergic pelvic nerve (neuropathic, neoplastic, traumatic,….) Diabetes, MS, amyloidosis, syphilis, heavy metal poisening Symptoms suggesting the Special evaluation History of anti-incontinence surgery & radical pelvic surgery – (urogynecologist ) Urge incontinence >2 - ( cystoscopy &… ) Hematuria & recurrent UTI – ( imaging studies & … ) physical findings suggesting the Special evaluation Prostate with a nodule or asymmetry Pelvic prolaps Neurologic disorder & spinal cord lesion Physical Findings suggesting the nature of Incontinence Parkinson & degenerative neurologic dis. ( uninhibited detrusor contractions ) Pelvic prolaps : cystocele , rectocele ( stress incontinence ) Palpation of distended bladder (overflow : prostate, neuropathic dis. ) Physical Findings suggesting transient Incontinence Fecal impaction (transient overflow) Atrophic vaginitis (transient detrusor overactivity ) (atrophic trigonitis & inflamation) Ancillary Tests Routine evaluation : U/A – PVR (post void residual)– NL<50 ml Simple bladder function tests : simple cystometry :(urgency<300 ml = detrusor overactivity ) stress testing: for women (pad test with full bladder, supine & standing Marshal test for surgery response : finger elevate the urethra & cough forcibly ) urine flowmetry : for men ( normal aged men >20 ml / s ) Ancillary Tests Selected patients ; - RFT - cystoscopy - urine cytology - imaging tests - formal cystometrography : (multilumen urethral catheter & rectal probe ) bladder pressure, intraabdominal pressure, urethral pressure, leak-point pressure, urethral flow rate, pelvic muscle electromyographic findings , …) Algorithm Treatment Self-treatment Transient causes treatment Irreversible causes treatment Collect urine & maintain hygiene Self-Treatment Changing pattern of fluid intake Identifying the location of the toilet Absorbent pads Herbal medication Management of Transient causes Urge-type : Acute UTI atrophic vaginitis delirium-hypoxia excessive fluid glycosuria hypercalciuria impaired mobility medication effects - antibiotic estrogen underlying dis. reduction control diabetes treat.hypercalcemia therapy D/C or change Management of Transient causes Sphincter malfunction : medication effects - D/C or change Overflow bladder : drug side effects - D/C or change fecal impact - disimpaction & stool softness Management of Non-Transient causes of urge incontinence Behavioral therapy – medication - surgery Behavioral therapy : bladder training (interval, 2 h-..longer) pelvic muscle exercises (Kegels) (for frail & cognitive impair. Less effective) Management of Non-Transient causes of urge incontinence Medication : oxybutinine – tolterodine propantheline – imipramine dicyclomine – calcium blocker NSAIDs Surgery : 1- augmentation cystoplasty (& a patch of intestine ) 2- urinary diversion (ileal urostomy ) 3- bladder denervation (subtrigonal phenol injections) sacral rhizotomy transvaginal denervation sacral dorsal root gaglionectomy Management of Non-Transient causes of stress incontinence Women : surgery – behavioral therapy medication - devices Men : behavioral therapy – medication surgery - Management of Non-Transient causes of stress incontinence Women : surgery:(6000 pt.-75-79% completely cure) (retropubic suspension procedure) behavioral : pelvic muscle exercises biofeedback techniques: (pressure gauges in the vagina provide auditory or visual display ) vaginal weights: (20-100 gr-placed in the vagina) ( for up to 15 min. using pelvic muscle contractions ). Medications : α-adrenergic agonist , estrogen Management of Non-Transient causes of stress incontinence Women : devices : pessaries occlusive devices Management of Non-Transient causes of stress incontinence Men : behavioral therapy medications- (α-adrenergic agonist ) Surgery : periurethral bulking injection ( first choice) placement of an artificial sphincter most often: ISD (intrinsic sphincter deficiency) after surgical trauma- radiation-urethra or nerve damage surgical interventions after prostatectomy/ waiting at least 6 month Management of Non-Transient causes of overflow incontinence Objectives : bladder drainage to prevent hydronephrosis Prostate enlargement : surgery : ( TUR ) – appropriate therapy drugs : delayed action & unsuitable New technologies : has not been defined (balloon dilatation - laser- coils-stents thermal therapy-) Exceptional circumstances ( neoplasia ) : ileourostomy Management of Non-Transient causes of overflow incontinence catheterization : three options - intermittent :(standard for inadequate detrusor contractions) ( 3 times/day or every 3-6 h. )( sterile or clean catheter- without antibiotic prophylactic ) ( rate of infection : 1-4 episodes / 100 days ) - indwelling : - suprapubic: ( foley- changed once a month ) ( when obstruction prevents passage of a catheter ) Management of Intractable incontinence Can not be controlled other than catheterization Environmental modifications : physical access facilities improvements in lighting avoiding tea, coffee, …. Devices & Collection systems absorbent pads & garments male candom catheters female paush devices penile clamps urethral catheters ( 14 f, 16f, 18f, ) Complications : infection, encrustation, dermatitis, Controversies The current recommendations : Expert opinion / evidence from research Different specialties / different approach The end