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Urine and Fecal Incontinence in Women Raissa Liem Rebecca Ayesha Rinda Martanti Roshni Manwani Urinary Incontinence in Women Definition • The International Continence Society, an organization charged with defining the various disorders of pelvic floor dysfunction, recently defined incontinence as “the complaint of any involuntary leakage of urine” Anatomy of Urinary bladder Epidemiology of urinary incontinence • Urinary incontinence affects 10 million people in the United States and 200 million people worldwide. • Urinary incontinence affects – 15-30% of the general geriatric population – 50-84% of the elderly persons in long-term care facilities. – up to 7% of children older than 5 years. • Incidence is 1.4% of adults aged 15-24 years and 2.9% of those aged 55-64 years. • Prevalence of female incontinence is reported at 38%, increasing with age from 20–30% during young adult life to almost 50% in elderly women. Anatomy of Incontinence Types of Urinary Incontinence Stress Urinary Incontinence Stress urinary incontinence occurs during periods of increased intra–abdominal pressure when the intravesical pressure rises higher than the pressure that the urethral closure mechanism can withstand (e.g., sneezing, coughing, or exercise) The most common form of urinary incontinence in women and is particularly common in younger women. Active women are more likely to notice symptoms of stress urinary incontinence. In a survey of 144 collegiate female varsity athletes, 27% reported stress incontinence while participating in their sport . The activities most likely to produce urinary loss were jumping, high–impact landings, and running. Urge Urinary Incontinence • It is the involuntary leakage of urine accompanied by or immediately preceded by urgency. – This is a symptom–based diagnosis and may or may not be caused by detrusor overactivity, which is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase. • More commonly found in older women • Women may also have related problems such as urgency, nocturia, and increased daytime frequency. • Increased daytime frequency occurs when the patient considers that she voids too often. (Note that the term pollakisuria is used to describe this condition in many countries.) Overflow Urinary Incontinence • Major contributing factor to overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction. • Symptoms of overflow incontinence include – – – – dribbling, urgency hesitancy, straining, a weak urine stream or low urine production even though your bladder feels full. • It’s more common in men, but overflow incontinence occurs in a significant number of women as well. Functional urinary incontinence • Functional incontinence is more common is elderly women and refers to incontinence that occurs because of factors unrelated to the physiologic voiding mechanism. • A woman who can't get to the bathroom quickly may often become incontinent. • Functional incontinence can be related to such factors as – decreased mobility, – musculoskeletal pain – poor vision Risk Factors of Urinary Incontinence • There is some evidence that age, pregnancy, childbirth, obesity, functional impairment, and cognitive impairment are associated with increased rates of incontinence or incontinence severity – – Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence.Plymouth, UK: Plymbridge Distributors Ltd, 2002:165–201. Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence in women. Urology 2003;62:16–23. • Pregnancy and delivery predispose women to stress urinary incontinence, at least during their younger years. • Of women who have not borne children, those who are pregnant leak more often than their nonpregnant counterparts; about half of women report symptoms of stress urinary incontinence during pregnancy, but in most, the symptom resolves after delivery. – Berek nNovak’s DIAGNOSIS OF URINARY INCONTINENCE Anamnesis Does the patient: - urinate during coughing, sneezing, walking, or jumping? stress incontinence - History of previous UTI - History of painful during urination - Does the urine contain/mix of blood? UTI - Often feel the urge to urinate and has urinated before came to the toilet? How is the frequency: - urination in a day - to wake up for urinating at night Does the urine come out: - at sleep? - When the stress arises? - During sexual intercourse? - Does the patient need to use tampon to prevent the urine come out? disease severity - Does the flow very slow? • Does the patient do contraction to urinate? urinary difficulty • Does the patient realise when the urine come out? overflow incontinesia • Does the patient still feel the urge to urinate after urination (anyang-anyangan)? vesicovaginal fistule • History: - Obstetric and gynecology - Other diseases: DM, stroke, chronic constipation - Previous operation - Medications related to urinary disorders diuresis, anticholinergic, alpha adrenergic blocker - Behaviour/habits daily urination, alcohol consumption From Anamnesis • Discover: - Type of incontinensia ( stress, urge, mixed, overflow, continue) - Severity (I,II,III), amont of tampon use in a day, episode in a day - Related to other diseases/infection - Related to life style/habits - Related to other medications Normal range • • • • Diuresis: 1000-1800 cc/hour Frequency : < 8x/hour Nocturia < 2x at night/morning Average urine volume 200-400 cc (max 400600 cc) Physical Examination General status Risk factors: - cardiovascular insufficiency - pulmonary disease (asthma) - occult neurologic processes (e.g., multiple sclerosis, stroke, Parkinson's disease, and anomalies of the spine and lower back), abdominal masses, and mobility Voiding Diary Residual urine <50 mL • First desire to void occurs between Cystometric capacity 150 and 250 mL infused • Strong desire to void does not occur until after 250 mL • Cystometric capacity between 400 and 600 mL • Bladder compliance between 20 and 100 mL/cm H2O measured 60 sec after reaching during filling, despite provocation • No stress or urge incontinence demonstrated, despite provocation • Voiding occurs as a result of a voluntarily initiated and sustained detrusor contraction • Flow rate during voiding is >15 mL/sec with a detrusor pressure of <50 cm H2O • No uninhibited detrusor contractions Neurologic • Mental status • Perineal sensation • Perineal reflexes • Patellar reflexes Abdominal examination • Masses Cardiovascular • Congestive heart failure • Lower extremity edema Mobility • Gait assessment Pelvic examination • Prolapse • Atrophy • Levator muscle palpation (symmetry, ability to squeeze) • Anal sphincter function • Test of urethral mobility (e.g., Q–tip test) Urethral Function tests • • • • • • Urinalysis Postvoid residual voulme Voiding cystometography Imaging test: USG, fluoroscopy, MRI Neurophysiologic test Electromyography Other examinations • Cough stress test • Pad test • Advance: - Urodynamics - uroflowmetry - Filling cystometry MANAGEMENT AND TREATMENT Non-surgical treatment • Lifestyle changes: obesity, postural changes, decreases caffeine intake • Physical therapy: Kegel exercise, pelvic floor muscle training • Behavioral therapy and bladder training • Vaginal and urethral devices include a - single–use triangularly shaped foam device with an adhesive hydrogel that adheres to the perimeatal area to keep urine from exiting the urethral meatus - a hat–shaped silicone patch that adheres by applying an adhesive gel to the edge of the device, squeezing the central dome, and creating a vacuum - The patch can be reapplied after voids and reused for up to 1 week. Medications Stress incontinence (The tone of the urethra and bladder neck is maintained in large part by α– adrenergic activity from the sympathetic nervous system) • imipramine (has a concomitant relaxing effect on the detrusor) • ephedrine, pseudoephedrine, phenylpropanolamine, and norepinephrine Urge incontinence and overactive bladder • anticholinergic agents effects on the bladder by blocking the activity of acetylcholine at muscarinic receptor sites Nocturia and nocturnal Enuresis • tricyclic antidepressants, particularly imipramine altering sleep mechanism, by providing anticholinergic or antidepressant effects, or by affecting antidiuretic hormone excretion Surgical treatment for stress Incontinence Retropubic Urethropexy (Colposuspension) Traditional Pubovaginal Sling Surgical treatment for Detrusor Overactivity • Neuromodulation: sacral nerve stimulation therapy • Botox injections • Augmentation cytoplasty and Urinary Diversion Surgical treatment of Fistule: Cytoscopy Fecal Incontinence Definition • Fecal incontinence is failure of control of the anal sphincters, with involuntary passage of faeces and flatus; it may be either psychogenic or organic in origin. Also called as encopresis and anal, bowel, or rectal incontinence. • (Dorland’s Illustrated Medical Dictionary 31st edition) • Fecal incontinence could cause psychologically and socially debilitating conditions. It can lead to social isolation, loss of selfesteem and self-confidence, and depression. Epidemiology The United States, it is reported that the prevalence of fecal incontinence in the general population is approximately 2-3% and vary greatly among the study population. In women, at 3-6 months after vaginal or cesarean delivery, there was 13-25%. Women almost twice the men. Anatomy External anal sphincter : • A subcutaneous portion • a superficial portion, • a deep portion exist. receives innervation from the pudendal nerve. Internal anal sphincter: • continuation of the inner circular smooth muscle of the bowel wall. • thickens over the last 2.5-4 cm of the rectum. • lies deep to the external anal sphincter, • its distal extent is just proximal to the subcutaneous portion of the external sphincter. • The internal anal sphincter is supplied by the autonomic nervous system. The levator complex is composed of : • the pubococcygeus, • the iliococcygeus, • the coccygeus muscles. The most medial fibers of the pubococcygeus make up the puborectalis. These fibers loop around the posterior aspect of the rectum and create an anterior displacement of the rectum known as the anorectal angle. The pelvic surface of the levator complex is innervated by sacral efferents from S2 through S4. The inferior surface is supplied by the perineal and inferior rectal branches of the pudendal nerve. Consequently, pudendal block does not abolish voluntary contraction of the pelvic floor but completely abolishes external anal sphincter function. Normal Physiology and Anatomy of anorectal region: Bowel function is controlled by: • anal sphincter pressure, • anorectal sensation, • rectal compliance, • colonic transit time, • stool volume and consistency. • adequate cognitive function with appropriate ability to access bathroom facilities are necessary for continence. If any of these factors are compromised, incontinence can occur. Continence requires the complex integration of: • signals among the smooth muscle of the colon and rectum, • the puborectalis muscle, • the anal sphincters, which is comprised of 2 components: – the internal anal sphincter (IAS) 0.3-0.5 cm expansion of the circular smooth muscle layer of the rectum – the external anal sphincter (EAS) 0.6-1.0 cm expansion of the levator ani muscles. • The IAS maintain continence at rest and contributes approximately 70-80% of the resting sphincter tone. • This is reinforced during voluntary squeeze by the EAS, the anal mucosal folds, and the anal endovascular cushions, which are further augmented by the puborectalis muscle, which forms a sling around the rectum and creates a forward pull to reinforce the anorectal angle. • The anorectal angle, which is approximately 90 degrees at rest, is created as the rectum perforates the levator complex. • Innervation of the EAS is from the pudendal nerve, a mixed motor and sensory nerve that arises from the second, third, and fourth sacral nerves (S2, S3, and S4). Innervation of the puborectalis arises more directly from these sacral nerves. Continence Process • Colonic contents @ rectum rectum distends sensation distension to S2, S3, and S4 parasympathetic nerves relaxation IAS (rectoanal inhibitory reflex) and EAS contract (rectoanal contractile reflex) contact of rectal contents with sensitive epithelial lining of the upper anal canal (rich sensory nerve endings, especially anal valves) contents are sampled as to their nature (ie, gas, liquid, or solid) equalization of the rectal and upper anal canal pressures. Defecation process • Anorectal angle straightens (due to squatting or sitting) + increased abdominal pressure by straining descent the pelvic floor, contraction of the rectum, inhibition of the external anal sphincter, and subsequent evacuation of the rectal contents. • If evacuation is not wanted, sympathetically mediated inhibition of the smooth muscle of the rectum and voluntary contraction of EAS and puborectalis musculature occur The anorectal angle becomes more acute and prevents the bolus of stool from descending further The contents of the rectum are forced back into the compliant rectal reservoir above the levators, which allows the IAS to recover and contract again. Causes of fecal incontinence include: Is multifactorial • Psychogenic • Organic : – constipation, – diarrhea, – muscle or nerve damage. weakened anal sphincter associated with aging or to damage to the nerves and muscles of the rectum and anus from giving birth. Organic Causes • Congenital abnormalities (such as spina bifida and myelomeningocele) • Medical conditions that may result in fecal incontinence include: – diabetes mellitus, – stroke, – spinal cord trauma, – degenerative disorders of the nervous system. Anal sphincter weakness • Obstetrical rupture of anal sphincter (chronic third- or fourth-degree perineal tears) • Injury related to surgical procedures – Internal sphincterotomy – Fistulotomy – Low anterior colorectal resection – Hemorrhoidectomy Neuropathy stretch injury Anatomic disturbances of the pelvic floor • Obstetric trauma • Chronic straining • Fecal impaction • Fistula • Rectal prolapse • Descending perineum syndrome Inflammatory conditions Neurologic conditions • Inflammatory bowel disease • Radiation enteritis • Infectious enteritis • • • • • • • • • Congenital anomalies Multiple sclerosis Parkinson disease Systemic sclerosis Spinal cord injury Stroke Dementia Diabetic neuropathy Diarrheal states Predisposing factors: Vaginal delivery as the most common predisposing factor to fecal incontinence • Vaginal delivery may result in : – internal or external anal sphincter disruption, Factors that are significantly associated with an increased risk of third-degree obstetric sphincter tears are : • primiparity, occiput posterior presentation, use of forceps, fetal weight greater than 4000 g, perineal tears, episiotomy, prolonged second stage of labor. • Damage to the pudendal nerve through overstretching and/or prolonged compression and ischemia. The pudendal nerve innervates the external anal sphincter muscle, anal canal skin, and coordinates reflex pathways. – anorectal function was unaltered in women undergoing cesarean delivery early in labor. – In women with advanced cervical dilation (>8 cm) at the time of cesarean delivery, they found delayed pudendal nerve terminal motor latency (PNTML) and reduced anal squeeze pressures. – In vaginal delivery decreased anal resting tone and squeeze pressures, EMG nerve damage. • This disruption of anal function sometimes is just due to defect in structural component, without any nervous damage. Not only among those who have prominent vaginal laceration. • In vaginal delivery using forceps increased latency of pudendal nerve (PNTML) sometimes the damage is permanent • However, some studies found that mostly anal incontinence that happen post partum, cease within 1 year after delivery. Age • Aging resulted in lower rectal volumes needed to inhibit anal sphincter tone, slowed pudendal nerve conduction, perineal descent at rest, and decreased anorectal sensory function. • in women older than 50 years anal canal squeeze pressure was significantly lower compared with that found in younger women. • Prevalence rate <30 years was 12.3%, compared with 19.4% in those older than 70 years. • Anal has many estrogen receptor menopausal women with HRT have better anal sensory and pressure function DIAGNOSIS Anamnesis • usually have extreme embarrassment over their condition Care should be given • type and duration of fecal incontinence, frequency of incontinent episodes, type of stool lost, impact of the disorder on the patient's life, history of associated trauma or surgery • True incontinence must be differentiated from pseudoincontinence, and patients may perceive drainage of mucous, pus, or blood from the perianal region as incontinence. • • • • • Medications and dietary habits systemic medical conditions that contribute An obstetric history Habits of straining, constipation Sexual abuse, regular anal intercourse Physical Examination • inspection of the perineal body and anus. • Speculum vaginal area • anal skin tags, hemorrhoids, anal fissures, scars, or chemical dermatitis, Rectal prolapse or fistulae • assessment of sensation of the perianal region • Digital examination to detect obvious anal pathology and provide an initial assessment of the anal resting tone • A bimanual digital rectal examination 1 digit in the rectum and 1 digit in the vagina Supporting examination Ultrasonography • transanal or endoanal ultrasonography allows the provider to perform a real-time, 360-degree evaluation of both the internal and external anal sphincters. • Sensitivity and specificity of ultrasonography findings are 98-100% for the external anal sphincter and 95.5% for the internal anal sphincter. • Could evaluate the rectum Anal manometry • to evaluate both the resting and squeeze pressures of the rectum. • to evaluate the rectoanal inhibitory reflex, rectal capacity, and rectal compliance. • Low manometric pressures are not predictive of anal sphincter defects. Women with known sphincter defects tend to have lower mean resting pressures; however, mean squeeze pressures may be unaffected. • Squeeze pressures are not significantly related to the presence of an external anal sphincter defect. Pudendal nerve terminal motor latency • helps evaluate the length of time required for a fixed electrical stimulus to travel along the pudendal nerve from the ischial spine to the anal verge. • Findings reflect the myelin function of the peripheral nerve, and the test allows for the evaluation of pelvic floor neuromuscular integrity. Electromyelogram • EMG helps evaluate the electrical activity generated by muscle fibers Defecography • Evacuation proctography (defecography) involves imaging the rectum with contrast material and observation of the process, rate, and completeness of rectal evacuation using fluoroscopic techniques. • Defecography helps to assess qualitatively the function of the anorectum and the adequacy of rectal emptying; static images measure the length of the anal sphincter, the anorectal angle, and perineal descent. Treatment Medical Therapy Conservative treatment bulking agents and biofeedback. The goal of medical therapy to reduce stool frequency and improve stool consistency. • A regular bowel regimen including daily laxatives should be established. • restricting fluid with intake in the patient who has incontinence of soft stool or liquid stool. • In patients with diarrhea due to noninfectious etiologies Loperamide . Other: atropine sulphate • Biofeedback is a safe, minimally invasive behavioral technique that uses auditory or visual feedback to reeducate the pelvic floor musculature. • The most commonly used techniques are rectal sensitivity training and anal sphincter strength training. • injectable materials may provide improvement in anal sphincter function. (e.g: silicone) Surgical Therapy Goal restoration of normal anatomy. • the anterior overlapping sphincteroplasty consists of dissecting out the external anal sphincter, dividing the scar tissue in the midline, and then overlapping the scar so that muscle is approximated to muscle as closely as possible. • the internal anal sphincter repair dissection along the intersphincteric plane and identification of the internal anal sphincter. The sphincter is then dissected free from the rectal mucosa and mobilized. The surgical technique varies depending on the bulk of scar tissue. The scar tissue is either divided or left intact as the sphincter is plicated. • Post anal technique • Muscle-wrap techniques have been developed in which striated muscles from the gracilis or gluteus muscles are transposed and wrapped around the anal canal to increase tone. • The artificial bowel sphincter (Acticon Neosphincter) was designed to act as a patient's own anal sphincter in cases of severe fecal incontinence. • Colostomy may be considered when all strategy are failed Outcome and prognosis • Initial outcome after sphincteroplasty is 64– 90% with short-term follow-up.The success rate starts to fall after the first few years and continues to fall with longer follow-up. Two long-term studies demonstrate that only half of the patients have satisfactory continence at 69-80 months postoperatively. References • Berek and Novak’s Gynecological 14th edition. • Altman D, Ekström Å, Forsgren C, et al. Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery. Am J Obstet Gynecol 2007;197:512.e1-512.e7. • Stepán J Jr, Karbanová J, Kalis V, Chaloupka P, Landsmanová J, Nosek J, Bukacová Z, Rokyta Z. Delivery, and anal incontinence later in life • William – obstetric • Alan G. Thorson, MDa,b,* .Anorectal physiology. USA:Surg Clin N Am 82 (2002) 1115–1123 • Massey et al. Peripheral Neuropathy in Pregnancy. Phys Med Rehabil Clin N Am 19 (2008) 149–162. • Toglia, Marc R. Pathophysiology of Anal Incontinence, Constipation, and Defecatory Dysfunction. Obstet Gynecol Clin N Am :36 (2009) 659–671. • Hannaway, Christine D, Tracy L Hull. Fecal Incontinence. Obstet Gynecol Clin N Am: 35 (2008) 249–269. • Brincat, Cynthia et al. Fecal incontinence in pregnancy and post partum. International Journal of Gynecology and Obstetrics 106 (2009) 236–238. • http://www.medicinenet.com/urinary_incontinence_in_women/art icle.htm • www.mayoclinic.com • http://emedicine.medscape.com/article/268674-media • Lewicky-Gaupp Christina, et al. Urinary and Anal Incontinence in African American Teenaged Gravidas during Pregnancy and the Puerperium. J Pediatr Adolesc Gynecol (2008) 21:21e26. • Omontosho, Tola B, Rebecca G. Rogers. Evaluation and Treatment of Anal Incontinence, Constipation, and Defecatory Dysfunction. Obstet Gynecol Clin N Am 36 (2009) 673–697. • Brummen, H Jorien, et al. Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J (2006) 17: 224–230. • Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence.Plymouth, UK: Plymbridge Distributors Ltd, 2002:165–201. • Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence in women. Urology 2003;62:16–23.