Urinary Incontinence A Practical Approach

What is urinary incontinence? Involuntary loss of urine

Epidemiology Prevalence Cost 10-30% in females age <64 15-30% in individuals in community >50% in long-term care Cost >$20 billions a year Mainly protective garment

Morbidity and mortality Psychological effects Depression Social withdrawal Skin infection Sleep deprivation

Pathophysiology Bladder hyper or hypoactivity Outlet obstruction or insufficiency

Start the work-up? History…history…history… Ask since patients are frequently embarrassed to discuss about urinary incontinence

Think through the possible causes of urinary incontinence What to ask? Think through the possible causes of urinary incontinence

Classifications? Urge Stress Overflow Mixed Functional

Most common type? Urge incontinence

What is urge incontinence? Overactive bladder

Causes of urge incontinence? Idiopathic Upper motor neuron problem Lack of CNS inhibition Stroke, cervical stenosis, multiple sclerosis Age-related Bladder irritation: UTI, tumor, and stones

Clinical presentation of urge incontinence? Urge sensation to void, a delay, then void Leak a large amount of urine from bladder contraction

What is stress incontinence? Leak of urine with increased abdominal pressure but without bladder contraction

Causes of stress incontinence? Insufficient urethral support from pelvic muscles and fascia Urethral sphincter insufficiency From operative trauma and scarring and mucosal atrophy due to menopause Leak urine without stress maneuver Urethral instability Controversial Urethral spontaneously relaxes

Clinical presentations of stress incontinence? Associated with increased intraabdominal pressure, such as coughing, laughing, sneezing Small amount of urine leakage occurs instantly after the stress maneuver

What is overflow incontinence? Urinary retention leading to leakage of urine when the intravesicular pressure exceeds that of urethral sphincter

Causes of overflow incontinence? Obstructive process BPH – commonly present with urinary retention rather than overflow incontinence Surgical correction for urinary incontinence Large cystocele that kinks the urethra Detrusor underactivity Peripheral neuropathy: diabetes mellitus, syphilis, vitamin B12 defiency Damage to spinal detrusor afferents: tumor, disc herniation Detrusor fibrosis from chronic obstruction

Clinical presentations of overflow incontinence? Obstructive symptoms: hesitancy, frequency, urgency, post-void dribbling Leaking urine continually Neurological problems

Mixed incontinence Stress and urge Detrusor hyperactivity with impaired contractility (DHIC): precipitant urgency and elevated postvoid residual without outlet obstruction

Functional Impaired mental status Impaired mobility Urinary tract infection Fecal impaction

Functional Medications Anticholinergic agents – retention, fecal impaction Diuretics – not thiazide Calcium blockers Alpha-blocker – relax urethral sphincter Narcotics – fecal impaction, sedation Alcohol – sedation

History? Usual: duration, frequency, aggravating, alleviating factors, associated symptoms Diary: time, leak?, amount, associated symptoms Neurologic symptoms

Physical exam? Mental status Mobility Pelvic exam Spinal Cystocele Anal wink Bulbocavernosus reflex Spinal Cervical stenosis Occult spina bifida

Tests? Postvoid residual Urinalysis Q-tip Bedside cystometry Normal: 50-150 mL Abnormal: >200 mL Urinalysis Q-tip Bedside cystometry Urodynamic tests – mainly for surgery and uncertain diagnosis

Treatment for urge incontinence? Bladder training: timed voiding & suppressing the urgency through relaxation technique Biofeedback Medications Oxybutynin – ER and patch have less side-effects Tolterodine – less side-effect than oxybutynin Estrogen but not estrogen/progesterone

Treatments for stress incontinence? Pelvic muscle exercise Biofeedback: weighed vaginal cone Pessary Medications Imipramine – alpha-agonist and anticholinergic effect may be used in mixed urge and stress incontinence Topical estrogen – treat mucosa atrophy and increase the number and sensitivity of alpha receptors Surgery Most effective treatment Burch retropubic urethropexy

Treatments for overflow incontinence? Relieve the obstruction Catherization Improve bladder emptying with Valsalva maneuver, Crede maneuver, “double” voiding

The End