1. Urinary Incontinence
A Practical Approach

2. What is urinary incontinence?
Involuntary loss of urine

3. 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

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

5. Pathophysiology Bladder hyper or hypoactivity
Outlet obstruction or insufficiency

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

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

8. Classifications?
Urge
Stress
Overflow
Mixed
Functional

9. Most common type?
Urge incontinence

10. What is urge incontinence?
Overactive bladder

11. 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

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

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

14. 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

15. 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

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

17. 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

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

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

20. Functional Impaired mental status Impaired mobility
Urinary tract infection
Fecal impaction

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

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

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

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

25. 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

26. 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

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

28. The End