2. Urinary Incontinence A Practical Approach

3. What is urinary incontinence? Involuntary loss of urine

4. Epidemiology Prevalence 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

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

6. Pathophysiology Bladder hyper or hypoactivity Outlet obstruction or insufficiency

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

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

9. Classifications? Urge Stress Overflow Mixed Functional

10. Most common type? Urge incontinence

11. What is urge incontinence? Overactive bladder

12. 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

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

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

15. 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

16. 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

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

18. 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

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

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

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

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

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

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

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

26. 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

27. 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

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