URINARY INCONTINENCE MADE EASY

1.What is the definition of urinary incontinence?

            ` Complain of any involuntary loss of urine`

2.What are the types of  urinary incontinence?

1. Stress incontinence (Urodynamic stress incontinence): Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder.

` patient pass urine when she coughs or laughs`

2. Urge incontinence: Involuntary leakage accompanied by or immediately preceded by urgency

` patient feel the urge to pass urine but unable to control it until reaching wash room/toilet`

3. Mixed: A combination of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing

4. Functional: The inability to hold urine due to reasons other than neuro-urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders, urinary infection, reduced mobility

3.What are the risk factors for urinary incontinence?

1.Age

2.Race – white women had a prevalence of urodynamic incontinence 2.3 times higher than african american women

3.Pregnancy – aggravated physiological response

4.Child birth – damage to pelvic floor muscle       pudendal and pelvic nerves.

                            Increase with parity

5. Menopause – estrogen deficiency

4. What are the causes for stress incontinence?

Urethral hypemobility

   Urogenital prolapse

Pelvic floor damage or denervation

    parturition

    pelvic surgery

    menapause

Urethral scarring

    vaginal/urethral surgery

     incontinence surgery

     urethral dilatation

      recurrent UTI

     radiotherapy

Raised intraabdominal pressure

      pregnancy

       chronic cough

       abdominal /pelvic mass

       fecal impaction

       ascitis

       (obesity)

 `support to the bladder neck is lost` is the main reason for SI

5. What is detrusor over activity?

Urodynamic observation characterized by involuntary contractions during the filling phase which may be spontaneous or provoked .

It can cause urge incontinence 

6. What is over active bladder ?

Overactive bladder (OAB) is defined as urgency that occurs with or without UI and usually with frequency and nocturia.

7. What are points to be assessed  in the history taking ?

1.Severity and quantity of urine lost and frequency of incontinence episodes

2.Duration of the complaint and whether problems have been worsening

3.Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)

4.Constant versus intermittent urine loss

5.Associated frequency, urgency, dysuria, pain with a full bladder

6.History of urinary tract infections (UTIs)

7.Concomitant fecal incontinence or pelvic organ prolapse

8.Coexistent complicating or exacerbating medical problems

9.Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies

10.History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures

11.Other urologic procedures

12.Spinal and central nervous system surgery

13.Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure

14.Medications

8.What are the medical problems can excerbate the incontinence?

·         Chronic cough

·         Chronic obstructive pulmonary disease (COPD)

·         Congestive heart failure

·         Diabetes mellitus

·         Obesity

·         Connective tissue disorders

·         Postmenopausal hypoestrogenism

·         CNS or spinal cord disorders

·         Chronic UTIs

·         Urinary tract stones

·         Benign prostatic hyperplasia

·         Cancer of pelvic organs

9. What are the medications that may be associated with urinary incontinence ?

·         

      Cholinergic or anticholinergic drugs

·         Alpha-blockers

·         Over-the-counter allergy medications

·         Estrogen replacement

·         Beta-mimetics

·         Sedatives

·         Muscle relaxants

·         Diuretics

·         Angiotensin-converting enzyme (ACE) inhibitors

10 .What are the investigation for the incontinence?

General practioner/outpatient

Midstream specimen of urine

Frequency volume chart

Pad test

Basic urodynamics study

Uroflowmetry

Cystometry

Videocysto urethrography

Specialized urodynamics study

Urethral pressure profilometry

Cystourethroscopy

Ultrasound

Cystourethrography

Intravenous urography

Electromyography

Ambulatory urodynamic

11. What are the management options for stress incontinence? 

Stress incontinence

Conservative

Pharmacological

Surgical

12. What are the conservative managements for stress incontinence?

PFMT(pelvic floor muscle training/ pelvic floor exercise)

Vaginal cones

electric stimulation

Biofeedback

13. What are the indication for conservative management?

Mild disease

Medically unfit for surgery

Does not wish to undergo surgery

Fertility wish

Pregnancy

14. How Pelvic floor muscle training is practiced? 

Women learn to consciously precontract the pelvic floor muscles before and during increases in abdominal pressure to prevent leakage

Strength training builds up long lasting muscle volume and thus provides structural support

Abdominal muscle training indirectly strengthens the pelvic floor muscles .

Mechanical compression of urethra posterior to the symphysis

PFMT is more effective if patients are given a structured programme to follow rather than simple verbal instruction.

It is unusual for anything more than mild urodynamic stress incontinence to be completely cured by the conservative measures and most women require surgery eventually

15 what are the surgical options available for stress incontinence?

Surgery is usually the most effective way of curing urodynamic stress incontinence and a 90% cure rate can be expected for an appropriate properly performed primary procedure .

1st operative procedure offers the best chance of cure and therefore it is very important to select the appropriate procedure for each  patient .

Vaginal surgeries

Urethral bulking agents

Retropubic midurethral tape procedures

Transobturator mid urethral tape procedures

Abdominal

Burch colposuspencion                                              

Laparascopic

Burch colposuspencion                                               

combined 

sling procedure 

Complex

 Neourethra

artificial sphincter

 urinary diversion

Burch colposuspension

   corrects both SI and cystocele

   may not be suitable if vagina is scarred/narrowed

   Detrusor overactivity may occur de novo or may be

   unmasked by the procedure .

   Rectoenterocele may be excerbated .

    Overall cure rate 70%.

Retro pubic mid urethral tape procedure

Tension free vaginal tape(TVT)

Polypropylene mesh is inserted vaginally at   midurethral level

Under local, spinal and general anesthesia

Complication –short term voiding difficulties

                           bladder perforation

                           de novo urgency

                            bleeding

 90% cure rate  

Trans obturator Tape(TOT)

Local ,regional or general anesthesia

Complication – nerve /vessel injurry

                                bladder injury

                                 vaginal erosion

                         

15. What is Urethral bulking agents?

intramural bulking agents (silicone, carbon-coated zirconium beads or hyaluronic acid/dextran copolymer) for the management of stress incontinence  if conservative management has failed. 

Although success rates with urethral bulking agents are generally lower than those with conventinonal continence surgery ,they are minimally invasive and have lower complication rates meaning that they remain a useful alternative in selected cases

16. What are the initial conservative management of urge incontinence due to detrusor over activity?

Regime suggested by Jarvis

Exclude pathology

Explain rationale to patient

void every 1.5h-  await or be incontinent

Increase interval by 30min(bladder re training)

Normal volume of fluids

Keep fluid balance chart

Give encouragement 

17. What are the management option available if conservative treatment for UI failed ?

DRUG treatment 

Drugs with mixed action – oxybutynin

                                                             propiverine

Antimuscarinic drugs – tolterodine

                                                       trospium

                                                       solifenacin

                                                       fesoterodine

Antidepressants     -    imipramine

Prostaglandin synthetase inhibitors

Anti diuretic agents – desmopressin

Tolterodine is as effective as oxybutynin,although since it has fewer adverse effects,patient tolerability and compliance are improved

commonly used drugs in srilanka are oxytocin and tolterodine.

Intravesical therapy

Intravesical therapy –capsaicin

                                          resiniferatoxin

                                          botulinum toxin

Botulinum toxin A

offer bladder wall injection with botulinum toxin A[7] to women with OAB caused by proven detrusor overactivity that has not responded to conservative management (including OAB drug therapy).

Neuro modulation

Peripheral neuromodulation

Sacral neuromodulation

Surgery

Clam cystoplasty

Urinary diversion

Detrusor myectomy