URINARY INCONTINENCE

RAHEEF MOHAMED ALATASSI

5TH YEAR MEDICAL STUDENT

IMAM MOHAMMED BIN SAUD UNIVERSITY

UROLOGY

Stress

Urge

Mixed

OBJECTIVES

• DEFINITION

• EPIDEMIOLOGY

• RISK FACTORS & ETIOLOGIES

• TYPES

• DIAGNOSIS

• MANAGEMENT

DEFINITIONEPIDEMIOLOGY

RISK FACTORS & ETIOLOGIES

DEFINITION

“ THE INVOLUNTARY LOSS OF URINE WHICH IS OBJECTIVELY DEMONSTRABLE AND A SOCIAL OR HYGIENIC PROBLEM.”

ANY INVOLUNTARY LEAKAGE OF URINE

URINARY INCONTINENCE

Common

Treatable

Significant Effect on Quality of

Life

EPIDEMIOLOGY

• COMMUNITY: 17% OLDER MEN, UP TO 30% OLDER WOMEN

• HOSPITAL: UP TO 50% OLDER MEN AND WOMEN

• ELDERLY (<65 Y): UP TO 10% IN MALE AND 15 % IN FEMALE

• F>M UNTIL AGE 80 YEARS, THEN M=F

ANATOMICAL STRUCTURES OF THE LOWER URINARY TRACT SYSTEM

The bladder and bladder neck

The urethra and urethral sphincter mechanism

The pelvic floor musculature

THE BLADDER

• IS A HOLLOW MUSCULAR ORGAN

• LIES IN THE ANTERIOR PART OF THE PELVIC CAVITY BEHIND THE SYMPHYSIS PUBIS

• IT IS OUTSIDE THE PERITONEAL CAVITY AND EXTENDS UPWARDS AS IT FILLS

• IT IS ANTERIOR TO THE RECTUM

THE BLADDER• EMBRYOLOGICALLY, THE BLADDER IS DERIVED

FROM THE HINDGUT.

• EXTERNAL FEATURES ARE THE APEX, BODY, FUNDUS AND  NECK.

• TRIGONE – A TRIANGULAR AREA LOCATED WITHIN THE FUNDUS

• IN ORDER TO CONTRACT DURING MICTURITION, THE BLADDER WALL CONTAINS SPECIALIZED SMOOTH MUSCLE, KNOWN AS DETRUSOR MUSCLE. 

NERVOUS SUPPLY OF BLADDERo The sympathetic nervous system o Hypogastric nerve (T12 – L2). o It causes relaxation of the detrusor muscle. o These functions promote urine retention.

o The parasympathetic nervous system o Pelvic nerve(S2-S4). o Increased signals from this nerve causes contraction of the detrusor

muscle. This stimulates micturition.

o The somatic nervous supply gives us voluntary control over micturition. It innervates the external urethral sphincter, via the pudendal nerve (S2-S4). It can cause it to constrict (storage phase) or relax (micturition).

Urethral Sphincters

Internal Urethral Sphincters

• Situated at the base of the bladder neck.

• Circular smooth muscle layer

• Normally in a state of contraction

• Involuntary control (under autonomic control)

• It is thought to prevent seminal regurgitation during ejaculation.

External Urethral Sphincters

• Skeletal muscle (Circular striated muscle fibres)• Reinforced by the pelvic

floor muscle • Voluntary control• During micturition, it

relaxes to allow urine flow.

FUNCTIONS OF THE PELVIC FLOOR • PELVIC FLOOR FORMED BY LEVATOR ANI MUSCLES (LARGEST

COMPONENT), COCCYGEUS MUSCLE AND FASCIA COVERINGS OF THE MUSCLES.

• FORMS A ‘SLING-LIKE’ SUPPORT FOR THE LOWER PELVIC ORGANS

• CONTRIBUTES TO THE ACTION OF THE

EXTERNAL SPHINCTER IN MAINTAINING

URETHRAL CLOSURE.

• CONTRIBUTES TO THE ACTION OF

THE ANAL SPHINCTER IN MAINTAINING

FAECAL CONTINENCE.

RISK FACTORS•DEPRESSION• STROKE•DIABETES• PARKINSON’S DISEASE•DEMENTIA (MODERATE TO SEVERE)•OBESITY, CHF, CONSTIPATION, TIAS, COPD, CHRONIC COUGH

AGING CHANGES• Decreased bladder capacity

• Reduced voiding volume

• Reduced flow rates

• Increased urine production at night• Detrusor over activity (20% of

healthy continent)• BPH

REVERSIBLE CAUSES OF UI

- Delirium or Drugs

- Restricted mobility

- Infection, impaction

- Polyuria

IP

RD

CAUSES OF TRANSIENT (ACUTE) INCONTINENCE

• D DELIRIUM• I INFECTION• A ATROPHIC VULVOVAGINITIS• P PSYCHOLOGICAL• P PHARMACOLOGIC AGENTS• E ENDOCRINE, EXCESSIVE UO• R RESTRICTED MOBILITY• S STOOL IMPACTION

Polyuria, frequency,

urgency

Alcohol Caffeine Diuretics

Urinary retention

AnticholinergicsAlpha

adrenergic agonists

Beta adrenergic

agonists

Calcium channel

blockers

Drugs Contributing to UI

TRANSIENT INCONTINENCE

• LOWER URINARY TRACT PATHOLOGY

• PRECIPITATED BY REVERSIBLE FACTOR

• 1/3 COMMUNITY DWELLING

• 1/2 HOSPITALIZED INCONTINENT AGED PATIENTS

• CAUSES: DELIRIUM, UTI, MEDS, PSYCHIATRIC DISORDERS, UO, STOOL IMPACTION

• RESTRICTED MOBILITY

TYPES OF URINARY INCONTINENCE

• TRANSIENT UI (ACUTE)

• ESTABLISHED UI (CHRONIC)

• URGE UI

• STRESS UI

•MIXED UI

• OVERFLOW UI

• “FUNCTIONAL” UI

STRESS UI

Sudden increase in abdominal pressure

Urethral pressure

-The complaint of involuntary leakage with effort or exertion or on sneezing or coughing.

-Due to either:1-poor pelvic floor.2-weak urethral sphincter.

-Very common in women.

URGE UI

Involuntary detrusorcontractions

Urethral pressure

The complaint of involuntary leakage accompanied by or immediately preceded by urgency.

Due to over activity of detrusor muscle.

OVERFLOW

Neurogenic/Atonic

Obstruction

•Urethral blockage•The Bladder is not able to empty properly

MANAGEMENT OF URINARY

INCONTINENCE

MAJOR POINTS NONPHARMACOLOGICAL THERAPY:

PHARMACOLOGICAL THERAPY:

A. URGENCY INCONTINENCE:

B. CHOOSING MEDICATION:

C. STRESS INCONTINENCE:

D. ADJUNCTIVE MEASURES:

SURGICAL THERAPY:

I/ URGENCY INCONTINENCE:

II/ STRESS INCONTINENCE:

1)TRANSURETHRAL BULKING AGENTS:

2) PERINEAL SLINGS:

3) ARTIFICIAL URINARY SPHINCTER:

FIRST: NONPHARMACOLOGICAL THERAPY• LIFESTYLE ADVICE (PARTICULARLY WEIGHT

LOSS AND DIETARY CHANGES).

• AVOIDANCE OF URETHRAL COMPRESSION DURING VOIDING.

SECOND: PHARMACOLOGICAL THERAPYA. URGENCY INCONTINENCE:

* “ANTIMUSCARINIC DRUGS” ARE THE MAIN PHARMACOLOGICAL AGENTS AVAILABLE FOR URGENCY INCONTINENCE, AND “ALPHA BLOCKERS” ARE USED FOR MEN WITH URGENCY INCONTINENCE WITH BPH.

CONT’ PHARMACOLOGICAL THERAPYB. CHOOSING MEDICATION:

* DESPITE THE LACK OF EVIDENCE TO GUIDE URGENCY INCONTINENCE THERAPY IN MEN, IT’S REASONABLE TO INITIATE PHARMACOLOGIC TREATMENT WITH ALPHA BLOCKERS (WHY ?)

CONT’ PHARMACOLOGICAL THERAPYC. STRESS INCONTINENCE:

* NO MEDICATIONS HAVE BEEN APPROVED IN THE US FOR THE TREATMENT OF STRESS INCONTINENCE.

* [DULOXETINE & SNRI] IS APPROVED FOR THIS INDICATION IN MANY EUROPEAN COUNTRIES.

CONT’ PHARMACOLOGICAL THERAPYD. ADJUNCTIVE MEASURES:

* INCLUDE INCONTINENCE PADS, INDWELLING CATHETERS, EXTERNAL URINARY CATHETERS & PENILE INCONTINENCE CLAMPS.

* THE TREATMENT OF URINARY INCONTINENCE WITH AN INDWELLING CATHETER IS USUALLY A POOR MANAGEMENT CHOICE (WHY ?)

CONT’ PHARMACOLOGICAL THERAPY

THIRD: SURGICAL THERAPYI/ URGENCY INCONTINENCE:

- MOST COMMON SURGICAL TREATMENT FOR URGENCY INCONTINENCE IS ----> SACRAL NERVE STIMULATION.

- IN THE MINORITY OF PATIENTS IN WHOM MEDICAL THERAPY IS INEFFECTIVE, TREATMENTS OPTIONS INCLUDE: ELECTRICAL STIMULATION.

CONT’ SURGICAL THERAPYII/ STRESS INCONTINENCE:

- MOST COMMONLY UTILIZED INTERVENTIONS FOR MALE ARE TRANSURETHRAL BULKING AGENTS, PERINEAL SLINGS & ARTIFICIAL URINARY SPHINCTER.

CONT’ SURGICAL THERAPY1) TRANSURETHRAL BULKING AGENTS:

CONT’ SURGICAL THERAPY2) PERINEAL SLINGS:

CONT’ SURGICAL THERAPY3) ARTIFICIAL URINARY SPHINCTER:

ANY QUESTIONS ?

THANK YOU