Urinary Incontinence

Dr. Eyad Z. AL-AqqadSpecial Urologist

Definition

INCONTINENCE:

Involuntary loss of urine or stool in sufficent amount or frequency to constitute a social and/or health problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence with concomatant fecal incontinence

How Common is Incontinence?

• Prevalence increases with age (but it is not a part of normal aging)

• 25-30% of community dwelling older women• 10-15% of community dwelling older men• 50% of nursing home residents; often associated with

dementia, fecal incontinence, inability to walk and transfer independently

Urinary Incontinence is Often Under-Diagnoses and Under-Treated

• Only 32% of primary care physicians routinely ask about incontinence

• 50-75% of patients never describe symptoms to physicians

• 80% of urinary incontinence can be cured or improved

Why is Incontinence Important?

• Social stigmata - leads to restricted activities and depression

• Medical complications - skin breakdown, increased urinary tract infections

• Institutionalization - UI is the second leading cause of nursing home placement

Anatomy of Micturition• Detrusor muscle• External and Internal sphincter• Normal capacity 300-600cc• First urge to void 150-300cc• CNS control

– Pons - facilitates– Cerebral cortex - inhibits

• Harmonal effects - estrogen

Peripheral Nerves in Micturition

• Parasympathetic (cholinergic) - Bladder contraction• Sympathetic - Bladder Relaxation• Sympathetic - Bladder Relaxation (β adrenergic)• Sympathetic - Bladder neck and urethral contraction (α

adrenergic)• Somatic (Pudendal nerve) - contraction pelvic floor

musculature

Peripheral Nerves in Micturition

Taking the History

• Duration, severity, symptoms, previous treatment, medications, GU surgery

• 3 P’s– Position of leakage (supine, sitting, standing)– Protection (pads per day, wetness of pads)– Problem (quality of life)

• Bladder record or diary

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Potentially Reversible CausesD - DeliriumI - InfectionA - Atrophic vaginitis or urethritisP - PharmaceuticalsP - Psychological disordersE - Endocrine disordersR - Restricted mobilityS - Stool impaction 2

Medications That May Cause Incontinence

• Diuretics• Anticholinergics - antihistamines, antipsychotics,

antidepressants• Seditives/hypnotics• Alcohol• Narcotics• α-adrenergic agonists/antagnists• Calcium channel blockers

Categories of Incontinence

• Urge incontinence• Stress incontinence• Overflow incontinence• Functional incontinence

Urge Incontinence

• Most common cause of UI >75 years of age• Abrupt desire to void cannot be suppressed• Usually idiopathic• Causes: infection, tumor, stones, atrophic

vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder

Stress Incontinence• Most common type in women < 75 years old• Occurs with increase in abdomenal pressure;

cough, sneeze, etc.• Hypermotility of bladder neck and urethra; associated

with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases)

• Intrinsic sphinctor problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

Overflow Incontinence

• Over distention of bladder• Bladder outlet obstruction; stricture, BPH, cystocele,

fecal impaction

• Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury, medications

Functional Incontinence

• Does not involve lower urinary tract• Result of psychological, cognitive or physical

impairment

Physical Examination

• Mental status• Mobility• Fluid overload• Abdominal exam• Neurologic exam• Pelvic• Rectal

Diagnostic Tests

• Stress test (diagnostic for stress incontinence; specificity >90%)

• Post-void residual• Blood Tests (calcium, glucose, BUN, Cr)

• Urine Culture• Simple (bedside) Cystometrics

Bladder Pressure-Volume Relationship

Interpretation of Post-Void Residual

PVR < 50cc - Adequate bladder emptyingPVR > 150cc - Avoid bladder relaxing drugsPVR > 200cc - Refer to UrologyPVR > 400cc - Overflow UI likely

Treatment Options

• Reduce amount and timing of fluid intake• Avoid bladder stimulants (caffeine)• Use diuretics judiciously (not before bed)• Reduce physical barriers to toilet (use bedside

commode)

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Treatment Options• Bladder training

– Patient education– Scheduled voiding– Positive reinforcement

• Pelvic floor exercises (Kegel Exercises)• Biofeedback• Caregiver interventions

– Scheduled toileting– Habit training– Prompted voiding

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Pharmacological Interventions• Urge Incontinence

– Oxybutynin (Ditropan)– Propantheline (Pro-Banthine)– Imipramine (Tofranil)

• Stress Incontinence– Phenylpropanolamine (Ornade)– Pseudo-Ephedrine (Sudafed)– Estrogen (orally, transdermally or transvaginally)

Surgical Interventions

• Urethral Hypermotility– Marshall-Marchetti-Kantz

procedure– Needle neck suspension

• Intrinsic sphincter deficiency– Sling procedure

Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years.

Other Interventions

• Pessaries• Periurethral bulking agents (periurethral injection

of collagen, fat or silicone)• Diapers or pads• Chronic catheterization

– Periurethral or suprapubic– Indwelling or intermittant

Pessaries

Indwelling Catheter