Urinary incontinence

Urinary IncontinenceDr. Nedaa Bahkali2012Definitions:Urinary incontinence is defined as involuntary leakage of urine.

Definitions:Stress urinary incontinence (SUI): involuntary urine leakage on exertion or with sneezing or coughing.

Urge urinary incontinence:women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay. If urge urinary incontinence is objectively demonstrated by cystometric evaluation, the condition is known as detrusor overactivity (DO). Definitions:Mixed urinary incontinence :When both stress and urge components are present, it is called.

Epidemiology:Prevalence of 25 - 55 %.Among women with urinary incontinence, the most common condition is stress incontinence, which represents 29 to 75 %of cases. Detrusor overactivity accounts for up to 33 % of incontinence cases. whereas the remainder is attributable to mixed forms.

Anatomy and Physiology of Micturition

Anatomy and Physiology of MicturitionDetrusor muscleExternal and Internal sphincterNormal capacity 500-600ccFirst urge to void 150cc

Anatomy and Physiology of Micturition

Anatomy and Physiology of Micturition

Anatomy and Physiology of Micturition

Storage ReflexAnatomy and Physiology of Micturition

Micturition ReflexRisks for Urinary Incontinence:AgePregnancyChildbirthMenopauseHysterectomyObesityChronically increased abdominal pressureChronic coughConstipationOccupational riskSmoking

Continence TheoriesPressure TransmissionUrethral SupportPressure TransmissionIn an ideally supported urogenital tract, increases in intra-abdominal pressure are equally transmitted to the bladder, bladder base, and urethra.

In women who are continent, increases in downward-directed pressure from cough, laugh, sneeze, and Valsalva maneuver are countered by supportive tissue tone provided by the levator ani muscle and vaginal connective tissue .

Pressure TransmissionIn those with a weakened supportive "backboard", however, downward forces are not countered. This leads to funneling of the urethrovesical junction, a patent urethra, and in turn, urine leakage. Pressure Transmission

Urethral SupportUrethral support is integral to continenc (1) ligaments along the lateral aspects of the urethra, termed the pubourethral ligaments; (2) the vagina and its lateral fascial condensation;(3) the arcus tendinous fascia pelvic;(4) levator ani muscles .

With loss of urethral support, the urethra's ability to close against a firm supportive backboard is diminished.

Urethral Support

Urethral Support

Urethral Support

DiagnosisHistory :Duration, severity, symptoms, previous treatment,(Urinary Frequency, Urinary Retention, volume of urine lost , Postvoid dribbling is classically associated with urethral diverticulum) medications, Past medical hx, GU surgery, Ob hxVoiding Diary

Symptom Comparison of Women with Stress or Urge IncontinenceUrge Incontinence

Stress Incontinence

Symptom

NoYes Urgency

NoYes Frequency with urgency

Yes

NoUrine leakage with increased intra-abdominal pressures

smallLargeAmount of urinary leakage with each incontinence episode

Yes

Often NoAbility to reach the toilet in time following an urge to void

Seldom

Usually

Waking to void at night

Medications That May Cause IncontinenceDiureticsAnticholinergics - antihistamines, antipsychotics, antidepressantsSeditives/hypnoticsAlcoholNarcotics-adrenergic agonists/antagnistsCalcium channel blockersPhysical ExaminationGeneral Inspection and Neurologic Evaluationevidence of atrophy.neurologic evaluation of the perineum:bulbocavernosus reflexnormal circumferential anal sphincter contraction, colloquially called an "anal wink",

Pelvic Support AssessmentPelvic Organ Prolapse Evaluation

Pelvic Support AssessmentQ-Tip Test

Diagnostic TestingUrinalysis and CulturePostvoid ResidualCystometricsUroflowmetryTreatment,,Treatment OptionsConservative/Nonsurgical:Pelvic Floor Strengthening ExercisesPelvic Floor Muscle Training (PFMT)

Electrical StimulationBiofeedback TherapyDietaryScheduled VoidingEstrogen Replacement

Treatment of Stress Urinary IncontinenceTreatment of Stress Urinary IncontinenceMedications:Pharmaceutical treatment plays a minor role in the treatment of women with SUI.imipramine is reasonable to aid urethral contraction and closure.Recently, duloxetine a selective serotonin and norepinephrine reuptake inhibitor, has been evaluated for the treatment of SUIPessaries

Surgical Treatment of Intrinsic Sphincteric DeficiencyPeriurethral Bulking Agents

Surgical Treatment of Anatomic Stress IncontinenceRetropubic UrethropexyPubovaginal SlingsMidurethral Slings

Treatment of Urge Urinary IncontinenceTreatment of Urge IncontinenceAntimuscarinics: tertiary amines that act to block the muscarinic receptors in response to acetocholineFirst lineOxybutinin (Ditropan)Tolteridine (Detrol)