Urinary incontinenceUrinary incontinence

Dr Mohammad Hatef KhorramiDr Mohammad Hatef Khorrami

UrologistUrologist

Fellowship of endourologyFellowship of endourology

isfahan university of medical scienceisfahan university of medical science

IncontinenceIncontinence

IncontinenceStress Urge mixed UnconsciousContinuousNocturnal enuresis

EpidemiologyEpidemiology

In women %3-%11In women %3-%11 In men %2- %6In men %2- %6

Mechanism of continenceMechanism of continence

Good complianceGood compliance sphinctersphincter

Structure of the BladderStructure of the Bladder

Ureter

Prostategland

Detrusorsmooth muscle

Externalurethral sphincter

Pelvic floor

Micturition ReflexMicturition Reflex

Brain Direction ofnerve impulse

Spinal cord

Bladder

Pelvic floor

Bladder Filling & Emptying CycleBladder Filling & Emptying Cycle

The cycle ofbladder fillingand emptying

1. Bladder fills

2. First desire tourinate (bladder

half full)

Urination 3. Urinationvoluntarily inhibiteduntil time and place

are right

Detrusor musclecontracts

Detrusor muscle relaxes

Urethralsphinctercontracts

Urethralsphincterrelaxes

EtiologyEtiology

Bladder abnormalityBladder abnormality Detrusor overactivityDetrusor overactivity Decreased bladder complianceDecreased bladder compliance

Sphincter abnormalitySphincter abnormality

Causes of detrusor overactivityCauses of detrusor overactivity

IdiopathicIdiopathic NeurologicNeurologic CVA,brain atrophy, brain CVA,brain atrophy, brain

tumor , MS, SCItumor , MS, SCI

Non neurogenicNon neurogenic UTI, obsruction,pelvic UTI, obsruction,pelvic

organ prolaps,bladder organ prolaps,bladder tumor, bladder stone,agetumor, bladder stone,age

Sphincteric abnormalitySphincteric abnormality

Men Men Prostate surgery,trauma, neurologicProstate surgery,trauma, neurologic

WomenWomen Urethral hypermobility,intrinsic sphincteric Urethral hypermobility,intrinsic sphincteric

insufficiency,neurogenicinsufficiency,neurogenic

Causes of transient incontinenceCauses of transient incontinence

DeliriumDelirium Infection Infection Athrophic vaginitisAthrophic vaginitis Psychologic Psychologic PharmacologicPharmacologic Excess urine productionExcess urine production Restricted mobilityRestricted mobility Stool impactionStool impaction

How to Recognize Patients How to Recognize Patients with incontinencewith incontinence

• Symptom assessment

• Medical history

• Physical examination

• Urinalysis

• Bladder diary

• Pad test

• Referral for medical evaluation and treatment

Medical HistoryMedical History

Other questions that your doctor/nurse might ask:

• History of previous surgery or radiotherapy involving the pelvic region

• Medications currently taking

• Main symptoms (complaints)

• Duration of symptoms

Physical ExaminationPhysical Examination

• Abdomen exam

• Rectal exam

• Pelvic exam

•Neurologic exam

UrinalysisUrinalysis

To rule out urinary tract urinary tract infectioninfection

Bladder DiaryBladder Diary

Helps patientsHelps patients record details of:

• Bladder symptoms• Type/amount of drinks taken• Time/amount of urine passed

Pad TestPad Test

A supplementary test used to confirm urine leakage and quantify the degree of urine loss.

Pad TestPad Test

Method:Method:

• Drink 500 ml of fluid as quickly as possible

Pad TestPad Test

Method (cont’d):Method (cont’d):

• Perform a series of physical tasks in a 1-hour period

• Walking

• Climbing stairs • Coughing vigorously • Running on the spot

Pad TestPad Test

Method (cont’d):Method (cont’d):

• The pad is re-weighed.• A weight gain of more than 1 g

signifies that the patient is incontinent.

Referral for FurtherReferral for FurtherEvaluation and TreatmentEvaluation and Treatment

Urodynamic testImagingEndoscopy

treatmenttreatment

Low bladder complianceLow bladder compliance DrugDrug EnterocystoplastyEnterocystoplasty Denervation Denervation

Treatment Treatment sphincteric dysfunctionsphincteric dysfunction

Behavioral modificationBehavioral modification DrugDrug Urethral bulking agentUrethral bulking agent surgerysurgery SlingSling Artificial sphincterArtificial sphincter

Management of Management of Overactive BladderOveractive Bladder

• Drug therapy • Bladder training• Incontinence pads and protective devices • Bladder self-catheterization • Pelvic floor exercises• Biofeedback• Review diet and food intake• Skin care and cleanliness• Surgery

Bladder TrainingBladder Training

A behavioural approach to the treatment of the overactive bladder, which is often used in combination with drug therapy.

Bladder TrainingBladder Training

Aims:Aims:

• Increase the time intervals between bladder emptying.

• Increase bladder capacity by teaching patients to resist and suppress the urge to pass urine.

Incontinence Pads and Incontinence Pads and Protective EquipmentProtective Equipment

Absorbent pads

Dribble pouch

Reusable underpantsdesigned to carrydisposable absorbent pads

All-in-one briefs

Chair and bed pads

Pelvic Floor ExercisesPelvic Floor Exercises

Also known as Kegel exercisesKegel exercises.

Pelvic Floor ExercisesPelvic Floor Exercises

Aim:Aim:

To strengthen the pelvic floor muscle and increase overall muscle tone.

BiofeedbackBiofeedback

Aim:Aim:

Helps patient identify the correct muscle for performing Kegel exercises

BiofeedbackBiofeedback

Source: Biofeedback Instrument Corporation

Review Diet and Fluid IntakeReview Diet and Fluid Intake

Some patients will try to reduce the risk of leakage by restricting their fluid intake.

Review Diet and Fluid IntakeReview Diet and Fluid Intake

However, drinking too little results in concentrated urine, which itself can irritate irritate the bladderthe bladder.

Review Diet and Fluid IntakeReview Diet and Fluid Intake

Therefore, it is important that patients are encouraged to drink appropriate amount of fluids.

Review Diet and Fluid IntakeReview Diet and Fluid Intake

ReduceReduce consumption of:

• Caffeine (i.e. tea andcoffee)

• Carbonated soft drinks

• Alcoholic drinks

Management of Management of Overactive BladderOveractive Bladder

• Drug therapy • Bladder training• Incontinence pads and protective devices • Bladder self-catheterization • Pelvic floor exercises• Biofeedback• Review diet and food intake• Skin care and cleanliness• Surgery

Role of NursesRole of Nurses

• Help to recogniserecognise patients who have problems maintaining continence

• Offer helphelp and adviceadvice to patients and relatives

ControlControl

ConfidenceConfidence

FreedomFreedom