Marsha K. Guess, MD, MSAssistant professor and Fellowship DirectorSection of Urogynecology & Reconstructive Pelvic SurgeryThe Departments of Obstetrics, Gynecology & Reproductive Sciences & UrologyURINARY INCONTINENCE
Urinary IncontinenceThe involuntary loss of urine
STATISTICS:10-60% of women report urinary incontinence
Only 10-20% seek medical care
Billions of dollars spent annually on incontinence products (in North America)
Nygaard, I. et al. JAMA 2008;300:1311-1316.
PSYCHOSOCIAL IMPACT
Higher prevalence of depression, embarrassment, loss of self esteem, anxiety Decrease in excursions outside home, social interactions, sexual activity
Major factor in the decision to place a relative in a nursing home
TYPES OF URINARY INCONTINENCEGenuine Stress Urinary IncontinenceDetrusor InstabilityIntrinsic Sphincter DeficiencyOverflow IncontinenceFunctional/Transient incontinence
PATHOPHYSIOLOGY OF SUI
ComplaintDefinitionDaytime frequencyvoids too often/day
Nocturia voids too often/night
Nocturnal enuresisloss of urine during sleep
Urgencysudden desire to void
Urinary incontinenceinvoluntary loss of urine with or immediately preceded by urgencyAbrams P et al. Am J Obstet Gynecol. 2002;287(1):116-126.SYMPTOMS ASSOCIATED WITH URGENCY INCONTINENCE
INTRINSIC SPHINCTER DEFICIENCYProblem with ability of urethra to close Drain pipe urethra
ISDRISK FACTORSAge
Trauma/childbirth
Previous Incontinence Surgery
Explore symptoms:
durationprecipitantsfrequencymost bothersome
Focus on medical, surgical, neurological & genitourinary history
diabetes mellitushx of previous incontinence surgery multiple sclerosisfailure of previous pharmacotherapymental statussymptoms of prolapse
Review voiding patterns/fluid intake
Obtain voiding diaryPATIENT EVALUATION
Problem with support of urethraGoal: stabilize urethraNormalAbnormalPHYSICAL EXAMINATION
EVALUATION OF URINARY INCONTINENCEPost-void residual UrinalysisUrine culture Urine cytologyHbA1CVoiding diaryUrodynamicsCystoscopy
VOIDING DIARY
Voiding Diary 11/18/05 TimeAmountLeaksDrinks7:00am100cc0cup with meds7:45am50cc18oz water8:15am25 cc212oz coffee9:00am150cc18oz water9:30am100cc012 oz coffee11:00am150cc01:15am50cc03:00pm75cc15:00pm90cc06:30pm120cc07:30pm100cc0cup with meds8:00pm100cc08oz water8:45pm50cc19:15pm25 cc08oz water10:00pm160cc110:30pm100cc011:00pm150cc11:15am50cc03:00am75cc05:00am90cc06:15am120cc1Total213092160
URODYNAMICS
CYSTOSCOPY
INDICATIONS FOR URODYNAMIC TESTINGPrevious failed surgeryWhen surgery is plannedUncertain etiology to incontinenceConcomitant prolapse (Potential incontinence)Failed medical treatment
Behavior modification
Bladder Training
Physiotherapy
Mechanical devices
Pharmacological TherapyCONSERVATIVE MANAGEMENT OF SUI
BIOFEEDBACK
GSUI PELVIC FLOOR EXERCISESKegels alone vs. Vaginal cones vs. Pressure biofeedback
All improved symptoms and QOL No significant difference between groupsLaycock et al. 2001
GSUI WEIGHT LOSS13 morbidly obese womenResults:9/12 with resolution of urinary symptoms post-opObjective and subjective improvement of stress and urge incontinence Bump et al. 199210 moderately obese women (mean BMI 38.3) 4 or more episodes of incontinence /dayResults:50% in incontinence episode with > 5% weight lossSubak et al. 2002
GSUI PESSARY
SURGICAL MANAGEMENT OF SUI
SLINGS FOR SUI
CONSERVATIVE MANAGEMENT OF UUIBehavior modificationBladder TrainingPharmacological TherapyElectrical Stimulation
ANTICHOLINERGIC SIDE EFFECTSDry mouth
Blurred vision
Drowsiness
Tachycardia
Constipation
ANTICHOLINERGIC CONTRAINDICATIONSNarrow angle glaucoma Intestinal obstruction
Cardiac arrhythmia
Myasthenia gravis
ELECTRICAL STIMULATION FOR UUI
BULKING AGENTS FOR ISD
BULKING AGENTS FOR ISD
BULKING AGENTS FOR ISD
BOTOX
Urogynecology includes a wide variety of lower urinary tract and pelvic floor disorders
Patient satisfaction is optimized when meticulous care is taken to adequately evaluate patients and individualize therapy
Patience is a virtue!!!!CONCLUSION
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