Urinary Incontinence - PowerPoint by Semaj1212

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									URINARY INCONTINENCE

Dr Fatima Z Ashrafi
DGO (Dub), FRCS (Edin), MRCOG (Lon), FRANZCOG

Gisborne Hospital, New Zealand

WHAT IS CONTINENCE?
Continence is the ability to pass urine or faeces voluntarily in a socially acceptable place.
The continent person can: recognize the need identify the correct place

hold on until he reaches the correct place reach the correct place pass urine or faeces when he gets there Incontinence - involuntary loss of urine which is objectively demonstrable & is social and hygienic problem.

INCIDENCE
• 1 in 3 female age 55 or more complain of incontinence. • 1 in 10 women will have surgery for prolapse or SI in life time. One third will need further surgery. • Urinary incontinence - not a recent medical or social phenomena. Disorders of urinary tract written in ancient times.
– – – – Women more willing to talk about it. Improved understanding of the diverse pathophysiology of incontinence. Advent of new treatment. Development of urology & urogynaecology as a specialty.

HOW DOES INCONTINENCE OCCUR?
Factors affecting the bladder: incompetent urethral closure weakness of pelvic floor muscles urethral obstruction overactive urethral closure underactive detrusor detrusor/sphincter dyssynergia unstable detrusor

Factors affecting our ability to cope with the bladder: impaired mental function other psychological factors mobility and dexterity problems environmental problems drug treatment

NERVE SUPPLY
• Bladder,bowel &sexual functions- parasympathetic & somatic via S2,3,4. • Sympathetic supply - T10-L2 segments - detrusor muscle. • Parasympathetic promotes micturition - contracting detrusor, relaxing urethra. • Sympathetic - B receptors in bladder - relaxation, A receptors in bladder neck increasing urethral resistance. • Central control - pontine center, receiving afferent and efferent from cerebral cortex, cerebellum and spinal center. • Normally detrusor is reflexly inhibited by sympathetic neurones (storage and filling), control acquired in infancy. Detrusor contraction mediated by parasympathetic supply. M3 receptors .

ANATOMY
• Bladder functions as low pressure reservoir allowing intermittent voiding within socially acceptable limits. • Continence is maintained as UCP is higher than expulsion pressure.

• Urethra supported by - Externally: pubourethral ligament,
striated muscle of pelvic floor. Internally : smooth muscle of urethra, ext urethral sphincter, periurethral collagen & connective tissue, submucosal venous plexus, mucosal coaptation of the urothelium.

• Proximal urethra is well supported so a rise in intraabdominal pressure is equally transmitted to bladder & urethra.

TYPES OF INCONTINENCE
Genuine stress incontinence Detrusor instability
Mixed (GSI and DI)

Overflow Fistulae

INCONTINENCE
• Genuine Stress Incontinence: Is the involuntary loss of urine in the absence of a detrusor contraction, the intravesical pressure exceeds the urethral pressure. There is not an associated desire to void.
Detrusor Instability Involuntary detrusor contractions either spontaneous or provoked which cannot be suppressed and may cause incontinence. It is associated with a strong desire to void. Abnormal nerve supply to bladder (spinal cord injury, spina bifida) - detrusor hyperreflexia. Overflow Incontinence is an involuntary loss of urine associated with over distension of the bladder. May present as SI or dribble. Due to bladder outlet obstruction or impaired detrusor contraction. More common in males.

•

•

Genuine Stress Incontinence

Hypermobility
excessive descent of bladder neck, so poor transmission of increase in ab pressure to proximal urethra.

Intrinsic Sphincter Deficiency
poor urethral closure due to scarring - surgery, childbirth, neurological injury

.

RISK FACTORS FOR STRESS INCONTINENCE
1 Increasing parity, probably related to obstetrical trauma 2 Increased intra-abdominal pressure a medical factors (eg smoking, chronic bronchitis or other pulmonary problems, constipation with chronic straining at stool, obesity (?)) b environmental factors (eg jobs requiring heavy lifting or straining) 3 Pelvic floor trauma and denervation injury a obstetric trauma b nonobstetric trauma (eg pelvic fractures and radical surgery)
4 Hormonal status and estrogen deficiency

5 Connective tissue disorders

Symptom

GSI (%) 57
29

Detrusor Instability 86
80

Frequency
Nocturia

Urgency Urge Incontinence
Stress Incontinence

46 37
99

92 88
26

COMMON DRUGS AFFECTING LOWER URINARY TRACT FUNCTION
• Sedative hypnotics Benzodiazepines Alcohol Diuretics Anticholingeric agents Antihistamines Antipsychotics Anti-Parkinsonian agents
Andrenergic agents Sympathomimetics

• •

Antidepressants Antispasmodics

•

Sympatholytics (Prazosin)

•

Calcium channel blockers

INCIDENCE OF NEUROPATHIC BLADDER IN NEUROLOGICAL DISEASE
Condition
Abdominoperineal resection
Radical hysterectomy Polio (almost always recovers) Diabetic neuropathy Lumbar disc disease Multiple sclerosis Presenting symptom Overall incidence

Incidence
10%-44%
7%-80% 4%-42% 2%-83% 6%-18% 2%-12% 33%-78%

Parkinsonism Stroke Meningomyelocele

37%-70% 34%-53% 97%

PATIENT ASSESSMENT
Patient history. Frequency, nocturia, urgency, urge incontinence, stress incontinence, voiding patterns, drinking habits, drugs, medical problems, quality of life. Frequently female pts present with mixed incontinence. Physical examination: general, abdominal, pelvic atrophic vaginitis, uterine descent, vaginal wall prolapse, pelvic muscle strength, S234.

Frequency/volume chart: intake, output, episodes of dampness, leaking, acts as a teaching aid. Urine examination Urodynamics

INCONTINENCE TREATMENT CONSERVATIVE
•
• •

Global: Evaluation of cough, change of medication, wt loss/
Pharmacological Behavioural Changes - adequate water (1.5 l/d) - Decrease dietary irritants - Manage constipation - Pelvic muscle exercises - Bladder retraining - instructing pt to void at predetermined intervals. Very successful in young motivated women(85%)

• Pelvic Muscle Exercises
- Verbal feedback / written instructions - Vaginal weights - Biofeedback

• Electrical Stimulation

URODYNAMIC TESTS
Flow studies Cystometry (+/- Videourodynamics)
Urethral pressure profilometry

Ambulatory urodynamics Electromyography

URODYNAMIC MEASUREMENTS
Bladder pressure - storage and voiding Abdominal pressure
Urethral pressure

Urine flow Bladder capacity Volume voided Residual

UROFLOWMETRY
Patient voids into a flow meter Flow rate Volume voided Residual - catheter - ultrasound

URINE FLOW RATES WOMEN
Under 50 years - 25 ml/sec Over 50 years - 18 ml/sec

FILLING / VOIDING CYSTOMETRY
• Bladder catheters - intravesical - pressure (pves) - fill - abdominal - pressure (pabd) - lying / sitting / standing - slow / medium / fast

• Rectal catheter • Position • Fill speed *

* frequency / volume chart

FILLING CYSTOMETRY
First desire to micturate

Capacity Detrusor activity

WHEN TO DO A CYSTOSCOPY?
Microscopic hematuria Abnormal cytology

Periurethral abnormality For reassurance

DETRUSOR INSTABILITY
• 2nd common cause of incontinence in UD studies.Incidence increases with age. Normal control of detrusor is lost. 15% incidence of DI following bladder neck surgery.

• Cost: Australia - 1997, NIH - $17.5 billion on urinary incontinence, $12.7 billion on overactive bladder, $13.8 on osteoarthritis, $11 billion on gynae & breast cancer • Important to identify DI prior to continence surgery as urgency may be worsened. Frequency, urgency, urge incontinence, key in door leaking are typical of DI.

DETRUSOR INSTABILITY
• Rarely completely cured by any form of treatment. Symptoms and QOL can be improved. Continence adviser essential member of continence service. Behavioural & conservative therapies are helpful • Anticholinergic drug eg Oxybutinin is used in DI. S/E: dry mouth, blurred vision, constipation, drowsines, urinary retention. A new antimuscarinic, Tolteradine is in market now. Darifenacin - highly selective M3 blocker - phase 3 trials.

• TCA, DDAVP, Ca channel blockers. • Oestrogen therapy : systemic no effect, topical decreases UTI. Good for atrophic vaginitis. • Surgical: cystodistension, clam cystoplasty, diversion procedures

SURGICAL APPROACH FOR THE TREATMENT OF GENUINE STRESS INCONTINENCE (GSI)
Operation
Anterior colporrhaphy

Indication
Significant uterovaginal prolapse. Should not be considered as first line procedure for GSI

Marshall-Marchetti-Krantz
Burch colposuspension Needle bladder neck suspension (Stamey)

Primary or secondary GSI
Primary or secondary GSI with cystocele GSI in the surgically difficult patient

Operation Suburethral sling procedures

Indication Severe recurrent GSI. Intrinsic urethral deficiency.

Periurethral bulk enhancing Surgically difficult agents (GAX pelvis/medically unfit, vaginal collagen/macroplastique/autolog scarring. ous fat)
Complex surgical procedures (eg artificial sphincter/ neourethra/ urinary diversion) TVT

Intractable recurrent urethral sphincter incompetence
Short hospital stay, rapid recovery. Bladder trauma 4%, voiding difficulty 10%, similar efficacy for colposuspension.

INCONTINENCE TREATMENT SURGICAL PROS:
Previous surgery - subjective and objective results
Procedure Marshall-Marchetti-Kranz Colposuspension Bladder sling All bladder neck suspensions Bladder buttress % continent 84.5 84.0 83.4 76.5 58.6

Most failures apparent immediately

CON’S
Significant potential for severe long term voiding problems post op - (less than 5%) • De novo detrusor instability • Erosion of synthetic materials • Lower urinary tract damage
• Infection

(7-27%) 3% 3%

CONCLUSION:

• Urinary incontinence is a common problem, causes distress to a large no of female population. • Current diagnosis and management involves good understanding of the condition and use of UD prior to continence surgery. • Therapy for DI is often long term and requires pt explanation of pathology and mode of action &S/E of drugs used. • In future, further understanding of pathophysiology of condition may lead to further advances.


								
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