Clinical treatment for urinary incontinence.pptx

Urinary incontinence

1. Clinical approach to Urinary Incontinence Done by : Yasmin Saidat Mahmoud Ababneh Supervised by : Dr . Lama Al.Muhaisen Jordan university of science and technology .

2. Defintion Involuntary loss of urine that is objectively demonstrable and that is severe enough to constitute a social or hygienic problem.

3. Pharmacology of incontinence a.-Adrenergic receptors. found in urethra. Stimulation cause contraction of urethral smooth muscle, preventing micturition . Drugs: ephed rine, imipramine , and estrogens. a.-Adrenergic blockers or antagonists relaxthe urethra, enhancing micturition . Drugs: phenoxybenzamine .

4. β-Adrenergic receptors. Found in detrusor muscle. Stimulation cause relaxation of the bladder wall, preventing micturition . Drugs: flavox ate and progestins .

5. Cholinergic receptors. Found in detrusor muscle Stimulation cause contraction of the bladder wall, enhancing micturition . Chlinergic drugs: bethanecol and neostigmine . Anticholinergic medications block the receptors, inhibiting micturition . Drugs: oxybutynin and prop antheline .

6. Clinical Apprach

7. History P.P: Age, parity . C.C: Duration, frequency and amount of leakage Precipitating factors: 3 P’s - Position of leakage (supine, sitting, standing) - Protection (pads per day, wetness of pads) - Problem (quality of life) Progression – is it worsening?

8. Irritative : If Frequency: 10-12 x/day OR urge incont . nocturia : 3-4 x/night . If no freq/ nocturia  think of stress incont . Dysuria , hematuria , urgencyUTI urge incont . Recurrent Hx of UTI  urge Obstructive : Hesitancy, dysuria , straining to void, poor or interrupted stream, retention of urine, incomplete emptying, terminal dribbling. Volume of urine leakage – large amounts go with overflow incont . Stones, tumors Lower urinary tract symptoms

9. Past obstetrics Hx : Mode of delivery, Birth Wt of her children . Gyne . Hx : Symptoms of urogenital prolapse : Feeling of mass that goes down while urinating Worse towards the end of the day Dragging backache Medical Hx : DM, HTN, Neurological problems,Disk prolapse Pelvic Surgeries? Trauma to the spine? Drugs: diuretics, psychotropic agents, Ca-channel blockers, alpha-blockers Any alteration in bowel habit? Smoker? Chronic cough?

10. Physical Exam. General look of the pt * Abdominal exam Respiratory exam Neurological exam * Pelvic exam * Asses pelvic floor muscle tone * Rectal exam Stress test * Cotton swab (Q-tip) test  urethral mobility *

11. Q-tip (cotton swab) Test

12. Investigation

13. Investigation You MUST rule out UTI first ! Midstream Urinalysis Blood test  KFT Bladder diary

14. Example Diary for Urge incontinence Day Time Comments Sunday, 5 th of March 7 am Woke up and needed to go to the toilet 7:30 Needed to go to the toilet again 8 am Breakfast – 300 ml grapefruit juice and 200 ml tea 8:15 am Passed about 100 ml 8:25 am Passed about 50 ml 9 am Pants a little damp, passed about 50 ml 9:15 am Dribbled a bit, changed pants 9:30 am Passed a few drops , bladder feels very “jumpy” and so on ….

15. Urodynamic studies Parameters measured during urodynamic   evaluation 1,2,34 1. Post void residual volume (PVR) 2. Uroflow 3. Pressure flow study 4. Cystometrogram (CMG) 5. Abdominal Leak-Point Pressure (ALPP) 6. Video urodynamics

16. Post void residual urine Distinguish between: true incontinence (Residual urine < 50 mL ). overflow incontinence (Residual urine >100 mL ).

17. 2. Uroflow Measurement of Urine Speed and Volume

18. 3. Pressure flow study Bladder pressures are measured simultaneously with a urinary flow rate during voiding . This helps to differentiate true urethral obstruction from detrusor failure. Obstruction = detrusor pressure more than 50 cm water and flow < 15 mL /s

19. 4.  Cystometrogram The pressure in the bladder and rectum/vagina is measured during bladder filling. Intra-abdominal pressure is subtracted from bladder pressure to give a real indication of  detrusorfunction . Residual Volume <50mL Sensation of fullness 200-225 mL Urge to void 400-500 mL No contractions are normal.

20. 5. Abdominal Leak-Point Pressure Measurement of bladder pressure during coughing or valsalva manoeuvre to determine the pressure in the bladder required to induce leakage. In hypermobility of the urethra, the ALPP will be more than 60 cm water. But with Intrinsic Sphincter Dysfunction, the ALPP is less than 60 cm water and often less than 20 cm water.

21. 6.Video Urodynamics : Urodynamic tests can be performed with equipment to take pictures of the bladder during filling and emptying. Contrast medium may be given via the catheter.

22. Other invistigation Urethral Pressure Measurement Normal Urethral closure pressure (UCP) = 50-100 cm H ₂ O If < 20  stress incont If UCP is high  voiding difficulties, hesitancy and urinary retention Urethrocystoscopy Ultrasonography

23. Findings & results in each Type of incontinence + management History Examination Investigation Findings

24. Stress Incontinence. The most common form of urinary incontinence. • Etiology. Rises in bladder pressure because of intraabdominal pressure increases (e.g., coughing and sneezing) are not transmitted to the proximal urethra because it is no longer a pelvic structure owing to loss of support from pelvic relaxation. • History. Loss of urine occurs in small amounts simultaneously with coughing or sneez ing. It does not take place when the patient is sleeping.

25. Examination. Pelvic examination may reveal a cystocele . Neurologic examination is normal. The Q-tip test is positive: when a lubricated cotton-tip applicator is placed in the urethra and the patient increases intraabdominal pressure, the Q-tip will rotate >30 degrees. Investigative studies. Urinalysis and culture are normal. Cystometric studies are normal with no involuntary detrusor contractions seen.

26. Management of stress incontinence Conservative Stop smoking, cut down on alcohol, caffeine. Pelvic floor muscle exercises ( Kegel exercise) Intravaginal device – large sized pessaries or cones used to elevate and support bladder neck and urethra . Success rate 70%. Medical Alpha agonists: Pseudoephedrine Phenylpropanolamine Enhance urethral closure and improve continence Do NOT give estrogen replacement unless she has atrophic vaginitis

27. Abdominal approach : aims to elevate the urethral sphincter so that It is again an intraabdominallocation ( urethropexy ). This is done by attachment of the sphincter to the symphysis pubis, using the Burch procedure as well as the Marshall­ Marchetti-Kranz (MMK) procedure. The success rate 85-90% 3 . Surgery

28. Vaginal approach : Suburethral sling procedures  severe + refractive cases T ension-free Vaginal Tape(TVT) -A modification of the sling procedure  uses tension-free synthetic (polypropylene) mesh placed at the level of mid urethra ( paraurethral ). -Minimally invasive It does not elevate the urethra but forms a resistant platform against intraabdominal pressure. periurethral bulking injections : (ovine collagen- contigen or calcium hydroxylapatite )

29. TVT

30. Urge (Hypertonic) Incontinence • Etiology. Involuntary rises in bladder pressure from idiopathic detrusor contrac tions that cannot be voluntarily suppressed. • History. Loss of urine occurs in large amounts often without warning. At day and night. The most common symptom is urgency.

31. • Examination. Pelvic examination= normal anatomy. Neurologic examination Is normal. • Investigative studies. Urinalysis and culture are normal . Cystometric studies show nor mal residual volume, but involuntary detrusor contractions are present even with small Volumes of urine in the bladder.

32. Behavioral Modification: First line tt . Organize fluid intake habit: ↓ fluid intake & avoid liquids during evenings Gradually ↑ the interval btw voidings “Training” Kegel ex. Medical Treatment to inhibit detrusor contractions Anticholinergic medications. N SAIDs to inhibit detrusor contractions. Tricyclic antid-dpressants . Calcium-channel blockers. 3 . Functional Electrical Stimulation Management of urge incontinence

33. Sensory Irritative Incontinence • Etiology. detrusor contractions stimulated by irritation from conditions: infection, stone, Tumor, or a foreign body. • History. Loss of urine occurs with urgency, frequency, & dysuria . At day or night. • Examination. Suprapubic tenderness , but otherwise the pelvic examin ation is unremarkable.

34. • Investigative studies. A urinalysis will show the following abnormalities: bacteria and WBCs; suggest an infection, RBCs; suggest a stone, Foreign body, or tumor. A urine culture is positive if an infection is present. Cystometric studies (which are usually unnecessary) would reveal normal residual volume with involuntary detrusor contractions present. • Management. Infections are treated with antibiotics. Cytoscopy is used to diagnose and remove stones, foreign bodies, and tumors

35. Overflow (Hypotonic) Incontinence • Etiology. Rises in bladder pressure occur gradually from an overdistended , hypotonic bladder. When the bladder pressure exceeds the urethral pressure, involuntary urine loss occurs but only until the bladder pressure equals urethral pressure. The bladder never empties. Then the process begins all over. This may be caused by denervated bladder (e.g., diabetic neuropathy, multiple sclerosis) or systemic medications ( e.g.,ganglionic blockers, anticholinergics ).

36. • History. Loss of urine occurs intermittently in small amounts. This can take place both day and night. The patient may complain of pelvic fullness Exnmination . Pelvic examination may show normal anatomy. The neurologic examination will show decreased pudendal nerve sensation.

37. • Investigative studies. Urinalysis and culture are usually normal, but may show an infec tion. Cystometric studies show markedly increased residual volume, but involuntary detrusor contractions do not occur. • Management. Intermittent self-catheterization may be necessary. Discontinue the offending systemic medications. Cholinergic medications to stimulate bladder contractions and a-adrenergic blocker to relax the bladder neck.

38. Bypass Fistula • Etiology. The normal urethral-bladder mechanism is intact, but is bypassed by urine Leaking out through a fistula from the urinary tract. • History. The patient usually has a history of either radical pelvic surgery or pelvic radi ation therapy. Loss of urine occurs continually in small amounts. At day and night.

39. • Examination. Pelvic examination may show normal anatomy. normal neurologic findings. • Investigative studies. Urinalysis and culture are normal. An intravenous pyelogram (IVP) will demonstrate dye leakage from a urinary tract fistula. • Management. Surgical repair of the fistula

40. Prevention Shortening of 2 nd stage of labor Reduce traumatic delivery If menopause  consider HRT

41. The End