Incontinence

Presented By-MD. Monsur Rahman
MPT in Musculoskeletal Disorders

1. INCONTINENCE Presented By MD . Monsur Rahman MPT in Musculoskeletal Disorders MMIPR,Mullana,Ambala

2. Introduction Continence The word continence comes from the Latin word  ”continentia”  which means holding back. Continence could appear as a poor urinary stream or an intermittent flow. It could also be used delay between trying to urinate and the flow actually beginning, or inability to completely empty the bladder Incontinence The complaint of any involuntary loss of urine (Abrams et  al. 2010 ).  It means a person urinates when they do not want to

3. Cont… Many Women do not discuss their Urinary Incontinence

4. Clinically Relevant Anatomy: Pelvic Floor The  pelvic floor  is made up of the muscles( levator ani, striated urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus), ligaments, and fascial structures The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles .

5. Cont… Pelvic floor act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra-abdominal pressure. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing involuntary loss of urine or rectal contents.

6. Incidence and Prevalence According to the U.S. Department of Health and Human Services , approximately 13 million people in the United States suffer from urinary incontinence & 400 million people around the world From a survey of disability in Bangladesh village residents(2006) aged ≥60 years.UI was reported as troublesome by 28% of villagers (particularly women) (Cherry et al. BMC Public Health 2012)

7. Types of Incontinence Acute Incontinence: Comes on suddenly and is usually caused by a new illness or condition. Chronic Incontinence Develops gradually over time or remains after other illness or conditions have been treated . Types of Chronic Incontinence Stress (urinary) incontinence Urgency (urinary) incontinence Mixed (urinary) incontinence

8. Incidence of chronic incontinence in women Stress Incontinence 50% Urge Incontinence 20% Mixed 30% (European Association of Urology guidelines on urinary incontinence-July 2017 )

9. Stress Incontinence It is involuntary escape of few drops of urine with increased intra-abdominal pressure as during- straining, sneezing , coughing , laughing & Sporting activities... etc.

10. Degrees of Stress Incontinence Grade I: Incontinence occurs only with severe stress, such as coughing, sneezing, etc … Grade II: Incontinence with moderate stress, such as rapid movement or walking up and down stairs Grade III: Incontinence with mild stress, such as standing.

11. Causes of Stress Incontinence(SI) Most common causes: Aging Nerve and vascular injury Lack of oestrogen hormones ( menopause) Trauma and stretching of vaginal delivery Congenital weakness of the internal urethral sphincter . Hysterectomy Pelvic denervation Genital prolapse

12. Cont.. Congenital defects as: Short urethra (less than 1 cm) Wide bladder neck Separation of symphysis pubis .

13. Risk Factors For SI Increasing number of vaginal deliveries, probably due to nerve or muscular trauma Risk increased by multiple pregnancies, prolonged labour or difficult deliveries. Pelvic floor trauma and nerve injury Obstetric trauma Pelvic fractures and radical surgery Hormonal status and estrogen deficiency Increasing intra-abdominal pressure Medical factors chronic bronchitis or pulmonary problems Constipation with chronic straining at stool Obesity

14. Urgency (urinary) incontinence Complaint of involuntary loss of urine associated with urgency ( a sudden, strong desire to pass urine) and an inability to get to the bathroom in time. Causes Infection /inflammation Neurological disease Obstruction Unknown

15. Mixed Incontinence A combination of both stress and urge incontinence . Complaint of involuntary loss of urine associated with urgency and also effort or physical exertion or on sneezing or coughing.

16. Diagnostic Procedures A large portion of women with urinary stress incontinence can be diagnosed from clinical history alone. Clinical history A detailed history differentiates between the different types of incontinence. Stress incontinence and detrusor instability frequently occur together. Gradual onset after menopause suggests oestrogen deficiency. History of vaginal repair or operation in the region of the bladder neck and history of any neurologic disease.

17. Physical Symptoms Limited fluids → Constipation → Straining → Increased incontinence due to pelvic floor muscle damage Limited activity → Weight gain → Decreased cardio-vascular fitness Disturbed sleep patterns Frequent bathroom visits

18. Psychological Symptoms Insecurity Anger Dependence Guilt Indignity Shame Embarrassment Depression

19. Sense of Self Loss of self-confidence Sexual difficulties Lack of attention to personal hygiene, skin breakdown Person felt older than they were

20. Social Interaction Reduction in social activities Socially isolated Psychological and functional decline

21. STRESS TEST The patient in the standing position, the two labia are separated, and the patient is asked to cough.If urine escapes, the patient is incontinent. If no urine escapes, the test is repeated while the index and middle fingers in the vagina press on the perineum to abolish reflex contraction of the levator ani muscles during straining . If still no urine escapes, the test is repeated while the patient is standing with the legs separated

22. Bonney Test If incontinence is due to descent of bladder neck or weakness of the sphincter. The index and middle fingers are placed on both sides of the urethra to elevate the bladder neck upwards . If no urine escapes on stress it means that the incontinence is due to descent of the bladder neck, but if urine still escapes it means weakness of the sphincter.

23. The Cotton-tip Applicator (Q-tip) Test A sterile applicator with a small piece of cotton at its tip is introduced to reach the bladder neck . The patient then strains maximally using the Valsalvamanoeuvre. The angle between the applicator and the horizontal is measured. In stress incontinence the change is more than 30 degrees indicating poor support and abnormal descent of bladder neck

24. Cystourethroscopy To exclude lesions in the urethra and bladder. The bladder neck is examined. It should close in response to straining . However, it opens in case of stress incontinence .

25. Cystourethrography Radio-opaque dye is injected by a catheter into the bladder. On straining, the lateral view will show absence of the posterior urethrovesical angle in more than 90% of cases. Funneling of the bladder neck in the antero-posterior view may be seen in some cases. The procedure is recorded on video tape (video Cystourethrography) to facilitate diagnosis and for education purposes.

26. Kegel Perineometer A  Kegel perineometer  or  vaginal manometer  is an instrument for measuring the strength of voluntary contractions of the pelvic floor muscles .   Arnold Kegel  (1894–1981) was the gynecologist who invented the Kegel Perineometer (used for measuring vaginal air pressure) and Kegel exercises (squeezing of the muscles of the pelvic floor).

27. Pelvic Floor Muscle Strength Modified Oxford grading system : Palpation of the pelvic floor muscles per the vagina in females and per the rectum in male patients. 0 - no contraction 1 – flicker Contraction 2 - weak squeeze, no lift 3 - fair squeeze, definite lift 4 - good squeeze with lift 5 - strong squeeze with a lift 

28. PERFECT Assessment P  - power, may use the Modified Oxford grading scale  E  - endurance, the time (in seconds) that a maximum contraction can be sustained   R  - repetition, the number of repetitions of a maximum voluntary contraction  F  - fast contractions, the number of fast (one second) maximum contractions  ECT  - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening Described by Jo Laycock

29. MANAGEMENTS Conservative Management Counseling Medication Physiotherapy Behavioral techniques Surgical Management

30. Medications Anticholinergics .  These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol) Mirabegron .Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. Alpha blockers.  In men with urge or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder . Topical estrogen.  For women, applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas.

31. Behavioral techniques Bladder training: start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until the urinating only every 2.5 to 3.5 hours . Double voiding : Double voiding means urinating, then waiting a few minutes and trying again . Scheduled toilet trips:  to urinate every two to four hours rather than waiting for the need to go . Fluid and diet management:   avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem.

32. Physiotherapy Management Kegel exercise , also known as  pelvic floor exercise , consists of repeatedly contracting and relaxing the muscles that form part of the  pelvic floor. Recommendations for Effective Strength Training 8 – 12 slow velocity close to max. contractions Starting 3 sets per day 2-4 days a week Intensity is more important than frequency

33. Medical devices Vaginal cone A   vaginal cone  (or  vaginal weight ) is a medical device specifically designed and shaped to exercise pelvic floor  muscles in order to strengthen them and restore proper bladder functions in women with urinary stress incontinence. These exercises are known as vaginal weightlifting .

34. Uses Generally around 15 minutes, twice a day ( Jorge Milhem Haddad et all,May-2011 )

35. Nerve stimulators The device may be implanted under the skin in the buttock and connected to wires on the lower back, above the pubic area or with the use of a special device, inserted into the vagina. Stimulating the sacral nerves can control urge incontinence if other therapies haven't worked .

36. SURGICAL TREATMENT Urehroplasty ( Kelly,kennedy,etc ….) Urethropexy ( Retropubic Urethropexy E.G. Marchall-marchitti-krantz , Etc….) Colposuspension ( Burch Operation,preyera , Etc….) Urethral Slings (Aldridge Operation,etc …..) Tension Free Vaginal Tape (TVT)

37. Kelly operation 1914 It consists of repair of cystocele and/or urethrocele . Vertical mattress sutures are then placed to plicate the whole urethra and bladder neck. This gives support to the urethra and restores the normal posterior urethrovesical angle. Operation is done for mild and moderate cases of stress incontinence. Long term success rate is 55-65%.

38. Vaginal tape operation (TVT) The cystoscopies is used by the assistant to make sure that the bladder is not pierced by the needle . The tape is adjusted by pulling on its ends, and continence is confirmed by asking the patient to cough . The ends of the tape are cut off and left free and not fixed to the tissues, Finally the vaginal and suprapubic incisions are closed. When stress occurs ,the recti will contract and pull on the tape to support the urethra and prevent escape of urine

39. References Messelink B et all,Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn 2005;24:374-380.  Natural Childbirth. Childbirth and your pelvic floor (accessed 15 March 2011).  Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 2003;61:37-49. Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa RP. Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence. Neurourol Dynam 2006;25:674-683.  Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urologic Nursing 1994;14:136-40.  Miller JM, Sampselle C, Ashton-Miller J, Son Hong G-R, De Lancey JOL. Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. Int Urogynecol J 2008;19:773-782.  Doughty DB. Promoting continence: simple strategies with major impact. Ostomy Wound Management 2003;49:46-52. Alewijnse D, Metsemakers JFM, Mesters I, van den Borne. Effectiveness of pelvic floor muscle exercise therapy supplemented with a health education program to promote long-term adherence among women with urinary incontinence. Neurology and Urodynamics 2003;22:284-295.   Zanetti MRD, de Aquino Castro R, Rotta AL, dos Santos PD, Sartori M, Girao MJBC. Impact of supervised physiotherapeutic pelvic floor exercises for treating female stress urinary incontinence. Sao Paulo Med J 2007;125:265-9.   Burgio KL. Current perspectives on management of urgency using bladder and behavioral training. J Am Academy Nurse Pract 2004;16:4-7. Payne CK. Behavioral therapy for overactive bladder. Urology 2000;55:3-6. Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008;148:459-474.

40. Thank You