Urinary incontinence

Diagnosis and treatment of UI

1. UrinaryIncontinence
Tevfik Yoldemir, MD, BSc, MA, PhD
tevfikyoldemir
yoldemirtevfik

2. Definition
•“Involuntarylossof urine or stool in
sufficient amount orfrequency to
constitute a social and/orhealthproblem.
•A heterogeneouscondition that ranges in
severity fromdribbling small amounts of
urine tocontinuousurinary
incontinence…”

3. Prevalence
•Affectsup 20% of community-dwelling
olderindividuals
•Affects up to 50 % of nursing home
residents
•Increasesgraduallyduringyouth
•Peaksaroundmiddleage
•Steadily increases in the elderly

4. Prevalance of UI among women
EPINCONTStudy[n=27.936]
Hannestad et al, J Clin Epidemiol 2003;53:1150-1157

5. Curr Med Res Opin
2004;20;(6):791-801

6. Risk factors

7. ReversibleCauses
• Delerium;dementia
• Infections:urinary,respiratory, skin
• Atrophicvaginitis, urethritis; alcoholingestion; acuteillness
• Pharmacologicalagents: diuretics, sedative/hypnotics
anti-cholinergics, calciumchannelblockersantidepressants,etc
• Psychologicalcauses: depression, grief/loss
• Endocrine disorders: Hyperglycemia ;excess urineoutput;
excessfluidintake
• Restricted mobility :physical restraints, musculoskeletal
disorders
• Stoolimpaction; chronicconstipation

8. Classificationsof Urinary
Incontinence
• Stress
• Urge
• Overflow
• Functional
• Mixedcomponent(detrusorhypercontractabilityand
impairedcontraction)
• Reflex(spinalcorddamage)

9. Stress
• Leakage with increase in intra-abdominal
pressure
• Urethralsphinctermalfunction(intrinsicweakness) /
bladderneckhypermobility
• Associated with weakening of pelvic floormuscle
• Loss of small to moderate amount of urine
• No evidence of urgency or nocturia

10. Urge
• Voidingdysfunctionassociatedwithinvoluntarylossof
urine
• Detrusoroveractivity
• Urgency
• Frequency
• Nighttime voiding
• Most common in older women

11. Overflow
• Involuntary loss of urine due to distention of the
bladder
• Filling occurs to the stretch limit of the bladder
• Underactive detrusorwith/without bladder outlet
obstruction
• LargePVR >400cc
• Dribbling, frequency
• Highratesof infections

12. Incontinence Assesment

14. Measurement of Bladder Base
Descent (The Q-tip Test)

15. Treatment
• BehavioralModification
• Pharmacotherapy
• UrethralInjection
• Surgery
• Devices
• Referral

16. BehavioralTreatment
StressIncontinence
1. Patienteducation
2. Kegelexercises
3. Dietmodification
4. Weightedvaginalcones
5. Pessary
6. Pelvic floor electrical stimulation
7. Weightreductions

17. BehavioralTreatment
UrgeIncontinence
1. Patienteducation
2. Timedvoiding
3. Habittraining
• urgeinhibition
• bladdertraining
4. Avoid caffeine and alcohol intake
5. Dietmodification

18. BehavioralTreatment
MixedIncontinence
1. Patienteducation
2. Treat the predominant type
3. Kegelexercises-81% reduction in urinary
leakage
4. Dietmodification
5. Bladdertraining

19. BehavioralTreatment
OverflowIncontinence
1. Patienteducation
2. “Doublevoidingtechnique”
3. Dietmodification
4. Avoidcaffeine/alcohol
5. Barrier product to prevent skin
breakdown

20. BehavioralTreatment
FunctionalIncontinence
1. Patienteducation
2. Environmentalterations
3. Grabbars/raisedseats
4. Caregiverassistance/education
5. Screenfordepression/cognitiveimpairment
6. Occupational/Physicaltherapy

21. PharmacologicalTreatment
• Anticholinergics=detrusorunderactivity, maycause
retention
• Cholinergics=detrusoroveractivity, maycausefrequency
• Alphaagonists=outletoveractivity, maycauseretention
• Alphablockers=outletunderactivity, maycausestress
incontinence

22. Anticholinergics
• Darifenacin(Enablex)
• Oxybutynin(UropanXL)
• Solifenacin(Vesicare)
• Tolterodine(Detrusitol)
• Trospium(Sanctura)
• Flavoxate(Urispas)

23. AlphaAgonists
• Phenylpropanolaminehydrochloride-no
longer marketed in U.S. (Intracerebral
hemorrhage)
• Pseudoephedrine(Sudafed)
• Midodrine(Proamatine)

24. AlphaBlockers
• Alfuzosin(Uroxatral)
• Doxazosin(Cardura)
• Tamsulosin(Flomax)
• Terazosin(Hytrin)

25. Physiologyof Stress
Incontinence
1. Urethral sphincter fails to protect against
lossof urine
–Intrinsicweakness
–Failuretocontract
2. Urethralhypermobility
3. Coexisttogether

26. PharmacologicalTreatmentof
StressIncontinence
1. Phenylpropanolaminehydrochloride/pseudoephedrine
/midodrine
• Reductionin padchanges
• Reductionin incontinenceepisodes
• Improvementin subjectivesymptoms
2. Duloxetine(Cymbalta)
• Inhibitorof serotonin/norepinephrinereuptake
• Increases serotonin/norepinephrinelevels in the sacral
spinalcord
• Increased contraction of urethral sphincters during urine
storage phase of micturitioncycle

27. Physiology& Pharmacological
TreatmentforOveractiveBladder
1. Neurogenic
–Cause-enhancedbladderC-fiber sensoryinput
–Abnormalatropine-resistantparasympathetictransmission
–Acetylcholinemediatesdetrusorcontraction
2. Anticholinergicversusplacebocontrol
–41% experienced a cure or improvement in urinary
incontinence,improvement in leakage episodes/24 hours,
number of voids in 24hours, volume at first contraction

28. Distribution/Functionof Muscarinic
ReceptorsThroughouttheBody
• M1:Cerebralcortex, hippocampus, salivaryglands, eye-
memory/cognition
• M2:Bladder, Heart, eye, hippocampus-heartrate/tear
secretion
• M3:Bladder,salivaryglands, eye, brain-bladder
contraction/ bowelmotility
• M4:Basalforebrain, salivaryglands
• M5:Substanianigra, eye-visualaccommodation

29. MuscarinicReceptorsAntagonists
• Detrusorcontraction –mediated by M3muscarinic
receptors
• Mainstayof treatment
• Choose an agent that is selective for thebladder

30. SurgicalTreatment
Indications:
–Failednonsurgicalmanagement
–Unable to tolerate side effects of medications
–Moredefinitivetherapy

31. Burch

32. Burch + PDR

33. TVT –1

34. TVT -2

35. TVT -3

36. TVT -4

37. TOT -1

38. TOT -2

39. Pessaries

41. www.yoldemir.
com