Urinary Incontinence

Urinary incontinence By Raheef Alatassi
A student to student guide

1. Urinary Incontinence Raheef Mohamed Alatassi 5 th Year Medical Student Imam Mohammed bin Saud University Urology Stress Urge Mixed

2. objectives Definition Epidemiology Risk factors & etiologies Types Diagnosis management

3. Definition Epidemiology Risk factors & etiologies

4. Definition “ The involuntary loss of urine which is objectively demonstrable and a social or hygienic problem .” Any involuntary leakage of urine

5. URINARY INCONTINENCE

6. Epidemiology Community: 17% older men, up to 30% older women Hospital: up to 50% older men and women Elderly (<65 y): up to 10% in male and 15 % in female F>M until age 80 years, then M=F

7. Anatomical Structures of the Lower Urinary Tract System The bladder and bladder neck The urethra and urethral sphincter mechanism The pelvic floor musculature

8. The Bladder Is a hollow muscular organ lies in the anterior part of the pelvic cavity behind the symphysis pubis It is outside the peritoneal cavity and extends upwards as it fills It is anterior to the rectum

9. The Bladder Embryologically , the bladder is derived from the hindgut . External features are the  apex ,  body ,  fundus  and  neck . Trigone  – a triangular area located within the fundus In order to contract during micturition, the bladder wall contains specialized smooth muscle, known as  detrusor muscle . 

10. Nervous Supply of bladder The sympathetic nervous system Hypogastric nerve  (T12 – L2) . It causes relaxation of the detrusor muscle. These functions promote urine retention . The parasympathetic nervous system Pelvic nerve (S2-S4). Increased signals from this nerve causes contraction of the detrusor muscle. This stimulates micturition. The somatic nervous supply gives us  voluntary control  over micturition. It innervates the external urethral sphincter, via the   pudendal nerve (S2-S4). It can cause it to constrict (storage phase) or relax (micturition).

11. Urethral Sphincters Internal Urethral Sphincters Situated at the base of the bladder neck. Circular smooth muscle layer Normally in a state of contraction Involuntary control (under autonomic control) It is thought to prevent seminal regurgitation during ejaculation. External Urethral Sphincters Skeletal muscle (Circular striated muscle fibres ) Reinforced by the pelvic floor muscle Voluntary control During micturition, it relaxes to allow urine flow.

12. Functions of the Pelvic Floor Pelvic floor formed by Levator ani muscles (largest component), Coccygeus muscle and Fascia coverings of the muscles. Forms a ‘sling-like ’ support for the lower pelvic organs Contributes to the action of the external sphincter in maintaining urethral closure. Contributes to the action of the anal sphincter in maintaining faecal continence.

13. Risk factors Depression Stroke Diabetes Parkinson’s Disease Dementia (moderate to severe) Obesity , CHF, Constipation, TIAs, COPD, Chronic cough

14. Aging Changes Decreased bladder capacity Reduced voiding volume Reduced flow rates Increased urine production at night Detrusor over activity (20% of healthy continent) BPH

15. Reversible causes of UI - Delirium or Drugs - Restricted mobility - Infection, impaction - Polyuria I P R D

16. Causes of Transient (Acute) Incontinence D Delirium I Infection A Atrophic Vulvovaginitis P Psychological P Pharmacologic agents E Endocrine, excessive UO R Restricted Mobility S Stool impaction

17. Drugs Contributing to UI

18. Transient Incontinence Lower urinary tract pathology Precipitated by reversible factor 1/3 Community dwelling 1/2 Hospitalized incontinent aged patients Causes: Delirium, UTI, Meds, Psychiatric disorders,  UO, Stool impaction Restricted mobility

19. Types of Urinary Incontinence Transient UI ( Acute) Established UI (Chronic) Urge UI Stress UI Mixed UI Overflow UI “Functional” UI

20. Stress UI Sudden increase in abdominal pressure Urethral pressure -The complaint of involuntary leakage with effort or exertion or on sneezing or coughing. -Due to either: 1-poor pelvic floor. 2-weak urethral sphincter. -Very common in women .

21. Urge UI Involuntary detrusor contractions Urethral pressure The complaint of involuntary leakage accompanied by or immediately preceded by urgency. Due to over activity of detrusor muscle.

22. Overflow Neurogenic/Atonic Obstruction Urethral blockage The Bladder is not able to empty properly

23. Management Of Urinary Incontinence

24. Major Points Nonpharmacological Therapy: Pharmacological Therapy: A. Urgency Incontinence: B. Choosing Medication: C. Stress Incontinence: D. Adjunctive Measures: Surgical Therapy: I/ Urgency Incontinence: II/ Stress Incontinence: 1)Transurethral Bulking Agents: 2) Perineal Slings: 3) Artificial Urinary Sphincter:

25. First: Nonpharmacological Therapy Lifestyle advice (particularly weight loss and dietary changes). Avoidance of urethral compression during voiding.

26. Second: Pharmacological Therapy Urgency Incontinence: * “ Antimuscarinic drugs” are the main pharmacological agents available for urgency incontinence, and “Alpha Blockers” are used for men with urgency incontinence with BPH.

27. Cont’ Pharmacological Therapy B. Choosing Medication: * Despite the lack of evidence to guide urgency incontinence therapy in men, it’s reasonable to initiate pharmacologic treatment with Alpha Blockers (WHY ?)

28. Cont’ Pharmacological Therapy C. Stress Incontinence: * No medications have been approved in the US for the treatment of stress incontinence. * [ Duloxetine & SNRI] is approved for this indication in many European countries.

29. Cont’ Pharmacological Therapy D. Adjunctive Measures: * Include incontinence pads, indwelling catheters, external urinary catheters & penile incontinence clamps. * The treatment of urinary incontinence with an indwelling catheter is usually a poor management choice (WHY ?)

30. Cont’ Pharmacological Therapy

31. Third: Surgical Therapy I/ Urgency Incontinence: - Most common surgical treatment for urgency incontinence is ----> Sacral Nerve Stimulation. - In the minority of patients in whom medical therapy is ineffective, treatments options include: electrical stimulation.

32. Cont’ Surgical Therapy II/ Stress Incontinence: - Most commonly utilized interventions for male are transurethral bulking agents, perineal slings & artificial urinary sphincter.

33. Cont’ Surgical Therapy 1) Transurethral Bulking Agents:

34. Cont’ Surgical Therapy 2) Perineal Slings:

35. Cont’ Surgical Therapy 3) Artificial Urinary Sphincter:

36. Any Questions ?

37. Thank you