This page has moved. Click here to view.

Urinary Incontinence

Prevalence of urinary incontinence

Impact of urinary incontinence on quality of life

• Emotional disturbance

• Poor sleep

• Social isolation

• Sexual difficulties

• Reduced mobility

• Reduced recreational activity

Normal bladder function

Language of Voiding Dysfunction

• Urinary incontinence- the involuntary loss of urine
• Detrusor hyperrefiexia -involuntary bladder contractions due to a neurologic condition.
• Detrusor instability- involuntary bladder contractions which are not dueto a neurologic condition.
• Overflow incontinence - leakage of urine at greater than normal bladder capacity. Associated with incomplete bladder emptying (impaired detrusor contractility vs. bladder outlet obstruction) and elevated postvoid residuals.
• Urinary urgency- a sudden, strong desire to void.
• Urge incontinence - involuntary loss of urine associated with a sudden, strong desire to void.
• Stress incontinence- involuntary loss of urine during coughing, sneezing or physical exertion such as sports activities, sudden changes of position, etc.
• Intrinsic sphincter deficiency - an intrinsic malfunction of the urethral sphincteric mechanism

Classification of voiding dysfunction

• Failure to store = urinary incontinence

• Failure to empty = urinary retention (or incontinence if overflow ["water over the dam"])

Overactive Bladder (i.e., detrusor instability or hyperrefiexia: a bladder contraction which occurs without the patient's permission or control)

• Etiologies

Obstructive

Age-related

Pelvic floodurethral disorder · Neurogenic · Myogenic

Bladder hypersensitivity

Idiopathic

• Symptoms (urge incontinence = the involuntary loss of urine associated with a sudden, strong urge to void.)

Can't make it to bathroom in time

Sensation of incomplete emptying

Frequent, strong urge to go before bladder full

Wakes up often at night or wets bed

• Basic Evaluation of Incontinent Patient

• Treatment

Treat reversible conditions (if present) first- UTI

Treat associated conditions - bladder outlet obstruction, stress urinary incontinence, prolapse

Potential therapies for overactive bladder

Pads and absorbent products

Behavioral therapy Electrical stimulation

Pharmacological

Surgery

Augmentation cystoplasty

Lower urinary tract reconstruction (urinary diversion)

Long-term catheterization

Behavioral therapy for overactive bladder

• Techniques

Fluid management- often a good idea when the patient walks into your office with a bottle of water and complains of incontinence!

Voiding frequency - go by the clock, don't wait for the urge or it may already be

Electrical stimulation

• Stimulation can be applied from external or internal source

• New system with implantable electrode recently approved by FDA- may be best for patients who fail other therapies such as behavior modification and pharmacological management.

Pharmacological therapy for urge incontinence

• Estrogen

Postmenopausal estrogen deficiency associated with:

Increased urinary incontinence

Increase frequency, nocturia, urgency and dysuria

Recurrent urinary tract infections

Urogenital atrophy

Mixed results in literature whether estrogen therapy for post-menopausal women with urinary symptoms is more effective than placebo

May be delivered orally or vaginally with cream

• Anticholinergics

Increases volume to first bladder contraction

Decreases magnitude of bladder contraction

Does no eliminate contraction

Does not increase"warning time"

Common meds:

Oxybutynin = Ditropan

Hyoscyamine = Cystospaz

Hyoscyamine sulfate = Levsin

Probantheline bromide = Probanthine

• Side effects

Blurry vision Tachycardia Drowsiness

Contraindicated in patients with narrow-angle glaucoma

Dry mouth - receptors which are blocked which mediate detrusor contraction are also involved with salivary secretion

The increased fluid intake (and resultant increased fluid output) can potentially cancel out the beneficial bladder volume-increasing effect of the medicine

• Tolterodine (Detrol)

New anticholinergic

More selective inhibition of bladder with less of an inhibitory effect on the salivary glands

Approximately eight times less inhibition of salivary glands in cats compared to oxybutynin

Efficacy- summary of phase III trials (using placebo, tolterodine 2 mg bid and oxybutynin 5 mg tid)

Number of micturitions/24 hours significantly less with tolterodine

and oxybutynin compared to placebo

Stress Urinary Incontinence (SI)

• Definition: urinary leakage which is brought about by an increase in abdominal pressure in the absence of a detrusor contraction.
• Typical Symptoms

Loss of urine with cough/sneeze

• Treatment

Depends on severity of incontinence and how much it affects the patient. This is often a quality of life issue which does not necessarily correlate with the degree of leakage. Choices include:Pads and absorbent products

Behavioral therapy

Electrical stimulation

Pharmacological

Surgery

Transvaginal suspension

Transabdominal suspension

Sling suspension

Periurethral collagen injection

Artificial urinary sphincter

Behavioral therapy for Stress Incontinence

• Techniques

Fluid management - decrease fluid intake

Electrical stimulation

• Stimulation can be applied from external or internal source
• No clear cut optimum delivery system or parameters (i.e., stimulus frequency and duration, pulse configuration)
• Specialized equipment needed
• New system with implantable electrode recently approved by FDA for urge incontinence, not yet approved for the treatment of SI

Medication

• Alpha-adrenergic agonists

Pseudophedrine (Sudafed)

Phenypropanolamine (Ornade)

Subjective improvement achieved most frequently in patients with mild (and

• Estrogen

• Transvaginal suspension (Pereyra, Raz, Stamey, Gittes)

For female stress urinary incontinence

Cure/dry and cure/dry/improvement rates of 67% and 82%, respectively, at 48 months or more

• Transabdominal suspension (Burch, MarshalI-Marchetti-Krantz)

For female stress urinary incontinence

Cure/dry and cure/dry/improvement rates of 84% and 90%, respectively, at 48 months or more

• Sling suspension (vaginal wall, rectus fascia, Gortex, cadaveric)

For female stress urinary incontinence]

Cure/dry and cure/dry/improvement rates of 83% and 87%, respectively, at 48 months or more

• Periurethral collagen injection

Most effective for females with intrinsic sphincteric dysfunction and lack of urethral hypermobility

Often need multiple injections to achieve optimal result

• Artificial urinary sphincter

For male and female stress urinary incontinence

Most commonly used in men with post-prostatectomy incontinence