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Urinary Incontinence

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Kegel Exercises: younger women, 30-80 times per day for 8 weeks ... Pelvic Floor Electrical Stimulation : in conjunction with Kegel Exercises. Management ... – PowerPoint PPT presentation

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Title: Urinary Incontinence


1
Urinary Incontinence
  • ACC Conference
  • May 30, 2007
  • John Meier

2
Definition
  • Urinary Incontinence is the involuntary loss of
    urine that is objectively demonstrable and a
    social or hygienic problem.
  • International Continence Society
  • Overactive Bladder is defined as urinary urgency,
    with or without urge incontinence, usually with
    urinary frequency and nocturia.
  • International Continence Society

3
Epidemiology
  • Prevalence
  • By Sex
  • Women
  • Young Adult 20-30
  • Middle Aged 30-40
  • Elderly 50
  • Men
  • Rates are 1/3 of those of women by age group
    until age 80 at which time rates converge
  • By Type
  • Women
  • 50 Stress
  • Then Mixed Stress-Urge
  • Least common is Urge but becomes more common as
    woman ages
  • Men
  • No specific delineation, Prostate disease impacts
    assessment

4
Epidemiology
  • Additional Facts
  • 13 million Americans affected, 11 million of whom
    are women
  • 1 in 4 women ages 30-59 have experienced an
    episode of urinary incontinence
  • 50 or more of the elderly persons living at home
    or in long term-care facilities are incontinent.

5
Epidemiology
  • Annual Direct Costs in 1995 Dollars
  • estimated as 16.3 billion, including 12.4
    billion (76) for women and 3.8 billion (24)
    for men.
  • Costs for community-dwelling women (8.6 billion,
    69 of costs for women) were greater than for
    institutionalized women (3.8 billion, 31).
  • Costs for women over 65 years of age were more
    than twice the costs for those under 65 years
    (7.6 and 3.6 billion, respectively).
  • The largest cost category was routine care (70
    of costs for women), followed by nursing home
    admissions (14), treatment (9), complications
    (6), and diagnosis and evaluations (1).
  • Costs were most sensitive to changes in
    incontinence prevalence, routine care costs, and
    institutionalization rates and costs.

6
Anatomy and Physiology
  • Pontine Micturition Center
  • Peripheral Micturition Center Bladder Reflex Arc
    of S2-S4
  • Filling (150-200 cc) sympathetic reflex--body
    relaxes, sphincter tightens, detrusor inhibited.
  • Further filling(350-500 cc) somatic (voluntary)
    tone increases (external sphincter)
  • 5. Voiding detrusor contraction with coordinated
    reflex ? somatic and
    sympathetic tone,
  • ? parasympathetic action (M3 receptors)

7
Risk Factors
  • Women childbearing, vaginal delivery,
    episiotomy, estrogen depletion, GU surgery
  • Men Prostate related pathology
  • Both Sexes
  • Age
  • Changes to Detrusor control overactive
  • Decreased Bladder capacity
  • Decreased Urinary flow rates
  • Decreased Renal Clearance
  • Changes in Fluid Balance
  • More Medications
  • Functional and Cognitive Impairment
  • Comorbid Diseases CHF, DM, Depression, CNS
    insults

8
Categories
  • Acute - DRIP
  • Urge Detrusor Hyperreflexia, Detrusor
    Instability
  • Stress Weakened Sphincter Function
  • Overflow Incomplete Bladder Emptying
  • Mixed Urge and Stress
  • Functional Physical or Cognitive Impairment
  • Rare Extraurethral Fistula, Spinal Cord Injury

9
Acute Urinary Incontinence
  • DRIP
  • Drugs, Delirium
  • Restricted Mobility, Retention
  • Infection, Impaction (fecal), Inflammation
    (atrophic urethritis, vaginitis)
  • Polyuric States (CHF, DM, Hypercalcemia)

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11
Urge
  • Definition Involuntary leakage accompanied by or
    immediately preceded by urgency.
  • Attributes abrupt urgency with moderate to large
    leakage
  • Etiology detrussor over activity (uninhibited
    bladder contractions)
  • Sequelae of
  • Age
  • Interrupted CNS inhibitory pathways
  • Bladder irritation
  • More common in older adults

12
Stress
  • Definition involuntary leakage on effort,
    exertion, sneeze or coughing.
  • Attributes most common cause in young women,
    second most common in older women and in men
    after TURP or radical prostatectomy
  • Etiology Intra-abdominal pressure exceeds the
    muscular strength of the sphincter
  • Impaired urethral support
  • Intrinsic sphincter deficiency

13
Overflow
  • Definition dribbling and/or continuous leakage
    associated with incomplete bladder emptying due
    to impaired detrussor contractility and/or
    bladder obstruction.
  • Attribute typically small volumes, elevated
    postvoid residual, associated urinary stream
    abnormalities
  • Etiology
  • Detrusor Under activity 5-10 of elderly,
    detrusor muscle changes, peripheral neuropathy,
    damage to efferents
  • Obstruction Men (prostate), Women (s/p
    corrective surgery, cystocele)

14
Mixed
  • Definition involuntary leakage associated with
    urgency as well as exertion, effort, sneezing or
    coughing
  • Attribute most common cause in women
  • Etiology overlap of
  • Detrusor over activity
  • Impaired urethral sphincter function

15
Work-Up I
  • Screening Question
  • Do you ever lose control of your urine and wet
    yourself?
  • Not Are you incontinent?

16
Work-Up II
  • History
  • Specific Symptoms
  • Acute/Chronic/Recurrent
  • Daily Pattern
  • Stress or Urge Pattern
  • Precipitants
  • Polyuria
  • Obstructive Symptoms
  • Hesitancy
  • Decreased Stream
  • Dribbling
  • Irritative Symptoms
  • Dysuria
  • Frequency
  • Previous Treatment
  • Pelvic Surgery or Radiation
  • Medications
  • Adrenergic or Cholinergic Modulators
  • Narcotics

17
Work-Up III
  • Physical Exam
  • General Cognitive and Physical function
  • Neurologic sacral dermatomes (S2-4)
  • Assess UMN vs. LMN
  • Rectal sphincter tone, impaction, prostate
  • Pelvic atrophic changes, cystocele, prolapse
  • Palpable Bladder

18
Work-Up IV
  • Laboratories (Initial)
  • Chemistries
  • Urinalysis Glucose (DM), Hematuria (UTI, Stones,
    etc), Nitrites/LE (UTI)
  • Urine Culture
  • B12 levels in the elderly

19
Work-Up V
  • Diagnostic Testing
  • Voiding Diary
  • Volumes (day and night) with associated
    symptoms/comments
  • Post-void Residual
  • Agency for Healthcare Research and Quality
    recommend measurement of PVR in all patients
    presenting with UI
  • Cut-off is 100 ml
  • If greater than 100 ml, evaluate for
    retention/obstruction
  • Urodynamic Testing

20
Urodynamic Testing
  • Urodynamic tests try to measure nerve and muscle
    function, pressures around the bladder, flow
    rates and other factors in an attempt to explain
    the urinary incontinence.
  • Cystometry catheter placed in the bladder and
    bladder progressively filled to point of 1) urge
    to void is sensed, 2) volume at which urge is
    uncontrollable and 3) any involuntary contraction
    is sensed
  • Multichannel Cystometrogram in a laboratory
    intra-abdominal pressures are measured with
    rectal or vaginal probe which allows more precise
    measurement of detrusor pressure.
  • Uroflowmetry measure urine flow rates.
  • Pure Stress Incontinence 91 sensitive, 51
    specific
  • Pure Urge Incontinence 73 sensitive, 55
    specific

21
Urodynamic Testing
  • Cochrane Review 2007 Urodynamic investigations
    for management of urinary incontinence in
    children and adults.
  • Question does urodynamic testing 1. improve
    clinical outcomes, 2. alter clinical decision
    making and 3. is one urodynamic test better and
    addressing points 1 and 2.
  • 52 potential studies but only 3 small trials
    involving 184 met the inclusion criteria and only
    two of the three yielded any useful data.
  • Findings of 128 women (no men or children), those
    investigated with urodynamic testing were more
    likely to receive active treatment with drugs or
    surgery
  • Recognize the need for a large definitive trial
  • At the present time, there are no clear
    guidelines for the role of urodynamic testing.

22
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23
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24
Management
  • Treatment is based upon the type of incontinence,
    its causes and patient capabilities
  • Pelvic Muscle Rehabilitation
  • Kegel Exercises younger women, 30-80 times per
    day for 8 weeks
  • Biofeedback in conjunction with Kegel Exercises
  • Vaginal Weight Training 15 min, bid, 4-6 weeks
  • Pelvic Floor Electrical Stimulation in
    conjunction with Kegel Exercises

25
Management
  • Behavioral Therapies
  • Bladder Training resist the urge and gradually
    expand intervals between voiding
  • Toileting Assistance routine and schedule
    voiding
  • Surgical Therapies
  • Bladder Neck suspension
  • Sling Procedure
  • Minimally invasive Needle Vaginal Suspension
  • Bulking injections

26
Management
  • Medications
  • Anticholinergics
  • Oxybutynin (Ditropan) not recommended for the
    elderly
  • Tolterodine (Detrol) most frequently prescribed
    as extended release 4 mg tablet po qday
  • OPERA trial and OBJECT trial favor extended
    release oxybutynin for efficacy and tolterodine
    for fewer side effects
  • Side Effects dry mouth, constipation,
    somnolence
  • Anti-muscarinic (M3 receptor antagonist)
  • Darifenacin (Enablex)
  • Solifenacin (Vesicare)
  • Side Effects dry mouth and constipation
  • Estrogen
  • Topical Estrogen 0.5 mg bid for 2 wks then once a
    week
  • Estradiol Ring replaced every 90 days
  • Estradiol tablet q day for 2 weeks and then one
    tablet q week
  • Topical estrogen most likely more effective

27
Management
  • Urge
  • Behavioral Treatment scheduled voids, pelvic MM
  • Lifestyle
  • Protective Pads
  • Bladder MM relaxants (anticholinergics with
    antimuscarinic activity) oxybutynin,
    tolteridine, trospium, solifenacin
  • Stress
  • Behavioral Treatment
  • Estrogen (topical) increase number/responsiveness
    of alpha receptors, potentiates alpha agonists
  • Alpha-Agonists imipramine (Mixed UI), duloxetine
  • Refer pessary, surgery (highest cure rates
    slings, bladder neck suspension)
  • Overflow
  • If BPH alpha-1 antagonist (terazosin) , 5-alpha
    reductase inhibitor (finesteride)
  • Refer further evaluation, surgery
  • Functional
  • Treat underlying infection, comorbidity
  • Commode, urinal, living space adaptations

28
Management
  • For those that are chronically incontinent
  • Scheduled toileting every 2-4 hours
  • Prompted Voiding check for dryness and encourage
    toilet use
  • Improved access to toilets mobility aides and
    raise level of toilets
  • Managing fluids and diet eliminate caffeine,
    fluid management and fiber for regular bowel
    movements
  • Disposable absorbent garments keep people dry

29
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30
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31
Overactive Bladder
  • Definition includes urinary urgency with or
    without urge incontinence, urinary frequency
    (voiding eight or more times in a 24-hour
    period), and nocturia (awakening two or more
    times at night to void).
  • Attributes International Continence Society
    classifies overactive bladder as a syndrome for
    which no precise cause has been identified, with
    local abnormalities ruled out by diagnostic
    evaluation
  • Etiology disorders of the lower urinary tract,
    neurologic conditions, behavioral factors such as
    caffeine intake, and a variety of commonly
    prescribed drugs
  • Ouslander, JD, Management of Overactive Bladder,
    New England Journal of Medicine, 2004 350786.

32
Overactive BladderAssociated Conditions
  • Urinary Tract Impairment
  • Bladder Abnormalities or inflammation
  • Impaired Bladder Contractility
  • Obstruction
  • Urinary Tract Infection
  • Women
  • Estrogen Deficiency
  • Sphincter Weakness
  • Men
  • Prostate Enlargement

33
Overactive BladderAssociated Conditions
  • Neurologic Disorders
  • Alzheimers Disease, Multi-infarct Dementia
  • Cervical or Lumbar Stenosis or Disk herniation
  • Diabetic Neuropathy
  • Multiple Sclerosis
  • Nerve Injury
  • Parkinsons Disease
  • Spinal Cord Injury
  • Stroke

34
Overactive BladderAssociated Conditions
  • Systemic Conditions
  • Abnormalities of Arginine Vasopressin
  • Congestive Heart Failure
  • Diabetes
  • Sleep Disorders
  • Venous Insufficiency
  • Functional Behavioral Problems
  • Constipation
  • Excess intake of Caffeine, Alcohol, Polydipsia
  • Impaired Motility
  • Psychologcial Disorders

35
Overactive BladderAssociated Conditions
  • Medications
  • Anticholinergic Agents
  • Calcium Channel Blockers
  • Cholinesterase Inhibitors
  • Diuretics
  • Narcotics

36
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37
Urinary IncontinencePatient Resources
  • http//www.niapublications.org/agepages/urinary.as
    p
  • Alliance for Aging Research
  • Bladder Health Council, c/o American Foundation
    for Urologic Disease
  • National Association for Continence
  • Simon Foundation for Continence

38
Sources
  • Annual Direct Cost of Urinary Incontinence,
    Leslie Wilson, PhD, Jeanette S. Brown, MD, Grace
    P. Shin, PharmD, Kim-Oanh Luc, PharmD and Leslee
    L. Subak, MD, Obstetrics Gynecology
    200198398-406
  • Incontinence, Urinary Comprehensive Review of
    Medical and Surgical Aspects, Michael
    OShaungnessy, MD, eMedicine, February, 2007.
  • Management of Overactive Bladder, Joseph G.
    Ouslander, M.D. N Engl J Med 2004 3502213, May
    20, 2004.
  • Overactive Bladder When and How to Treat, David
    Mobley, MD, Neil Baum, MD, Resident and Staff
    Physician, April 2005, 9-20.
  • Urinary Incontinence, Thomas Finucane MD, James
    Wright, MD Principles of Ambulatory Medicine
    Sixth Edition, Lippincott, Williams Wilkins,
    2003, pp 727-743.
  • Urinary Incontinence, UpToDate,2007.
  • Urinary Incontinence in Elderly Women Findings
    From the Health, Aging, and Body Composition
    Study R A. Jackson, MD , E Vittinghoff, PhD,
    Obstetrics Gynecology 2004104301-307
  • Urinary Incontinence Guide to Diagnosis and
    Management, National Guideline Clearinghouse,
    http//www.guideline.gov/
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