Urinary Incontinence

1
Urinary Incontinence

• Elise Hughes-Watkins, MD
• February 2001

2
The Problem

• Urinary incontinence (UI) is common, yet it
  remains an underreported and underdiagnosed
  condition.
• An estimated 13 million Americans are affected.
• Direct medical costs have been estimated at 16
  billion to 26.3 billion per year in the U.S.
• UI decreases quality of life, decreases
  participation in social activities and may be
  associated with increased risk of depression.
• UI contributes to caregiver burden and is an
  important factor in nursing home admissions.

3
Epidemiology

• Prevalence estimates range from 26 to 57 in
  adult women depending on epidemiologic methods
  used and the population studied
• Ratio of WomenMen 41 in lt60 y.o. age group
• Ratio of WomenMen 21 in gt60 y.o. age group
• Urge incontinence accounts for 2/3 cases of
  geriatric incontinence (regardless of dementia)

4
Definition

• Urinary incontinence is the inability to control
  urination which results in unintended urinary
  flow or leakage

5
Normal Bladder Function and Continence

• Detrusor muscle
• under simultaneous sympathetic and
  parasympathetic control
• Filling phase
• sympathetic tone predominates
• allows relaxation of detrusor and tightening of
  internal sphincter

6
Normal Bladder Function and Continence

• Voluntary voiding
• sensation of bladder fullness mediated by
  proprioceptive fibers in detrusor
• reflex arc between detrusor and brainstem
  initiates bladder contraction via increase in
  parasympathetic and decrease in sympathetic
  stimulation
• reflex under cortical inhibition
• voiding occurs with release of inhibition and
  voluntary relaxation of external sphincter
• urethrovesicular angle changes to allow full
  drainage of bladder

7
Classification of UI

• 6 major subtypes of urinary incontinence
• Stress
• Urge (overactive bladder)
• Overflow
• Mixed
• Functional
• Other (deformity/lack of continuity)

8
Stress incontinence

• Signs Symptoms
• urine leakage triggered by coughing, sneezing,
  laughing, lifting, exercising, straining
• usually worse standing than supine
• small to moderate volumes of urine
• infrequent nocturnal leakage
• little post-void residual

9
Stress incontinence

• Causes
• urethral hypermobility due to pelvic floor laxity
• aging
• difficult or multiple vaginal deliveries
• hysterectomy
• other perineal injury (e.g. radiation)
• intrinsic urethral sphincter deficiency
• autonomic neuropathy
• inadequate estrogen levels
• partial denervation

10
Stress incontinence
11
Urge incontinence (overactive bladder, detrusor
instability)

• Symptoms
• Frequent abrupt, intense urge to urinate that
  cannot be voluntarily suppressed
• moderate to large volumes of urine
• nocturnal wetting
• perineal sensation intact

12
Urge incontinence (overactive bladder, detrusor
instabiliy)

• Cause
• Inappropriate contraction of detrusor muscle
  during bladder filling
• idiopathic
• related to aging (unclear mechanism)
• decreased cortical inhibition (CVA, Parkinsons
  disease, Alzheimers disease, brain tumor)
• bladder irritation (UTI, bladder CA, stones)

13
Urge incontinence

• Reflex incontinence (FYI)
• variant of overactive bladder caused by SCI, MS,
  neurosyphilis, or cord compression
• loss of central control leads to detrusor
  spasticity and functional outlet obstruction
• symptoms
• frequent voiding without warning
• moderate volumes
• equal frequency day and night
• decreased perineal sensation and sphincter
  control
• sacral reflexes intact

14
Urge incontinence (overactive bladder)
15
Overflow incontinence

• Signs Symptoms
• Frequent voiding/dribbling (worse after fluid
  load or diuretic)
• small volumes
• without warning
• slow or weak flow
• incomplete bladder emptying
• feel need to strain
• nocturnal wetting
• Bladder hypotonic/flaccid and palpably distended
• Large post-void residual (PVR)

16
Overflow incontinence

• Causes
• long-standing outlet obstruction
• detrusor chronically overstretched
• detrusor insufficiency
• lower motor neuron damage due to peripheral
  neuropathy or sacral cord injury
• impaired sensation
• peripheral neuropathy, Vit B12 deficiency, SCI
• medications that reduce detrusor tone
• anticholinergics, antidepressants,
  antipsychotics, anti-Parkinsonians, narcotics,
  Ca-channel blockers, vincristine

17
Overflow incontinence
18
Mixed Incontinence

• Refers to patients with both stress incontinence
  and urge incontinence.
• Helpful to identify the most bothersome symptom
  and treat accordingly (more on this later).

19
Functional Incontinence

• Inability to void independently due to impairment
  of physical and/or cognitive function
• disabling illness, bedridden
• frontal lobe dysfunction, lack of awareness
• deliberate incontinence (rare)
• Patient may have other types of incontinence that
  are amenable to treatment
• Pure functional incontinence should be a
  diagnosis of exclusion

20
Deformity or Lack of Continuity

• Causes
• Vesicovaginal or ureterovaginal fistula, often as
  complication of hysterectomy or other pelvic
  surgery
• Ectopic ureters
• Diverticulae

21
Diagnosis in the Primary Care Setting

• Screening questions
• History
• Bladder diary
• Physical exam
• PVR, UA and U Cx

22
Screening questions

• See handout

23
History

• Identify contributing medical factors
• DM
• CVA
• Lumbar disc disease
• Chronic lung disease
• fecal impaction
• cognitive impairment

• OB/Gyn Hx
• gravity/parity
• of vaginal, instrument assisted and C/S
  deliveries
• interval between deliveries
• previous hysterectomy, vaginal and/or bladder
  surg
• pelvic XRT
• trauma
• estrogen status

24
History

• Bowel hx
• frequency of bowel movements
• length of time to evacuate
• splinting of vagina or perineum during defecation
• fecal incontinence

• Meds
• prescription drugs
• non-prescription drugs

25
Bladder Diary

• 24-48 hours
• Requires literacy and significant amount of time
  and work by patient
• see sample in handout

26
Physical Exam

• If screen () for UI
• Have pt void as normally and completely as
  possible immediately before exam
• Record volume voided
• Determine PVR within 10 minutes by
  catheterization (send urine for UA Cx)
• PVR gt 100ml considered abnormal

27
Physical Exam

• Cardiopulm cough, CHF
• Abdom
• diastasis recti
• HSM, masses, ascites
• bladder distention
• Neuro L-S nerve roots (DTRs, LE strength,
  sharp/dull sensation and bulbocavernous and
  clitoral sacral reflexes)
• bulbocavernous lightly brush labia majora
• clitoral lightly tap clitoris
• both should produce reflex contraction of
  external anal sphincter

28
Physical Exam

• Pelvic
• signs of inflammation, infection, atrophy
• increase afferent sensation can cause urgency,
  frequency, dysuria and overactive bladder
• estrogen deficiency can contribute to UI
• urethral diverticula (distal bulge under urethra)
• assess levator ani muscle function during
  bimanual exam
• normal hold contraction 5-10 sec
• weak or absent contraction may indicate need for
  biofeedback training sessions with a pelvic floor
  PT

29
Physical Exam

• Pelvic
• signs of urine leakage with vigorous cough
• leakage in supine after bladder emptying
  indicates increased risk of intrinsic sphincter
  deficiency-- may not respond to conservative
  treatment
• Rectal
• anal sphincter tone
• fecal impaction
• occult blood
• rectal lesions

30
Urodynamic testing

• PVR simple test for overflow incontinence
• Cystometry dx of complicated mixed conditions
• Normal sense filling between 100-200ml
• non-urgent desire to void at 250-350ml
• detrusor contraction at 400-550ml
• Uroflowmetry info on outflow obstruction
• Cystoscopy detects structural abnormalities,
  inflammation, masses
• IVP detects structural abnormalities, urethral
  narrowing, incomplete bladder emptying

31
Primary Care Management

• General recommendations
• restrict fluid loads, coffee, tea, alcohol
• limit diuretic use give in am if needed
• avoid anticholinergic meds when possible give in
  lowest possible doses
• AVOID indwelling catheters (increase risk of
  infection, exacerbate detrusor instability,
  leakage)

32
Primary Care Management

• Behavioral techniques
• focus on strengthening or retraining
• help improve all types of incont except
  functional
• in 1 small study, crossing the legs helped 73 of
  women with stress incontinence prevent leakage
  almost completely
• Kegel exercises
• designed to strengthen pelvic floor muscles
• should be primary treatment for stress
  incontinence
• also helpful for urge incontinence without nerve
  damage

33
Primary Care Management

• Medications
• see handout

34
Indications for referral

• Suspected cord lesion or other neurologic
  injury-----gtNeurology
• Outflow tract obstruction, large hypotonic
  bladder and PVR gt 100ml----gtUrology
• Refractory stress incontinence----gtsurgeon
  specializing in correction of pelvic incompetence
• Refractory detrusor instability or hypotonia---gt
  biofeedback specialist

35
References

• 1. Bump RC, Norton PA. Epidemiology and Natural
  History of Pelvic Floor Dysfunction. ObGynClin
  Dec 199825(4)723-746
• 2. Culligan PJ, Heit M. Urinary Incontinence in
  Women Evaluation and Management. AmFamPhys Dec
  200062(11)2433-44,2447,2452
• 3. Goroll(ed). Primary Care Medicine, 4th ed.
  Lippincott Williams Wilkins. 2000 (776-778)
• 4. Harrisons Principles of Internal Medicine,
  14th ed. McGraw-Hill. 1998(40-42)
• 5. Thom DH, Brown JS. Reproductive and Hormonal
  Risk Factors for Urinary Incontinence in Later
  Life A Review of the Clinical and
  Epidemiological Literature. JAGS Nov
  199846(11)1411-1417
• 6. Visco AG, Figuers C. Nonsurgical Management
  of Pelvic Floor Dysfunction. ObGynClin Dec
  199825(4)849-865