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URINARY INCONTINENCE
RAHEEF MOHAMED ALATASSI
5TH YEAR MEDICAL STUDENT
IMAM MOHAMMED BIN SAUD UNIVERSITY
UROLOGY
Stress
Urge
Mixed
DEFINITION
“ THE INVOLUNTARY LOSS OF URINE WHICH IS OBJECTIVELY DEMONSTRABLE AND A SOCIAL OR HYGIENIC PROBLEM.”
ANY INVOLUNTARY LEAKAGE OF URINE
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
ANATOMICAL STRUCTURES OF THE LOWER URINARY TRACT SYSTEM
The bladder and bladder neck
The urethra and urethral sphincter mechanism
The pelvic floor musculature
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
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.
NERVOUS SUPPLY OF BLADDERo The sympathetic nervous system o Hypogastric nerve (T12 – L2). o It causes relaxation of the detrusor muscle. o These functions promote urine retention.
o The parasympathetic nervous system o Pelvic nerve(S2-S4). o Increased signals from this nerve causes contraction of the detrusor
muscle. This stimulates micturition.
o 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).
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.
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.
RISK FACTORS•DEPRESSION• STROKE•DIABETES• PARKINSON’S DISEASE•DEMENTIA (MODERATE TO SEVERE)•OBESITY, CHF, CONSTIPATION, TIAS, COPD, CHRONIC COUGH
AGING CHANGES• Decreased bladder capacity
• Reduced voiding volume
• Reduced flow rates
• Increased urine production at night• Detrusor over activity (20% of
healthy continent)• BPH
REVERSIBLE CAUSES OF UI
- Delirium or Drugs
- Restricted mobility
- Infection, impaction
- Polyuria
IP
RD
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
Polyuria, frequency,
urgency
Alcohol Caffeine Diuretics
Urinary retention
AnticholinergicsAlpha
adrenergic agonists
Beta adrenergic
agonists
Calcium channel
blockers
Drugs Contributing to UI
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
TYPES OF URINARY INCONTINENCE
• TRANSIENT UI (ACUTE)
• ESTABLISHED UI (CHRONIC)
• URGE UI
• STRESS UI
•MIXED UI
• OVERFLOW UI
• “FUNCTIONAL” UI
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.
URGE UI
Involuntary detrusorcontractions
Urethral pressure
The complaint of involuntary leakage accompanied by or immediately preceded by urgency.
Due to over activity of detrusor muscle.
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:
FIRST: NONPHARMACOLOGICAL THERAPY• LIFESTYLE ADVICE (PARTICULARLY WEIGHT
LOSS AND DIETARY CHANGES).
• AVOIDANCE OF URETHRAL COMPRESSION DURING VOIDING.
SECOND: PHARMACOLOGICAL THERAPYA. 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.
CONT’ PHARMACOLOGICAL THERAPYB. 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 ?)
CONT’ PHARMACOLOGICAL THERAPYC. 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.
CONT’ PHARMACOLOGICAL THERAPYD. 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 ?)
THIRD: SURGICAL THERAPYI/ 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.
CONT’ SURGICAL THERAPYII/ STRESS INCONTINENCE:
- MOST COMMONLY UTILIZED INTERVENTIONS FOR MALE ARE TRANSURETHRAL BULKING AGENTS, PERINEAL SLINGS & ARTIFICIAL URINARY SPHINCTER.