Dr mansooreh yaraghi Fellowship of pelvic floor INTRODUCTION Prevalence In older women17 to 55 Younger and middleaged women 12 to 42 Universal screening in women Difficult topic for patients ID: 934559
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Slide1
Slide2women with urinary incontinence
Dr
mansooreh
yaraghi
Fellowship of pelvic floor
Slide3INTRODUCTION:PrevalenceIn older women:17 to 55 %
Younger and middle-aged women: 12 to 42%
Universal screening in women:
Difficult topic for patients
Slide4Screening:Women whoHave had Children
Comorbid
conditions associated with increased risk for urinary incontinence (diabetes, obesity, neurologic disease)
Over 65 years of age
Should specifically be asked about symptoms of urinary incontinence
Slide5INTRODUCTION:Should not be dismissed simply as an age-related inconvenience:Herald a serious underlying condition (neurologic disease or malignancy)Specialized testing and referral to a specialist are required in only a minority of cases.
Slide6CLASSIFICATION:Urge urinary incontinence(UUI):
Typically have symptoms of involuntary leakage of urine accompanied by
urgency
The amount of leakage:
From a few drops to completely soaked undergarments.
Common triggers:
Running
water, hand washing, and cold weather exposure.
Urgency incontinence is believed to be partly caused by detrusor
overactivity
CLASSIFICATION:Stress urinary incontinence(SUI):Involuntary leakage with effort, exertion, sneezing , coughing, laughing
Anytime an increase in intra abdominal pressure exceeds urethral sphincter closure
Provoked by minimal or no activity when there is severe sphincter dysfunction
Slide8Stress urinary incontinence:Most common type in younger womenIncidence is highest in women between 45 and 49 years oldMixed incontinence
In middle-aged and older women, it often coexists with urgency incontinence
CLASSIFICATION:
Slide9Overflow incontinence: Involuntary, continuous, urinary leakage or dribbling and incomplete bladder emptyingImpaired detrusor contractility Bladder outlet obstructionRare in women
Scarring from prior surgery for incontinence
Significant pelvic organ prolapse
CLASSIFICATION:
Slide10Overflow incontinence:Other associated symptoms :weak or intermittent urinary stream, hesitancy, frequency, and nocturiaWhen the bladder is very full: stress leakage can occur
Can point to an underlying cause
CLASSIFICATION:
Slide11Uncategorized incontinence:Cannot be classified into one of the above categories on the basis of signs and symptomsCertain clinical features, with some overlapMany women have features of more than one type of incontinence
The type of incontinence does not correspond precisely to a specific underlying
pathophysiology
CLASSIFICATION:
Slide12Causes:Genitourinary system causesIntra urethral incontinence
Extra urethral Incontinence
Systemic conditions
Functional and Transient Incontinence(DIAPPERS)
Medications
Slide13Intra urethral incontinenceOlder women : several physiologic changes in the lower urinary tract : Involuntary detrusor contractions or overactivity Decreased detrusor contractilityLow estrogen levels
Changes in fluid excretion patterns
Decrease in urethral closure pressure
Causes:
Slide14Intra urethral incontinence:Interstitial cystitis (painful bladder syndrome): Younger womenUrgency incontinence :can be an atypical manifestation of interstitial cystitis
Characterized by urgency and frequent voiding of small amounts of urine, often accompanied by
dysuria
Pelvic organ prolapse (
cystocele
)
Causes:
Slide15Extra urethral Incontinence:Observation of urine leakage through channels other than the urethraStress or continuous leakage
Congenital:
Bladder exstrophy
Ectopic
ureter
Traumatic:
Vesicovaginal
(developing nations)
Ureterovaginal
Vesicouterine
Causes:
Slide16Systemic conditions:Congestive heart failure : Nocturia
Neurologic disorders:
stroke, multiple sclerosis, Parkinson disease, disc
herniation
, spinal cord injury, normal pressure hydrocephalus, or
subacute
combined degeneration
Diabetes mellitus:
Increased urine volume and frequency :in uncontrolled hyperglycemia
Overflow incontinence and poor urinary stream :in diabetic autonomic neuropathy.
CAUSES:
Slide17Systemic conditions :Diabetes insipidus :Polyuria , which must be differentiated from urinary frequency or nocturiaCancers:
Urinary frequency :urethral cancers
Hematuria
should raise concern for bladder cancer.
Sleep disorders:
Depression:
nocturia
Obesity:
CAUSES:
Slide18CAUSES:
Functional and Transient Incontinence:(DIAPPERS)
Slide19CAUSES:Medications:Diuretics:
Polyuria
, frequency, urgency
Caffeine:
Frequency, urgency
Alcohol
Sedation , impaired mobility ,
diuresis
Narcotic
analgesics:
Urinary retention, fecal
impaction , sedation
, delirium
Anticholinergic
agents:
Urinary retention, voiding
difficulty
Slide20Antihistamines: Anticholinergic actions, sedationPsychotropic agentsAntidepressants:
Anticholinergic
actions, sedation
Antipsychotics:
Anticholinergic
actions, sedation
Sedatives/hypnotics:
Sedation, muscle relaxation , confusion
CAUSES:
Medications:
Slide21Alpha-adrenergic blockers: Stress incontinenceAlpha-adrenergic agonists: Urinary retention, voiding difficultyCalcium-channel blockers:
Urinary retention, voiding difficulty
CAUSES:
Medications:
Slide22Angiotensin - converting enzyme inhibitors:cough worsens stress and possibly urge leakage in persons with impaired sphincter functionEstrogen:Worsens stress and mixed leakage in womenGABAnergic agents(gabapentin
,
pregablin
):
Pedal edema :
nocturia
and nighttime incontinence
NSAID:
Pedal edema:nocturnal polyuria
CAUSES:
Medications:
Slide23Oral contraceptives: Stress, urge, and mixed incontinenceCholinesterase inhibitorsAlone may increase incontinenceIncreased functional impairment when combined with anti incontinence antimuscarinic
agents
Beta blockers:
Urge incontinence
Lithium:
Polyuria
CAUSES:
Medications:
Slide24Warrant Consultation:Uncertain diagnosis and inability to develop a reasonable treatment plan based on the basic diagnostic evaluationLack of correlation between symptoms and clinical
findings
Slide25Failure to respond to the patient’s satisfaction to an adequate therapeutic trial, and the patient is interested in pursuing further therapy.Consideration of surgical intervention, particularly if previous surgery failed or the patient has a high surgical risk.Warrant Consultation:
Slide26The presence of other comorbid conditions:Incontinence associated with recurrent symptomatic urinary tract infectionPersistent symptoms of difficult bladder emptying
History of previous
anti incontinence
surgery, radical pelvic surgery, or pelvic radiation
therapy
Warrant Consultation:
Slide27The presence of other comorbid conditions:Symptomatic pelvic prolapse, especially if beyond hymenAbnormal postvoid residual urine
Neurologic condition such as multiple sclerosis or spinal cord lesions or injury
Warrant Consultation:
Slide28Fistula or suburethral diverticulumHematuria without infection
Warrant Consultation:
Slide29Slide30Slide31EVALUATION:Characterizing and classifying the type of incontinenceidentifying reversible or serious underlying History
Physical examination
Urinalysis
Slide32Additional evaluation :in the presence of complex medical conditions or worrisome findings on history and physical examination specific clinical tests:Bladder stress testPostvoid residual
Additional laboratory tests
Radiographic imaging
Referral to a specialist
EVALUATION:
Slide33History:Urinary symptomsFrequencyVolumeonset of incontinenceTiming
Severity
Duration
Hesitancy
precipitating triggers
Nocturia
Slide34Intermittent or slow streamIncomplete emptyingContinuous urine LeakageStraining to voidDegree of bother and effect on quality of life (QOL) Underlying causesLiving environment:Access to toilets or toilet substitutes
Social factors such as living arrangements, social contacts, and caregiver involvement
History:
Slide35Questions:Do you ever leak urine/water when you don’t want to?
1.Do
you leak urine when you cough, sneeze
,
laugh or exercise
?
(stress incontinence)
2.
Do you ever have such an uncomfortably strong need
to urinate
that if you don’t reach the toilet you will leak
?
(sense of urgency)
3.If “yes” to question 2, do you ever leak before you reach the toilet?
(urge incontinence)
Slide36Questions:4.How many times during the day do you urinate? (Frequency)
5.How many times do you void during the night after going to bed?
(Frequency)
6. Have you wet the bed in the past year?
(bedwetting)
7. Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry or on the way to the bathroom ?
(sense of urgency)
Slide37Questions:8. Do you ever leak during or after sexual intercourse? (leaking with intercourse)
9. How often do you leak
?
(severity)
Questions 2 through 9:
symptoms associated with detrusor overactivity
10. Do you find it necessary to wear a pad , tissue or cloth in your underwear to catch urine because of your leaking?
(severity)
Questions:11. Have you had bladder, urine, or kidney infections? (urinary tract infection and
neoplasia
)
12. Are you troubled by pain or discomfort when you urinate
?
(urinary tract infection and
neoplasia
)
13. Have you had blood in your urine
?
( urinary tract infection and
neoplasia
)
Slide3914. Do you find it hard to begin urinating? (voiding Dysfunction)15. Do you have a slow urinary stream or have to strain to pass your urine? (voiding Dysfunction)16. After you urinate, do you have dribbling or a feeling that your bladder is still full?
(voiding Dysfunction)
Questions:
Slide40Slide41Voiding (bladder) diarieshistories of frequency and severity:often inaccurate and misleadingmore reliable
incontinence frequency
Severity
associated events or symptoms such as coughing, urgency, and pad use
volume of urine loss during incontinent episodes
Bedwetting
The maximum voided volume
Slide42can be helpful:NocturiaHigh urinary frequency or incontinence frequencyUnclear historymixed incontinence: the predominant, more bothersome component for the individualNeither sensitive nor specific for determining the urodynamic cause of incontinence
excessive frequency and volume of fluid intake:
restriction of excessive oral fluid intake
combined with scheduled voiding
improve symptoms of stress and urge incontinence
Voiding (bladder) diaries
Slide43Voiding (bladder) diaries at least 2 days.(1-7days:3days) 4 things every time you pass or leak urine:The time The amount of urine that pass
leaked any urine (were "wet") or not (were "dry")
Whether anything special may have caused you to go (for instance, "just had coffee," "coughed," "was running to the bathroom," "just took my water pill")
Start the record in the morning the first time you go to the bathroom after you get up.
Slide44Voiding (bladder) diaries:the time you got up and the time you went to bed. a special receptacle (called a "hat"). Place the hat in the toilet to catch the urine every time you go. Look at how high the urine fills the hat, and write down the amount from the numbers on the inside of the hat. Remember to empty the hat after each time you go.If you leak urine and cannot measure the amount that came out, write down your best guess.
Slide45Slide46Quality of life:
Depression
Anxiety
Work
Relationships
Social life
Sexual function
validated instruments (ICIQ, Kings Health Questionnaire)
used to assess treatment efficacy for women with urinary incontinence.
Slide47Systemic symptoms:Onset of incontinence
Abdominal or pelvic pain
Hematuria
Lower extremity weakness
Changes in gait
Cardiopulmonary
Neurologic symptoms
Slide48Weight changesMental status changesFunctional statusMobilityCognitive statusChanges in bowel function
Detailed medication history
Alcohol and caffeine intake
Systemic
symptoms:
Slide49Past medical &surgical history:GynecologicNeurologicObstetric historiesDiabetes, stroke, and lumbar disk diseaseChronic pulmonary disease:
strong coughing worsen symptoms of stress incontinence.
Chronic severe constipation:
Voiding difficulties, urgency, stress
incontinence,increased
bladder capacity, and POP
prior surgical trauma to the lower urinary tract
Hysterectomy
Vaginal repair
Pelvic cancer
Pelvic radiotherapy
Surgery for incontinence
Slide50Drugs:Altering drug dosage Changing to a drug with similar therapeutic effectiveness but with fewer lower urinary tract side effectsWill often improve or “cure” the offending urinary tract symptom
Slide51Physical examination:The cardiovascular examination:volume overload (rales
, pedal edema)
The abdominal examination:
masses or tenderness.
abdominal examination is not sensitive for detecting bladder distension
Slide52The extremities:joint mobility, function, and muscular atrophy or wasting.The neck examination:with osteoarthritis:neck movement and evaluate for interosseous muscle wasting of the hands.
These changes, especially if a
Babinski
reflex is also
present:cervical
spondylosis
or
stenosis
causing detrusor overactivity
Physical examination:
Slide53Detailed pelvic examination:Inspect the vaginal mucosa :atrophy (thinning, pallor, loss of rugae)narrowing of the introitus
vault
stenosis
inflammation (erythema,
petechiae
,
telangiectasia
, friability)
Vaginal discharge
Palpate bimanually :
masses or tenderness.
Palpation of the anterior vaginal wall and urethra :
urethral discharge or tenderness : urethral
diverticulum
, carcinoma, or inflammatory condition of the urethra
Physical examination:
Slide54Detailed pelvic examination:Assess the adequacy of pelvic support, and assess for pelvic organ prolapse, by a split-speculumCough once: looking for urethral leakageurethra remains firmly fixed or swings quickly forward (urethral hypermobility),
anterior wall support defect
posterior wall support defect
Pelvic organ prolapse often coexists with urinary incontinence
Rectal exam
Physical examination:
Slide55Q-Tip Test:measurement of the axis change with straining
sterile, lubricated cotton-tipped applicator
transurethrally
into the bladder, withdrawn slowly until definite resistance is felt (at the bladder neck)
supine
lithotomy
The resting angle in relation to the horizontal
With
goniometer
or protractor
Maximum straining angle from the horizontal at cough and Valsalva maneuver
Not affected by the amount of urine in the bladder
Maximum straining angle >30° :abnormal
Slide56Urethral mobility in continent women:AgeParitysupport defects of the anterior vaginal wallurethral hypermobility” is common in asymptomatic women. wide overlap in measurements between the continent and incontinent women
no longer considered useful in helping with diagnosis or treatment of incontinence
Q-Tip Test:
Slide57Detailed neurologic examination must be performed in :Sudden onset of incontinence (especially urge)Known neurologic diseaseNew onset of neurologic symptoms
Physical examination:
Slide58Screening neurologic examination:Mental status Sensory Motor function of both lower extremitiesLumbosacral neurologic examination:Pelvic floor muscle strength
Anal sphincter resting tone
Voluntary anal contraction
Perineal sensation
Physical examination:
Slide59Mental status:Level of consciousnessOrientationMemory
Speech
Comprehension.
Disorders with mental status
aberrations&changes
in bowel or bladder function:
Senile and
presenile
dementia
Brain tumors
Stroke,
Parkinson’s disease
Normal pressure hydrocephalus.
Physical examination:
Slide60Perineal sensation:Light touchPinprickTemperaturePeripheral sensationResting and volitional tone of the anal sphincter Anal wink
Vibration
Physical examination:
Slide61Physical examination:Babinski reflexPatellar, ankle reflexTwo reflexes of sacral reflex:
Anal reflex
stroking the skin adjacent to the anus causes reflex contraction of the external anal sphincter muscle.
The
bulbocavernosus
reflex:
Contraction of the
bulbocavernosus
and
ischiocavernosus
muscles in response to tapping or squeezing of the clitoris
These reflexes can be difficult to evaluate clinically
Not always present, even in neurologically intact women
Slide62Bladder stress test:Full bladderStandRelaxSingle vigorous coughClinician observes directly
Negative test is less useful
Positive bladder stress test :Does not require treatment unless the patient reports significant bother related to the incontinence.
Slide63Slide64