women with urinary incontinence - PowerPoint Presentation

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women with urinary incontinence

Dr

mansooreh

yaraghi

Fellowship of pelvic floor

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INTRODUCTION:PrevalenceIn older women:17 to 55 %

Younger and middle-aged women: 12 to 42%

Universal screening in women:

Difficult topic for patients

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Screening: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

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INTRODUCTION: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.

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CLASSIFICATION: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

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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

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Stress 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:

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Overflow 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:

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Overflow 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:

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Uncategorized 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:

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Causes:Genitourinary system causesIntra urethral incontinence

Extra urethral Incontinence

Systemic conditions

Functional and Transient Incontinence(DIAPPERS)

Medications

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Intra 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:

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Intra 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:

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Extra 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:

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Systemic 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:

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Systemic 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:

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CAUSES:

Functional and Transient Incontinence:(DIAPPERS)

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CAUSES: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

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Antihistamines: Anticholinergic actions, sedationPsychotropic agentsAntidepressants:

Anticholinergic

actions, sedation

Antipsychotics:

Anticholinergic

actions, sedation

Sedatives/hypnotics:

Sedation, muscle relaxation , confusion

CAUSES:

Medications:

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Alpha-adrenergic blockers: Stress incontinenceAlpha-adrenergic agonists: Urinary retention, voiding difficultyCalcium-channel blockers:

Urinary retention, voiding difficulty

CAUSES:

Medications:

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Angiotensin - 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:

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Oral 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:

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Warrant Consultation:Uncertain diagnosis and inability to develop a reasonable treatment plan based on the basic diagnostic evaluationLack of correlation between symptoms and clinical

findings

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Failure 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:

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The 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:

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The 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:

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Fistula or suburethral diverticulumHematuria without infection

Warrant Consultation:

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EVALUATION:Characterizing and classifying the type of incontinenceidentifying reversible or serious underlying History

Physical examination

Urinalysis

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Additional 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:

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History:Urinary symptomsFrequencyVolumeonset of incontinenceTiming

Severity

Duration

Hesitancy

precipitating triggers

Nocturia

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Intermittent 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:

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Questions: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)

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Questions: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)

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Questions: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)

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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

)

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14. 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:

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Voiding (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

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can 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

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Voiding (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.

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Voiding (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.

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Quality 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.

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Systemic symptoms:Onset of incontinence

Abdominal or pelvic pain

Hematuria

Lower extremity weakness

Changes in gait

Cardiopulmonary

Neurologic symptoms

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Weight changesMental status changesFunctional statusMobilityCognitive statusChanges in bowel function

Detailed medication history

Alcohol and caffeine intake

Systemic

symptoms:

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Past 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

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Drugs: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

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Physical examination:The cardiovascular examination:volume overload (rales

, pedal edema)

The abdominal examination:

masses or tenderness.

abdominal examination is not sensitive for detecting bladder distension

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The 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:

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Detailed 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:

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Detailed 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:

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Q-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

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Urethral 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:

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Detailed neurologic examination must be performed in :Sudden onset of incontinence (especially urge)Known neurologic diseaseNew onset of neurologic symptoms

Physical examination:

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Screening 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:

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Mental 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:

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Perineal sensation:Light touchPinprickTemperaturePeripheral sensationResting and volitional tone of the anal sphincter Anal wink

Vibration

Physical examination:

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Physical 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

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Bladder 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.

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