URINARY INCONTINENCE IN WOMEN

1. URINARY INCONTINENCE IN WOMEN Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang

3. adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial DEFINISI

4. Inkontinensia urin • Kondisi lazim, merugikan  kesehatan, fungsi, kualitas hidup • Prevalensi: 11,3 - 62,7% • Paling umum: SIU; 14,7-52% • Tx: farmako, nonfarmako, bedah • 1st choice: Non invasif • LODP; kuno tp efektif • Arnold Kegel; 84% sembuh

5. Klasifikasi • Stress incontinence • Overactive bladder • Overflow incontinence • Continue incontinence

6. STRESS INCONTINENCE Stress incontinence is the involuntary loss of urine when the intravesical pressure exceeds the maximum urethral closure pressure in the absence of detrusor activity

7. Incompetence of urethral closure mechanism ETIOLOGY STRESS URINARY INCONTINENCE

8. Sphincter urethra eksterna (rhabdosphincter) Otot peri-urethra dari dasar panggul Muara urethra eksterna Kandung kemih Urethra Jaringan kolagen Otot polos urethra dan jaringan ikat Otot detrusor

9. PELVIC FLOOR SI CAUSES STRESS INCONTINENCE • Anatomic support of urethral and the urethrovesical junction damage (Urethral hypermobility)  Descent of the bladder neck and proximal urethra  Pressure transmission Decreases  stress incontinence • Components of the internal mechanism damage (ISD)  Loss of the urethral resistance  Urethral closure pressure Decreases  stress incontinence ISD

10. PELVIC FLOOR A B DESCENT OF THE BLADDER NECK AND PROXIMAL URETHRA

11. RISK FACTORS URETHRAL HYPERMOBILITY • Child birth • Age • Menopause • Chronic intra abdominal pressure (chronic cough, constipation, obesity) • Pelvic denervation

12. Risk Factors: INTRINSIC SPHINCTER DYSFUNCTION (ISD 10%) • Multiple prior operations • Trauma • Radiation • Neurogenic disorders including diabetes mellitus • Atrophic changes lack of estrogen • Mielodysplacia

13. DETERMINANTS OF STRESS INCONTINENCE Resting urethral closure pressure Stress pressure transmission Intraabdominal pressure increases

14. SYMPTOM AND SIGN • SYMPTOM • Patient complaint of involuntary urine loss with physical exercise, coughing, sneezing, laughing • SIGN • Urine is loss from urethra immediately upon increasing intraabdominal pressure (e.g. Coughing sneezing, laughing)

15. Diagnosis : • Anamnesis tentangsimptomstresinkontinensia • Residuurin < 50 cc • Kapasitaskandungkemih> 400 cc • Tesbatukpositifatauvalsavapositif

16. Pemeriksaanpenunjang : • Daftarharianberkemih • Urinalisis • Tes Batuk • tes PAD • Urodinamik

17. 1 hour Pad test (ICS)

18. Classification

19. TREATMENT OPTIONS • Conservative • Surgical/ modulatory therapies

20. STRESS INCONTINENCE TREATMENT • Conservative • Pelvic floor exercises • Weighted vaginal Cones • Electrostimulation • Positive fedback/perineometri • Devices (e.g. pessary) • Pharmacotherapy

21. STRESS INCONTINENCE TREATMENT SURGICAL TREATMENT • Anterior colporraphy • Transvaginal Needle Bladder Neck suspension • Retropubic suspension • Marshall - Marchetti – Krantz • Burch colposuspension • Sling procedures (e.g. TVT-TVT-O) • Artificial sphincter

22. Burch colposuspension

25. 2002 ICS TERMINOLOGY: OVERACTIVE BLADDER Overactive bladder (OAB) is a symptom syndrome • Urgency, with or without urge incontinence, usually with frequency and nocturia • these symptoms are suggestive of detrusor overactivity (urodynamically demonstrable involuntary bladder contractions) but can be due to other forms of voiding or urinary dysfunction • these terms can be used if there is no proven infection or other obvious pathology Abrams P et al. Neurourol Urodyn.2002;21:167-178.

26. 2002 ICS DEFINITIONS • Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer • Increased daytime frequency is the complaint by the patient that he/she voids too often by day (equivalent to polyuria) • Nocturia is the complaint that the individual has to wake at night 1 or more times to void Abrams P et al. Neurourol Urodyn. 2002;21:167-178.

27. ETIOLOGY OVERACTIVE BLADDER • Detrusor hyperreflexia or Neurogenic detrusor overactivity • Detrusor instability or Idiopathic detrusor overactivity

30. Patofisiologi • fase pengisian, tekanan normal vesica urinaria  <10cm H2O - 15cm H2O. • otot detrussor vesica urinaria selalu berkontraksi pada tekanan <15cm H2O, sehingga pasien akan merasa ingin berkemih, dan sulit ditahan  Overactive Detrussor.

31. DIAGNOSTIC INCONTINENCE URINE History Questions • Do you leak urine when you cough, sneeze, or laugh? • Do you ever have such an uncomfortable strong need to urinate that if you don,t reach the toilet you will leak? • If “yes” to question 2, do you ever leak before you reach the toilet? • How many times during the day do you urinate? • How many times do you void during the night after going to bed? • Have you wet the bed in the past year? • Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry? • Do you ever leak during oe after sexual intercourse? • Do you find it necessary to wear a pad because of leaking ? • How after do you leak? • Have you had bladder, urine, or kidney infection? • Are you troubled by pain or discomfort when you urinate? • Have you had blood in your urinate? • Do you find it necessary to wear a pad because of your leaking? • Do you find it hard to begin urinating? • Do you have as slow urinary stream or have to strain to pass your urine? • After you urinate, do you have dribbling or a feeling that you bladder is still full?

32. Evaluation urological history 1 Elicit stress incontinence 2 – 8 elicit detrusor instability (overactive bladder) 3 urge 4 - 5 frequncy 6 bed wetting 8 leaking with intercourse 2 and 7 urgency 9 and 10 severity 11 – 13 infection and neoplasm 14 – 17 elicit voiding disfunction symptom

33. EXAMINATION • Physical examination • Gynecologic examination • Neurologic examination

34. LABORATORY TESTS • Urinalysis • to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria Fantl JA et al. Agency for Healthcare Policy and Research; 1996; AHCPR Publication No. 96-0686.

35. URINARY DIARY Your Daily Bladder Diary This diary will help you and your healthcare team. Bladder diaries help show the causes of bladder control trouble. The “sample” line (below) will show you how to use the diary. Your name: J. Doe Date: March 31, 2003

36. URODYNAMICS

37. OVERACTIVE BLADDER TREATMENTConservative • Behavioral modification therapies • dietary modification • bladder training • No Stress .. • pelvic floor muscle exercises • adjunct therapies • scheduled/assisted voiding

38. OVERACTIVE BLADDER TREATMENTConservative Antimuscarinics

39. MUSCARINIC RECEPTOR DISTRIBUTION

40. SURGICAL / MODULATORY THERAPIES • Denervation • central • peripheral and perivesical • Acupuncture • Electroacupunture • Electrical stimulation/neuromodulation • Overdistention • Augmentation cystoplasty

41. OVERFLOW INCONTINENCE • Chronic urinary retention with resultant overflow incontinence is uncommon in women • Aetiology • Bladder hypothonia / antonia • Postoperative trauma • Inflammation • Pelvic mass • Drugs • Neuropathic bladder • Postoperative for stress incontinence • Urethral stenosis/strictura • Treatment • Catheterisation • Drug • Urethral dilatation • Causal

42. RETENSIO URIN DEFINISI : Retensiourin : tidakadanyaprosesberkemihspontan 6 jam setelahkatetermenetapdilepaskan, ataudapatberkemihspontandenganurinsisa > 200ml (kasusObstetri) danurinsisa > 100ml (kasusGinekologi)

43. RETENSIO URIN PASCA SEKSIO SESAREA DISEBABKAN OLEH : • Anestesia • Rasa nyeri luka insisi dinding perut • reflek menginduksi spasme otot levator • pasien enggan untuk mengkontraksikan dinding perut guna memulai pengeluaran urin 3. Manipulasi kandung kemih 4. Jika SC akibat distosia PK II (iritasi, edema)

44. RETENSIO URIN PASCA BEDAH GINEKOLOGI BIASANYA DISEBABKAN OLEH : • Anestesia • Rasa nyeri • Edema • Spasme otot-otot pubokoksigeus

45. GEJALA RETENSIO URIN • Kencing tidak lampias • Waktu BAK lama • Frekuensi BAK lebih sering • Tidak bisa BAK • Kandung kemih merasa penuh • Distensi abdomen

46. DIAGNOSIS • Anamnesis : Gejala retensio urin • Pemeriksaan fisik • Teraba massa diatas simpisis • pemeriksaan bimanual

47. DIAGNOSIS • PEMERIKSAAN URIN SISA (dengan kateter) Setelah 6 jam kateter dilepas diukur urin sisa RETENSIO URIN JIKA : • Pasca bedah Ginekologi : urin sisa >100 ml • Pasca bedah Obstetri : urin sisa >200 ml

48. DIAGNOSIS • USG Dapat memeriksa secara non invasif • Pemeriksaan uroflowmetri normal jika flow rate > 15-20 ml/detik Gangguan berkemih : • penurunan flow rate • perpanjangan waktu berkemih

49. Penatalaksanaan • Kateterisasi • Obat-obatan : • Obat-obat yang meningkatkan kontraksi kandung kemih dan menurunkan resistensi uretra : • Yang bekerja pada sistem saraf parasimpatis obat koligernik ~ asetik kolik bekerja di “end organ”  efek muskarinik contoh : betanekhol, karbakhol, metakholin • Yang bekerja pada sistem saraf simpatis contoh : fenoksibenzamin

50. Penatalaksanaan c.Obat yang bekerja pada otot polos Mempengaruhi kerja otot otot detrusor. contoh : Prostaglandin E2 III Pemberian cairan Banyak minum 3 liter/24 jam Gunanya mencegah kolonisasi bakteri IV Antibiotika: sesuai kultur