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Urine incontinence

Urine incontinence. Definition. ❏ the involuntary leakage of urine sufficiently severe to cause social or hygiene problems ❏ continence is dependent on: 1) compliant reservoir (involuntary smooth muscle of bladder neck)

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Urine incontinence

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  1. Urine incontinence

  2. Definition ❏ the involuntary leakage of urine sufficiently severe to cause social or hygiene problems ❏ continence is dependent on: 1) compliant reservoir (involuntary smooth muscle of bladder neck) 2) sphincteric efficiency (voluntary striated muscle of external sphincter; intact mucosa, intact pelvic floor supports)

  3. Epidemiology ❏ affects all ages ❏ more frequent in the elderly, affecting 5-15% of those living in the community and 50% of nursing home residents ❏ F:M = 2:1

  4. Classification • Stress • Urge • Overflow • Total • Functional

  5. Stress incontinence ❏ stress: urine loss with sudden increase in intra-abdominal pressure (e.g. coughing or sneezing) ––> usually only lose a few drops of urine • weakness of pelvic floor musculature (child bearing, previous abdominal/pelvic surgery) • damage/weakness of urethra or sphincter (e.g. hypoestrogen of menopause, child bearing) • mechanism: proximal urethra drops below pelvic floor and transmission of increased intra-abdominal pressure is not distributed evenly; pelvic floor supports weak (bladder pressure > urethral pressure) • Dx by stress test • degrees: mild: sneezing, coughing; moderate: leaks when walking; severe: leaks when standing up

  6. Urge incontinence ❏ urge: urine loss preceded by strong, unexpected urge to void • local bladder irritation (e.g. cystitis, stone, tumour, infection) • associated with inflammatory or neurogenic disorder • urodynamics - uninhibited contractions if unstable bladder (detrusor - hyperreflexia /instability); small bladder capacity if irritable bladder

  7. Overflow incontinence ❏ overflow: urine loss when intravesical pressure exceeds urethral pressure (due to retention and over distension) • obstructive (e.g. BPH, stricture) • hypotonic bladder (e.g. DM, autonomic neuropathy, anticholinergic meds) • urodynamics: large bladder capacity

  8. Total incontinence ❏ total: constant or periodic loss of urine without warning • loss of sphincteric efficiency (previous surgery, nerve damage, cancerous infiltration) • abnormal connection between urinary tract and skin thereby bypassing sphincter (bladder exstrophy, epispadias, vesico-vaginal fistulae, ectopic ureteral orifices)

  9. Functional incontinence ❏functional: urine loss caused by inability to reach toilet in time • physical immobility

  10. Assessment ❏ history +/– voiding diary ❏ physical exam: GU, DRE, neurologic ❏ labs: urinalysis, urine C+S, renal profile ❏ other investigations: • catheterization with post-void residuals • U/S • cystoscopy • VCUG • urodynamic studies – cystometrogram (CMG), uroflowmetry

  11. Management ❏ goals • improvement or cure • improvement in quality of life • low pressure system with minimal tubes and devices

  12. Management ❏ stress • Kegel’s exercises • topical estrogen cream • injectable agents • surgery (cystourethropexy slings)

  13. Management ❏ urge • antispasmodics (oxybutinin) • anticholinergics (propanthaline, tolterodine) • tricyclic antidepressants (imipramine)

  14. Management ❏ overflow • catheterization • further treatment directed at underlying cause of urinary retention

  15. Management ❏ total • usually surgical correction of underlying etiology or urinary diversion

  16. Management ❏ other treatments • pads • bladder training (timed voiding patterns) • self-stimulated voiding • condom drainage • penile clamp

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