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Urinary Incontinence

Urinary Incontinence. Dr. Ghadeer Alshaikh 481 GYN Department of Obstetrics and Gynecology. Statistics:. 10-60% of women report urinary incontinence 50% of women that have had children develop prolapse Only 10-20% seek medical care. Physical Limitations or cessation of physical activities.

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Urinary Incontinence

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  1. Urinary Incontinence Dr. Ghadeer Alshaikh 481 GYN Department of Obstetrics and Gynecology

  2. Statistics: • 10-60% of women report urinary incontinence • 50% of women that have had children develop prolapse • Only 10-20% seek medical care

  3. Physical • Limitations or cessation of physical activities Sexual • Avoidance of sexualcontact and intimacy Occupational • Absence from work • Decreased productivity Social • Reduction in social interaction • Alteration of travel plans • Increased risk of institutionalization of frail older persons Domestic • Requirements for specialized underwear, bedding • Special precautions with clothing Impact of Urinary Incontinence on Quality of Life Psychological • Guilt/depression • Loss of self-respect and dignity • Fear of: • being a burden • lack of bladder control • urine odor • Apathy/denial Quality of Life

  4. Compounding Problems: • Embarrassment leads to silence • Time constraints lead to inadequate attention • Knowledge limits lead to patients accepting • Technology limits lead to inadequate investigation • Resource limits lead to inadequate access

  5. Types of Urinary Incontinence: • Stress incontinence • Urge incontinence • Mixed • Overflow incontinence • Functional incontinence • Miscellaneous (UTI, dementia)

  6. Stress Incontinence: • Loss of urine with increases in abdominal pressure • Caused by pelvic floor damage/weakness or weak sphincter(s) • Symptoms include loss of urine with cough, laugh, sneeze, running, lifting, walking

  7. Urge Incontinence: • Loss of urine due to an involuntary bladder spasm (contraction) • Complaints of urgency, frequency, inability to reach the toilet in time, up a lot at night to use the toilet • Multiple triggers

  8. Mixed Incontinence: • Combination of stress and urge incontinence • Common presentation of mixed symptoms • Urodynamics necessary to confirm

  9. Chronic Urinary Retention: • Outlet obstruction or bladder underactivity • May be related to previous surgery, aging, development of bad bladder habits, or neurologic disorders • Medication, such as antidepressants • May present with symptoms of stress or urge incontinence, continuous leakage, or urinary tract infection

  10. Functional and Transient Incontinence: • Mostly in the elderly • Urinary tract infection • Restricted mobility • Severe constipation • Medication - diuretics, antipsychotics • Psychological/cognitive deficiency

  11. Unusual Causes of Urinary Incontinence: • Urethral diverticulum • Genitourinary fistula • Congenital abnormalities (bladder extrophy, ectopic ureter) • Detrusor hyperreflexia with impaired contractility

  12. Causes of Incontinence: Inherited or genetic factors • Race • Anatomic differences • Connective tissue • Neurologic abnormalities

  13. Risk factors for Incontinence: External factors • Pregnancy and childbirth • Aging • Hormone effects • Nonobstetric pelvic trauma and radical surgery • Increased intra-abdominal pressure • Drug effects

  14. Urogenital Damage/dysfunction: • Vaginal delivery • Aging • Estrogen deficiency • Neurological disease • Psychological disease

  15. Aging: • Gravity • Neurologic changes with aging • Loss of estrogen • Changes in connective tissue crosslinking and reduced elasticity

  16. Pregnancy and Childbirth: • Hormonal effects in pregnancy • Pressure of uterus and contents • Denervation (stretch or crush injury to pudendal nerve) • Connective tissue changes or injury (fascia) • Mechanical disruption of muscles and sphincters

  17. Hormone Effects: • Common embryonic origin of bladder urethra and vagina from urogenital sinus • High concentration of estrogen receptors in tissues of pelvic support • General collagen deficiency state in postmenopausal women due to the lack of estrogen (falconer et al., 1994) • Urethral coaptation affected by loss of estrogen

  18. Increased Intra-abdominal Pressure: • Pulmonary disease • Constipation/straining • Lifting • Exercise • Ascites/hepatomegaly • Obesity

  19. Drug Effects: Alpha-blocking agents • Terazosin • Prazosin • Phenoxybenzamine • Phenothiazines • Methyldopa • Benzodiazepines

  20. Patient Evaluation: • History • Physical examination • Urinalysis • PVR - if indicated • Symptoms of incomplete emptying • Longstanding diabetes mellitus • History of urinary retention • Failure of pharmacologic therapy • Pelvic floor prolapse • Previous incontinence surgery

  21. Patient History: • Focus on medical, neurologic, genitourinary history • Review voiding patterns/fluid intake • Voiding diary • Review medications (rx and non-rx) • Explore symptoms (duration, most bothersome, frequency, precipitants) • Assess mental status and mobility

  22. Symptoms: • Frequency • Nocturia • Dysuria • Incomplete emptying • Incontinence • Urgency • Recurrent infections • Dyspareunia • Prolapse

  23. Physical Examination: • General examination • Edema, neurologic abnormalities, mobility, cognition, dexterity • Abdominal examination • Pelvic and rectal exam - women • Examination of back and lower limbs • Observe urine loss with cough

  24. Urinalysis: • Conditions associated with overactive bladder • Hematuria • Pyuria • Bacteriuria • Glucosuria • Proteinuria • Urine culture

  25. Postvoid Residual Volume (PVR): • If clinically indicated accurate PVR can be done by • Catheterization • Ultrasound • PVR of <50 ml is considered adequate, repetitive PVR >200 ml is considered inadequate • Use clinical judgement when interpreting PVR results in the intermediate range (50-199 ml)

  26. Treatment: Non-surgical • Fluid management • Reduce caffeine, alcohol, and smoking • Bladder retraining • Pelvic floor exercises • Pessaries • Continence devices

  27. Treatment: Non-surgical • Hormone replacement therapy • Medication to help strengthen the urethra • Medication to help relax the bladder

  28. Non-surgical Treatment: Fluid management • Avoid caffeine and alcohol • Avoid drinking a lot of fluids in the evening

  29. Non-surgical Treatment: Bladder retraining • Regular voiding by the clock • Gradual increase in time between voids • Double voiding

  30. Non-surgical Treatment: Physiotherapy • Pelvic floor exercises (Kegels) • Biofeedback • Electrical Stimulation • Vaginal cones

  31. Vaginal Cones

  32. Pelvic Floor Muscle Training • Kegels • Biofeedback • Electrical Stimulation • Vaginal Cones

  33. Non-surgical Treatment: Pessaries • Support devices to correct the prolapse • Pessaries to hold up the bladder

  34. Treatment : Pessaries

  35. Non-surgical Treatment: Hormone replacement • Systemic • Local • Vaginal cream • Vaginal estrogen ring

  36. Non-surgical Treatment: Medication to strengthen the urethra • Cold medication • Ornade

  37. Non-surgical Treatment: Medication to relax the bladder • Oxybutynin (ditropan) • Toteridine (detrol) • Flavoxate (urispas) • Imipramine (elavil)

  38. Surgery: • For stress incontinence • Theories: • 1) bladder neck elevation • 2) integral theory (ulmsten)

  39. Surgery: • Burch repair • Marshall-marchetti-krantz repair • Sling • Needle suspension • Injections • Tension free vaginal tape

  40. Treatments : Surgical Abdominal approaches :Open retropubiccolposuspension : Burch or MMK

  41. TVT

  42. TVT-O (TOT)

  43. Summary • Urinary incontinence occurs in about 30% of women, all women should be asked about bothersome incontinence • Interview alone often indicates if the problem is from stress or urge incontinence and can suggest first line therapy • Stress incontinence can be treated effectively with surgery, which for most cases is minimally morbid or invasive

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