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Üriner İnkontinans - www.jinekolojivegebelik.com
 

Üriner İnkontinans - www.jinekolojivegebelik.com

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Üriner İnkontinans - www.jinekolojivegebelik.com

Üriner İnkontinans - www.jinekolojivegebelik.com

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  • Full Name Full Name Comment goes here.
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  • Thanks for the post.
    Urinary system incontinence is a problem where a person can not manage pee. It is an unsuccess of the systems that control pee passage from the bladder. A person falls short to regulate the bladder and its behavior. The bladder empties itself as it wishes. There is constantly a urine leak somehow despite of how hard a victim does best to regulate and manage it. Male urinary system incontinence develops in different types. There are therapies available for male urinary incontinence treatment.
    http://www.fortisurology.com/urology.html
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Üriner İnkontinans - www.jinekolojivegebelik.com Üriner İnkontinans - www.jinekolojivegebelik.com Presentation Transcript

  • Urinary Incontinence Duke Family Medicine Joyce A Copeland, MD
  • Definition
    • Unintentional leakage of urine at inappropriate times
  • Epidemiology
    • 13,000,000 Americans
      • Before age 60
        • 5:1 female
      • After age 50
        • 2:1 female
      • 50% of homebound and institutionalized
      • Community
        • Men > 60: 10-15%
        • Women > 60: 20-35%
  • Under-reported
    • Identified <50% of the time
      • Considered normal part of aging
      • “ untreatable” or only surgery works and not interested
  • Complications
    • Medical
      • Decubitus ulcers
      • UTIs
      • Sepsis
      • Renal failure
      • Increased mortality
    • Social
      • Loss of self-esteem
      • Restriction of social and sexual activities
      • Depression
      • Dependence
      • Nursing home placement
    • Economic
      • >$16,000,000,000
  • Mechanism of micturation
    • Multilayered contractile muscle of bladder
    • Components
      • Detrusor muscle
      • Pelvic nerves
      • Spinal nerves
      • Cerebral centers
  • Physiology
    • Bladder fills  neural impulse  Pelvic nerves  spinal cord  subcortical and cortical cerebral centers
      • Subcortical: basal ganglia and cerebellum  subconscious relaxation of bladder to allow filling without urge to void
    • Filling continues  bladder distention  reaches conciousness  cortical recognition in frontal lobe  urge to void: volitional delay of urination
    • Desire to urinate  neural impulse from cortex to spinal cord and pelvic nerves to detrusor muscle  Cholinergic action  Contract  empty bladder
    • Other receptor chemicals
      • Also prostaglandin receptors
      • Calcium channel dependent
    • Alpha-adrenergic innervation: Contraction of urinary sphincter
      • Agonist  strengthen contractions, eg. Pseudoephedrine
      • Blockade  impair contraction, eg terazosin
    •  -adrenergic innervation: Relaxation of sphincter
      •  -Blocker  impair relaxation  unopposed alpha-adrenergic activity  contraction of sphincter
    Sphincter mechanism
  • Anatomy
    • Relationship of bladder to urethra and the abdominal cavity
      • Continence requires proper angulation
      • Effective transmission in intra-abdominal pressure
      • Prevent loss of urine with increase of intra-abdominal pressure
  • Categories
    • Urge incontinence
      • Increases frequency with age and decrease cognitive function
    • Stress incontinence
      • Most prevalent in elderly, predominant in women
    • Overflow bladder
      • Least common
      • Risks for hydronephrosis, renal damage
      • More common in men: BPH
    • Mixed: Urge and stress
  • Urge incontinence
    • Inability to delay voiding after sensation of fullness
    • Bladder contractions overwhelm cerebral center inhibition
    • Causes
      • Inflammation or irritation
      • Central impairment
      • High urine volume load
    • Impaired mobility prevents response: “functional” incontinence
  • Stress Incontinence
    • Malfunction of sphincter
      • Leak with increase in intra-abdominal pressure
    • Common causes
      • Pelvic prolapse
      • Urethral hypermobility
      • Displacement of urethra and bladder neck
    • Intrinsic sphincter deficiency
  • Overflow incontinence
    • Urinary retention with bladder distention
      • Leakage
      • Dribble
    • May mimic stress incontinence
  • Overflow: sources
      • Medication: Relaxation of detrusor
      • Neuropathy
        • Diabetes, MS, etc
      • Mechanical
        • BPH
        • Impaction
        • Stricture
      • Idiopathic
  • Mixed Incontinence
    • Stress + Overactive bladder
    • Identify most bothersome symptom
  • Functional Incontinence
    • Physical impairment
    • Cognitive impairment
  •  
  • DIAPPERS
    • D elirium, confusional state
    • I nfections
    • A trophic vaginitis or urethritis
    • P harmaceuticals
    • P sychological conditions, especially depression
    • E ndocrine/excessive urine production
    • R estricted mobility, urinary retention
    • S tool: impaction
  • Contributing factors
    • Pregnancy, childbirth, vaginal delivery
    • Estrogen depletion
    • Pelvic surgery
    • Immobility
    • Neurological disorders
    • Pelvic injury or radiation
    • Chronic disease
  • Symptoms
    • Problems holding or emptying bladder
    • Leak with cough, laugh, lift, sneeze
    • Leak on route to toilet
    • Frequency during day, nocturia
      • Urge awakens
    • Leak during physical activities
    • Use absorbent pads
      • Frequency of change
    • Urine staining
  • Symptoms present
    • Bowel and voiding habits
    • Other urinary sx
      • Nocturia, dysuria, hesitancy, change in stream, strain, hematuria, pain
    • Fluid intake
    • Caffeine
    • Change in bowel or bladder fct
    • Most bothersome sx
  • More questions
    • Precipitants
      • Surgery, injury, radiation, trauma, new onset dx, new medication
    • Treatment expectations
    • Environmental and functional assessment
    • Mental status prn
  •  
  • Voiding Diary
    • 24 hour voiding pattern
      • Times
      • Fluid intake
      • Urine volume estimate
      • Accidental leaks
      • Sensation/urge
  • Identify Reversible Causes
  •  
  • Exam
    • Cardiopulmonary
      • Signs of failure
      • Evidence of pulmonary disease
        • Cough
        • Medication
  • Exam
    • Endocrine
      • Diabetic Retinopathy
      • Adrenal
      • Thyroid
      • Obesity
    • Mobility
  • Exam
    • Neurological
      • Neuropathy
      • Cognition
      • Cerebrovascular
      • Affect and mood
      • Spinal cord integrity
    • LS nerve assessment
      • DTRs
      • Sensation
      • Strength
      • Perineal reflexes
  • Regional reflexes
  • Exam
    • Abdomen
      • Distention
      • Hepatomegaly
      • Pregnancy
      • Musculature
      • Masses
    • Rectal
      • Impaction
      • Masses
      • Sensation
      • Prostate size, etc
  • Exam
    • Genital
      • Mass, foreskin, Glans, skin
    • Pelvic
      • Vaginal mucosa
      • Friability
      • Pelvic musculature
      • Inflammation
        • Discharge (pyridium test)
      • Diverticula
      • Bimanual
        • Levator ani function
          • 5-10 seconds
  • Exam
    • Pelvic or rectal mass
    • Prolapse
      • Uterine, cystocele, cystourethrocele, rectocele, enterocele
    • Cough stress test
      • Supine
        • If positive with relatively empty bladder consider internal sphincter deficiency
  • Post-void residual volume
    • US: less risk but more cost
    • Post void volume
      • Within 10 minutes of voiding
    • Cath post voiding
      • 50-100 ml okay
      • > 200 ml definitely abnormal
    • Ultrasound
  • Lab
    • Urinalysis
      • Hematuria
        • Kidney stone
        • Malignancy
          • Cytology
      • Infection
      • Glycosuria
    • Bun, Cr with urinary retention
    • PSA
  • Special studies
  • Urge Incontinence
    • Urge
      • Loss of urine a/w strong desire to void
      • Frequency
      • Unable to get to toilet quickly enough after 1st urge
      • Sensation of incomplete emptying
      • No specific physical findings
  • Treatment: Urge
    • Behavioral therapy
      • Bladder training
        • Improves in 50%
        • More effective than oxybutynin
      • Pelvic floor exercises: Kegel
        • 81% reduction
        • vs. 69% with oxybutynin
      • Biofeedback
        • May help to learn Kegel
        • Does not decrease UI frequency vs. Kegel alone
  • Non-pharmacological
    • Bladder and pelvic floor training
    • Access to toilet
    • Reasonable fluid intake
      • 49-64 oz per day  40-50 oz urine output
    • Avoid constipation: fiber
    • Limit caffeine and alcohol
    • Review medications and modify if possible
  • Bladder training
    • Advising the patient to control the urge to void
      • schedule urination at specific intervals
      • increase interval over time
      • teach methods to tighten pelvic muscles
      • goal 3-4 hours between voiding
    • Prompted voiding: cognitively impaired
      • Caretaker assists patient to toilet at scheduled intervals regardless of urge to void
  • Medication: Urge
    • Oxybutynin
      • Nonselective anticholinergic
      • Transdermal patches
    • Tolterodine
      • Selective anticholinergic
      • Less impact on salivary glands
    • Long acting formulations
      • More effective
      • Fewer anticholinergic effects
    • Patch
      • More effective than placebo
      • As effective as oral versions
      • More cutaneous side effects
  • Medication: Urge
  • Treatment: Urge
    • Electrical therapy
      • Severe refractory urge incontinence
      • Generator in s.c. tissue of lower back or buttocks
        • Lead placed through sacral foramen
        • Stimulate S3 sacral nerve
        • Decrease detrusor muscle contractions
        • $10,000
        • Plus surgical costs for implantation
            • Medicare covers
  • Treat Stress Incontinence
    • Stress
      • Momentary leakage with sneezing, coughing, laughing, etc.
      • When bladder full or partially full
      • Stops with reduction of intra-abdominal pressure
  • Treatment: Stress
  • Intravaginal devices
    • Tampons, diaphragms
    • Pessaries
      • Hodge
      • Incontinence dish
      • Incontinence ring
  • Pessaries
  •  
    • External devices
      • Condom catheters
      • Abrasion, maceration, ischemia, necrosis, edema
      • Absorbent products
    • Biofeedback
    • Vaginal weights
    • Electrical stimulation
      • 52-72% success
    • Medication
  • Surgical INJECTABLE BULKING AGENTS
  • Catheterization
    • Risks
      • Discomfort
      • Trauma
      • Infection
    • 6-28% of NH patients
      • expedience
      • Undesirable due to high morbidity
      • Bacteruria in 100%
      • Prophylactic antibiotics ineffective
      • Change q 30 days
    • Intermittent catheterization
    • Suprapubic catheter
  • Pseudostress Incontinence
    • Sustained leakage with increased I/A pressure
    • Poorly inhibited detrusor stimulated by repetitive transient increase I/A pressur
      • cough for example
    • Urodynamic testing indicated to differentiate
  • Mixed Incontinence
    • Mixed incontinence
      • Treat predominant symptom
  • Monitor
    • Failure to respond
      • Further evaluation
  • No presumptive Diagnosis
    • Referral: Urology/urogynecology
      • Multichannel or subtracted cystometrography
      • Urine flowmetry
      • Urethral pressure profiles
      • Urethral sphincter electromyography
      • Endoscopy, imaging
  • Identify Need for Referral
  • References
    • Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients
      • http://www.aafp.org/afp/980600ap/weiss.html
    • Anticholinergic Drugs for Overactive Bladder: Cochrane Review
      • http://www.aafp.org/afp/20060101/cochrane.html#c3
    • Selecting Medications for the Treatment of Urinary Incontinence
      • Weiss B. AFP. Vol. 71/No. 2 (January 15, 2005)
      • http://www.aafp.org/afp/20050115/315.html
    • Urinary Incontinence in Women: Evaluation and Management
      • Culligan P, Heit M. AFP. Vol. 62/No. 11 (December 1, 2000)
      • http://www.aafp.org/afp/20001201/2433.html