Üriner İnkontinans - www.jinekolojivegebelik.com

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Üriner İnkontinans - www.jinekolojivegebelik.com

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    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

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

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