Urinary Incontinence
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Urinary Incontinence

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    Urinary Incontinence Urinary Incontinence Presentation Transcript

    • Urinary Incontinence
      • Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.
      • Affects physical, psychological, social well being -> Reduce quality of life
      • Prevalence, ↑ with age
      • Common in institutionalized women, those in residential nursing homes
    • Some definitions…
      • Stress incontinence is loss of urine on physical effort
      • Urge Incontinence is an involuntary loss of urine associated with a strong desire to void.
      • Overflow Incontinence occurs without any detrusor effort when the bladder is over-distended.
      • Urgency is a sudden desire to void
      • Frequency is passing of urine seven or more/day or being awoken from sleep more than once a night to void.
    •  
    • Classification of Incontinence
      • URETHRAL CAUSES
      • Urethral Sphincter Incompetence (Urodynamic stress Incontinence)
      • Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic)
      • Retention with overflow
      • Congenital causes
      • Miscellaneous
      • EXTRA URETHRAL CAUSES
      • Congenital causes
      • Fistula
    • 1. URETHRAL CAUSES
    • 1a : Urodynamic Stress Incontinence
      • Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction.
      • Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ±
      • Examination: Stress incontinence when cough, look for prolapse, cystourethroceles
        • Also asses her vaginal capacity and her ability to elevate bladder neck.
      • Urodynamic studies will define cause of incontinence
      • Causes of USI
        • Damage to nerve supply of pelvic floor and urethral sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries)
        • Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince
        • Congenital cause (nulliparous women) – Connective tissue disorder esp collagen
        • Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation
    • 1b: Detrusor Over-activity
      • Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked.
      • Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties
      • Examination: Any mass that may compress bladder, prolapse TRO
      • Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw
    • 1c: Retention with overflow
      • Insidious failure of bladder empting may lead to chronic retention and finally, when normal voiding is ineffective, to overflow incontinence
      • Caused by: LMN/UMN lesions, urethral obstructions, pharmacological
      • Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence
      • Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux
    • 1d: Congenital
      • Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence
      • Rx with urethral reconstruction or artificial urinary sphincter
    • 2. EXTRA URETHRAL CAUSES
    • 2A: Congenital
      • Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period
      • Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains
    • 2B: FISTULA
      • Abnormal opening between the urinary track and outside.
      • Obstetric cause : Obstructive labour with compression of bladder between presenting head and bony pelvis
      • Gynecological cause : AW pelvic surgery, radiotherapy, pelvic malignancy
      • Treated by primary closure or surgery
    • INVESTIGATIONS
      • Urine C&S- tro Infections
      • Pad test
      • Measure Postvoidal Residual Volume by bladder ultrasound or urethral catheter >100mL in more than one occasion->+
      • Cough Stress Test. 250mL into bladder
      • Abdominal leak point pressure
      • Urodynamic studies
        • Uroflowmetry. Bladder outlet obstruction
        • Cystometry. Detrusor activity, differentiate involuntary detrusor contraction or increase intraabdominal pressure
      • Cystogram
        • Stress incontinence, Cystocele, Sphincter activity, fistula
      • Cystoscopy
        • Tumors, stones
    • Treatment
        • Palliative – Fluid restriction, Protective perineal pads, Bladder retraining, Pelvic Floor exercise (Kegel)
        • Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms
        • Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance
        • Colposuspension Operation, Artificial Sphincter
    •