Clinical approach to urinary incontinence

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  • Mode of delivery: vaginal? If yes, was it assisted (forceps)? If so  more likely stress incontinenceBirth wt of her children is imp bcz it indicates weakening of her pelvic floor muscles
  • General look of the pt: is she obese?Pelvic exam: usually normal but sometimes u may find large fibroids or masses. With a speculum in place, the clinician observes whether the tissue lining your vagina shows atrophy or other signs that it lacks estrogen. That would indicate that your urethral lining (not visible during the exam) is likely to show a similar lack of this hormone.Pelvic floor tone: put ur hand though the vagina and ask pt to squeeze, assess the strength of the pelvic floor muscles and feel whether the bladder or the uterus are prolapsed. The clinician may ask you to contract your muscles as if you were trying to avoid urinating or passing gas. Abd exam: During the abdominal exam, press on the abdomen to feel bladder and check other areas for hernias, tenderness, or any signs of tumor, infection, scarring from previous surgeries, or an impacted bowel.Stress test: ensure having full bladder and ask pt to lie in lithotomy position, as her to cough  look for any urine leakage, if –ve repeat in standing position. This test is usually performed at the beginning of your physical, when you have a full bladder. Afterward, you can urinate to increase your comfort during the rest of the exam. Neuro exam: check tone reflexes with a hammer, assess muscle strength, and observe whether pt can distinguish the touch of something sharp from something dull. women, Also, to test whether the pudendal nerve function is intact, gently tap the clitoris and look for a subtle muscle contraction of the anus, which is a normal reflex.Resp exam: look for problems that cause chronic cough*Occasionally, if stress incontinence is suspected but is not observed during the exam, the clinician may give you a pre-weighed pad to wear while doing a series of exercises. The pad is then weighed again to determine how much leakage has occurred. You may also be sent home with a package of pads to wear and save in sealed plastic bags over a 24-hour period, so that total leakage can be estimated
  • This test determines the mobility and descent of the urethrovesical junction on straining and allows differentiation from anterior vaginal laxity alone. With the pt in the lithotomy position, the examiner inserts a lubricated cotton swab in the urethra to the level of the urethrovesical junction and measures the angle between the cotton swab and the horizontal. The pt then strains maximally, which produces descent of the urethrovesical junction. Along with the descent, the cotton swab moves, producing a new angle with the horizontal. The normal angle is up to 30 degress. In pts with pelvic relaxation and Sressincont the change in cotton swab angle ranges from 30 to 60 degress or more.
  • Note – volumes quoted are your best estimate, especially if you have had an accident it can be hard to be certain how much urine is passed on each occasion. For drinks, you can get the volumes from the containers, or use a favourite cup or mug. These examples assume you are not wearing protection or a collecting device. If you do wear protection, you can record either the volume in the collecting bag or whether the pad was wet enough to need changing. Note the size of pad you were wearing, because often people wear a much more absorbent pad overnight or for travelling, than they might do around the house.
  • Clinical approach to urinary incontinence

    1. 1. Done by : Yasmin Saidat Mahmoud Ababneh Supervised by : Dr . Lama Al.Muhaisen Jordan university of science and technology .
    2. 2. Defintion  Involuntary loss of urine that is objectively demonstrable and that is severe enough to constitute a social or hygienic problem.
    3. 3. Pharmacology of incontinence a.-Adrenergic receptors.  found in urethra. Stimulation cause contraction of urethral smooth muscle, preventing micturition. Drugs: ephedrine, imipramine, and estrogens. a.-Adrenergic blockers or antagonists  relaxthe urethra, enhancing micturition.  Drugs: phenoxybenzamine .
    4. 4. β-Adrenergic receptors. Found in detrusor muscle. Stimulation cause relaxation of the bladder wall, preventing micturition. Drugs: flavoxate and progestins.
    5. 5. Cholinergic receptors. Found in detrusor muscle Stimulation cause contraction of the bladder wall, enhancing micturition. Chlinergic drugs: bethanecol and neostigmine . Anticholinergic medications block the receptors, inhibiting micturition. Drugs: oxybutynin and propantheline .
    6. 6. History P.P: Age, parity . C.C: Duration, frequency and amount of leakage Precipitating factors:  3 P’s - Position of leakage (supine, sitting, standing) - Protection (pads per day, wetness of pads) - Problem (quality of life) Progression – is it worsening?
    7. 7. Irritative:  If Frequency: 10-12 x/day OR urge incont.  nocturia: 3-4 x/night.  If no freq/nocturia  think of stress incont.  Dysuria, hematuria, urgencyUTI urge incont.  Recurrent Hx of UTI  urge Obstructive:  Hesitancy, dysuria, straining to void, poor or interrupted stream, retention of urine, incomplete emptying, terminal dribbling.  Volume of urine leakage – large amounts go with overflow incont.  Stones, tumors Lower urinary tract symptoms
    8. 8. Past obstetrics Hx: Mode of delivery, Birth Wt of her children . Gyne. Hx: Symptoms of urogenital prolapse: • Feeling of mass that goes down while urinating  Worse towards the end of the day  Dragging backache Medical Hx: DM, HTN, Neurological problems,Disk prolapse Pelvic Surgeries? Trauma to the spine? Drugs: diuretics, psychotropic agents, Ca-channel blockers, alpha- blockers Any alteration in bowel habit? Smoker? Chronic cough?
    9. 9. Physical Exam. 1. General look of the pt * 2. Abdominal exam 3. Respiratory exam 4. Neurological exam * 5. Pelvic exam * 6. Asses pelvic floor muscle tone * 7. Rectal exam 8. Stress test * 9. Cotton swab (Q-tip) test urethral mobility *
    10. 10. Q-tip (cotton swab) Test
    11. 11. Investigation
    12. 12. Investigation  You MUST rule out UTI first !  Midstream Urinalysis  Blood test  KFT  Bladder diary
    13. 13. Example Diary for Urge incontinence Day Time Comments Sunday, 5th of March 7 am Woke up and needed to go to the toilet 7:30 Needed to go to the toilet again 8 am Breakfast – 300 ml grapefruit juice and 200 ml tea 8:15 am Passed about 100 ml 8:25 am Passed about 50 ml 9 am Pants a little damp, passed about 50 ml 9:15 am Dribbled a bit, changed pants 9:30 am Passed a few drops, bladder feels very “jumpy” and so on ….
    14. 14. Urodynamic studies Parameters measured during urodynamic evaluation 1,2,34 1. Post void residual volume (PVR) 2. Uroflow 3. Pressure flow study 4. Cystometrogram (CMG) 5. Abdominal Leak-Point Pressure (ALPP) 6. Video urodynamics
    15. 15. 1. Post void residual urine Distinguish between:  true incontinence (Residual urine < 50 mL).  overflow incontinence (Residual urine >100 mL).
    16. 16. 2. Uroflow Measurement of Urine Speed and Volume
    17. 17. 3. Pressure flow study Bladder pressures are measured simultaneously with a urinary flow rate during voiding . This helps to differentiate true urethral obstruction from detrusor failure. Obstruction = detrusor pressure more than 50 cm water and flow < 15 mL/s
    18. 18. 4. Cystometrogram The pressure in the bladder and rectum/vagina is measured during bladder filling. Intra-abdominal pressure is subtracted from bladder pressure to give a real indication of detrusorfunction. Residual Volume <50mL Sensation of fullness 200-225 mL Urge to void 400-500 mL No contractions are normal.
    19. 19. 5. Abdominal Leak-Point Pressure Measurement of bladder pressure during coughing or valsalva manoeuvre to determine the pressure in the bladder required to induce leakage. In hypermobility of the urethra, the ALPP will be more than 60 cm water. But with Intrinsic Sphincter Dysfunction, the ALPP is less than 60 cm water and often less than 20 cm water.
    20. 20. 6.Video Urodynamics: Urodynamic tests can be performed with equipment to take pictures of the bladder during filling and emptying. Contrast medium may be given via the catheter.
    21. 21. Other invistigation  Urethral Pressure Measurement  Normal Urethral closure pressure (UCP) = 50-100 cm H₂O  If < 20  stress incont  If UCP is high  voiding difficulties, hesitancy and urinary retention  Urethrocystoscopy  Ultrasonography
    22. 22. Findings & results in each Type of incontinence + management  History  Examination  Investigation Findings
    23. 23. Stress Incontinence. The most common form of urinary incontinence. • Etiology. Rises in bladder pressure because of intraabdominal pressure increases (e.g., coughing and sneezing) are not transmitted to the proximal urethra because it is no longer a pelvic structure owing to loss of support from pelvic relaxation. • History. Loss of urine occurs in small amounts simultaneously with coughing or sneezing. It does not take place when the patient is sleeping.
    24. 24. Examination.  Pelvic examination may reveal a cystocele.  Neurologic examination is normal.  The Q-tip test is positive: when a lubricated cotton-tip applicator is placed in the urethra and the patient increases intraabdominal pressure, the Q-tip will rotate >30 degrees. Investigative studies.  Urinalysis and culture are normal.  Cystometric studies are normal with no involuntary detrusor contractions seen.
    25. 25. Management of stress incontinence 1. Conservative  Stop smoking, cut down on alcohol, caffeine.  Pelvic floor muscle exercises (Kegel exercise)  Intravaginal device – large sized pessaries or cones used to elevate and support bladder neck and urethra. Success rate 70%. 2. Medical Alpha agonists: 1. Pseudoephedrine 2. Phenylpropanolamine  Enhance urethral closure and improve continence  Do NOT give estrogen replacement unless she has atrophic vaginitis
    26. 26. Abdominal approach: aims to elevate the urethral sphincter so that It is again an intraabdominallocation (urethropexy). This is done by attachment of the sphincter to the symphysis pubis, using the Burch procedure as well as the Marshall- Marchetti-Kranz (MMK) procedure.  The success rate 85-90% 3. Surgery
    27. 27. Vaginal approach:  Suburethral sling procedures  severe + refractive cases  Tension-free Vaginal Tape(TVT) -A modification of the sling procedure  uses tension-free synthetic (polypropylene) mesh placed at the level of mid urethra (paraurethral). -Minimally invasive It does not elevate the urethra but forms a resistant platform against intraabdominal pressure.  periurethral bulking injections : (ovine collagen- contigen or calcium hydroxylapatite)
    28. 28. TVT
    29. 29. Urge (Hypertonic) Incontinence • Etiology. Involuntary rises in bladder pressure from idiopathic detrusor contrac tions that cannot be voluntarily suppressed. • History. Loss of urine occurs in large amounts often without warning. At day and night. The most common symptom is urgency.
    30. 30. • Examination.  Pelvic examination= normal anatomy.  Neurologic examination Is normal. • Investigative studies.  Urinalysis and culture are normal  . Cystometric studies show normal residual volume, but involuntary detrusor contractions are present even with small Volumes of urine in the bladder.
    31. 31. 1. Behavioral Modification:  First line tt.  Organize fluid intake habit: ↓ fluid intake & avoid liquids during evenings  Gradually ↑ the interval btw voidings “Training”  Kegel ex. 2. Medical Treatment to inhibit detrusor contractions  Anticholinergic medications.  NSAIDs to inhibit detrusor contractions.  Tricyclic antid-dpressants.  Calcium-channel blockers. 3. Functional Electrical Stimulation Management of urge incontinence
    32. 32. Sensory Irritative Incontinence • Etiology. detrusor contractions stimulated by irritation from conditions: infection, stone, Tumor, or a foreign body. • History. Loss of urine occurs with urgency, frequency, & dysuria. At day or night. • Examination.  Suprapubic tenderness , but otherwise the pelvic examination is unremarkable.
    33. 33. • Investigative studies.  A urinalysis will show the following abnormalities: bacteria and WBCs; suggest an infection, RBCs; suggest a stone, Foreign body, or tumor.  A urine culture is positive if an infection is present.  Cystometric studies (which are usually unnecessary) would reveal normal residual volume with involuntary detrusor contractions present. • Management. Infections are treated with antibiotics. Cytoscopy is used to diagnose and remove stones, foreign bodies, and tumors
    34. 34. Overflow (Hypotonic) Incontinence • Etiology. Rises in bladder pressure occur gradually from an overdistended, hypotonic bladder. When the bladder pressure exceeds the urethral pressure, involuntary urine loss occurs but only until the bladder pressure equals urethral pressure. The bladder never empties. Then the process begins all over. This may be caused by denervated bladder (e.g., diabetic neuropathy, multiple sclerosis) or systemic medications (e.g.,ganglionic blockers, anticholinergics).
    35. 35. • History. Loss of urine occurs intermittently in small amounts. This can take place both day and night. The patient may complain of pelvic fullness Exnmination.  Pelvic examination may show normal anatomy.  The neurologic examination will show decreased pudendal nerve sensation.
    36. 36. • Investigative studies.  Urinalysis and culture are usually normal, but may show an infection.  Cystometric studies show markedly increased residual volume, but involuntary detrusor contractions do not occur. • Management. Intermittent self-catheterization may be necessary. Discontinue the offending systemic medications. Cholinergic medications to stimulate bladder contractions and a-adrenergic blocker to relax the bladder neck.
    37. 37. Bypass Fistula • Etiology. The normal urethral-bladder mechanism is intact, but is bypassed by urine Leaking out through a fistula from the urinary tract. • History. The patient usually has a history of either radical pelvic surgery or pelvic radiation therapy. Loss of urine occurs continually in small amounts. At day and night.
    38. 38. • Examination.  Pelvic examination may show normal anatomy.  normal neurologic findings. • Investigative studies.  Urinalysis and culture are normal.  An intravenous pyelogram (IVP) will demonstrate dye leakage from a urinary tract fistula. • Management. Surgical repair of the fistula
    39. 39. Prevention 1. Shortening of 2nd stage of labor 2. Reduce traumatic delivery 3. If menopause  consider HRT
    40. 40. The End

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