This is a medical educational presentation.

1. DR POLY BEGUM
Assistant Professor
Diabetic Association Medical College,
Faridpur

2. Urinary incontinenceUrinary incontinence
Quality of LifeQuality of Life
• UI imposes a significant psychosocial impactUI imposes a significant psychosocial impact
on individuals, their families, and caregivers.on individuals, their families, and caregivers.
• UI results in a loss of self-esteem and aUI results in a loss of self-esteem and a
decrease in ability to maintain an independentdecrease in ability to maintain an independent
lifestyle.lifestyle.
• Dependence on caregivers for activities ofDependence on caregivers for activities of
daily life increases as incontinence worsensdaily life increases as incontinence worsens.
April 7, 2016 2
Dr Poly Begum

3. Definition of UrinaryDefinition of Urinary
IncontinenceIncontinence
““ The involuntary lossThe involuntary loss
of urineof urine
which is objectivelywhich is objectively
demonstrabledemonstrable
and a social orand a social or
hygienic problem.”hygienic problem.”
April 7, 2016 3
Dr Poly Begum

4. April 7, 2016 4
Dr Poly Begum

5. PrevalencePrevalence
The reported incidence of UI varies widely,
ranging from 8% – 41% in women over 65
years. It becomes more common as women
age, particularly after menopause.
April 7, 2016 5
Dr Poly Begum

6. April 7, 2016 6Dr Poly Begum

7. Mechanism of urinary continence
Normally intraurethral pressure at rest and with stress is
much higher (20-50cm of water) then the intravesical
pressure (10 cm of water). This is maintained by -
• Apposition of the longitudinal mucosal folds.
• Submucosal vascular plexus (hermetic seal).
• Abundant deposion of collagen and elastic tissues
througout the circumference of the urethra.
• Tonic contraction of the smooth muscles in the
proximal urethra and bladder neck.
• Rhabdosphincter in the midurethra and levetor Ani
muscles. 7April 7, 2016
Dr Poly Begum

8. 1. Autonomic nervous system control
Nerve coming from the spinal cord and go
directly to the bladder
When bladder gets fuller, signals are sent to the
brain
1. Central nervous system
Voluntary control to choose when to void.
April 7, 2016
Dr Poly Begum
8

9. University of North Carolina School of Medicine Center for Aging and Health
Physiology
April 7, 2016 9
Dr Poly Begum

10. Normal Voiding Cycle
Filling & storage phase
Emptying
phase
Bladder filling
Normal desire
to voidFirst sensation
to voidBladder filling
Bladderpressure
Abrams P, Wein AJ. The Overactive Bladder — A Widespread and Treatable
Condition. Stockholm, Sweden: Erik-Sparre Medical AB; 1998.April 7, 2016 10
Dr Poly Begum

11. Patho-physiology of UrinaryPatho-physiology of Urinary
IncontinenceIncontinence
Basic pathology of incontinence is the rise of
intravesical pressure over that of maximum
urethral pressure. It may be due to
mechanical injury to the supports of the
bladder neck following childbirth,
truma(surgery) or due to ageing overactivity
of the detrusor muscles, may also be
associated.
April 7, 2016 11
Dr Poly Begum

12. April 7, 2016
Dr Poly Begum
12

13. Uncontrolled Contraction of the
Bladder Muscle
Normal bladder Patients with
urge
incontinence
Patients with
urge or
frequency
Urethral resistance Uncontrolled bladder
muscle contractions
April 7, 2016 13
Dr Poly Begum

14. Aging ChangesAging Changes
• Decreased bladder capacity
• Reduced voiding volume
• Reduced flow rates
• Increased urine production at night
April 7, 2016 14
Dr Poly Begum

15.  Age
 Pregnancy
 Vaginal delivery, caesarian section
 Menopause
 Hysterectomy
 Obesity
 Chronic cough
 Constipation
 Urinary tract infections
 Functional impairment
 Cognitive impairment
Risk Factors for UI
April 7, 2016 15
Dr Poly Begum

16. Reversible causes of UI
- Delirium or Drugs
- Restricted mobility
- Infection, impaction
- Polyuria
II
PP
RR
DD
April 7, 2016 16
Dr Poly Begum

17. April 7, 2016 17
Dr Poly Begum

18. April 7, 2016 18

19. April 7, 2016 19
Dr Poly Begum

20. April 7, 2016 20
Dr Poly Begum

21. Stress UIStress UI
The complaint of
involuntary
leakage with effort
or exertion or on
sneezing or
coughing
Sudden increase in
abdominal pressure
Urethral pressure
April 7, 2016 21
Dr Poly Begum

22. Urge UIUrge UI
The complaint
of involuntary
leakage
accompanied by
or immediately
preceded by
urgency
Involuntary detrusor
contractions
Urethral pressure
April 7, 2016 22
Dr Poly Begum

23. Overactive bladderOveractive bladder
• Includes urinary urgency with or without
urge incontinence, urinary frequency,
and nocturia
• Associated with involuntary contractions
of the detrusor muscle
April 7, 2016 23
Dr Poly Begum

24. Overactive Bladder
Symptom:
“Experiencing a strong urge to go
to the bathroom.”
Urinary Urgency
April 7, 2016 24
Dr Poly Begum

25. Overactive Bladder Symptom:
“Going to the bathroom frequently.”
“Have to go to the bathroom, where the
bladder wakes me up at night.”
Urinary Frequency
April 7, 2016 25
Dr Poly Begum

26. Overactive Bladder Symptom:
“Loosing involuntary urine accompanied with the
strong desire to void.”

Urge Urinary Incontinence
April 7, 2016 26
Dr Poly Begum

27. Mixed UIMixed UI
The complaint
of involuntary
leakage
associated with
urgency and
also with
exertion,
effort,
sneezing,
or coughing
Sudden increase in
abdominal pressure
Involuntary detrusor
contractions
Urethral pressure
April 7, 2016 27
Dr Poly Begum

28. OverflowOverflow
Neurogenic/Atonic
Obstruction
•Urethral blockage
•The Bladder is not able
to empty properly
April 7, 2016 28
Dr Poly Begum

29. Functional IncontinenceFunctional Incontinence
• Immobility
• Aphasia
• Environment
• Psychological
April 7, 2016 29
Dr Poly Begum

30. Continual IncontinenceContinual Incontinence
This is also described as true
incontinence. In this condition urine
flows continuously by day and night. It is
caused by some form of urinary tract
fistula.
April 7, 2016 30
Dr Poly Begum

31. Evaluation of PatientsEvaluation of Patients
April 7, 2016 31
Dr Poly Begum

32. -History--History-
• Fluid intake pattern
• Number of continent and incontinence
episodes
• Night time urgency
• Voiding Pattern
– Quality of stream
– Incomplete voiding
April 7, 2016 32
Dr Poly Begum

33. -History--History-
• OB/GYN history
• Medications
• Neurologic history
– Back pain, back surgery
– Stroke
– Numbness, weakness, balance problems
April 7, 2016 33
Dr Poly Begum

34. -Quantification of symptoms--Quantification of symptoms-
Voiding diary day and night for >24 hours:
– Document of fluid intake
– Quantification of urine output with voiding hat
– Uncontrolled loss of urine at day and night
– Degree of urge to go to the bathroom
– Use and number of pads
April 7, 2016 34
Dr Poly Begum

35. April 7, 2016 35
Dr Poly Begum

36. April 7, 2016 36
Dr Poly Begum

37. April 7, 2016 37
Dr Poly Begum

38. April 7, 2016 38
Dr Poly Begum

39. April 7, 2016 39
Dr Poly Begum

40. April 7, 2016 40
Dr Poly Begum

41. April 7, 2016 41
Dr Poly Begum

42. April 7, 2016 42
Dr Poly Begum

43. April 7, 2016 43
Dr Poly Begum

44. April 7, 2016 44
Dr Poly Begum

45. April 7, 2016 45
Dr Poly Begum

46. April 7, 2016 46
Dr Poly Begum

47. April 7, 2016 47
Dr Poly Begum

48. April 7, 2016 48
Dr Poly Begum

49. April 7, 2016 49
Dr Poly Begum

50. April 7, 2016 50
Dr Poly Begum

51. April 7, 2016 51
Dr Poly Begum

52. April 7, 2016 52
Dr Poly Begum

53. April 7, 2016 53
Dr Poly Begum

54. April 7, 2016 54
Dr Poly Begum

55. Pelvic Floor ExercisesPelvic Floor Exercises
April 7, 2016 55
Dr Poly Begum

56. April 7, 2016 56
Dr Poly Begum

57. April 7, 2016 57
Dr Poly Begum

58. April 7, 2016 58
Dr Poly Begum

59. April 7, 2016 59
Dr Poly Begum

60. April 7, 2016 60
Dr Poly Begum

61. TVT – tension free vaginal tape
April 7, 2016 61
Dr Poly Begum

62. TOT - Transobturator TapeTOT - Transobturator Tape
April 7, 2016 62
Dr Poly Begum

63. April 7, 2016 63
Dr Poly Begum

64. April 7, 2016 64
Dr Poly Begum

65. April 7, 2016 65
Dr Poly Begum

66. April 7, 2016 66
Dr Poly Begum

67. April 7, 2016 67

68. April 7, 2016 68
Dr Poly Begum

69. April 7, 2016 69
Dr Poly Begum

70. April 7, 2016 70
Dr Poly Begum

71. 71

72. OxybutyninOxybutynin
• Both anticholinergic and smooth muscle
relaxant properties
• 15-58% greater reduction in urge UI than
placebo
• Dose: 2.5 -5 mg qd-qid, 20 mg/d maximum
April 7, 2016 72
Dr Poly Begum

73. Tolterodine tartrateTolterodine tartrate
• Pure muscarinic receptor antagonist
• Dry mouth most common side effect
• 3 RCT compared tolterodine (2 mg bid) to oxybutynin
(5 mg tid): Equally effective and superior to placebo
• Decreased urge U(I in study of 293 pts:47%
tolterodine, 71% oxybutynin, 19% placebo, dry
mouth 86% oxybutynin, 50% tolerodine
April 7, 2016 73
Dr Poly Begum

74. SolefenacinSolefenacin
• Dose 5 to 10 mg daily
• Long acting muscarinic receptor antagonist,
selective for M3
• Undergoes hepatic metabolism involving
cytochrom P450
• Several multinational trials with over 800
pts, vs placebo, showed efficacy low side
effects (2% dry mouth)
April 7, 2016 74
Dr Poly Begum

75. April 7, 2016 75Dr Poly Begum

76. April 7, 2016 76
Dr Poly Begum

77. April 7, 2016 77
Dr Poly Begum

78. April 7, 2016 78
Dr Poly Begum

79. April 7, 2016 79
Dr Poly Begum

80. April 7, 2016 80
Dr Poly Begum

81. April 7, 2016 81
Dr Poly Begum

82. April 7, 2016 82
Dr Poly Begum

83. April 7, 2016 83
Dr Poly Begum

84. Urinary incontinenceUrinary incontinence
Overflow IncontinenceOverflow Incontinence
• Involuntary loss of urine associated withInvoluntary loss of urine associated with
overdistension of the bladderoverdistension of the bladder
• It may have a variety of presentations,It may have a variety of presentations,
including frequent or constant dribbling, orincluding frequent or constant dribbling, or
urge or stress incontinence symptoms.urge or stress incontinence symptoms.
• Overflow UI may be caused by an underactiveOverflow UI may be caused by an underactive
or acontractile detrusor, or to bladder outletor acontractile detrusor, or to bladder outlet
or urethral obstruction leading toor urethral obstruction leading to
overdistension and overflow.overdistension and overflow.
April 7, 2016 84
Dr Poly Begum

85. Treatment of Overflow incontinenceTreatment of Overflow incontinence
• If any obstruction, Surgical treatment has to
be done .
• In case of non-obstructive group, continuous
catheter drainage is required.
April 7, 2016
Dr Poly Begum
85

86. April 7, 2016 86
Dr Poly Begum

87. SummarySummary
• Behavioral treatment is effective for treating
stress and urge UI and OAB
• Drugs are effective for treating urge UI and
OAB.
• New selective agents for urge and OAB based
on new understanding of bladder and urethral
function
• Caution needed in dosing, especially in older
patients
April 7, 2016 87
Dr Poly Begum

88. April 7, 2016 88
Dr Poly Begum

89. April 7, 2016 89
Dr Poly Begum