Downloaded 98 times
![Differentiating ‘lone ISD’ from ISD with
hypermobility
• Urodynamic valsalva leak point pressure
(VLPP) < 60 cm water believed to be diagnostic [
60-90 equivocal; > 90 excludes diagnosis]
• Urethral pressure profile (Urethral pressure –
detrusor pressure) < 20cm water.
• Conflicting evidence that low VLPP or UPP
predicts failure following sling/tape procedures.
• Detrusor LPP (leakage of urine from bladder in
absence of abdominal contraction; DLPP > 40cm
water suggests possible urethral dilatation)](https://image.slidesharecdn.com/urinaryincontinence-final-170725133622/75/Urinaryincontinence-final-70-2048.jpg)
More Related Content
![Incontinence & Female Urology [Dr.Edmond Wong]](https://cdn.slidesharecdn.com/ss_thumbnails/incontinencefemaleedmond-140716213134-phpapp01-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Urinaryincontinence final
Urinaryincontinence final
- 1. Urinary Incontinence Guides Dr.Rachana AgrawalDr.Ruchika Garg Asst. professor Asst. professor Dept of OBGY. Dept of OBGY. S.N.M.C, Agra S.N.M.C, Agra Presented By Dr.Kokila. B.T. Junior Resident Dept. of OBGY, SNMC , Agra
- 2. DEFINITION • UI isdefined by the International Continence Society as 'the complaint of any involuntary leakage of urine’ that is objectively demonstrable and cause a social or hygienic Inconvenience for day to day activity
- 3. DEFINITIONS • Urinary incontinenceis defined as involuntary leakage of urine. • Urgency incontinence is involuntary leakage accompanied by urgency. Urgency is the complaint of a sudden and compelling desire to pass urine that is difficult to defer.
- 4. Mechanism of continencein women 4 factors contribute to female continence: • Bladder compliance • Efficient urethral sphincter • Efficient urethral support • Adequate urethral mucosal co-aption
- 6. NORMAL URETHRAL CLOSURE • Combinationof intrinsic and extrinsic factors.
- 7. EXTRINSIC FACTORS: • levatorani • endopelvic fascia • and its attachments to pelvic sidewalls and urethra
- 8. INTRINSIC FACTORS • Striatedmuscle of urethral wall • Vascular congestion of submucosal venous plexus • Smooth muscle of urethral wall and blood vessels • Epithelial coaptation of the folds of urethral lining • Urethral elasticity • Tone of urethra- α- adnerergic receptors of the sympathetic system
- 9.
- 10. Urinary Incontinence • Epidemiology •Quality of Life • Risk Factors and Causes • Types of Urinary Incontinence • Evaluation • Treatment
- 11.
- 12. Urinary incontinence Epidemiology • Althoughthe prevalence of UI increases with age, UI should not be considered a normal part of the aging process.
- 13. • Nearly 16million women in india have UI. • 9 million have urge incontinence or OAB. • Remaining 7 million women need surgical treatment..
- 14. Stress Urinary incontinence •Prevalence of SUI increases with age initially, • peaks around the fourth or fifth decade, • and then increases with increasing age. • m/c in white than black.
- 15. Mixed and urgeUrinary incontinence • Generally increases with age, eventually overtake SUI, by sixth and seventh decade. • UUI, more common in black women
- 16. Urinary incontinence Epidemiology • Fornon institutionalized persons older than 60 years of age, women have twice the prevalence of men • Whites > Blacks, Hispanics and Asians • Family history -Mother +/- sister
- 17. Risk Factors andCauses
- 18. Urinary incontinence Risk factors •Immobility/chronic degenerative disease • Impaired cognition • Medications • Morbid obesity • Diuretics • Smoking • Fecal impaction • Delirium • Environmental barriers • High-impact physical activities • Diabetes • Stroke
- 19. Urinary incontinence Risk factors-m/cin women • Estrogen depletion-postmenopausal women • Pelvic muscle weakness- Pregnancy/vaginal delivery/episiotomy • Childhood nocturnal enuresis • Race
- 20. Urinary incontinence Causes • Conditionsaffecting the lower urinary tract • Drug side effects • Increased urine production • Impaired ability or willingness to reach a toilet
- 21. Urinary incontinence Conditions affectingthe lower urinary tract • Urinary tract infection • Atrophic vaginitis/urethritis • Pregnancy/vaginal delivery/episiotomy • Stool impaction
- 22. Urinary incontinence Pharmacologic Causes •sedatives • loop diuretics • alcohol • caffeine • cholinergics (donepezil) • awareness, detrusor activity Func & O UI • Diuresis overwhelms bladder capacity Urge & O UI • Polyuria, awareness Urge & Functional UI • Polyuria, detrusor activity Urge • detrusor activity Urge Culligan PJ Urinary Incontinence in women Evaluation and Management AFP 12-1-01
- 23. Pharmacologic Causes, Continued alpha-agonists urethral sphincter tone retention and Overflow alpha-antagonists urethral sphincter tone Stress
- 25. Urinary incontinence Increased urineproduction • Metabolic (hyperglycemia, hypercalcemia) • Excess fluid intake • Volume overload • Venous insufficiency with edema • Congestive heart failure
- 26. Urinary incontinence Impaired abilityor willingness to reach a toilet • Delirium • Chronic illness, injury, or restraint that interferes with mobility • Psychological
- 27.
- 28. Urinary incontinence Quality ofLife • UI imposes a significant psychosocial impact on individuals, their families, and caregivers. • UI results in a loss of self-esteem and a decrease in ability to maintain an independent lifestyle. • Dependence on caregivers for activities of daily life increases as incontinence worsens.
- 29. Urinary incontinence Quality ofLife • UI is often undetected and underreported by hospital and nursing home personnel.
- 30. Types of UrinaryIncontinence • Transient UI (Acute) • Established UI (Chronic) – Urge UI – Stress UI – Mixed UI – Overflow UI
- 31. Causes of Transient(Acute) Incontinence • D Delirium • I Infection • A Atrophic Vulvovaginitis • P Psychological • P Pharmacologic agents • E Endocrine, excessive UO • R Restricted Mobility • S Stool impaction
- 32. Classification of Urinary Incontinence Urethral •GSI • Detrusor overactivity • Mixed (GSI and DO) • Overflow incontinence (acute and chronic) • Functional and others • Congenital(epispadius) Extra urethral • Acquired 1. Fistulae 2. Vesical 3. Urethral 4. Ureteral • Congenital 1. Ectopic ureter and others
- 33. Classification of urinary incontinence •Stress urinary incontinence (SUI) • Urge urinary incontinence (UUI) • Mixed urinary incontinence • Other 1. Transient causes (DIAPERS) 2. Urethral diverticulum 3. Vesico-vaginal fistula Ectopic urethrae
- 36. Urinary incontinence Stress Incontinence(SUI) ICS definitions (Abrams 2003) • SUI is defined as involuntary urine loss coincident with an increase in intra- abdominal pressure (coughing, sneezing, laughing, or other physical activities ), in the absence of a detrusor contraction or an overdistended bladder.
- 37. Stress urinary incontinence •Urodynamic stress incontinence is noted during urodynamic testing (filling cystometry) and is defined as the involuntary leakage of urine during increases in abdominal pressure in the absence of a detrusor contraction.
- 38. Theories of SUIdevelopment (i) Urethral position theory (Kelly, Bonney, Einhorning) – failed transmission of intra- abdominal pressure to the urethra (ii) Intrinsic sphincter deficiency (McGuire) – poor periurethral support tissues (iii) Hammock theory (DeLancey) – lax pubococcygeus backplate (iv) Integral theory (Petros and Ulmstein) – weak pubourethral ligaments Probably multifactorial, incorporating all features of above.
- 39. Types of stressincontinence on basis of supports: 1. Incontinence caused by anatomic hypermobility of urethra (extrinsic) 2. Incontinence caused by intrinsic sphincteric weakness or deficiency.
- 40. Urethral hypermobility • Bladderbase descent leads to urethra exiting true pelvis. • Thus raised intraabdominal pressure unequally transmitted to bladder vs. urethra and leakage occurs
- 41. • Risk factorsfor urethral hypermobility 1. Pregnancy (esp. prolonged labour) 2. Vaginal delivery (esp. instrumental) 3. Pelvic surgery ,Obesity, 4. Chronic cough ,Chronic consipation 5. Autonomic neuropathy (DM, MS, Shy- Drager)
- 42. Sphincter deficiency without descent(ISD) • Bladder neck already open at rest; • very low increase in intraabdominal pressure results in urinary leakage • Risk factors for pure ISD – 1. Neuropath 2. Trauma or 3. previous surgery 4. Radiation Poor oestrogenisation
- 43. Urinary incontinence Stress Incontinence •The most common cause in women is intrinsic urethral sphincter deficiency which may be due to congenital sphincter weakness in patients with myelomeningocele, epispadias, or pelvic denervation. • Another cause is urethral hypermobility, or significant displacement of the urethra and bladder neck during exertion (pressure)
- 44. • Originally believedthat 2 types of stress incontinence based on UDS findings: Genuine stress incontinence (GSI) and intrinsic sphincter deficiency (ISD) • However, it is known that many women with urethral hypermobility are not incontinent, implying that a sphincter defect present in all. • SUI however may or may not be associated with concomitant bladder base descent, which may be important for subsequent surgical treatment.
- 45. • Nowadays allpatients considered to have ISD, with varying degrees of urethral hypermobility.
- 46. Classification of SUI(Blaivas and Olson 1988) • Based on position of bladder base in relation to the inferior margin of the pubic symphysis (IMPS), and whether or not the Bladder neck is open at rest
- 48. Evaluation of StressUrinary Incontinence • History • Clinical examination • Investigations 1. Basic investigations 2. Specialised investigations • Management
- 49. HISTORY- detailed andaccurate 1. Incontinent symptoms- how long, frequency, severity, day or night,precipitating factors, quality of life. 2. Other symptoms-frequency, nocturia, urgency, enuresis, voiding difficulty, dysuria, hematuria. 3. Any previous continence treatment 4. Gynecological- menopause, pelvic mass, pelvic floor prolapse, bowel dysfuntion
- 50. 5. Medical- chroniccough, constipation, diabetes mellitus or insipidus neurological history, and its control 6. Surgical- previous pelvic surgery, continent surgery, radical surgery for gynecological malignancy, instrumental delivery. 7. Drugs- for constipation, diuretics, sedatives, alcohol, anticholinergics, alpha adrenergics, alpha adnergic blockers may be causative.
- 51. Grade of GSI(Clinical) •Grade I: Incontinence on cough or sneeze • Grade II: With mild exercise • Grade III: Even with change if posture
- 52. Physical examination • Generalcondition- mobility. Obesity, blood pressure, cognitive status, edema etc • Lungs- chronic bronchitis, asthmatics • Abdominal- abdominal and pelvic mass, scars, anal sphincter tone and fibroid. • Pelvic- estrogenisation, vulval excoriations, and …
- 53. • Stress test-Observation of leakage of urine with valsalva or cough. Should be performed in supine position; if no leak repeat in standing position Usually suggested by short time lag between cough and leak • Speculum examination -Ideally Simms speculum in left lateral position; allows identification of anterior and posterior compartment prolapse
- 54. Vaginal examination • Excludesobvious vaginal,cervical or adnexal masses • Vaginal grip graded by Oxford grading system (Laycock 1992) Whilst very limited evidence that vaginal grip predicts outcome of PFMT, NICE expert advice recommends grip test
- 55. NO MORE RECOMMENDED •Q-tip test -Lubricated ear bud in urethra. Deviation > 30 degrees diagnostic. Not recommended by NICE (NR)
- 57. Bonney’s test • Withoutemptying the bladder • Place 2-finger on each side of the urethra and exert upward pressure against the subpubic angle. Pt is requested to cough. • If no urine escapes, operative correction can be planned. • Very difficult to do without compressing urethra hence cannot diagnosis urethral hypermobility Not recommended by NICE (NR)
- 58. • Marshall testEquivalent to Bonney test except clamp to avoid inadvertent compression of urethra Impractical and unneccesary Not recommended by NICE
- 59. • Miyazaki’s modificationof Bonney’s test • anterior vaginal wall is streched superiorlaterally till lateral pelvic wall by ring forceps. • Demonstration of leakage of urine with coughing or vulsalva in lying down position and may be even in standing.
- 60. Neurological examination • Spinabifida occulta, lower limbs and skin sensation and anal reflexes (S2-S4), Multiple sclerosis, parkinson’s disease. • Abbreviated neurological examination 1. Afferent = Perineal sensation, bulbocavernosus (but absent in 30%) 2. Motor = Spreading of toes (S3)
- 61. Investigations • Basic investigations •Specialised investigations
- 62. Basic investigations • Urinalysis-to rule out infection, glycosuria and hematuria. • Biochemical tests- RFT, RBS • Post void residual urine- via catherterization or ultrasound estimation post voiding. normal- <50 ml, high RU (>200 ml)- impaired detrusor contractility – overflow incontinence
- 63. Post-Void Residual (PVR) •Measure volume of urine left in bladder after voiding by catheter or bladder scan • < 50-100 Normal • 100—400 Monitor until consistently less than 200cc. • > 400cc—Insert Foley catheter
- 64. PAD TEST • Highfalse negative rates; better with long-term testing but no relation to outcome of Rx. • Not recommended by NICE
- 66. Specialised investigations • Uroflowmetry-objective assessment of voiding function - Bladder volume should be > 150 ml to assess the flow rate. - Flow rate should be > 20 ml per second in normal women • Filling and voiding cystometry - measues the pressure- volume relationship of bladder to diagnosis DI, GSI and voiding disorders
- 67. • Urethral pressureprofilometry (resting and stress UPP) - A UPP of <20 cm of H2O or a negative pressure transmission ratio indicates instrinsic sphincter deficiency as a cause of GSI • Valsalva Leak Point Pressure(VLPP) Measures the urethral opening or leak point pressure during vulsalva maneuver. - <60 cm H2O indicates intrinsic sphincter deficiency.
- 68. Urodynamics • NICE recommendationthat UDS not required for straightforward ‘lone’ SUI • Not recommended prior to commencincg conservative therapy • beneficial prior to surgery • Multichannel recommended vs. single channel
- 69. Indication for urodynamics •Mixed symptoms (suspicion of OAB) • Previous failed incontinence surgery • Suspicion of neuropathic bladder or voiding dysfunction
- 70. Differentiating ‘lone ISD’from ISD with hypermobility • Urodynamic valsalva leak point pressure (VLPP) < 60 cm water believed to be diagnostic [ 60-90 equivocal; > 90 excludes diagnosis] • Urethral pressure profile (Urethral pressure – detrusor pressure) < 20cm water. • Conflicting evidence that low VLPP or UPP predicts failure following sling/tape procedures. • Detrusor LPP (leakage of urine from bladder in absence of abdominal contraction; DLPP > 40cm water suggests possible urethral dilatation)
- 71. Ultrasound- • detection ofpelvic mass, structural abnormalities (bladder diverticula, hydronephrosis), • estimation of residual urine. • Transperineal USG – demonstrate urethral hypermobility and descent of bladder neck with vulsalva
- 72. • Videocystourethrography (VCU)- -Cystometry and radiological imaging of bladder/ urethra with contrast. - Used in evaluating women with failed continence surgery. - Detects position and mobility of bladder neck, ureteric reflux , incontinence
- 73. • Intravenous Pyelogramor micturiting cystogram - Demonstrate the presence of fistula and to assess renal function. • Cystourethroscopy- visualize disease at bladder/ urethra (e,g. tumors, stone, interstitial cystitis). Not indicated in GSI
- 74. CYSTOSCOPY • No evidencefor routine cystoscopy, except in the presence of dipstick haematuria . • No evidence for the routine use of imaging, except USG for the determination of PVR
- 75. • Pediatric foley’sTest- to see intrinsic sphincter deficiency. - No. 8 french is introduced in the urethra. The bulb in inflated and try to remove the catheter. - If it comes out, it confirm the diagnosis • Carbon dioxide cystometry- not very accurate • Water cystometry- time consuming , but more accurate • Three swab test- to differentiate between vesicovaginal fistula and uretrovaginal fistula
- 76. MANAGEMENT • Life stylechanges • Conservative management • Pharmacotherapy • Surgical treatment
- 77. Life style changes •Use of incontinent pads and garments • Caffeine withdrawal • Stop smoking • Restriction of fluid to one liter a day • Treat cough ,constipation , weight reduction.
- 78. • Pelvic floorexercises- during puerperium • Estrogen replacement therapy in postmenopausal women • Bladder drill- (6 weeks course)asked to urinate at designated intervals and resist the urgency in between
- 79. Conservative management Indicated- • Ptrefuses or undecided • Pt is mentally or physically disabled • Childbearing • Uncontrolled detrusor instability or voiding difficulty
- 80. Conservative treatment • Pelvicfloor muscle training (Kegel exercises) Regular contractions of pelvic floor muscles and stop the urinary stream in between for few secs. • 10-20 ten second contractions 3-4 times/day for 3 months+ (recommended by NICE)
- 82. Electrical stimulation • Stimulationof pudendal nerve with electrodes placed in the vagina or anus. • Produces contraction of levator ani, external urethral sphincter, and anal sphincters • Accompanied by a reflex inhibition of the detrusor. • Reduces detrusor overactivty and stress incontinence in 50-70 % • (E-Stim; requires vaginal probe) and magnetic therapy (EM waves generated by special chair – no vaginal probe required)
- 83. • Bladder retraining– - gradual increase in voiding interval from 1- 3 hrs during day time. - Supression of urge with distraction or relaxation techniques (to prevent leakage). - Avoidance of caffeinated beverages • Acupuncture • Hypnosis • Weighed vaginal cones- of graded weight placed inside vagina- pt attempts to keep the cone falling out by squeezing the pelvic floor. 10-20 minutes a day
- 84. • Devices- 1. Elevatingdevices- for mild GSI, - Reusuable foam, pessary or prosthesis - Elevate n support bladder neck - S.E- UTI, Soreness of vaginal mucosa. 2. Occlusive devices- occluding both external and internal urethra -for pt while awaiting surgery
- 85. Medical treatment • Topicalvaginal oestrogen Improves ‘hammock’ tone and urethral mucosal coaption • Side-effects vaginal burn, itch, spotting Risks of malignancy with long-term oestrogen treatment – (BNF)
- 86. Pharmacologic treatment Stress Incontinence:Urethral Sphincter Insufficiency • The rationale for pharmacologic therapy: high concentration of -adrenergic receptors in the bladder neck, bladder base, and proximal urethra. • Sympathomimetic drugs with alpha- adrenergic agonist activity presumably cause muscle contraction in these areas and thereby increase bladder outlet resistance.
- 87. Pharmacologic treatment Stress Incontinence:Urethral Sphincter Insufficiency • Pharmacotherapeutic strategies include: – drugs with -adrenergic agonist activity, – estrogen supplementation both for direct effect on urethral mucosal and periurethral tissues and for enhancement of -adrenergic response – -adrenergic-blocking drugs that may allow unopposed stimulation of -receptor-mediated contractile muscle responses.
- 88. Duloxetine • Serotonin (5-HT)and NA reuptake inhibitor (SNRI) • Potentiates the physiological effects of endogenous 5-HT and NA, enhancing the CNS’s natural continence control mechanism • Acts chiefly in sacral spinal cord to increase pudendal nerve activity – augmenting urethral rhabdosphincter. • 2 doses- 20mg and 40mg ( bd,tds) • Not recommended as first or second-line treatment by NICE: alternative in those unfit for surgery
- 89. Urge urinary incontinence ICSdefinitions (Abrams 2003) • The symptom is involuntary leakage of urine accompanied by or immediately preceded by urgency.
- 90. Urinary incontinence Urge Incontinence •It is usually associated with involuntary detrusor contractions or detrusor instability (DI).
- 91. DI- subdivided into 1.Primary (idiopathic) 2. Secondary to bladder outlet obstruction 3. Neuropathic or detrusor hyperreflexia
- 92. ETIOLOGY: -postjunctional supersensitivity, - -altered adrenoreceptor function, - afferent nerve dysfuction, - imbalance of neurotransmitters and - primary or acquired myogenic deficit. Co existing conditions- pelvic organ prolapse, feces incontinence
- 93. Urinary incontinence Urge Incontinence •Elderly: detrusor hyperactivity with impaired bladder contractility is common (DHIC) – involuntary detrusor contractions, yet must strain to empty their bladders either incompletely or completely.
- 94. Urinary incontinence Urge Incontinence •DHIC generally have symptoms of UI and an elevated PVR, but they may also have symptoms of obstruction, stress incontinence, or overflow incontinence.
- 95. Urinary incontinence Urge Incontinence •When a causative neurologic lesion is established, the DI is called detrusor hyperreflexia (DH) .
- 96. Urinary incontinence Urge Incontinence •Stroke is associated with DH. • Suprasacral spinal cord lesions/multiple sclerosis: DH is commonly accompanied by detrusor sphincter dyssynergia (DSD) (inappropriate contraction of the external sphincter with detrusor contraction). • This can result in the development of urinary retention, vesicoureteral reflux, and subsequent renal damage
- 97. Urinary incontinence Overflow Incontinence •Involuntary loss of urine associated with overdistension of the bladder • It may have a variety of presentations, including frequent or constant dribbling, or urge or stress incontinence symptoms. • Overflow UI may be caused by an underactive or acontractile detrusor, or to bladder outlet or urethral obstruction leading to overdistension and overflow.
- 98. Urinary incontinence Overflow Incontinence •The bladder may be underactive or acontractile secondary to drugs, neurologic conditions such as diabetic neuropathy, low spinal cord injury, or radical pelvic surgery that interrupts the motor innervation of the detrusor muscle. • The detrusor muscle may also be underactive from idiopathic causes.
- 99. Urinary incontinence Overflow Incontinence •Although an outlet obstruction is rare in women, it can occur as a complication of an anti-incontinence operation and because of severe pelvic organ prolapse.
- 100. Urinary incontinence Overflow Incontinence •In patients with suprasacral spinal cord injury or multiple sclerosis, DSD can cause obstruction when the external sphincter muscle inappropriately and involuntarily contracts rather than relaxes at the same time the detrusor contracts
- 101. Urinary incontinence Functional Incontinence •Urine loss may be caused by factors outside the lower urinary tract such as chronic impairment of physical or cognitive functioning, or both. • This diagnosis should be one of exclusion, however, because some immobile and cognitively impaired individuals have other types and causes of UI that may respond to specific therapies.
- 102. Urinary incontinence Functional Incontinence UIcan often be improved or "cured" by improving the patient's functional status, 1. treating other medical conditions, 2. discontinuing certain types of medication, 3. adjusting the hydration status, even if a lower urinary tract abnormality is present.
- 103. Overactive bladder (OAB)and Urge urinary incontinence • Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia.
- 104. Types of OAB •OAB that occurs with incontinence is known as 'OAB wet'. • OAB that occurs without incontinence is known as 'OAB dry'.
- 105. Mixed urinary incontinence ICSdefinitions (Abrams 2003) • The complaint of an involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing.
- 106. Evaluation History • Fluid intake •Caffeine • Smoking • Diabetes Examination • Exclude demonstrable stress incontinence • Exclude palpable bladder Voiding diary Post-micturition residual Urinalysis Urinary cytology (?) Urodynamics
- 107. Lower Urinary Tract Impairmentsof Function Store Release Bladder Urethra URGE STRESS OVERFLOW OBSTRUCTIVE PVR PVR 0-100 PVR > 200
- 108. Pharmacologic treatment Urge Incontinence.Detrusor instability • Anticholinergic agents: (First Line). • Oxybutynin (2.5 mg bd- 5mg tds)is the anticholinergic agent of choice. • Anticholinergic agents block contraction of the normal bladder and unstable bladder
- 109. Pharmacologic Treatment : URGE •Anticholinergic agents (first line) – Darifenacin(7.5-10 mg OD) – Oxybutinin(5mg tds) – Solifenacin(5-10mg od) – Tolterodine(4 mg od) – Trospium (20mg bd) • Variety of preparations: Immediate Release; Extended Release; Transdermal **ALL these drugs suppress the detrusor contractility and MAY CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!
- 110. • Solifenacin mayhave better efficacy in urge incontinence (Star trial) • NICE recommend non-proprietary immediate release (IR) oxybutynin first line (>60 yrs 2.5mb bd; otherwise 5mg bd up to qds) • Propiverine(15mg BD), flavoxate(100- 200mg qid), propantheline and imipramine(50mg at night) not recommended by NICE
- 111. • If poorlytolerated then tolterodine, solifenacin, darifenacin, trospium, or transdermal oxybutynin. • Tolterodine reserved for troublesome side- effects • trospium reserved for CNS side-effects, and • solifenacin for treatment failures .
- 112. Contraindications • Myasthenia gravis •Narrow-angle glaucoma • Toxic megacolon • Bowel obstruction
- 113. Desmopressin • Highly effectivein reducing nocturia in adults, with sustained long-term responses • Side effects-Headache, nausea and daytime urinary frequency • Mild hyponatraemia more common in elderly (post-Rx monitoring for 3 days recommended if given to elderly pt)
- 114. Intravesical Botulinum toxin •Binds to pre-synaptic nerve terminals, leading to inhibition of ACh release and failed neuromuscular transmission • Specifically stops endovesicles fusing with plasma membrane . • Botulinum toxin A only recommended (short duration of response with botulinum toxin B) • Typically 10IU/ml BoTox 20-30 injections of 1 ml into detrusor..
- 115. Surgical treatment • Surgeryis recommended for stress incontinence in men and women and may be recommended as first-line treatment for selected patients who are unable to comply with other nonsurgical therapies. • Surgery in the management of urge incontinence is uncommon. • Surgical treatment is considered only in highly symptomatic patients in whom nonoperative management has failed.
- 116. Surgical treatment • Symptomsof overflow or incontinence secondary to urethral obstruction can be addressed with a surgical procedure to relieve the obstruction.
- 117. Urinary Incontinence Other measures •Intermittent catheterization. • Indwelling urethral catheterization. • Suprapubic catheters. • External collection systems. (external female catheter) • Pelvic organ support devices (pessaries) • Absorbent pads or garments
- 118.
- 119.
- 120. UI Summary • Lookfor reversible causes and Rx • Check PVR (>200 cc investigate further) • Start with behavioral interventions before medications • Referral and urodynamic studies if no response to usual measures • Early referral if underlying GU tract pathology present