Urinary Incontinence

1. S
URINARY
INCONTINENCE:
AN APPROACH
DR SUKANDA JAILI

2. URINARY INCONTINENCE
(UI)
S ANY INVOLUNTARY LOSS OF URINE
S SYMPTOM OR SIGN
S NOT A DIAGNOSIS

3. WOMAN MAN

4. CONSEQUENCES
S SOCIALLY
S HYGENIC
S IMPACT QUALITY OF LIFE
S DEPRESSION
S BATHROOM MAPPING
S DISABILITY AND DEPENDENCY

5. MYTH.....&...FACT
S IF by the patient is bothered by UI,she will tell me..
S UI is “natural after birth”
S UI is normal part of aging
S “If I get surgery for UI, I will end up with a bag..”

6. AGEING…
S NOT CAUSE OF URINARY INCONTINENCE
S AGE RELATED CHANGES IN LOWER URINARY
TRACT ANATOMY AND PHYSIOLOGY
S CHRONIC ILLNESS – SYSTEMIC
DISTURBANCES

7. PREDISPOSING …..
S HIGHER PARITY
PREGNANCY,CHILDBIRTH &
PHYSICAL
STRAINING DURING LABOUR

8. PREDISPOSING …
S MENOPAUSE
S HORMONAL CHANGES

9. PREDISPOSING
S OBESITY
S WORKLOAD ON PELVIC
FLOOR

10. PREDISPOSING….
S USE OF SITTING TOILET

11. PREVALENCE
S ESTIMATED 15 TO 30 %
S 50% STRESS UI
S 15% URGE UI
S 35% MIXED UI
S 5 TO 8% LEAK 1 OR > PER WEEK
S >60 YEARS OLD – WOMAN 2X MORE THAN MAN

12. In Asia…..
S MALAYSIA 13.1 % 7.9%
S SINGAPORE 11.8% 4.3%
S PHILLIPPINES 13.9% 8%
S THAILAND 20.3% 14.1%
S KOREA 22.6% 28.6%
S Asia Pacific Continence Advisory Board (APCAB) 1998
WOMEN MEN

13. URINARY INCONTINENCE
S SEVERITY OF INCONTINENCE
S VOLUME
S TYPE OF INCONTINENCE
S NO OF PADS
S CHANGES OF UNDERWEAR REQUIRED IN 24 HRS

14. CAUSES
S URETHRAL SPHINCTER INCOMPETENCE
S SPHINCTER DYSFUNCTION
S ABNORMAL BLADDER NECK SUPPORT
S DETRUSOR OVERACTIVITY
S IDIOPATHIC
S NEUROGENIC
S MIXED INCONTINENCE

15. CAUSES
S OVERFLOW INCONTINENCE
S HYPOTONIC DETRUSOR
S URETHRAL OBSTRUCTION (RARE)

16. CAUSES
S URETHRAL DIVERTICULA
S CONGENITAL ABNOMALY
S ECTOPIC URETER,SPINA BIFIDA OCCULTA
S PHARMACOLOGICAL CAUSE
S DIURETIC,TRANQUILLIZER,CHOLINERGIC AGENTS
S FISTULA
S URETHRAL,VESICAL,URETER

17. AIM
S DETERMINE THE CAUSE
S DETECT RELATED URINARY TRACT PATHOLOGY
S EVALUATE PATIENT PHYSICAL,MENTAL
STATUS,COMORBIDS,MEDICATION & ENVIRONMENT

18. HISTORY
S DETAILED PAST AND PRESENT
MEDICAL,SURGICAL,UROLOGIC,GYNAECOLOGY
HISTORY
S TO CHARACTERIZE THE TYPE OF INCONTINENCE

19. HISTORY
S EVALUATE THE FREQUENCY,SEVERITY,PATTERN
S ESTABLISHED OTHER ASSOCIATED URINARY SYMPTOM
S STRAINING,INCOMPLETE VOIDING AND DYSURIA

20. HISTORY
S TO ESTABLISH PRECIPITATING FACTORS
S BOWEL HABITS,MEDICATION AND FLUID INTAKE
S VOIDING HABITS
S ASSESSMENT OF MOBILITY,LIVING
CONDITION,MENTAL STATUS,SOCIAL ENVIRONMENT

21. HISTORY
S DESIRE FOR TREATMENT AND THE EXTENT OF
TREATMENT THAT IS ACCEPTABLE
S ESTABLISH PATIENT SUPPORT INCLUDING
CAREGIVERS
S COGNITIVE FUNCTION
S ABILITY TO DESCRIBE SYMPTOMS,QUALITY OF
LIFE,PREFERENCES AND GOALS FOR CARE

22. PHYSICAL EXAMINATION
S THE MORE COMPLICATED THE HISTORY & MORE
EXTENSIVE AND/OR INVASIVE THE PROPOSED
THERAPY/INVESTIGATION – THE MORE COMPLETE
THE EXAMINATION

23. PHYSICAL EXAMINATION
S GENERAL STATUS
S MENTAL STATUS
S BMI
S MOBILITY
S ABDOMINAL EXAMINATION
S MASS
S BLADDER DISTENTION
S SURGICAL SCAR

24. PHYSICAL EXAMINATION
S PELVIC EXAMINATION
S PERINEUM &EXTERNAL GENITALIA
S TISSUE QUALITY & SENSATION
S COUGH STRESS TEST
S VAGINAL EXAMINATION –
PROLAPSE,CYST,DISCHARGED
S BIMANUAL EXAMINATION
S PELVIC FLOOR MUSCLE EVALUATION
S ANORECTAL EXAMINATION

25. S ASSOCIATED PELVIC ORGAN PROLAPSE
S PREVIOUS ABDOMINAL OR PELVIC SURGERY

26. Cough Stress test
S Bladder volume at least 250 cc or symptomatic fullness
S Reliable and simple test for the diagnosis of stress
urinary incontinence
S Screening test before requiring further evaluation with
more urodynamic test
S Recommended for both clinical research and clinical
practice.

27. S ESTIMATION OF POST VOID RESIDUAL URINE (RU)
S CATHETER OR ULTRASOUND
S GOOD CLINICAL CORRELATION BETWEEN THE TWO
S Coombs GM, Millard RJ (1994). The accuracy of portable us scanning in the measurement of
residual urine. J Urol
S < 30% OF VOIDED VOLUME OR < 150 ML
S RENAL FUNCTION ASSESSMENT

28. S URINALYSIS
S HIGHLY RECOMMENDED
S URINE DIPSTICK HAS LOW SENSITIVITY AND HIGH
SPECIFICITY TO DETECT UTI
S Pels RJ, Bor DH et all (2000).JAMA . Dispstick urinalysis screening of asymptomatic adults for
urinary tract disorders.
S URINE CULTURE & MICROSCOPIC EXAMINATION

29. S EXAMINATION ALONE INSUFFICIENT – NEEDS
TOOLS TO SUPPLEMENT INFORMATION OBTAINED
FROM HISTORY & EXAMINATION
S BLADDER DIARY
S QUESTIONNAIRES

30. BLADDER DIARY
S FREQUENCY VOLUME CHART,VOIDING DIARY
S AMONG BEST POSSIBLE MEANS OF OBTAINING
OBJECTIVE DATA ON SUBJECTIVE SYMPTOMS
S Abrams P, Cardozo L, Magnus F et al (2002). The standardization of terminology of lower urinary
tract function.International Continence Society. Neurourol Urodynam.

31. USEFUL IN…
S DETERMINE VOLUME FLIUD INTAKE
S NORMAL FLUID VOLUME CONSUMED AT IN
APPROPRIATE TIMES.
S EXCESSIVE INTAKE OF ALCOHOL OR CAFFIENE
S MAXIMAL VOIDED VOLUME – REPRESENT
FUNCTIONAL BLADDER CAPACITY

32. BLADDER DIARY

33. BLADDER DIARY
S OPTIMUM DURATION NOT STANDARDISED
S COMPLIANCE DECREASES WITH LENGTH OF THE DIARY
S 72 HOURS DIARY (3 DAYS ) – SIGNIFICANTLY
CORRELATES WITH 7 DAYS DIARY
S Grouttz A,Blaivas JG, Chaikin DC et al (2002).Voiding and incontinence
frequencies:variability of voiding diary data and required dialy length. Neurourol Urodyn
21:205-209
S ENCOMPASS WORK AND LEISURE DAY

34. Quality of Life measures
S Incontinence Impact Questionnaire (IIQ-7)
S Urogenital Distress Inventory (UDI-6)
S Both specific for incontinence in female population
S Evaluation prior to & success of therapy
S Recommended for clinical studies
S Optional for clinical practise

35. OTHERS…
S CYSTOSCOPY
S <2% BLADDER LESION FOUND IN INCONTINENCE PATIENTS
S SHOULD NOT BE PERFORMED ROUTINELY IN PATIENTS WITH
URINARY INCONTINENCE TO EXCLUDE NEOPLASM
S Cundiff GW,Bent AE.The contribution of urethrocystoscopy to evaluation of lower
urinary tract dysfunction in women (IUJ 2006).
S RECOMMENDED IF ASSOCIATED WITH
HAEMATURIA,SUSPECTED FISTULA,RECURRENT
CYSTITIS,BLADDER PAIN
S Ludviksson K. The value of cllinical examination of the female incontinence
patient (Acta Obstet Gynecol Scan,2007)

36. OTHERS..
S IMAGING
S PELVIC AND ABDOMINAL ULTRASOUND
S IMAGING OF UPPER AND LOWER URINARY TRACT
- TRANSPERINEAL ULTRASOUND
S UROFLOWMETRY
S URODYNAMIC STUDY

37. TREATMENT
S DEPENDS ON THE CAUSE OF UI
S LIFESTYLE MODIFICATION
S MEDICAL TREATMENT
S SURGICAL TREATMENT
S CISC

38. Conservative treatment
S Pelvic floor rehabilitation
S Bladder retraining
S Pelvic floor exercises
S Voiding techniques
S Vaginal Devices eg tampon, Contiform
S Vaginal oestrogen

39. Continence devices
S Contiform vaginal device
S Urethral plug not available
S Trials suggest some
improvement in leakage cf no
treatment

40. Pelvic Floor Rehabilitation
S Supervised PFMT, at least 3 months
S Use of a dedicated pelvic floor physiotherapy
service or continence nurse advisor
S Women receiving supervision more likely to report improvement than
women doing PFMT with little or no supervision
S Cochrane update 2014
S Supports recommendation that PFMT be included in
first-line conservative management for any type of
incontinence

41. URGE INCONTINENCE
S CONSERVATIVE TREATMENT
S FLIUD INTAKE
S BLADDER TRAINING
S PHARMACOLOGICAL TREATMENT
S BOTOX INJECTION
S NEUROMODULATION

42. S URINARY STRESS INCONTINENCE

43. Urinary Incontinent procedures
S Ideal patient
S Urodynamic stress incontinence only
S Normal uroflowmetry
S Normal bladder capacity
S No overactive bladder
S No previous incontinence procedures
S Normal BMI
S No significant medical conditions
S Completed childbearing

44. Urinary incontinent procedure
S Ideal pre-operative situation
S Initial conservative management
S Exclude pathology, infection
S Bladder diary
S Pelvic floor rehabilitation
S Education regarding diet, fluids, bowel, weight control etc
S Compliance
S Treatment of overactive bladder symptoms
S Confirm diagnosis
S Realistic expectations of outcomes of procedure

45. S Over 200 surgical techniques
S MMK cyto-urethropexy (1949) and modifications
S Burch colposuspension (1961) – open and laparoscopic
S Anterior colporrhaphy and Kelly plication (1913)
S Needle suspension techniques (Pereyra 1959), Stamey modification (1973)
S Pubovagional sling procedures – gracilis muscle (1907), pyramidalis muscle (1910), fascia
lata (1933)
S Aldridge sling with rectus fascia (1942) - modifications of sling material (autologous,
cadaveric, synthetic) and fixation
S Bone anchors
S Periurethral bulking
S TVT (1995) and modifications
S TOT (2001) and modifications
S Stem cell therapy
Surgical management of USI

46. S Colposuspension (open or laparoscopic)
S Until recently, considered the Gold Standard
S Midurethral slings (synthetic)
S Retropubic - New Gold Standard
S Bulking agents
S Other surgical options
Surgical options for USI

47. Vaginal incisions – ‘mid-urethra’ but variations in exit sites, delivery of
sling
S Retropubic – first generation
S eg TVT – first described 1995
S SPARC (2001), Advantage etc
S Transobturator – second generation (2001)
S Eg TVT-O (2005 – de Leval), Monarc
S Modified Transobturator
S eg TVT-Abrevo (2012)
S Single incision “Minislings” – third generation
S eg TVT-S (2006); Mini-Arc (2007)
Midurethral slings

48. S Periurethral injection to narrow the bladder neck
S Complications – voiding problems long-term
(2%), UTI , denovo urgency (up to 13%)
S Cure rates – 40-60%
S Long-term follow up > 8 years
S 24 women, polyacrylamide hydrogel (Bulkamid)
S 15 no further treatment, 7 mid-urethral slings, 2 top-up
bulking
S No local adverse reaction
S Results of later mid-urethral sling not affected
S Moritsen L et al. Acta Obstet Gynecol Scand 2014
Bulking Agents

49. Conclusion
S Pre-operative
S Counselling
S Conservative management
S Optimise conditions prior to surgery eg treat OAB
S Surgery
S Choice of surgery – what is best not what is
convenient
S Avoidable complications
S Recognise and treat
S Skill at cystoscopy
S Do not over tension
S Surgical technique

50. SUMMARY
S ACCURATE HISTORY REQUIRED TO DETERMINE
PATIENT SYMPTOMS AND THOROUGH
EXAMINATION ASCERTAINS PATIENT SIGN
S EXTENT OF EVALUATION MUST BE TAILORED TO
THE INDIVIDUAL PATIENTS
S IMPACT ON PATIENT QUALITY OF LIFE MUST BE
ADDRESS

51. S