Urinary incontinence By Raheef Alatassi A student to student guide

1. URINARY INCONTINENCE
RAHEEF MOHAMED ALATASSI
5TH YEAR MEDICAL STUDENT
IMAM MOHAMMED BIN SAUD UNIVERSITY
UROLOGY

2. OBJECTIVES
• DEFINITION
• EPIDEMIOLOGY
• RISK FACTORS & ETIOLOGIES
• TYPES
• DIAGNOSIS
• MANAGEMENT

3. DEFINITION
EPIDEMIOLOGY
RISK FACTORS &
ETIOLOGIES

4. DEFINITION
“ THE INVOLUNTARY LOSS OF URINE WHICH IS
OBJECTIVELY DEMONSTRABLE AND A SOCIAL
OR HYGIENIC PROBLEM.”
ANY INVOLUNTARY LEAKAGE OF URINE

5. URINARY INCONTINENCE
Common
Treatable
Significant Effect
on Quality of Life

6. EPIDEMIOLOGY
• COMMUNITY: 17% OLDER MEN, UP TO 30% OLDER WOMEN
• HOSPITAL: UP TO 50% OLDER MEN AND WOMEN
• ELDERLY (<65 Y): UP TO 10% IN MALE AND 15 % IN FEMALE
• F>M UNTIL AGE 80 YEARS, THEN M=F

7. ANATOMICAL STRUCTURES OF THE LOWER
URINARY TRACT SYSTEM
The bladder and bladder neck
The urethra and urethral sphincter mechanism
The pelvic floor musculature

8. THE BLADDER
• IS A HOLLOW MUSCULAR ORGAN
• LIES IN THE ANTERIOR PART OF THE
PELVIC CAVITY BEHIND THE SYMPHYSIS
PUBIS
• IT IS OUTSIDE THE PERITONEAL CAVITY
AND EXTENDS UPWARDS AS IT FILLS
• IT IS ANTERIOR TO THE RECTUM

9. THE BLADDER
• EMBRYOLOGICALLY, THE BLADDER IS
DERIVED FROM THE HINDGUT.
• EXTERNAL FEATURES ARE
THE APEX, BODY, FUNDUS AND NECK.
• TRIGONE – A TRIANGULAR AREA LOCATED
WITHIN THE FUNDUS
• IN ORDER TO CONTRACT DURING
MICTURITION, THE BLADDER WALL CONTAINS
SPECIALIZED SMOOTH MUSCLE, KNOWN
AS DETRUSOR MUSCLE.

10. NERVOUS SUPPLY OF BLADDER
o The sympathetic nervous system
o Hypogastric nerve (T12 – L2).
o It causes relaxation of the detrusor muscle.
o These functions promote urine retention.
o The parasympathetic nervous system
o Pelvic nerve(S2-S4).
o Increased signals from this nerve causes contraction of the detrusor muscle.
This stimulates micturition.
o The somatic nervous supply gives us voluntary control over micturition. It
innervates the external urethral sphincter, via the pudendal nerve (S2-S4). It can
cause it to constrict (storage phase) or relax (micturition).

11. Urethral Sphincters
Internal Urethral Sphincters
• Situated at the base of the
bladder neck.
• Circular smooth muscle layer
• Normally in a state of
contraction
• Involuntary control (under
autonomic control)
• It is thought to prevent
seminal regurgitation during
ejaculation.
External Urethral Sphincters
• Skeletal muscle
(Circular striated muscle
fibres)
• Reinforced by the pelvic floor
muscle
• Voluntary control
• During micturition, it relaxes
to allow urine flow.

12. FUNCTIONS OF THE PELVIC FLOOR
• PELVIC FLOOR FORMED BY LEVATOR ANI MUSCLES (LARGEST
COMPONENT), COCCYGEUS MUSCLE AND FASCIA
COVERINGS OF THE MUSCLES.
• FORMS A ‘SLING-LIKE’ SUPPORT FOR THE LOWER PELVIC
ORGANS
• CONTRIBUTES TO THE ACTION OF THE
EXTERNAL SPHINCTER IN MAINTAINING
URETHRAL CLOSURE.
• CONTRIBUTES TO THE ACTION OF
THE ANAL SPHINCTER IN MAINTAINING
FAECAL CONTINENCE.

13. RISK FACTORS
• DEPRESSION
• STROKE
• DIABETES
• PARKINSON’S DISEASE
• DEMENTIA (MODERATE TO SEVERE)
• OBESITY, CHF, CONSTIPATION, TIAS, COPD,
CHRONIC COUGH

14. AGING CHANGES
• Decreased bladder capacity
• Reduced voiding volume
• Reduced flow rates
• Increased urine production at night
• Detrusor over activity (20% of healthy
continent)
• BPH

15. REVERSIBLE CAUSES OF UI
- Delirium or Drugs
- Restricted mobility
- Infection, impaction
- Polyuria
I
P
R
D

16. 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

17. Polyuria,
frequency,
urgency
Alcohol Caffeine Diuretics
Urinary
retention
Anticholinergics
Alpha
adrenergic
agonists
Beta
adrenergic
agonists
Calcium
channel
blockers

18. TRANSIENT INCONTINENCE
• LOWER URINARY TRACT PATHOLOGY
• PRECIPITATED BY REVERSIBLE FACTOR
• 1/3 COMMUNITY DWELLING
• 1/2 HOSPITALIZED INCONTINENT AGED PATIENTS
• CAUSES: DELIRIUM, UTI, MEDS, PSYCHIATRIC DISORDERS, 
UO, STOOL IMPACTION
• RESTRICTED MOBILITY

19. TYPES OF URINARY
INCONTINENCE
• TRANSIENT UI (ACUTE)
• ESTABLISHED UI (CHRONIC)
• URGE UI
• STRESS UI
• MIXED UI
• OVERFLOW UI
• “FUNCTIONAL” UI

20. STRESS UI
Sudden increase in
abdominal pressure
Urethral pressure
-The complaint of
involuntary leakage with
effort or exertion or on
sneezing or coughing.
-Due to either:
1-poor pelvic floor.
2-weak urethral sphincter.
-Very common in women.

21. URGE UI
Involuntary detrusor
contractions
Urethral pressure
The complaint
of involuntary leakage
accompanied by or
immediately preceded by
urgency.
Due to over activity of
detrusor muscle.

22. OVERFLOW
Neurogenic/Atonic
Obstruction
•Urethral blockage
•The Bladder is not able
to empty properly

23. MANAGEMENT OF
URINARY INCONTINENCE

24. MAJOR POINTS
 NONPHARMACOLOGICAL THERAPY:
 PHARMACOLOGICAL THERAPY:
A. URGENCY INCONTINENCE:
B. CHOOSING MEDICATION:
C. STRESS INCONTINENCE:
D. ADJUNCTIVE MEASURES:
 SURGICAL THERAPY:
I/ URGENCY INCONTINENCE:
II/ STRESS INCONTINENCE:
1)TRANSURETHRAL BULKING AGENTS:
2) PERINEAL SLINGS:
3) ARTIFICIAL URINARY SPHINCTER:

25. FIRST: NONPHARMACOLOGICAL THERAPY
• LIFESTYLE ADVICE (PARTICULARLY WEIGHT
LOSS AND DIETARY CHANGES).
• AVOIDANCE OF URETHRAL COMPRESSION
DURING VOIDING.

26. SECOND: PHARMACOLOGICAL THERAPY
A. URGENCY INCONTINENCE:
* “ANTIMUSCARINIC DRUGS” ARE THE MAIN
PHARMACOLOGICAL AGENTS AVAILABLE
FOR URGENCY INCONTINENCE, AND
“ALPHA BLOCKERS” ARE USED FOR MEN
WITH URGENCY INCONTINENCE WITH BPH.

27. CONT’ PHARMACOLOGICAL THERAPY
B. CHOOSING MEDICATION:
* DESPITE THE LACK OF EVIDENCE TO
GUIDE URGENCY INCONTINENCE THERAPY
IN MEN, IT’S REASONABLE TO INITIATE
PHARMACOLOGIC TREATMENT WITH ALPHA
BLOCKERS (WHY ?)

28. CONT’ PHARMACOLOGICAL THERAPY
C. STRESS INCONTINENCE:
* NO MEDICATIONS HAVE BEEN APPROVED
IN THE US FOR THE TREATMENT OF STRESS
INCONTINENCE.
* [DULOXETINE & SNRI] IS APPROVED FOR
THIS INDICATION IN MANY EUROPEAN
COUNTRIES.

29. CONT’ PHARMACOLOGICAL THERAPY
D. ADJUNCTIVE MEASURES:
* INCLUDE INCONTINENCE PADS,
INDWELLING CATHETERS, EXTERNAL
URINARY CATHETERS & PENILE
INCONTINENCE CLAMPS.
* THE TREATMENT OF URINARY
INCONTINENCE WITH AN INDWELLING
CATHETER IS USUALLY A POOR
MANAGEMENT CHOICE (WHY ?)

30. CONT’ PHARMACOLOGICAL THERAPY

31. THIRD: SURGICAL THERAPY
I/ URGENCY INCONTINENCE:
- MOST COMMON SURGICAL TREATMENT FOR
URGENCY INCONTINENCE IS ----> SACRAL NERVE
STIMULATION.
- IN THE MINORITY OF PATIENTS IN WHOM MEDICAL
THERAPY IS INEFFECTIVE, TREATMENTS OPTIONS
INCLUDE: ELECTRICAL STIMULATION.

32. CONT’ SURGICAL THERAPY
II/ STRESS INCONTINENCE:
- MOST COMMONLY UTILIZED INTERVENTIONS FOR
MALE ARE TRANSURETHRAL BULKING AGENTS,
PERINEAL SLINGS & ARTIFICIAL URINARY
SPHINCTER.

33. CONT’ SURGICAL THERAPY
1) TRANSURETHRAL BULKING AGENTS:

34. CONT’ SURGICAL THERAPY
2) PERINEAL SLINGS:

35. CONT’ SURGICAL THERAPY
3) ARTIFICIAL URINARY SPHINCTER:

36. ANY QUESTIONS
?

37. THANK
YOU