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Urinary Incontinence

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Urinary Incontinence

  1. 1. Urinary Incontinence
  2. 2. <ul><li>Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. </li></ul><ul><li>Affects physical, psychological, social well being -> Reduce quality of life </li></ul><ul><li>Prevalence, ↑ with age </li></ul><ul><li>Common in institutionalized women, those in residential nursing homes </li></ul>
  3. 3. Some definitions… <ul><li>Stress incontinence is loss of urine on physical effort </li></ul><ul><li>Urge Incontinence is an involuntary loss of urine associated with a strong desire to void. </li></ul><ul><li>Overflow Incontinence occurs without any detrusor effort when the bladder is over-distended. </li></ul><ul><li>Urgency is a sudden desire to void </li></ul><ul><li>Frequency is passing of urine seven or more/day or being awoken from sleep more than once a night to void. </li></ul>
  4. 5. Classification of Incontinence <ul><li>URETHRAL CAUSES </li></ul><ul><li>Urethral Sphincter Incompetence (Urodynamic stress Incontinence) </li></ul><ul><li>Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic) </li></ul><ul><li>Retention with overflow </li></ul><ul><li>Congenital causes </li></ul><ul><li>Miscellaneous </li></ul><ul><li>EXTRA URETHRAL CAUSES </li></ul><ul><li>Congenital causes </li></ul><ul><li>Fistula </li></ul>
  5. 6. 1. URETHRAL CAUSES
  6. 7. 1a : Urodynamic Stress Incontinence <ul><li>Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction. </li></ul><ul><li>Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ± </li></ul><ul><li>Examination: Stress incontinence when cough, look for prolapse, cystourethroceles </li></ul><ul><ul><li>Also asses her vaginal capacity and her ability to elevate bladder neck. </li></ul></ul><ul><li>Urodynamic studies will define cause of incontinence </li></ul>
  7. 8. <ul><li>Causes of USI </li></ul><ul><ul><li>Damage to nerve supply of pelvic floor and urethral sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries) </li></ul></ul><ul><ul><li>Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince </li></ul></ul><ul><ul><li>Congenital cause (nulliparous women) – Connective tissue disorder esp collagen </li></ul></ul><ul><ul><li>Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation </li></ul></ul>
  8. 9. 1b: Detrusor Over-activity <ul><li>Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked. </li></ul><ul><li>Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties </li></ul><ul><li>Examination: Any mass that may compress bladder, prolapse TRO </li></ul><ul><li>Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw </li></ul>
  9. 10. 1c: Retention with overflow <ul><li>Insidious failure of bladder empting may lead to chronic retention and finally, when normal voiding is ineffective, to overflow incontinence </li></ul><ul><li>Caused by: LMN/UMN lesions, urethral obstructions, pharmacological </li></ul><ul><li>Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence </li></ul><ul><li>Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux </li></ul>
  10. 11. 1d: Congenital <ul><li>Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence </li></ul><ul><li>Rx with urethral reconstruction or artificial urinary sphincter </li></ul>
  11. 12. 2. EXTRA URETHRAL CAUSES
  12. 13. 2A: Congenital <ul><li>Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period </li></ul><ul><li>Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains </li></ul>
  13. 14. 2B: FISTULA <ul><li>Abnormal opening between the urinary track and outside. </li></ul><ul><li>Obstetric cause : Obstructive labour with compression of bladder between presenting head and bony pelvis </li></ul><ul><li>Gynecological cause : AW pelvic surgery, radiotherapy, pelvic malignancy </li></ul><ul><li>Treated by primary closure or surgery </li></ul>
  14. 15. INVESTIGATIONS <ul><li>Urine C&S- tro Infections </li></ul><ul><li>Pad test </li></ul><ul><li>Measure Postvoidal Residual Volume by bladder ultrasound or urethral catheter >100mL in more than one occasion->+ </li></ul><ul><li>Cough Stress Test. 250mL into bladder </li></ul><ul><li>Abdominal leak point pressure </li></ul>
  15. 16. <ul><li>Urodynamic studies </li></ul><ul><ul><li>Uroflowmetry. Bladder outlet obstruction </li></ul></ul><ul><ul><li>Cystometry. Detrusor activity, differentiate involuntary detrusor contraction or increase intraabdominal pressure </li></ul></ul><ul><li>Cystogram </li></ul><ul><ul><li>Stress incontinence, Cystocele, Sphincter activity, fistula </li></ul></ul><ul><li>Cystoscopy </li></ul><ul><ul><li>Tumors, stones </li></ul></ul>
  16. 17. Treatment <ul><ul><li>Palliative – Fluid restriction, Protective perineal pads, Bladder retraining, Pelvic Floor exercise (Kegel) </li></ul></ul><ul><ul><li>Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms </li></ul></ul><ul><ul><li>Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance </li></ul></ul><ul><ul><li>Colposuspension Operation, Artificial Sphincter </li></ul></ul>

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