Urinary Incontinence

武功密笈

小黃藏書

~ Urinary Incontinence ~

AHCPR guldeline

ª Definition:

1). Incontinence: involuntary urine loss that is a social or hygienic problem

2). Stress incontinence: incontinence occurring under conditions of increased intra-abdominal

pressure

3). Urge incontinence: incontinence accompanied by a strong desire to void

4). Mixed incontinence: stress and urge incontinence occurring together

5). Unconscious incontinence: incontinence occurring without urgency and without conscious

recognition of leakage

6). Frequency: the number of voids per day, from waking in the morning until falling asleep at

night

7). Nocturia: the number of times the patient is awakened from sleep to void at night

8). Nocturnal enuresis: urinary incontinence during sleep

ª Differential Diagnosis:

Extraurethral Incontinence

Transurethral Incontunence

Congenital:

Ectopic ureter
Bladder exstrophy
Other

Acquired (fistula):

Ureteric
Vesical
Urethral
Complex combinations

Genuine stress incontinence:

Bladder neck displacement (anatomic hypermobility)
Intrinsic sphincteric dysfunction
Combined

Detrusor overactivity:

Idiopathic detrusor instability
neuropathic detrusor hyperreflexia

Mixed incontinence

Urinary retention with bladder distention and overflow:

Genuine stress incontinence
Detrusor hyperactivity with impaired contractility
Combinations

Urethral diverticulum

Congenital urethral abnormalities (eg. epispadias)

Uninhibited urethral relaxation (“urethral instability”)

Functional and transient incontinence

ª Investigation:

1). Basic evaluations:

? History:

Review of symptoms:

General medical history: DM, vascular diseases, chronic lung diseases, or neurological

conditions (eg. multiple sclerosis, stroke, Parkinson’s disease, anomalies of the spine and

low back), etc.

Past operative history

Current medication: sedatives, alcohol, anticholinergic/drug with anticholinergic

properties, α-agonist, α-blocker, Ca⁺⁺-channel blocker, etc.

– Drugs with anticholinergic properties: antihistamines, antidepressant, antipsycotics,

opiates, antispasmodics, and drugs for Parkinson’s disease.

‚ Physical Examination:

Check for possible underlying medical diseases

PV: to evaluate urethral support with full bladder and standing position
The patient’s complaint should be reproduced by the physician and confirmed with the

patient, particularly if surgery is contemplated.

ƒ U/A: to rule out infection, which can be associated with incontinence

„ Postvoid Residual Urine:

- Incomplete bladder emptying is a frequent cause of incontinence.

… Frequency/Volume Bladder Chart:

Measurement: 24-hour urine output, total number of daily voids, average voided

volume, functional bladder capacity (largest volume voided in normal daily life)

Normal Value:

¤ Daily urine output: 1500-2500 ml

¤ Total number of daily voids: 7 or 8

¤ Average voided volume: approximately 250 ml

¤ Functional bladder capacity: 400-600 ml

† Urodynamic Studies:

Bladder filling test:

w Measurement: voiding volume, residual urine, and functional bladder capacity.

w Reading:

? Urge incontinence: urgency accompanying urine loss during bladder filling

‚ Stress incontinence: urine loss when abdominal pressure increases.

ƒ Mixed incontinence: the presence of both urge and stress incontinence

Multichannel urodynamic studies:

a). Uroflowmetry

b). Cystometry: to measure pressure/volume relationship of bladder

w Two phases: filling cystometry and voiding cystometry

w Simple cystometry: measuring bladder pressure only during filling

w Subtracted cystometry:

° An attempt to measure the pressure exerted in the bladder by detrusor

total intravesical pressure (Pves), intra-abdominal pressure (Pabd),

to give true detrusor pressure (Pdet)

Pdet = Pves - Pabd

° Measurement and its normal value:

? Residual urine: < 50 ml

‚ First desire to void: occurring between 150-250 ml infused

ƒ Strong desire to void: not occurring until > 250 ml

„ Cystometric capacity : 400-600 ml

… Bladder compliance: between 20-100 ml/cm H₂O measured 60

seconds after reaching cystometric capacity

† No uninhibited detrusor contractions during filling, despite provocation

‡ No stress or urge incontinence demonstrated, despite provocation

ˆ Voiding occurs because of a voluntarily initiated and sustained

detrusor contraction

‰ Flow rate during voiding: > 15 ml/sec, with Pdet < 50 cm H₂O

c). Pressure-flow voiding studies

d). Urethral pressure profile:

w Generated by slowly pulling a pressure-sensitive catheter through the urethra

from the bladder, which is usually filled with a consistent volume of fluid

w Pclose = Pure - Pves

(Pclose: urethral closure pressure, Pure: urethral pressure, Pves: bladder pressure)

e). Leak-point pressure:

w The intravesical (or intra-abdominal) pressure measured at the moment that

stress incontinence occurs

2). Others:

- Urine Cytology, IVP, Cystoscopy with Biopsy, etc.

ª Extraurethral Causes of Incontinence: (urine loss through abnormal opening)

1). Bladder exstrophy

2). Ectopic ureter

3). Urinary Fistula:

· Worldwide, the most common cause of fistula: obstructed labor

· In the industrialized world, the most common cause of fistula:

surgery, malignancy, and radiotherapy

· Repair of fistula:

j Timing: after a waiting period of 3 months to allow the resolution of inflammation

and formation of scar tissue

k Key points to closure of a vesicovaginal fistula:

wild mobilization of tissue planes, close approximation of tissue edges,

closure of the fistula in several layers, and meticulous attention to postoperative

bladder drainage for 10-14 days.

　

ª Stress Urinary Incontinence:

1). Definition:

- Urine leaks when intra-abdominal pressure rises and becomes a social or hygienic problem.

2). Conditions resulting stress incontinence:

genuine stress incontinence, detrusor contraction provoked by coughing or change of

position, incomplete bladder emptying, or a urethral diverticulum

3). GSI:

è Diagnosis:

A urodynamic diagnosis

Demonstrable urinary leakage when intravesical pressure exceeds the maximum urethral closure pressure in the absence of a detrusor contraction

è Biobehavioral Model: ~ interaction of three variables

Biologic strength of the sphincteric mechanism
Level of physical stress on the closure mechanism
The woman’s expectations about urinary control

è Two Types:

À GSI caused by anatomic hypermobility of urethra

- more prevalent, accounting for 80-90% of stress urinary incontinence

Á GSI caused by intrinsic sphincteric weakness or deficiency

less common, and more challenging to treat

S Effective urethral closure is maintained by the interaction of extrinsic urethral support and intrinsic

urethral integrity

4). Treatment:

¬ Non-surgical management:

¥ Muscle strengthening: eg. Kegel exercise

¥ Drug therapy:

a). a -adrenergic drugs (possible complication: hypertension)

Drugs	Dose
Imipramine	10-25 mg po bid/tid
Phenylpropanolamine	50-75 mg po bid
Pseudoephedrine	30-60 mg po tid/qid
Ephedrine	15-30 mg po bid/tid
Norephedrine	100 mg po bid

b). estrogen therapy: for postmenopausal women with urogenital atrophy

¥ Electrical stimulation

Surgical management:

¥ Anterior colporrhaphy:

° Indications: cystocele without significant stress incontinence

° Mechanism: to prevent excessive displacement of endopelvic fascia beneath the

urethra so that urethra can be closed during coughing or sneezing

° Methods:

a). simple plication of the bladder neck

b). elevation of the bladder neck by placating the fascia under the urethra

c). elevation and fixation of the bladder neck by passing sutures lateral to the

urethra and driving the needles anteriorly into the back of the pubic

symphysis for fixation

° Advantage:

a). Avoid abdominal incision.

b). Allow the operation to be performed in conjunction with other vaginal

surgery.

° Disadvantage: long-term success rate only 35-65%

¥ Operations to correct stress incontinence resulting from anatomic hypermobility

(retropubic bladder neck suspension, needle suspension procedures)

Retropubic urethropexy:

° Indication: stress incontinence with hypermobility of urethra/bladder neck

° Mechanism: to correct anatomic hypermobility of urethra/bladder neck

° Methods:

a). Marshall-Marchetti-Krantz operation:

periurethral fascia « back of pubic symphysis

b). Burch colposuspension:

fascia at the level of bladder neck « iliopectineal (Cooper’s) ligament

c). Turner-Warwick vagino-obturator shelf procedure:

endopelvic fascia and/or vagina « fasia of obturator internus muscle

° Advantage: long-term success rate 80-90%

° Complications:

a). urethral kinking or obstruction g voiding difficulty

b). osteitis pubis, when suture is put directly into the pubic symphysis

c). enterocele, uterine prolapse, vaginal vault eversion, when opening the

rectouterine pouch of Doaglas by pulling up on the ant. vagina and then

elevating the post. Vagina

„ Culdoplasty is recommended at the time of bladder neck suspension

to reduce the incidence of future prolapse

Transvaginal urethropexy (Needle suspension procedures):

° Indication: stress incontinence resulting primarily from anatomic hypermobility

of bladder neck and urethra

° Mechanism: suspension of the urethra and bladder neck through a technique

that involves passage of sutures between the vagina and ant. abdominal wall

° Advantage: simple, short operation duration

° Disadvantage:

a). 5-year success rate ? 50%

b). perforation of bladder of urethra

c). infection

d). granulation formation around sutures

e). prolapse development

f). chronic pulling pelvic pain created by suture material

g). nerve entrapment syndrome

¥ Operations to correct stress incontinence resulting from intrinsic sphincteric weakness

or dysfunction (sling operations, periurethral injections)

Sling operation:

° Indication: complicated stress incontinence, usually from intrinsic weakness

a). demonstrable stress incontinence with normal urethral support

b). stress incontinence with a low leak-point pressure

c). stress incontinence with very heavy occupational lifting

d). stress incontinence with severe chronic obstructive lung disease

e). stress incontinence with posthysterectomy vaginal vault eversion

° Mechanism:

a). creating some degree of outlet obstruction (major)

(compressing the urethral lumen at the level of the bladder neck to

compensate for a faulty urethral closure mechanism)

b). providing urethral support

° Complication: obstructed voiding

Periurethral injection:

° Indication: intrinsic urethral failure

° Mechanism: injection of material around the periurethral tissue to facilitate their

coaptation under conditions of increased intra-abdominal pressure

° Material utilized:

Polytef, Contigen (allergic reaction < 3%), Teflon, etc.

° Long-term success rate: poorly studied

¥ Salvage operations (intentionally obstructive sling operations, implantation of an

artificial urinary sphincter, urinary diversion) ~ a last ditch effort for cure

° Indication: scarred, fibrotic, nonfunctional urethra

ª Urinary Incontinence Caused by Detrusor Overactivity:

* The most common form of incontinence in older women

* The second most common form of urinary incontinence overall

* Detrusor overactivity:

j Detrusor hyperreflexia:

when this occurs as the result of a known neuropathologic process relevant to bladder

disorder (eg. stroke, Parkinson’s disease, multiple sclerosis)

k Detrusor instability:

when there is no evidence of neuropathology

* Diagnosis:

¬ Symptoms:

- sudden, unexpected loss of large volumes of urine

- leakage associated with a sudden urge to urinate that cannot be control

Cystometry:

phasic pressure waves (intravesical/detrusor) that produce urgency and urge incontinence

* Treatment: (initially ¬ + ; long-term management based on )

¬ Drug therapy: mainly anticholinergic

Drug	Dose
Propantheline bromide	15-30 mg po qid
Hyoscyamine sulfate	0.125-0.25 mg po q4-6h
Hyoscyamine sulfate, extended release	0.375 mg po bid
Oxybutynin chloride	5-10 mg po tid/qid
Dicyclomine hydrochloride	20 mg po qid

- Anti-cholinergic adverse effects:

dry month, increased heartbeat, constipation, blurred vision

Behavior therapy: timed voiding, gradual increases in the interval between voids, until the

cycle or urgency, frequency, and urge incontinence is broken

- poor response in patients with detrusor hyperreflexia

ª Mixed Incontinence:

* Treatment alternatives:

j to determine and treat the most bothersome component

k to treat urge incontinence first, and proceeding with surgery only if stress incontinence persists

　

ª Functional or Transient Incontinence:

ò “DIAPPERS”: (reversible causes of incontinence)

Delirium

Infection

Atrophic urethritis and vaginitis

Pharmacologic causes

Psychological causes

Excessive urine production (eg. diabetes, hypercalcemia, or excessive fluid intake)

Restricted mobility

Stool impaction

ò Medical reversible condition

ò Appropriate medical intervention can cure or improve the continence problem without resorting to

other forms of treatment

　

Filename: Urinary Incontinence