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~ 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
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- 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
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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)
¤ 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:
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
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