1、Overview of Urinary Incontinence in Adults,Christina M. Bordeau, D.O. Internal Medicine, PGY-3 October 28, 2012,Goals and Objectives,Provide the clinician with a basic, yet comprehensive, overview of urinary incontinence pathophysiology Equip the physician with a basic understanding of proper evalua
2、tion and assessment of patients with urinary complaints within the adult population Establish the indications for and procedures involved in urodynamic testing No commercial investments, endorsements, nor bias,Urinary Incontinence: Definition,International Continence Society The “involuntary leakage
3、 of urine” Stress Urinary Incontinence is “involuntary leakage on effort or exertion, or on sneezing or coughing” Urinary Urgency is “the complaint of a sudden compelling desire to pass urine which is difficult to defer” Urgency Incontinence is “the complaint of involuntary leakage accompanied by or
4、 immediately preceded by urgency” Overactive Bladder Syndrome is “urgency with or without urgency incontinence, usually increased daytime frequency and nocturia”.,Urinary Disorders,Three categories: Storage Voiding Postmicturition,Voiding Symptoms,Slow urinary stream Splitting or spraying Intermitte
5、ncy or hesitancy with flow Straining to void Incomplete emptying Postmicturition dribble,Case Report,Mrs. M.A. is an 84-year-old female Alzheimers Dementia 87-year-old husband reports her urinary incontinence is worsening and is causing increased caregiver stress Occasional incontinence 5yrs Past 6
6、months has had at least 3 episodes of urine loss daily, at least 1 of these during the night Doing more laundry and restricting social activities to minimize embarrassment,Case Report 2,She minimizes the concern Reports only occasional urine loss Independent in self-care but needs assistance with sh
7、opping and complex meal preparation Medications: Donepezil 10mg daily, 7 months ago Nifedipine XR 30mg daily HCTZ 25mg daily for HTN ASA 81mg daily Oxazepam 30mg QHS PRN sleep,Case Report 3,Describes small-volume urine loss with coughing or laughing Loss of moderate volumes of urine (enough to drip
8、down her leg) if she “doesnt get to the bathroom right away” (within two minutes) upon urge Occasionally wakes up wet and needs to go to the toilet immediately upon awakening Coffee in the AM 3 cups of tea between lunch and bedtime Denies EtOH and tobacco use Restricted fluid intake,UI / Fast Facts,
9、25 million US/predominantly 15-20 Billion US $ diagnosis 25%-35% of adults and 50% of the 1.5 million NH residents Up to 60% of NH patients are incontinent vs. 30% of elderly people living at home are incontinent Underdiagnosed and underreported : Great Myth 50%-70% of women fail to seek medical eva
10、luation and treatment SI affects 15%-60% of women of all ages 1/4 of nulliparous, young, college athletes experience SI in sports,Bladder Physiology,Urine storage Sympathetic (T/L) Detrusor relaxation Smooth & striated muscle of urethra contract Micturition Parasympathetic (Sacral) Detrusor contract
11、ion vs. smooth & striated muscle of urethra relax,Normal Neurophysiology,Autonomic and Somatic Nervous Systems No differences in neuroanatomy between sexes Vesicourethral innervation may be influenced and functionally modified by hormones in women,Cortical Neurophysiology Normal 2,Normal voiding fun
12、ction requires higher cortical areas of the brain Central coordination occurs in Pontine Micturition Center Parietal lobes and thalamus receive and coordinate the bladder detrusor afferent stimuli Frontal lobes and basal ganglia modulate with inhibitory signals Cerebellum receives sensory input from
13、 bladder and pelvic floor muscles and is thought to coordinate bladder contraction with striated sphincter relaxation and to maintain tone of the pelvic floor musculature. Conscious inhibition of the micturition reflex is controlled by part of the medial wall of the anterior frontal cortex and the a
14、nterior cingulate gyrus.,Reflex Neurophysiology Normal 3,Coordination occurs in sacral micturition center (S2-4) Urine storage depends upon sympathetic neural activity Bladder distention results in afferent input from sensory neurons in bladder wall urethral motor neurons in Onufs nucleus contractio
15、n of striated urogenital sphincter muscles via pudendal nerve,Reflex Neurophysiology Normal 4,Simultaneously, spinal sympathetic reflex (T11-12) via hypogastric nerves results in alpha-adrenergic contraction of urethral smooth muscle with increased tone at the vesical neck and inhibition of parasymp
16、athetic transmission inhibits detrusor contraction Urethral pressure detrusor pressure = storage Increases in abdominal pressure maintained by fascial and muscular urethral support hammock compressing urethra to help maintain continence; also when pelvic floor muscles are contracted,Pelvic Floor,Sup
17、portive Fxn: Muscular and CT (Endopelvic Fascia) Levator Ani (Puborectalis, pubococcgeus and iliococcygeus) and coccygeus muscles,Pelvic Floor 2,Somatic NS: Controls striated external urethral sphincter and levator ani muscle via pudendal nerve and S2-S4. Inhibitionrelaxation of bladder outlet and p
18、elvic floor in voiding. CNS: Voluntary control and modification of micturition reflexes,Urethra,Funnels at the urethrovaginal junction The urethra becomes more patent and has reduced closing pressure and continence is lost Mechanical closure/integrity of the urethra is necessary to prevent SUI Closu
19、re/integrity requires mucosal surface coaptation intact viscoelastic properties of urethral epithelium, healthy vascular plexus and contraction of surrounding musculature,Regional Defects of Micturition,Central Peripheral Neurological Musculoskeletal Congenital,Voluntary Control of Micturition,Disru
20、ption of Central Control = dysfunctional storage and voiding patterns Lesions in cortical centers result in urge incontinence, enuresis and urethral spasm Stroke Alzheimers Disease, Multi-infarct Dementia, Parkinson Disease MS with suprapontine lesions involuntary detrusor contractions in synchrony
21、with urethral relaxation neurogenic detrusor overactivity with urgency/frequency and urgency incontinence,Voluntary Control of Micturition 2,High spinal cord or UMN lesions neurogenic detrusor overactivity Detrusor contractions are not synchronized with urethral relaxation detrusor-sphincter dyssyne
22、rgia (urinary retention) Seen in acute spinal cord trauma, cervical or lumbar stenosis, disc herniation or chronic SC conditions, ie: MS,Voluntary Control of Micturition 3,LMN lesions Injury to peripheral nervous system contraction of detrusor muscle overflow incontinence Peripheral neuropathy : Dia
23、betes Injury to Pelvic Plexus : Resection surgery : Radical Hysterectomy or rectal surgery Parasympathetic innervation is mainly affected,Muscular Causes of Urine Storage and Evacuation Dysfunction,Detrusor muscles functional ability to contract appropriately is altered by: Age, atrophy, trauma or m
24、uscular innervation Overactive bladder tissue demonstrates increases in elastin, collagen and segments of denervated muscle Raised intracellular calcium levels: ATP phosphorylation, protein kinases, and potassium and calcium channels Abnormal number of intercellular connections used for communicatio
25、n between smooth muscle cells inappropriate detrusor contractions,Transient Incontinence,“Transient Incontinence” UI that develops due to temporary underlying condition: UTIs, atrophic vaginitis, urethritis or prostatitis Dysuria and urinary urgency Physiologic conditions may lead to polyuria and UI
26、: Diabetes insipidus, psychogenic polydipsia, hyperglycemia, hypercalcemia, fluid overload (CHF), delirium, fecal impaction,Chronic Incontinence,Persistent Stress Urge Overflow Functional Mixed,Conditions and Factors Affecting Urine Storage and Evacuation,UI reflects multiple impairments Intact func
27、tional ability to toilet oneself Potentially reversible contributors to UI: DIAPPERS: Dementia/delirium Infection Atrophic Vaginitis Psychological Pharmacologic Endocrine Restricted mobility Stool impaction,Stress Urinary Incontinence,Concepts of pressure transmission, anatomic support and urethral
28、integrity Continence during physical stress requires anatomic urethral support and integrity Ideal support: 1. Ligaments along the lateral aspects of urethra : pubourethral ligaments 2. Anterior vaginal wall and its lateral fascial condensation 3. Arcus tendinous fascia pelvis 4. Levator ani muscles
29、,SUI 2,Genuine Stress Incontinence Leakage that occurs with an increase in abdominal pressure without a rise in true detrusor pressure (pDet),SUI 3,Lift, laugh, cough, sneeze Due to inadequate closure of the external urethral sphincter Urethral hypermobility with loss of support of the urethra,Urge
30、Incontinence,Detrusor overactivity Overactive Bladder: dry vs. wet Dx Urgency or leakage with a contraction that patient cannot suppress Involuntary ctx in filling phase: spontaneous vs. provoked Leak large volumes of urine Neurogenic detrusor overactivity: MS, Parkinson Disease, stroke, spinal cord
31、 injuries, spinal stenosis, Dementia,Urethra Defects,Prior etiologies of such defects: Retropubic surgery with denervation or scarring of the urethra and supporting tissue Prior pelvic radiotherapy Hypoestrogenism Diabetic neuropathy Childbirth associated trauma,Pharmacological Causes,Use of diureti
32、cs Anticholinergic medications Alcohol Psychotropic medications Narcotics Alpha agonists or antagonists Beta mimetics Calcium channel blockers,Overflow Incontinence,Outlet obstruction or poor detrusor contractility and incomplete bladder emptying Men: BPH Urethral strictures Frequent loss of small v
33、olumes of urine,Functional Incontinence,Urinary leakage that occurs as a result of factors not directly associated with bladder Cognition and mobility limitations Transient: ie: hip fx Dementia and vascular disorder: cannot recognize sensation of full bladder Cannot manipulate clothing or use toilet
34、,Mixed Incontinence,More than one type of UI at a time Most common: stress and urge Detrusor Hyperactivity with Impaired Contractility Urinary urgency and frequency caused by uninhibited detrusor contractions Bladder does not contract adequately nor empty completely,Fecal Incontinence,Distal colon a
35、nd rectum: S2-S4 reflex arc Patients with UI, particularly urge incontinence, may also experience problems with fecal incontinence Chronic constipation exacerbates UI symptoms,Evaluation and Treatment,History and Physical Examination Diagnostic Modalities Pharmacologic and Non-pharmacologic Regimens
36、 Pediatrics,Evaluation,History and Physical Examination Nature of leakage, frequency, duration Obstetrics, GU surgery, radiation or trauma Pelvic, genital and rectal exam, valsalva Voiding Diaries Laboratory Tests: UTI, hematuria, upper tract imaging and cystoscopy Serum electrolytes, creatinine, ca
37、lcium, blood glucose PVR: 200mL = probable bladder outlet obstruction or detrusor dysfunction,Cystometry: DO vs. SI,Cystometrogram: Measures bladder storage pressure during filling / bladder volume in filling, storage and voiding / detrusor activity and bladder sensation, stability, capacity and com
38、pliance (V/P). Urethral and rectal (or vaginal) catheters Pves=Total Bladder Pressure Pdet=Pressure exerted on bladder by Pabd Pabd=RC Pves-Pabd=Pdet,Cystometry 2,Bladder capacity Maximum cystometric capacity Volume at which subject with normal bladder sensation can no longer delay voiding Fullness
39、first perceived = 100-200mL Normal capacity = 400-500mL Functional bladder capacity Voiding diary Largest # of urine bladder can empty in a single urination,Uroflowmetry,Well-hydrated patient voids into a uroflowmeter Rate of urine flow over time / “Flow curve” Most common / Non-invasive,Urinary Flo
40、w Rate,Detrusor action x outlet resistance 20-25mL/s 25-30mL/s Suspect obstruction 15mL/s Definite evidence of obstruction 10mL/s ”Supervoiders”=rates far above normal,Uroflowmeter,Leak Point Pressure,Urethral Pressure Profile Measured at rest with urethral catheter Max UCP is highest pressure along
41、 functional length of urethra Max urethral closure pressure correlates with SI severity and surgical outcomes If +leakageAbd/Valsalva LPP=Pves at which +leakage without detrusor contraction,Pressure Flow Studies,Obstruction vs. Detrusor Failure Uroflowmetry+Pdet (rectal or vaginal catheter for Pabd)
42、 + urethral catheter for Pves to calculate Pdet during voiding. Bladder filled until patient feels “full” and asked to void Measure Pdet at Flowmax High Pdetobstruction: BPH : POP Low Pdetdetrusor failure,Electromyography,Evaluate striated urethral sphincter and pelvic floor Perineal surface-patch e
43、lectrodes or needle electrodes (GS) Nl EMG R/O Neurological Ds Silence is #1 sign onset of micturition Detrusor Sphincter Dyssynergia,Video Urodynamics,Fluoroscopy + bladder + urethral pressure during cystoscopy Helpful with UI with POP Artificially low Pdet Vesicoureteral reflux from poor bladder c
44、ompliance Bladder diverticula Chronic bladder outlet obstruction,Therapies,Urodynamic Studies Guide diagnosis and therapy Conservative Treatment Dietary Modification and Weight Loss Timed voiding and Bladder Retraining Pelvic Floor Muscle Exercises Pessaries: POP Pads and Absorbent Products Pharmaco
45、logic Treatments,Therapies 2,Stress UI Surgery, pelvic floor physiotherapy, and anti-incontinent devices Estrogen Vaginal: Premarin Cream 0.625mg/g cream, Vagifem 25ug or 10ug vaginal tablet, Estring 2mg vaginal tablet, Estrogel 2.5mg daily Antidepressants Stress or mixed TCA: Imipramine 10-25mg QHS
46、 Moderate to severe: SNRI: Duloxetine 40-60mg BID,Therapies 3,Urge UI Dietary changes, behavioral modification, pelvic-floor exercises and/or anticholinergics and surgical intervention. Anticholinergics : Dry mouth, blurred vision, GI discomfort, constipation Oxybutynin (Ditropan) 2.5mg daily QHS Ox
47、ybutynin XL Oxytrol patch, Tolterodine (Detrol) Tolterodine LA, Darifenacin (Enablex) Solifenacin (Vesicare) Trospium (Trosec),Therapies 4,BPH Alpha blockers: Postural hypotension, dizziness Alfluzosin Doxazosin (Cardura) 1-4mg daily Tamsulosin 0.4-0.8mg daily Tamsulosin CR Terazosin (Hytrin) 1-5mg
48、daily QHS,Therapies 5,Mixed incontinence Often requires anticholinergics and surgery. Overflow incontinence Type of catheter or diversion regimen. Functional incontinence Self-limited when the underlying cause is identified and treated in an appropriate fashion. In general: #1 choice for treatment i
49、s the least invasive, with the least number of potential complications for the patientmedications or exercises,Therapies 6,Surgical Treatments BURCH Coloposuspension Sling Procedures TVT Procedure/Polypropylene Bulking Agent Injection Therapy Glutaraldehyde crosslinked bovine collagen Neuromodulatio
50、n Prevention and Continence Promotion,Pediatrics,Anatomic Abnormalities Posterior Urethral Valves Lower urinary tract dysfunction (DO) and impaired compliance Bladder Extrophy Vesicoureteral Reflux DO or anatomic Ureterovesical Junction abnormality For all: consider UDS, at least once, in children with PUV, urethral stricture, ectopic ureterocele, vesicoureteral reflux and bladder extrophy Consider regular uroflowmetry and PVR in management an follow-up of children with PUV, US, EU, VUR and BE.,
