Incontinence Paul M. Fine MD Basics Description Incontinence is a complaint of any involuntary leakage of urine.

Types of incontinence (percentage of total):

o

Stress urinary incontinence (S I) (!"#): $eakage %it& p&ysical e'ertion rge (((#): $eakage %it& a strong )esire to voi) Mi'e) (("#): *om+ination of stress an) urge

o o

See Stress rinary Incontinence, -veractive Bla))er, an) Incontinence Surgeries.

.ge/0elate) Factors Most stu)ies s&o% increasing prevalence %it& age relate) to: rogenital atrop&y 1ypoestrogenism

Increasing prevalence of me)ical illnesses Increasing nocturnal )iuresis Increasing use of me)ications Impairments in mo+ility Impairments in cognition

2pi)emiology .1*P0 estimates 34 million .mericans are incontinent5 33 million are %omen. 36748# in community/+ase) population an) up to 68# in long/term care are incontinent.

rinary incontinence is more prevalent t&an ot&er c&ronic )iseases in %omen inclu)ing &ypertension, )ia+etes, an) )epression. 9(: +illion in S annually spent on urinary incontinence, inclu)ing pa)s an) )iapers.

0isk Factors Pre)isposing factors: o Female se'

o o

0ace: *aucasians &ave more stress incontinence Family &istory of stress incontinence

Inciting factors:

o o o o

*&il)+irt& 1ysterectomy 0a)ical pelvic surgery 0a)iation

Promoting factors:
o o o o o o o o

-+esity $ung )isease Smoking Menopause *onstipation 0ecreation -ccupation Me)ications

Decompensating factors:
o o o o

.ging Dementia De+ility 2nvironment

;enetics 3st/)egree relative %it& stress incontinence increases risk *ollagen <uality, synt&esis, an) meta+olism Pat&op&ysiology Stress incontinence: o Insufficient uret&ral closure pressure:

ret&ral &ypermo+ility )uring =alsalva ne<ual pressure transmission from a+)omen an) +la))er to uret&ra Intrinsic uret&ral sp&incter )eficiency

rge incontinence:
o

ncontrolle) +la))er contraction

Mi'e) incontinence:

*om+ination of t&e a+ove

Diagnosis Signs an) Symptoms 1istory 1o% many times in t&e past %eek )i) you lose urine into your clot&ing, un)er%ear, or pa)> o During an activity suc& as coug&ing, snee?ing, laug&ing, running, e'ercising, or lifting>
o

@it& suc& a su))en strong nee) to urinate t&at you coul) not reac& t&e toilet in time>

Do you &ave to (signs of overactive +la))er):

o o o

rinate A every 4 &ours> @ake up at nig&t more t&an t%ice to urinate> 1ave su))en strong urges to urinate an) +arely make it to t&e +at&room in time>

0evie% of Systems *omplete general me)ical &istory: o Dia+etes: Polyuria, nocturia

o o o o

Beurologic con)itions: rinary retention an) overflo% incontinence Prior spinal or +ack surgery Severe art&ritis5 limite) mo+ility *urrent me)ications:

Diuretics: Polyuria, nocturia .nti&ypertensives: Decrease) uret&ral tone

$ifestyle an) )iet:

.lco&ol: Polyuria *affeine: Stimulates +la))er contraction

-+stetric &istory:
o o

$arge +a+ies =aginal versus cesarean versus forceps

;ynecologic an) urologic surgical &istory:

o o

Prior anti/incontinence surgery Prior &ysterectomy

Prior surgery for pelvic organ prolapse

;ynecologic symptoms in)icating nee) for &ysterectomy suc& as severe )ysmenorr&ea, menometrorr&agia, symptomatic fi+roi)s Symptoms of pelvic organ prolapse suc& as seeing or feeling a +ulge or vaginal pressure .ssociate) fecal incontinence

P&ysical 2'am .+)ominal e'am: o Palpate for masses causing )ecrease) +la))er capacity.

Pelvic e'am:
o o

rogenital atrop&y is possi+le cause of )ecrease) uret&ral closure. tero/vaginal prolapse ()uring =alsalva or %it& patient stan)ing):

Distal anterior vagina: ret&ral &ypermo+ility .pical: *ervi' or vaginal cuff Posterior vagina (rectocele, enterocele)

Bimanual e'am:

terine fi+roi)s: Decrease) +la))er capacity .)ne'al masses: Decrease) +la))er capacity

.+ility to perform a Cegel s<uee?e

0ectal e'am to rule out fecal impaction Beurologic e'am:

o

Bul+ocavernosus refle':

Stroke la+ia to stimulate anal contraction In)icates intact sacral sensory an) motor refle' arc for +la))er an) pelvic floor muscles

$o%er e'tremity refle'es

Tests

Bla))er )iary may +e &elpful for patient to recor) urinary leakage, urgency, fre<uency, an) nocturia for 3 %eek . to rule out infection Post voi) resi)ual volume:
o

Measure +y cat&eter imme)iately after voi)ing

o o

S&oul) +e D388 m$ A(88 m$ suggests possi+le uret&ral kinking from vaginal prolapse or poor +la))er contraction )ue to neurologic pro+lem.

E/tip test for uret&ral &ypermo+ility:

o

Insert cotton s%a+ %it& Fylocaine Gelly into +la))er, t&en %it&)ra% until resistance of uret&rovesical Gunction felt 1ave patient perform ma'imal =alsalva Measure angle of )eflection of en) of s%a+ from &ori?ontal:

o o

D48H is normal A48H in)icates uret&ral &ypermo+ility an) loss of normal uret&ral anatomic support

Stan)ing coug& stress test:

o o o

Fill +la))er %it& 488 m$ of sterile %aterIsaline Patient stan)s an) coug&s forcefully -+serve for su))en urinary leakage5 t&is is o+Gective confirmation of stress incontinence.

P.!J $a+s ro)ynamics (patient generally referre) to urologist or urogynecologist for t&is): Measures storage (cystometrogram) an) emptying function (uroflo%) of +la))er using small cat&eters an) electronic measurement of pressure an) volume May )emonstrate +la))er muscle ()etrusor) involuntary contraction (relative contrain)ication for anti/incontinence surgery)

May )emonstrate voi)ing pattern suggestive of uret&ral kinking or o+struction (also relative contrain)ication for anti/incontinence surgery) May )emonstrate neurologic +la))er )ysfunction May )emonstrate urinary leakage %it& =alsalva or coug&, confirming S I May )emonstrate urinary leakage %it& involuntary )etrusor contraction confirming urge incontinence

Imaging Some urologists an) urogynecologist use transla+ial ultrasonograp&y to visuali?e uret&ral an) +la))er anatomic relations&ips. Differential Diagnosis Type of incontinence +ase) on symptoms:

o o o

Stress urinary incontinence rge urinary incontinence Mi'e) urinary incontinence

Type of incontinence +ase) on uro)ynamics:

o o o

;enuine or uro)ynamic stress incontinence Detrusor overactivity associate) incontinence Mi'e) uro)ynamic stress an) )etrusor overactivity incontinence

Infection Suspect TI if recent onset of incontinence, especially associate) %it& urgency an) fre<uency Meta+olicI2n)ocrine Suspect )ia+etes if large volume +la))er capacity or polyuria TumorIMalignancy 0ule out +la))er tumor or cancer if &ematuria %it&out infection in patient A68 +y referral for cystoscopy. Trauma -+stetric trauma Drugs Diuretics may aggravate incontinence, urgency, an) fre<uency. .nti&ypertensives may aggravate incontinence +y lo%ering uret&ral resistance. -t&erIMiscellaneous 1ig&/impact e'ercise may aggravate S I $imite) mo+ility +y c&ronic art&ritis or ot&er c&ronic illness may promote urge incontinence Management ;eneral Measures Be&avioral an) )ietary mo)ifications: Decrease caffeine Decrease alco&ol

Performance of pelvic floor muscle (Cegel) e'ercise )aily is effective for all types of urinary incontinence Time) voi)ing .voi)ance of +la))er overfilling .voi)ance of &ig&/impact activities *om+ination of +e&avioral an) me)ication t&erapy is synergistic (+etter t&an eit&er alone)

Me)ication (Drugs) .ntic&olinergics for urge incontinence an) )etrusor overactivity:

o o o o o o

Detrol $. (7! mgI)ay PDitropan F$ 6736 mgI)ay P2na+le' J.6736 mgI)ay P=esicare 6 mgI)ay PSantura (8 mg +.i.). P-'ytrol skin patc& applie) t%iceI%k

Dulo'etine (Kantreve) for stress incontinence (not availa+le in S) !8 mg +.i.). Imipramine 387(6 mg t.i.). P- for urge, stress, an) mi'e) incontinence. -ff/ la+el usage.

Surgery In)icate) for stress incontinence or mi'e) incontinence nonresponsive to me)ical t&erapy: o ;enerally "8# effective
o

Mi)/uret&ral slings (minimally invasive):

Transvaginal tape (T=T) is effective for intrinsic sp&incteric )eficiency (ISD) Transo+turator tape (T-T)

Burc& or Mars&al/Marc&etti/Crant? uret&rope'y (re<uires a+)ominal incision) Pu+ovaginal sling is most effective for ISD. 0e<uires vaginal an) a+)ominal incision. Periuret&ral inGection of +ulking agents (office proce)ure) especially for ISD %it&out uret&ral &ypermo+ility

May aggravate pree'isting or cause )e novo urge incontinence +y uret&ral o+struction May +e performe) %it& concomitant &ysterectomy an)Ior pelvic organ prolapse repair

Follo%up .fter surgical t&erapy for urinary incontinence: : %eeks, 4 mont&s, 3 year, t&en annually .fter initiating +e&avioral an)Ior me)ication t&erapy: !7: %eeks:
o o

*onfirm correct Cegel s<uee?e +y e'am May nee) to try a )ifferent antic&olinergic me)ication )epen)ing on efficacy an) si)e effects

T&en in 4 mont&s as nee)e), follo%e) +y annually

Disposition Issues for 0eferral ncertain )iagnosis Failure to respon) to +e&avioralIme)ical t&erapy in urge incontinence

1istory of prior ra)ical pelvic surgery or ra)iation t&erapy 1istory of faile) prior anti/incontinence surgery Suspecte) meta+olic, en)ocrine, or neurologic etiology for t&e incontinence Bee) for uro)ynamics to clarify )iagnosis Bee) for surgical t&erapy +eyon) your scope of competency an) e'perience

Prognosis Me)icationIBe&avioral t&erapy for urge incontinence is effective in LJ8# of patients. Surgical t&erapy for stress incontinence is effective in L"8# of patients.

Me)icationIBe&avioral an) surgical t&erapies are eac& L68# effective in mi'e) incontinence. . com+ination of t&ese t&erapies may +e re<uire) to ac&ieve "8# effectiveness.

Bi+liograp&y Bump 0*, et al. 2pi)emiology an) natural &istory of pelvic floor )ysfunction. -+stet *ynecol *lin Bort& .m. 3""M5(6(!):J(47J!:. consensus.ni&.govI(88:I(88:*esareanS-S8(JStatement&tml.&tm 1ampel *, et al. Definition of overactive +la))er an) epi)emiology of urinary incontinence. rology 3""J568(suppl :.):!73!. Miscellaneous .++reviations N ISDOIntrinsic sp&incteric )eficiency N S IOStress urinary incontinence N T=TOTransvaginal tape N T-TOTranso+turator tape *o)es I*D"/*M JMM.4 rinary incontinence JMM.43 rge incontinence JMM.4M -verflo% incontinence :(6.: Stress incontinence Patient Teac&ing N .*-; Patient 2)ucation Pamp&let: rinary Incontinence N .*-; Patient 2)ucation Pamp&let: Surgery for rinary Incontinence Prevention N 2lective primary cesarean )elivery &as not yet +een )emonstrate) as efficacious in prevention of urinary incontinence. N T&ere is insufficient evi)ence to evaluate fully t&e +enefits an) risks of cesarean )elivery on maternal re<uest as compare) to planne) vaginal )elivery, an) more researc& is nee)e).

N ntil <uality evi)ence +ecomes availa+le, any )ecision to perform a cesarean )elivery on maternal re<uest s&oul) +e carefully in)ivi)uali?e) an) consistent %it& et&ical principles.