Cjane Padilla

URINARY INCONTINENCE Complaint of involuntary leakage of urine Involuntary urination Result of overfunctioning/underfunctioning of the urethra, bladder or both Enuresis – urinary incontinence primarily in children Nocturnal enuresis – bed-wetting Types of incontinence 1. Stress a. Urethral under-activity – urethral sphincter no longer resists the flow of urine from the bladder during periods of activity b. Occurs during: exercise, lifting, coughing, sneezing 2. Urge urinary incontinence Bladder over-activity Associated with urinary frequency and urgency with or without urge incontinence The detrusor muscle is overactive and contracts inappropriately during the filling phase. 3. Overflow incontinence Urethral overactivity and/or bladder underactivity The bladder is filled but unable t empty causing the urine to leak past a normal outlet and sphincter Causes 1. BPH3. Cytocele – in women 2. Prostate cancer4. Formation o surgical overcorrection after UI surgery Mixed incontinence Bladder over activity + urethral under activity Functional incontinence Occurs in patients with cognitive and mobility deficit Type Definition Etiology Clinical Correlates Stress Increased abdominal pressure .Weakened pelvic floor .urethral hypermobility .bladder neck prolapse .History of pelvic surgey .multiparity .cytocele/rectocele exam .atrophic vaginitis exam Urge Involuntary bladder contraction .neurologic disorder .infection .intrinsic bladder lesion .idiopathic .spinal cord injury, stroke .UTI . Bladder stone,tumor Overflow Bladder is unable to empty fully . bladder outlet obstruction .detrusor muscle weakness .autonomic neuropathy .adverse drug reaction . BPH . Diabetes mellitus Total Constant or periodic loss of urine in settings outside normal voiding conditions .urethral sphincter abnormality . abnormal anatomic connections . vesicoenteric fistulas .ectopic ureter Functional Physical/cognitive impairment . inability or unwillingness to use the toilet Acute Acute onset of incontinence . delirium .medications . restricted mobility . infection . fecal impaction . inflammation . Polyuric states . diabetes mellitus or insipidus . hypercalcemia . diuretic treatment Clinical Manifestation 1. Stress UI - urinary leakage with physical activity 2. Urge UI – nocturia and nocturnal incontinence 3. Overflow – rare Signs and Symptoms 1. Lower abdominal fullness 2. Pain 3. Hesitancy 4. Straining to void 5. Decreased force of stream 6. Interrupted stream 7. Sense of incomplete bladder emptying 8. Urinary frequency and urgency Bladder overactivity vs Urethral underactivity 1. Bladder Overactivity a. Urgency b. Frequency with urgency c. Nocturnal incontinence 2. Urethral underactivity a. Leaking during physical activity b. Ability to reach the toilet in time following an urge to void. c. Sometimes urgency may occur Diagnostic Tests 1. Stress UI Observe urethral meatus while strains 2. Urge UI Urinalysis and urine culture: TRO UTI 3. Overflow UI Digital rectal exam Transrectal ultrasound, TRO prostate enlargement Renal function tests, TRO renal failure Drug Therapy 1. Overactive bladder/ Urge UI a. Anticholinergic / Antispasmodic Oxybutinin – first line drug therapy, α-adrenergic inhibitor ADR: antimuscarinic effect Tolterodine – muscarinic receptor antagonist CI: fluoxetine, sertraline, fluvoxamine, macrolide antibiotics, imidazoles, grapefruit juice Trospium Chloride – quaternary ammonium anticholinergic Equivalent to oxybutinin and tolterodine Solifenacin succinate and Darifenacin – antagonists of M1, M2 and M3 muscarinic receptors b. Tricyclic antidepressants Imipramine, Doxepine, nortriptyline, desipramine c. Estrogen Estradiol d. Serotonin-Norepinephrine reuptake inhibitors 2. Stress UI a. α-adrenergic agonists – more effective in combination with estrogen Pseudoephedrine b. Estrogen - Oral, intramuscular, vaginal, transdermal. Maximum renal pressure, functional urethral length c. Imipramine d. Duloxetine – inhibitor of serotonin+norepinephrine reuptake. Increase urethral and external urethral sphincter muscle tone during storage phase 3. Overflow UI a. Cholinomimetics Bethanecol – CI: asthma, CVD. Never give IV/IM NonPharmacologic Management of Urinary Incontinence 1. Lifestyle modification Smoking cessation Weight reduction Good bowel hygiene Dietary modification 2. Scheduling regimens a. Timed voiding – using the toilet in a timed schedule that does not change b. Habit retraining – using the toilet with adjustments in voiding intervals 3. Patterned urge response toileting (PURT)- use of an electronic monitoring device to identify the timing of incontinent episodes 4. Prompted voiding – scheduled toileting that involves a prompt from a caregiver 5. Bladder training – teaching of urge controlled strategies using relaxation and distraction techniques, self-monitoring and reinforcement techniques. Sometimes in conjunction with drug therapy 6. Pelvic floor muscle rehabilitation and exercise – regular practice of pelvic floor contractions for urge inhibition 7. Vaginal weight training – used in combination with pelvic floor muscle exercise at least twice a day 8. Biofeedback – use of electronic instrument to display visual or auditory information about bladder activity 9. Nonimplantable electrical stimulation – used to inhibit bladder overactivity 10. Extracorporeal magnetic innervations – induce pelvic floor muscle contraction 11. Anti incontinence devices – pessaries and other intravaginal devices used to support the bladder neck , relieve minor pelvic organ prolapse, and change pressure transmission to the urethra