Diagnosis and treatment of UI

1. Urinary Incontinence
Tevfik Yoldemir, MD, BSc, MA, PhD
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2. Definition
• “Involuntary loss of urine or stool in
sufficient amount or frequency to
constitute a social and/or health problem.
• A heterogeneous condition that ranges in
severity from dribbling small amounts of
urine to continuous urinary
incontinence…”

3. Prevalence
• Affects up 20% of community-dwelling
older individuals
• Affects up to 50 % of nursing home
residents
• Increases gradually during youth
• Peaks around middle age
• Steadily increases in the elderly

4. Prevalance of UI among women
EPINCONT Study [n=27.936]
Hannestad et al, J Clin Epidemiol 2003;53:1150-1157

5. Curr Med Res Opin
2004;20;(6):791-801

6. Risk factors

7. Reversible Causes
• Delerium;dementia
• Infections:urinary,respiratory, skin
• Atrophic vaginitis, urethritis; alcohol ingestion; acute illness
• Pharmacological agents : diuretics, sedative/hypnotics
anti-cholinergics, calcium channel blockers antidepressants,etc
• Psychological causes: depression, grief/loss
• Endocrine disorders: Hyperglycemia ;excess urine output;
excess fluid intake
• Restricted mobility :physical restraints, musculoskeletal
disorders
• Stool impaction; chronic constipation

8. Classifications of Urinary
Incontinence
• Stress
• Urge
• Overflow
• Functional
• Mixed component (detrusor hypercontractability and
impaired contraction)
• Reflex (spinal cord damage)

9. Stress
• Leakage with increase in intra-abdominal
pressure
• Urethral sphincter malfunction (intrinsic weakness) /
bladder neck hypermobility
• Associated with weakening of pelvic floor muscle
• Loss of small to moderate amount of urine
• No evidence of urgency or nocturia

10. Urge
• Voiding dysfunction associated with involuntary loss of
urine
• Detrusor overactivity
• Urgency
• Frequency
• Night time voiding
• Most common in older women

11. Overflow
• Involuntary loss of urine due to distention of the
bladder
• Filling occurs to the stretch limit of the bladder
• Underactive detrusor with/without bladder outlet
obstruction
• Large PVR >400cc
• Dribbling, frequency
• High rates of infections

12. Incontinence Assesment

14. Measurement of Bladder Base
Descent (The Q-tip Test)

15. Treatment
• Behavioral Modification
• Pharmacotherapy
• Urethral Injection
• Surgery
• Devices
• Referral

16. Behavioral Treatment
Stress Incontinence
1. Patient education
2. Kegel exercises
3. Diet modification
4. Weighted vaginal cones
5. Pessary
6. Pelvic floor electrical stimulation
7. Weight reductions

17. Behavioral Treatment
Urge Incontinence
1. Patient education
2. Timed voiding
3. Habit training
• urge inhibition
• bladder training
4. Avoid caffeine and alcohol intake
5. Diet modification

18. Behavioral Treatment
Mixed Incontinence
1. Patient education
2. Treat the predominant type
3. Kegel exercises-81% reduction in urinary
leakage
4. Diet modification
5. Bladder training

19. Behavioral Treatment
Overflow Incontinence
1. Patient education
2. “Double voiding technique”
3. Diet modification
4. Avoid caffeine/alcohol
5. Barrier product to prevent skin
breakdown

20. Behavioral Treatment
Functional Incontinence
1. Patient education
2. Environment alterations
3. Grab bars/raised seats
4. Caregiver assistance/education
5. Screen for depression/cognitive impairment
6. Occupational /Physical therapy

21. Pharmacological Treatment
• Anticholinergics=detrusor underactivity, may cause
retention
• Cholinergics=detrusor overactivity, may cause frequency
• Alpha agonists=outlet overactivity, may cause retention
• Alpha blockers=outlet underactivity, may cause stress
incontinence

22. Anticholinergics
• Darifenacin (Enablex)
• Oxybutynin (Uropan XL)
• Solifenacin (Vesicare)
• Tolterodine (Detrusitol)
• Trospium (Sanctura)
• Flavoxate (Urispas)

23. Alpha Agonists
• Phenylpropanolamine hydrochloride-no
longer marketed in U.S. (Intracerebral
hemorrhage)
• Pseudoephedrine (Sudafed)
• Midodrine (Proamatine)

24. Alpha Blockers
• Alfuzosin (Uroxatral)
• Doxazosin (Cardura)
• Tamsulosin (Flomax)
• Terazosin (Hytrin)

25. Physiology of Stress
Incontinence
1. Urethral sphincter fails to protect against
loss of urine
– Intrinsic weakness
– Failure to contract
2. Urethral hypermobility
3. Coexist together

26. Pharmacological Treatment of
Stress Incontinence
1. Phenylpropanolamine hydrochloride /pseudoephedrine
/midodrine
• Reduction in pad changes
• Reduction in incontinence episodes
• Improvement in subjective symptoms
2. Duloxetine (Cymbalta)
• Inhibitor of serotonin/norepinephrine reuptake
• Increases serotonin/norepinephrine levels in the sacral
spinal cord
• Increased contraction of urethral sphincters during urine
storage phase of micturition cycle

27. Physiology & Pharmacological
Treatment for Overactive Bladder
1. Neurogenic
– Cause-enhanced bladder C-fiber sensory input
– Abnormal atropine-resistant parasympathetic transmission
– Acetylcholine mediates detrusor contraction
2. Anticholinergic versus placebo control
– 41% experienced a cure or improvement in urinary
incontinence, improvement in leakage episodes/24 hours,
number of voids in 24 hours, volume at first contraction

28. Distribution/Function of Muscarinic
Receptors Throughout the Body
• M1:Cerebral cortex, hippocampus, salivary glands, eye-
memory/cognition
• M2:Bladder, Heart, eye, hippocampus-heart rate/tear
secretion
• M3:Bladder,salivary glands, eye, brain-bladder
contraction/ bowel motility
• M4:Basal forebrain, salivary glands
• M5:Substania nigra, eye-visual accommodation

29. Muscarinic Receptors Antagonists
• Detrusor contraction –mediated by M3 muscarinic
receptors
• Mainstay of treatment
• Choose an agent that is selective for the bladder

30. Surgical Treatment
Indications:
– Failed nonsurgical management
– Unable to tolerate side effects of medications
– More definitive therapy

31. Burch

32. Burch + PDR

33. TVT –1

34. TVT -2

35. TVT -3

36. TVT -4

37. TOT -1

38. TOT -2

39. Pessaries

41. www.yoldemir.