important stuffs in management aspect are mentioned here

1. Management of Overactive
Bladder/Urgency Incontinence
DEEP BASNET
PAHS
16TH OCTOBER 2015

2. URGENCY INCONTINENCE
Inflammation
(cystitis/ urethritis)
Bladder mass
(tumor, polyp,
stone)
Psychogenic
Neurological
(stroke, dementia,
MS)

3. Urgency incontinence
A sudden involuntary contraction of the muscular wall of the bladder
causing urinary urgency, an immediate unstoppable urge to urinate
Urge incontinence (motor)- The result of detrusor muscle overactivity
(detrusor instability, DI)
 Sensory urgency - An intense desire to void that is not associated with
detrusor pressure
More common in old women (12-15% in women >40 yrs)

4. Overactive bladder
Incontinence occurs when the detrusor muscles contracts spontaneously or
on provocation during the filling phase while attempting inhibition of
micturition
Associated with
◦ Decrease bladder capacity
◦ Decrease sensation
◦ Central nerve system inhibition

5. Etiology
Functional & psychosomatic
Detrusor hyperreflexia (neuropathy)
Diabetic neuropathy, cerebrovascular accident, multiple sclerosis, spinal injury & parkinsonism
Following surgery for GSI if the bladder neck is placed too high and tightly sutured
(frequency varies depending upon type of surgery undergone)
Idiopathic (10%-M, 30%- F)
Urinary infection

6. Pathophysiology
 Incompetent bladder neck  urine in
proximal urethra detrusor
overactivity  incotinence
 Increased alpha-adrenergic activity
increased contraction
 Change in detrusor smooth muscle
property (due to atherosclerosis or
neuropathy) inappropriate detrusor
overactivity

7. Symptoms
A woman develops involuntary escape of urine with urge to urinate
Frequency more than seven times during the day and at least once
during the night
Bedwetting during sleep
DI also occurs during sexual intercourse and with sound of water, hand-
washing

8. Investigation
Neurological examination especially in an old woman
Perineal sensation
Pelvic muscle tone
Bulbocavernous reflex- gentle clitoral stroke produce anal sphincter contraction
Cranial nerve examination
Blood sugar
Maintenance of urinary diary

9. Contd...
Urine culture
indicated if the urinary infection is the cause of frequency
and urge
Cystometry
The normal pressure of 15 cm water at 200 ml exceeds
in detrusor instability
Ultrasound
shows a thick bladder wall more than 6 mm in
detrusor instability and residual volume

10. Management
General measures
◦ Psychotherapy for psychosomatic problems
◦ Neurological problems and diabetes should be managed properly
Behavioural therapy
◦ Limit the intake of fluid
◦ Reduce tea and coffee, non smoking
◦ Bladder retraining

11. Bladder retraining
Useful for idiopathic DI
Can be achieved by bladder drill
Bladder drill instruct to void by the
clock at progressively increasing intervals
over a 6 weeks time period

12. Drug therapy
Aims are
◦ Inhibit bladder contractility
◦ Increase bladder neck and urethral resistance
Anticholinergic drugs useful
◦ Urispas (flavoxate) is a musculotropic & direct action on the
muscles, 200mg TID, antispasmodic & analgesic
◦ side effect: headache, nausea, constipation, dry mouth & blurred
vision
◦ Contraindication: glaucoma & cognitive impairement

13. Dosage and side effects of anticholinergic
drugs to manage detrusor instability

14. POSTERIOR TIBIAL
NERVE STIMULATION
(PTNS)

15. If the drug fails, PTNS should be tried
Neuromodulation is indirectly applied on the 3rd sacral nerve via a
needle electrode and connected to a stimulator
30 min stimulation 3 monthly

16. Contd..
Transvesical injection of phenol:
A volume of 10 ml of 6% phenol injected into trigone, 60% benefit for a short period but at end
of 1 year only 2% are relieved
Augmentation calm cystoplasty: augmentation of bladder capacity with 25cm length
segment of ileum  95% cure
Botox (botulinum toxins A) inhibit ACH release at the neuromuscular junction
increase bladder compliance & its capacity (has higher rate of urinary retention and
infection)

17. Some points to consider…
Oestrogen cream improves incontinence in post menopausal women
DDAVP is synthetic ADH analogue – cures nocturnal enuresis
Side effects: Nausea, hyponatremia and fluid retention
Contraindicated in coronary artery disease, hypertension and epilepsy in
elderly women
Dose and route: 20-40mcg/ intranasal at night
Medical therapy is applied for 5-12 failures and then only the nerve
stimulation and surgery should be applied

19. Type Mechanism History Diagnostic Test Treatment
Stress
incontinence
Bladderneck has
fallen out of its
normal intra-
abdominal
position
Painless loss of
urine concurrent
with valsalva; no
urge to void
Physical
examination; loss
of bladder exam;
cystometric
examination
Urethropexy to
return proximal
urethra back to
intra abdominal
position
Urge
incontinence
Detrusor muscle
is overactive and
contracts
unpredictably
Urge component
“I have to go to
the bathroom
and cant make it
there in time”
Cytometric
examination
shows
uninhibited
contractions
Anti cholinergic
medication to
relax detrusor
muscle (surgery
may worsen)
Overflow
incontinence
Overdistended
bladder due to
hypotonic
bladder
Loss of urine with
valsalva;
dribbling;
diabetes or spinal
cord injury
Post void residual
(catheterization)
shows large
amount of urine
Intermittent self
catheterization
Fistula Communication
between bladder
or ureter and
Constant leakage
after surgery or
prolonged labour
Dye into bladder
shows vaginal
discolouration
Surgical repair of
fistulous tract

20. Symptom Comparison of Women with Stress or Urge Incontinence

21. References
Williams textbook of Gynecology, 2nd edition
Shaws textbook of Gynecology, 16th edition
Jeffcoate’s Principles of Gynecology, 8th edition
Case files , Obstetrics and gynecology, 2nd edition