Urinary Incontinence in Women Dr. Hazem Al-Mandeel Associate Professor Department of Obstetrics and Gynecology College of Medicine, King Saud University

Prevalence of Urinary Incontinence (UI) Prevalence of UI in Europe for women was 35% - 40.% Prevalence of UI in Canada was 50% Prevalence of UI in Far Asia was 22% - 50% Prevalence of UI in Saudi was 29% - 41% Prevalence of UI in Qatar was 20.6%

Implications of Incontinence o Medical: o Skin ulcers o Skin rashes o UTI o Falls o Social: o Loss of self-esteem o Social restriction o Depression o Economic: o Personal costs

Quality of Life Impact  Impact on lifestyle and avoidance of activities  Fear of losing bladder control  Embarrassment  Impact on relationships  Increased dependence on caregivers  Discomfort and skin irritation

Differential Dx of Urinary Incontinence in Women Genitourinary o Stress incontinence o Detrusor overactivity o Mixed incontinence o Urogenital Fistula o Urethral diverticulum Non-genitourinary Functional (Neurogenic, cognitive, psychological, physical impairment) Environmental Pharmacologic Metabolic

Reversible causes of incontinence (DIAPPERS)  D elirium  Urinary Tract I nfection  A trophic vaginitis  P harmaceuticals  P sychological  E ndocrine (D.M)  R estricted mobility  S tool impaction

Common Types of Urinary Incontinence  Stress incontinence  Urge incontinence  Mixed  Overflow incontinence  Functional incontinence

Stress Incontinence:  Involuntary loss of urine on effort or with physical exertion (causing increases in intra-abdominal pressure)  Caused by pelvic floor damage/weakness or weak sphincter(s)  Symptoms include loss of urine with cough, laugh, sneeze, running, lifting, walking  Most common type in younger women (< 65 yrs.)

Risk factors for SUI  Age  Childbearing  Obesity  Increased intra-abdominal pressure  Estrogen depletion (Menopause)

Urge Incontinence:  Involuntary loss of urine associated with urgency (due to an involuntary detrusor contractions)  Complaints of urgency, frequency, inability to reach the toilet in time, up a lot at night to use the toilet  Multiple triggers

Causes of Urge Incontinence Neurogenic:  CVAs  Cerebral Tumors  Cerebral Aneurysm  Cerebral Hemorrhage  Multiple Sclerosis  Parkinson's Disease  Spinal cord injury Idiopathic Other conditions  UTI  Atrophic Urethritis  Urogenital Prolapse  Fecal Impaction  Bladder tumor  Bladder stone

Mixed Incontinence:  Combination of stress and urge incontinence  Common presentation of mixed symptoms  Urodynamics necessary to confirm

Stress : 49% Urge : 22% Mixed : 29%

Overflow Incontinence Large bladder volumes result in an intra- vesical pressure greater than the urethral closure pressure  Causes: o Atonic Bladder o Outlet Obstruction

Chronic Urinary Retention:  Outlet obstruction or bladder underactivity  May be related to previous surgery, aging, development of bad bladder habits, or neurologic disorders  Medication, such as antidepressants  May present with symptoms of stress or urge incontinence, continuous leakage, or urinary tract infection

Functional and Transient Incontinence :  Mostly in the elderly  Urinary tract infection  Restricted mobility  Severe constipation  Medication - diuretics, antipsychotics  Psychological/cognitive deficiency

Diagnosis of Urinary Incontinence  History  Physical  Voiding Diary  PVR  Urinalysis  Urodynamics

Patient History:  Focus on medical, neurologic, genitourinary history  Review voiding patterns/fluid intake  Voiding diary  Review medications  Explore symptoms (duration, most bothersome, frequency, precipitants)  Assess mental status and mobility

Symptoms:  Frequency  Nocturia  Dysuria  Incomplete emptying  Incontinence  Urgency  Recurrent infections  Dyspareunia  Prolapse

Physical Examination:  General examination  Edema, neurologic abnormalities, mobility, cognition, dexterity  Abdominal examination  Pelvic and rectal exam - women  Examination of back and lower limbs  Observe urine loss with cough

Urinalysis:  Conditions associated with overactive bladder  Hematuria  Pyuria  Bacteriuria  Glucosuria  Proteinuria  Urine culture

Postvoid Residual Volume (PVR):  If clinically indicated accurate PVR can be done by  Catheterization  Ultrasound  PVR of 200 ml is considered inadequate  Use clinical judgment when interpreting PVR results in the intermediate range ( ml)

Treatment : Stress Incontinence  Nonsurgical  Pelvic floor muscle training (Kegel)  Biofeedback  Electrical stimulation  Pessaries  Medications  Surgical : recreating urethral support  Abdominal  Vaginal

Kegel Exercise 10 – 20 repetitions three times per day Hold contraction for 5 to 10 seconds A set can be done to suppress urgency Results take 6 – 8 weeks to manifest NOT to be done while voiding Improvement & cure rates as high as 60%

Treatment : Electrical Stimulation

Treatment : Pessary

Treatments : Surgical  Abdominal approaches  Open retropubic colposuspension (Burch)  Pubo-vaginal sling  Midurethral tape procedure (e.g. TVT, TOT,TVTO, Mini Slings)  Periurethral Bulking Agents

Treatment Modalities for OAB Behavioural Modification Drug Treatment Neuromodulation (for refractory cases) Surgical Treatment (for refractory cases)

Behavioral Modification Education Toileting programs Bladder retraining Lifestyle changes Pelvic Floor muscle exercises

Bladder Retraining Bladder Drill : –Increase intervals between voids –Aim for q2-3h Timed Voids (spinal cord) –Voiding times pre-selected e.g.. q2h –Interval based on avoiding leakage Prompted Voids –Fixed time interval between voids –Third party prompt –Interval based on avoiding leakage

Lifestyle Interventions Elimination of bladder irritants Manage fluid intake Cessation of smoking Weight reduction Bowel regulations Use diuretics judiciously (not before bed) Reduce physical barriers to toilet (use bedside commode)

Drug Treatment of OAB DrugLevel of evidence Antimuscarinics Tolterodine Trospium Darifenacin Solifenacin Propantheline 1 A 2 B Drugs with mixed actions Oxybutynin Propiverine Flavoxate Dicyclomine 1 A 2 D 3 C Antidepressants Imipramine3 C Vasopressin analogues Desmopressin1 A International Consultation on Incontinence, 2004

Treatment: Overflow Incontinence  Self Intermittent Catheterization  ?Alpha Blockers  ? Cholinergic Agents

Treatment: Mixed Incontinence Treat the component which is most troubling to the patient