URINARY INCONTINENCE Urology Division, Surgery Department Medical Faculty, University of Sumatera Utara

Definition The involuntary loss of urine May denote a symptom, a sign or a condition Symptom  the patient’s complaint of involuntary urine loss Sign  objective demonstration of urine loss The condition  the underlying cause Prevalence 38%, increasing with age

Classification Anatomic or genuine urinary stress incontinence Urge incontinence Neuropathic incontinence Congenital incontinence False (overflow) incontinence Posttraumatic or iatrogenic incontinence Fistulous incontinence

URINARY INCONTINENCE BLADDER RELATED URGE INCONTINENCE  Detrusor overactivity  Hyperreflexia  Instability  Poor / Low Compliance  Small Capacity OVERFLOW INCONTINENCE / NON CONTACTILE / AREFLEXIE  BPH with chronic retention  Diabetic bladder neuropathy  Complete parasympathetic lessions SPHINCTER RELATED STRESS INCONTINENCE  Anatomic / urethral hypermobility  Intrinsic Sphincter Deficiency (ISD) SPHINCTER RELATED STRESS INCONTINENCE  Anatomic / urethral hypermobility  Intrinsic Sphincter Deficiency (ISD)

Combined problem associated with incontinence Detrusor overactivity with outlet obstruction Detrusor overactivity with impaired bladder contractility Sphincteric incontinence with impaired bladder contractility Sphincteric incontinence with detrusor overactivity

URINARY STRESS INCONTINENCE Women after middle age (with repeated pregnancies) A result of weakness of the pelvic floor

Sign & symptom Symptom : complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Sign : - can be observed as the involuntary leakage of urine from the urethra - a cough stress test by asking the patient to cough with a full bladder and the objectively assess the leakage of urine

Main risk factors Predisposing factors : - Familiar predisposition - Gender  higher in women - Anatomic, neurological and muscular abnormalities Inciting factors : - pregnancy/childbirth/parity - side effect of pelvic surgery & radio therapy

Promoting factors : - obesity - constipation - lung disease & smoking - UTI - neurological disease - menopause - drugs / medication Decompensating factors : - age - dementia & debility - drugs / medication

The most studied and proven risk factors are : - age - obesity - parity

Diagnosis Detailed history : degree of leakage, its relation to activity, position and state of bladder fullness, timing of its onset, course of its progression Past surgical and obstetric history, medication taken, dietary habits, systemic disease

Treatment Conservative treatment : - lifestyle intervention (weight loss, stop smoking) - pelvic floor muscle training Pharmacological treatment : - α1-adrenoceptor agonists - tricyclic antidepressants - oestrogens Surgical treatment

URGE INCONTINENCE Involuntary loss of urine, accompanied or immediately preceded by urgency Basic feature : detrusor instability and the loss of urine while attempting to inhibit micturation OAB (overactive bladder)  urgency, frequency, nocturia Etio : neuropathic injuries (spinal cord injury), obstruction, inflammation, diabetes, BPH, iatrogenic

Diagnosis Detailed history Physical examination Urinalysis Identification of modifiable causes usch as impaired mobility

Normal Control of Voiding:

Overactive Bladder:

Treatment Lifestyle modification (fluid management) Behavioral techniques (bladder training) Anticholinergic therapy (tolteridine, oxybutynin, trospium) Medical management is more efficacious Surgical procedures (bladder reconstruction or urinary diversion)

MIXED URINARY INCONTINENCE Occurrence of stress-related incontinence with symptomatic urinary urgency and UI Detrusor dysfunction and is associated with urethral sphincter underactivity Incidence increases with advancing age, most commonly in women > 60 years old

Therapy Behavioral therapy Anticholinergic  70% cases have symptomatic improvement Surgical

OVERFLOW INCONTINENCE Involuntary loss of urine associated with bladder overdistention 2 primary process are involved : - urinary retention caused by bladder outlet obstruction - inadequate bladder contraction

Diagnosis Overflow bladder is detected by measuring post-void residual urine volume with USG or urethral catheterization immediately after urinates N 200 mL  overflow bladder

Treatment Initial treatment  focus on reversible causes (cystocele, pelvic organ prolapse, etc) If precipitating element not be found  conservatively : adjustment fluid intake and timed voiding

WR’08