1. Josh Karram PGY1 Riverside June 2016
Urinary Incontinence
Josh Karram PGY1 Riverside
June 2016

2. Overview Why it matters? Normal physiology
Identify historical & physical traits to aid in diagnosis and classification of urinary incontinence
Identify reversible causes of urinary incontinence
Approach to treatment

3. Why it matters? Prevalence is high Affects quality of life
More likely to:
Have depression
Limited social & sexual function
Have increased dependence on caregivers

4. Normal Physiology
Bladder fills  stretch receptors activated  signal sent via S2-S4  spinal cord  sensory cortex where need to void is perceived
Threshold volume is reached (unique to the person) triggers awareness of need to void
External urinary sphincter at bladder outlet stays contracted until ready to void; micturition inhibitory centre in frontal lobe also helps inhibit
Decision made to void  signal to micturition centre  simultaneously contracts detrusor smooth muscle (via parasympathetic cholinergic nerve fibres) and relaxes internal sphincter (alpha sympathetic nerve fibres), striated muscles and pelvic floor

5. Normal Physiology
CNS
MSK/Anatomy

6. How do we classify incontinence?
Typically broken down into 5 different categories
Stress
Urge
Mixed
Overflow
Functional

7. Case 1 52 yo F G4P4 – all SVDs no complications/instrumentation BMI 30
Going through menopause
Recently on health kick – wants to lose weight
Certain exercises at gym causing her to leak urine
Also noticed with coughing or laughing
No urgency, frequency, dysuria, or nocturia
Self-conscious
Otherwise healthy; no medications

8. Stress Pathophysiology:
Loss of urethral “support” (sphincter and/or pelvic floor weakness) allows for hypermobility and/or intrinsic sphincter deficiency
Increased abdominal pressure leads to opening of urethra and leakage

9. Stress Risk factors Vaginal delivery Instrumental vaginal delivery
Obesity
Poor tissue
Connective tissue disease, radiation, smoking, lack of estrogen, surgery
Chronic cough
Prostate surgery

10. Stress
History
Leaks during physical activity or increased intra-abdominal pressure:
Coughing
Laughing
Sneezing
Jumping
Lifting
Exercise
Walking
Rising from chair
Usually starts as small volumes and can often predict when it will happen
No nocturia
Normal urge to void
Normal voiding stream

11. Stress Physical Exam Pelvic exam Estrogen deficiency?
atrophy
Cough stress test
Good sensitivity and specificity
Full bladder (but comfortable)
Separate labia, patient to forcibly cough once
Supine +/- standing
+ve if urine leaks with onset and cessation of cough
Levator ani muscle strength – normally 5-10s
Cough
False positive if not enough urine/force; contraction of other pelvic muscles; obstructing prolapse
Delayed 5-15 s may be stimulation of bladder from cough – urge

12. Stress Treatment Weight loss Fluid optimization
Constipation management
Smoking cessation

13. Stress Treatment Proper absorbent pads Pelvic floor muscle training
Kegels
Isolate muscles that stop urine flow
3 sets; 8-12 contractions; 8-10s each; 3x/day
Vaginal weights
Biofeedback
Supervised pelvic floor physiotherapy

14. Stress Treatment con’t Continence pessary Surgery
Midurethral sling – gold standard
Tension free vaginal tape (TVT) or trans obturator tape (TOT)
May also consider:
Bladder neck sling
Periurethral bulking
Radiofrequency denaturation
Bladder neck sling - reserved for women in whom mid urethral slings contraindicated/unsuccessful
Bulking agents often for those wishing to delay surgery

15. Stress Medications Vaginal estrogen ring Vaginal estrogen cream
Alpha adrenergic agonists (pseudoephedrine, phenylephrine)
Increase resting urethral tone
Weak evidence
Duloxetine (Cymbalta)
Incontinence reduction
Not a good stand alone option but for depressed patient with concurrent stress incontinence, may be helpful

16. Case 2 41 yo G2P2 – SVDs no instrumentation
Frequency & urgency – sometimes makes it; sometimes doesn’t
Having to get up in the night 2-3x
No dysuria
Otherwise healthy
Admits that she loves her coffee and wonders if that could be contributing

17. Urge Pathophysiology:
Involuntary detrusor contractions during the filling of the bladder
+/- full bladder
2 subtypes
Sensory – result of local irritation, inflammation or infection
Neurologic – most often caused by loss of cerebral inhibition of detrusor contractions

18. Urge Risk factors Irritation Loss of neurologic control
cystitis, prostatitis, atrophic vaginitis, prior pelvic radiation therapy
Loss of neurologic control
Stroke, dementia, spinal cord injury, Parkinson’s

19. Urge History Examination Urgency, frequency, nocturia Usually normal
Small or large volumes
May be stimulated by change in body position or with sensory stimulation
If they make it to the toilet – overactive bladder; if they don’t - urge incontinence
Usually normal
May consider urodynamic testing
Cystoscopy if smokers or hematuria

20. Urge Treatment Lifestyle changes Review medications
Caffeine elimination
Weight loss
Optimize fluid intake
Smoking cessation
Constipation management
Review medications
Pelvic floor strengthening – can be more effective than medications
Bladder training
Distraction
Sacral nerve modulation
Bladder training – finding natural interval then
Try distraction
Try prompted/scheduled toileting
Sacral nerve stimulator – can be vaginal, anal or percutaneous of the posterior tibial nerve

21. Urge
Medical therapy
Anticholinergic medications – antagonize M2/M3 muscarinic receptors of bladder; selective/long-acting agents preferred
Selective - darifenacin & solifenacin; non-selective - oxybutynin and tolterodine
Increases storage, decreases urgency
Side effects: dry eyes, dry mouth, constipation
CI – narrow angle glaucoma, urinary retention, myasthenia gravis, dementia, GI obstruction/retention
Beta-adrenergic agonists – mirabegron
Relax detrusor; SE N/D, HA, dizziness, constipation, HTN
Bladder Botox – lasts 3-6 months
M2/M3 selective agents preferred; non-selective bind M1 receptors in brain and can unmask cognitive dysfunction
Trial 4-8 weeks

22. Urge Surgery Implanted devices
Stimulate sacral, paraurethral and pudental nerves
Refractory to all other treatment
Costly and risk of surgical complications

23. Mixed
Stress
Urge
Mixed

24. Overflow Pathophysiology
Urine loss associated with overdistension of bladder
Typically by an underactive bladder and/or outlet obstruction
Common example is benign prostatic hyperplasia

25. Overflow Risk factors Presentation Physical examination DM
Spinal cord injury MS
Bladder distension injuries
Obstruction – prolapse
BPH
Anticholinergic medications
Presentation
Constant wetness/dribbling
+/- urge
+/- sensation of incomplete emptying
Physical examination
Wet vulva
Palpable bladder
High PVR – U/S scan vs I/O catheter

26. Overflow Treatment MRI if suspicious of MS Remove obstruction
Clean intermittent catheterization
Sacral nerve modulation
MRI if suspicious of MS
One of the earlier complaints for first presentation of MS

27. Functional Secondary to impairment Unable to make it to the toilet
May be physical or cognitive
Unable to make it to the toilet
May also be in combination with previously mentioned etiologies
Risk factors
Dementia
Physical frailty
Inability to ambulate
Mental health disorder

28. Putting it all together
History
HPI
Urgency, frequency, nocturia
Leakage with cough, sneeze, laugh, increased intra-abdominal pressure
Constantly wet, dribble, incomplete void
Dysuria
PMHx
Bowel, back, gynecologic or bladder surgery; pelvic radiotherapy
CHF, COPD, neurological & MSK conditions,
Prostate pathology
Cognitive changes/functional abilities
Constipation
Gyne/ObHx
Estrogen status, deliveries and type, time in between

29. Putting it all together
Free tools available
3 incontinence questions – popular tool
Categorizes urinary incontinence in middle-aged to older women
Stress
Sensitivity 0.86
Specificity 0.6
Urge
Sensitivity 0.75
Specificity 0.77

30. Putting it all together
Still not sure?
Can also consider use of a voiding diary
Short term may be as helpful as longer term – easier on you and the patient
Help clarify situations, frequency, volume

31. Functional Inquiry Effects on:
Work
ADLs
Sleep
Sexual Activity
Social interactions
Interpersonal relationships
General perception of health
Quality of life
Identify the most bothersome symptom – this will help direct management

32. Putting it all together
MEDICATIONS!
Recent changes?
Some contribute by increasing urine production or impairing neuro functioning rather than having direct effect on urinary tract
List from:
Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), (9),

33. Putting it all together
Physical Exam
CVS – arteriovascular disease; volume status
RESP – chronic cough?
GI – evidence of constipation, masses
GU – bladder distension, vaginitis and atrophy, cough test
NEURO – signs of stroke, impaired mental state, spinal stenosis, peripheral neuropathy; lumbosacral nerve root testing
MSK – mobility
DERM – irritation from incontinence

34. Transient Causes of Urinary Incontinence (DIAPPERS)
Delirium
Infection (acute UTI)
Atrophic vaginitis
Pharmaceuticals
Psychological disorder, especially depression
Excessive urine output
Reduced mobility (e.g. functional) or reversible urinary retention (e.g. drug-induced)
Stool impaction
Sudden onset
<6 weeks duration

35. Putting it all together
Investigations
Creatinine
Urinalysis
Urine culture
MoCA
Post void residual
Recommended to diagnose overflow
<50ml negative; ml indeterminate; >200ml positive
U/S or I/O catheter

36. Diagnostic Approach Diagram from:
Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), (9),

37. Indications for Referral
Associated recurrent symptomatic UTIs
Associated new-onset neurologic symptoms, muscle weakness, or both
Marked prostate enlargement
Pelvic organ prolapsed past the introitus
Pelvic pain associated with incontinence
Persistent hematuria
Persistent proteinuria
Post void residual >200ml - obstruction
Previous pelvic surgery or radiation
Uncertain diagnosis

38. SAMP
List 3 indications for referral of urinary incontinence

39. Indications for Referral
Associated recurrent symptomatic UTIs
Associated new-onset neurologic symptoms, muscle weakness, or both
Marked prostate enlargement
Pelvic organ prolapsed past the introitus
Pelvic pain associated with incontinence
Persistent hematuria
Persistent proteinuria
Post void residual >200ml - obstruction
Previous pelvic surgery or radiation
Uncertain diagnosis

40. SAMP
List 3 causes of reversible urinary incontinence

41. Transient Causes of Urinary Incontinence (DIAPPERS)
Delirium
Infection (acute UTI)
Atrophic vaginitis
Pharmaceuticals
Psychological disorder, especially depression
Excessive urine output
Reduced mobility (e.g. functional) or reversible urinary retention (e.g. drug-induced)
Stool impaction
Sudden onset
<6 weeks duration

42. SAMP
What non-pharmacologic treatment can be used for both urge and stress incontinence?

43. References
Culligan, P. J., & Heit, M. (2000). Urinary incontinence in women: evaluation and management. American family physician, 62(11),
Hersh, L., & Salzman, B. (2013). Clinical management of urinary incontinence in women. American family physician, 87
Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), (9),