1. Urinary incontinence Dr Mohammad Hatef Khorrami Urologist Fellowship of endourology isfahan university of medical science

2. Incontinence Incontinence Stress Urge mixed Unconscious Continuous Nocturnal enuresis

3. Epidemiology In women %3-%11 In women %3-%11 In men %2- %6 In men %2- %6

4. Mechanism of continence Good compliance Good compliance sphincter sphincter

5. Structure of the Bladder Ureter Prostate gland Detrusor smooth muscle External urethral sphincter Pelvic floor

6. Micturition Reflex Brain Direction of nerve impulse Spinal cord Bladder Pelvic floor

7. Bladder Filling & Emptying Cycle The cycle of bladder filling and emptying 1. Bladder fills 2. First desire to urinate (bladder half full) Urination 3. Urination voluntarily inhibited until time and place are right Detrusor muscle contracts Detrusor muscle relaxes Urethral sphincter contracts Urethral sphincter relaxes

8. Etiology Bladder abnormality Bladder abnormality Detrusor overactivity Detrusor overactivity Decreased bladder compliance Decreased bladder compliance Sphincter abnormality Sphincter abnormality

9. Causes of detrusor overactivity Idiopathic Idiopathic Neurologic Neurologic CVA,brain atrophy, brain tumor, MS, SCI CVA,brain atrophy, brain tumor, MS, SCI Non neurogenic Non neurogenic UTI, obsruction,pelvic organ prolaps,bladder tumor, bladder stone,age UTI, obsruction,pelvic organ prolaps,bladder tumor, bladder stone,age

10. Sphincteric abnormality Men Men Prostate surgery,trauma, neurologic Prostate surgery,trauma, neurologic Women Women Urethral hypermobility,intrinsic sphincteric insufficiency,neurogenic Urethral hypermobility,intrinsic sphincteric insufficiency,neurogenic

11. Causes of transient incontinence Delirium Delirium Infection Infection Athrophic vaginitis Athrophic vaginitis Psychologic Psychologic Pharmacologic Pharmacologic Excess urine production Excess urine production Restricted mobility Restricted mobility Stool impaction Stool impaction

12. How to Recognize Patients with incontinence Symptom assessment Medical history Physical examination Urinalysis Bladder diary Pad test Referral for medical evaluation and treatment

13. Medical History Other questions that your doctor/nurse might ask: History of previous surgery or radiotherapy involving the pelvic region Medications currently taking Main symptoms (complaints) Duration of symptoms

14. Physical Examination Abdomen exam Rectal exam Pelvic exam Neurologic exam

15. Urinalysis urinary tract infection To rule out urinary tract infection

16. Bladder Diary Helps patients Helps patients record details of: Bladder symptoms Type/amount of drinks taken Time/amount of urine passed

17. Pad Test A supplementary test used to confirm urine leakage and quantify the degree of urine loss.

18. Pad Test Method: Drink 500 ml of fluid as quickly as possible

19. Pad Test Method (cont’d): Perform a series of physical tasks in a 1-hour period Walking Climbing stairs Coughing vigorously Running on the spot

20. Pad Test Method (cont’d): The pad is re-weighed. A weight gain of more than 1 g signifies that the patient is incontinent.

21. Referral for Further Evaluation and Treatment Urodynamic test Imaging Endoscopy

22. treatment Low bladder compliance Low bladder compliance Drug Drug Enterocystoplasty Enterocystoplasty Denervation Denervation

23. Treatment sphincteric dysfunction Behavioral modification Behavioral modification Drug Drug Urethral bulking agent Urethral bulking agent surgery surgery Sling Sling Artificial sphincter Artificial sphincter

24. Management of Overactive Bladder Drug therapy Bladder training Incontinence pads and protective devices Bladder self-catheterization Pelvic floor exercises Biofeedback Review diet and food intake Skin care and cleanliness Surgery

25. Bladder Training A behavioural approach to the treatment of the overactive bladder, which is often used in combination with drug therapy.

26. Bladder Training Aims: Increase the time intervals between bladder emptying. Increase bladder capacity by teaching patients to resist and suppress the urge to pass urine.

27. Incontinence Pads and Protective Equipment Absorbent pads Dribble pouch Reusable underpants designed to carry disposable absorbent pads All-in-one briefs Chair and bed pads

28. Pelvic Floor Exercises Kegel exercises Also known as Kegel exercises.

29. Pelvic Floor Exercises Aim: To strengthen the pelvic floor muscle and increase overall muscle tone.

30. Biofeedback Aim: Helps patient identify the correct muscle for performing Kegel exercises

31. Biofeedback Source: Biofeedback Instrument Corporation

32. Review Diet and Fluid Intake Some patients will try to reduce the risk of leakage by restricting their fluid intake.

33. Review Diet and Fluid Intake irritate the bladder However, drinking too little results in concentrated urine, which itself can irritate the bladder.

34. Review Diet and Fluid Intake Therefore, it is important that patients are encouraged to drink appropriate amount of fluids.

35. Review Diet and Fluid Intake Reduce Reduce consumption of: Caffeine (i.e. tea and coffee) Carbonated soft drinks Alcoholic drinks

36. Management of Overactive Bladder Drug therapy Bladder training Incontinence pads and protective devices Bladder self-catheterization Pelvic floor exercises Biofeedback Review diet and food intake Skin care and cleanliness Surgery

37. Role of Nurses recogniseHelp to recognise patients who have problems maintaining continence helpadviceOffer help and advice to patients and relatives

38. Control Confidence Freedom