1. Urinary Incontinence Girija Charugundla

2. Definition UI is the involuntary loss of Urine that leads to a hygiene or social problem

3. Prevalence 1.Increases with age (not a part of normal aging) 2. 25 – 30% community dwelling women, 10 – 15% community dwelling men 3.About 1/3 of patients in acute care setting 4.Greater than 50% of residents in nursing homes associated with dementia, immobility and Fecal Incontinence

4. Anatomy of lower Urinary Tract 1.Muscular storage and contractile organ called detrusor (smooth muscle) 2.Smooth muscle sphincter located in Proximal urethra (internal sphincter) 3.Distal peri-urethral striated muscle (external sphincter)

5. Physiology of Micturation 1.Autonomic (sympathetic and Para-sympathetic) and somatic (voluntary) nervous systems coordinate micturation 2.Normal bladder fills passively with little change in intravesicle pressure (facilitated by CNS inhibition of Para-sympathetic activity) and the sphincters remain closed (facilitated by reflex increase in alfa- adrenergic and somatic tone) 3.For voiding para-sympathetic mediated bladder contraction coincides with coordinated sphincter relaxation

6. Urinary Changes With Normal Aging 1.Increase in post void residual volume (PVR), Involuntary bladder contraction (urgency) nocturia 1-2 times at night 2.Decrease in bladder capacity and force of contraction, ability to postpone voiding (frequency), urethral compliance and strength of pelvic floor muscle

7. - Delirium - Infection, urinary (symptomatic) - Atrophic urethritis- vaginitis - Pharmaceuticals - Psychological disorders - Endocrine disorders/ excessive urine production - Restricted mobility - Stool impaction Potentially reversible causes of Incontinence (Transient Incontinence)

8. Lower Urinary Tract Dysfunction Failure to Store -Hyperactive or Overactive Bladder - Incompetent Sphincter Failure to Empty -Under-active Bladder - Obstruction

9. Types of Urinary Incontinence Stress Urge Overflow Functional

10. Urge Incontinence 1.Most common cause of UI over age 75years 2.Abrupt desire to Void (Urgency that can not be suppressed) 3.Usually idiopathic 4.Other causes- bacterial cystitis bladder tumor, bladder stones, atrophic vaginitis/ urethritis, stroke, Parkinson ’ s disease, dementia

11. Stress Incontinence 1.Most common in women especially less than 75 years 2.Hyper mobility of bladder neck and urethra, aging, hormonal, multiple child birth, hysterectomy, pelvic surgery 3.Intrinsic sphincter deficiency, previous pelvic or anti-incontinence surgery, pelvic radiation, trauma, neurogenic disorders

12. Overflow Incontinence 1.Over distension of the bladder causing constant or frequent dribbling 2.Bladder outlet/ stricture obstruction cystocele, BPH, Fecal impaction 3.Acontractile bladder (AKA: Detrusor hypo mobility, atonic bladder, Diabetes, MS, Lumber spinalstenosis, spinal cord injury, and medications

13. Functional Incontinence 1.Does not involve lower urinary tract 2.Result of Physical and /or cognitive impairment (arthritis, stroke, dementia)

14. Mixed Incontinence 1.When a combination of the above types exists 2.Most common combination is Detrusor overactivity (urge incontinence) and outlet incompetence (stress incontinence)

15. Office Work Up 1.Ask the question “ in the past year have you ever lost urine or gotten wet? ” if “ yes ” “ have you lost urine on at least 6 separate days? ” 2.Duration, severity, symptoms, previous treatment, medication, previous anti- incontinence surgery 3.Bladder record, frequency, type, and number of incontinent episodes

16. Physical Examination 1.Assess mental status 2.Assess mobility 3.Look for peripheral edema or evidence of CHF 4.Abdominal exam 5.Neurologic- evaluation of lumbosacral nerves, focal findings, peripheral neuropathy 6.Pelvic exam- atrophic vaginitis, cystocele, uterine prolapse, rectocele, para vaginal muscle tone, mass 7.Rectal- sphincter tone (active of resting), to asses integrity of sacral flexes (S2-S4), fecal impaction

17. Pad test/cough stress test 1.Perform with a full bladder, patient standing 2.Instantaneous leakage with cough- stress 3.Specificity greater than 90% 4.Leakage delayed or persists after cough- suspect urge UI

18. Post-voidal residual volume (PVR) 1.Perform within 5min of voiding 2.Catheterization or bladder ultrasound - PVR less than 50cc adequate bladder emptying -PVR less than 100cc adequate bladder emptying greater than 65 years - PVR more than 200cc refer to specialist

19. Basic lab evaluation for UI 1.Calcium, glucose 2.BUN/ Cr- if PVR is greater than 200cc 3.UA and culture

20. Simple Cystometry 1.Useful when unsure of type of UI 2.Office based procedure 15-20min 3.3 determines bladder capacity and stability 4.Correlates with multichannel systometrogram

21. Management of UI 1.Behavior therapy 2.Pharmacological therapy 3.Surgery 4.Pessaries 5.Peri-urethral bulking agents 6.Occlusive devices 7.Garments and pads 8.Catheters

22. Behavioral intervention 1.Reduce amount and timing of fluid intake 2.Avoid bladder stimulant such as caffeine, ETOH 3.Use diuretics judiciously 4.Make toilet easier to get to by Suggesting bed side commode

23. 1.Bladder retraining 2.Pelvic muscle (kegel) exercises Patient dependent behavioral intervention

24. Caregiver dependent behavioral intervention 1.Scheduled toileting 2.Habit training 3.Prompted voiding

25. Current therapy for UI 1.Oral medications 2.Trandermal oxybutynine 3.Intravesicle therapy 4.Botulinum toxins 5.Interstim system

26. Treatment for stress incontinence 1.Meds 2.Surgical techniques 3.Pessary 4.Peri-urethral bulking agents

27. Therapy for overflow incontinence 1.Meds to relieve obstruction 2.Surgery to relieve obstruction 3. Intermittent catheterization