lecture 56: urinary incontinence and pelvic relaxation

95%

___% of children achieve urinary continence by 5

•achieved some degree of continence prior to incontinence

•consider stress of psychological or physical abuse

define secondary urinary incontinence

nocturnal enuresis

the most common cause of functional urinary incontinence in children

-genetic risk (chromosome 12 and 13q)

-attention deficit disorders

-small bladder, nocturnal polyuria, nocturnal detrusor over-reactivity, disorder of sleep or arousal states

risk factors of nocturnal enuresis

•Comorbid constipation is common and effective treatment is integral to management of incontinence

comorbid condition of daytime incontinence

reassurance and fluid restriction before consideration of treatment

evaluation of urinary incontinence in children under 5

urine dipstick

screening tool for infection, kidney disease ,and glucosuria

serum electrolytes, calcium, glucose and creatinine

screenings for polyuria

stress incontinence

•involuntary leakage of urine that occurs when intra-abdominal/intra-vesical pressure exceeds urethral pressure

urge incontinence

•involuntary leakage that occurs due to involuntary contractions of the bladder, uninhibited detrusor contractions

•occurs when both stress incontinence and urge incontinence are present

define mixed incontinence

overflow incontinence

occurs when the bladder is unable to contract thus overfills and overspills past urethra, ineffective detrusor muscle

vaginitis, UTI

infectious ddx of urinary incontinence

•Stress incontinence

•Detrusor overactivity

•Mixed types

•Overflow incontinence

ddx of filling and storage disorders

urethral diverticulum

-diverticulum collects small volumes of urine

-distal to sphincter--> intermittent leaking without trigger of small volumes

•Typically, post obstetric trauma, surgery or radiation

a fistula causing incontinence is usually secondary to

fistula

•Urine not leaking out of urethra meatus, leaking into alternate space and making its way to outside

urethral diverticulum

intermittent leaking without triggering of small volumes

cystocele

vagina weakness of anterior fascia--> bulging of anterior vaginal wall

•As enlarges cystocele may kink bladder neck and result in obstruction of urine outflow and present as urinary retention

later complication of cystocele

anal wink and bulbocavernosus reflexes to assess sacral reflex pathway

how do you assess motor and sensory function of pelvis/urethra

urinalysis-- all should be screened for UTI

screening test for ALL PTS with complaints of incontinence

stress test

ask patient to Valsalva and observe for urine leakage, preferably standing

after patient empties bladder, measure remaining volume by catheter drainage or ultrasound calculation

how do you do a post-void residual to evaluate for urinary incontinence in-office

post void residual

in office procedure that only documents partial emptying, not incontinence

normal is less than 35 ml

->100 ml should be investigated

normal value of post void residual

urinary diary

1.documents triggers for incontinence, bladder irritants

Lubricated Q-tip is placed in the urethral meatus. With Valsalva, in healthy woman little movement occurs and no leakage of urine. In woman with stress incontinence, with Valsalva, the visible Q-tip end will move up toward the ceiling and a positive test is defined by movement of at least 30 degrees. Often urine loss is observed, but not required to have a positive test.

how do you perform the Q tip test

visible Q-tip end will move up toward the ceiling and a positive test is defined by movement of at least 30 degrees.

define a positive Q tip test

activieis (runninng, jumpping laughing)

-obesity--> atrophy of bladder tissues, intrinsic weakness of pelvic support

most common etiologies of stress incontinence

urinary stress incontinence

incontinence that is primarily an anatomic problem--> loss of support of the urethral vesical junctionn

-associated with anterior vaginal wall prolapse

•With valsalva the urethra is displaced downward thus decreasing intraurethral pressure

•When pressure in bladder exceeds that in urethra, leakage occurs because sphincter can not hold urine back

anatomy of stress incontinence

•Age

•Multiparity- previous vaginal deliveries or vaginal trauma

•Body weight

•Previous pelvic surgery ex. Hysterectomy

•Smokers

•Constant straining

risk factors for stress incontinence

urge incontinence

•Occurs when bladder becomes unstable and has contractions that are not controlled, small continual contractions of detrusor.

urge incontinence

-no bladder inhibition, there is a large volume of leaking, complete emptying

stress incontinence

•Results in small spurts of urine loss and incomplete emptying

urge incontinence

pt usually has intense urge to void then leaks prior to making it to the restroom

-usually associated with frequency, worse at night

-voiding diary very helpful in diagnosis

urge incontinence

most common incontinence in men

mixed incontinence

urodynamic testing is very helpful to assess for

urodynamic testing

•Evaluation of urine storage, bladder emptying and sphincter control mechanisms

•Multichannel urethral pressure profiles demonstrate urethral leak point

•Measure bladder capacity, volume at first urge, volume at incontinence

•Demonstrates repetitive detrusor muscle contraction in urge incontinence

overflow incontinence

-incomplete bladder emptying due to detrusor weakness or obstruction

-usually neuro issue with no bladder contraction

-no perception of bladder fullness

overflow incontinence

•Leaks when bladder pressure is higher than urethral pressure

•Continuous small amount of leaking – few, or no triggers to incontinence

-weight loss minimum 8%

-pelvic floor training/kegel exercises

-fluid management: max 2 L per day

-vaginal pessarrries

-bulking agents

main treatments for stress incontinence

vaginal pessaries

-provides mechanical support to weakened tissues in tx of stress incontinence

-fitted to individual pt

•vaginal trauma, vaginitis, urinary retention, retention

of foreign body, abrasions, adhesions

risks of vaginal pessaries

bulking agents

pyrolytic carbon-coated beads and calcium hydroxylapatite

• injected periurethrally or transurethrally

•less invasive but less effective than surgery

-tx of stress incontinence

-anticholinergics

-antimuscarinnics: act on bladder M2 and M3 receptors to inhibit involuntary detrusor contractions

-onabotulinumtoxin A: inhibit Ach

Rx tx for urge incontinence

bladder traininng

neurostimulation using tibial nnerve

non pharm tx for urge incontinence

•Bladder retraining

•Self cath

•Will not respond to incontinence surgery, prolapse surgery may be indicated

mannagement of overflow incontinence

•Primarily a break or tear in connective tissue and endopelvic fascia which results in loss of support of vaginal wall and organs

most common cause of pelvic organ prolapse

•Age

•Multiparity- previous vaginal deliveries or vaginal trauma

•Large infant birth weights

•Body weight

•Previous pelvic surgery ex. Hysterectomy

•Smokers

•Constant straining

•Connective tissue disease

•Family history

risk factors for pelvic prolapse

cystocele (bladder)

anterior vaginal wall prolapse

enterocele (small bowel)

apical vaginal wall prolapse

rectocele

posterior wall prolapse

Vaginal bulge, pressure, incontinence, prolonged urination, partial emptying, frequency, nocturia

symptoms of cystocele

•Some women report “splinting” – compressing vaginal wall to accomplish rectal emptying

•Constipation, rectal fullness, increases straining and promotes circular pattern

• Also produces pressure on the bladder

symptoms of rectocele

•support of cardinal and uterosacral ligaments, lengthening these ligaments

uterine prolapse is due to a defect in

procedentia

complete prolapse of cervix or uterus below the vestibule

1st degree- noticeable defect of support

2nd degree- half of vaginal wall involved

3rd degree- prolapse to vaginal opening

4th degree- prolapse beyond vestibule

what are the degrees of pelvic organ prolapse?

•Untreated risk includes urinary retention, UTI, hydroureter, obstruction.

risks of not treating pelvic organ prolapse

1.Pelvic floor exercises for the mild cases

2.Changes in activities (i.e. lifting and straining). Treat constipation.

3.Pessaries- requires adequate levator muscle tone

non surgical treatments for pelvic organ prolapse

colporraphy

plication of connective tissue – tying together colpometrium, vaginal incision, recurrence rates high, augmentation with mesh or animal graft

-surgical treatment of pelvic organ prolapse

At time of hysterectomy, augment support to vaginal apex

how do you prevent pelvic organ prolapse in hysterectomy?

NE through B receptors

NT that inhibits detrusor muscle contraction

alpha receptors

receptor that stimulates internal sphincter contraction

spinobulbospinal reflex

Micturition is fundamentally a ___________ facilitated and inhibited by higher brain centers such as the pontine micturition center and, like defecation, subject to voluntary facilitation and inhibition.