URINARY INCONTINENCE
By : Ayu Soraya
Outline
• Introduction
• Epidemiology and Prevalence
• Phatopysiology
• Clinical Presentation
•Treatment of UI
•Evaluation Therapeutic Outcome
INTRODUCTION
• Urinary Incontinence (UI) is the complaint of
involuntary leakage of urine.
UI may occur as a result of abnormalities :
Urethra (including the bladder outlet and
urinary spinchter)
Bladder
Combination of both
Pharmacotherapy , A Phatopysiologic Approach 7Ed, 2008 The McGraw-Hill
Epidemiology and Prevalence
• 40-50% in the elderly population will suffer from bladder
disease in the U.S.
• Risk increases with age,
• At any age, is more than
twice as common in
females than in males
European study showed a
prevalence of
between 12% and 22% in all ages
and an increase to 30–40% in ages
over 75 years
(Hampel et al. 1997).
RISK FACTOR OF UI :
• Age
• Child Birth
• Number of Pregnancy
• Hysterectomy
• Obesity
• Smoking
• Hormone changes (Menopause)
• Medications
Medication can increase or cause
urinary incontinence
• Diuretic increase urin output
• Calcium channel blocker increase oedema
• Non-steroid anti inflamatory drugs increase oedema
• Corticosteroids increase oedema
• Sedative reduce the awarness of the need to
urinate
• Cholinesterase Inhibitor reduce capacity of the
emptying bladder
• Antidepressant reduce capacity of the emptying
bladder
PHATOPYSIOLOGY
Normal Voiding Cycle
PHATOPYSIOLOGY
• UI occurs as a result of overfunctioning or
underfunctioning of the urethra, bladder, or
both.
• Acetylcholine is the neurotransmitter that
mediates both volitional and involuntary
contractions of the bladder.
• Bladder smooth muscle cholinergic receptors
are mainly of the M2 variety
PHATOPYSIOLOGY
Patients with urge
Normal Bladder incontinence
CLINICAL PRESENTATION
TYPE OF UI :
• Urethral Underactivity (Stress Urinary
Incontinence)
• Bladder Overactivity (Urge Urinary
Incontinence)
• Urethral Overactivity and/or Bladder
Underactivity (Overflow Incontinence)
• Mixed Incontinence or Other Type of Urinary
Incontinence
Urethral Underactivity
(Stress Urinary Incontinence)
The patient usually notes UI during activities such as exercise, running,
lifting, coughing, and sneezing. Occurs much more commonly in
women
Symptoms
• Urine leakage with physical activity (volume is proportional to
activity level).
• No UI with physical inactivity, especially when supine (no nocturia).
• May develop urgency and frequency as a compensatory mechanism
(or as a separate component of bladder overactivity).
Diagnostic Tests
• Observation of urethral meatus while patient coughs or strains
Bladder Overactivity
(Urge Urinary Incontinence)
Can have bladder overactivity and UI without urgency if sensory input
from the lower urinary tract is absent.
Symptoms
• Urinary frequency (>8 micturitions per day), urgency with or
without urge incontinence;
• nocturia (≥1 micturition per night) and enuresis may be present.
Diagnostic Tests
• Urodynamic studies are the gold standard for diagnosis.
• Urinalysis and urine culture should be negative (rule out urinary
tract infection as cause of frequency)
Urethral Overactivity and/or Bladder
Underactivity (Overflow Incontinence)
Urethral overactivity usually is due to prostatic enlargement (males) or cystocele
formation or surgical overcorrection following stress incontinence surgery in women.
Symptoms
Lower abdominal fullness, hesitancy, straining to void, decreased force of stream,
interrupted stream, sense of incomplete bladder emptying.
May have urinary frequency and urgency.
Abdominal pain if acute urinary retention is present.
Signs
Increased postvoid residual urine volume.
Diagnostic Tests
• Digital rectal examination or transrectal ultrasound to rule out prostatic
enlargement.
• Renal function tests to rule out renal failure due to acute urinary retention
DIAGNOSIS
• Patient with UI should undergo a basic
evaluation, that includes :
Hystory
• Fluid intake pattern
• Number of continent and incontinence episodes
• Night time urgency
• Voiding Pattern
• Neurologic hystory, etc
Physical examination
Urinalysis
Differentiating Bladder Overactivity
from Urethral Underactivity
Symptom Bladder Urethral
Overactivity Underactivity
Urgency (strong, sudden desire to void) Yes Sometimes
Frequency with urgency Yes Rarely
Leaking during physical activity(e.g., No Yes
coughing, sneezing, lifting)
Amount of urinary leakage with each episode Large if present Usually small
of incontinence
Ability to reach the toilet in time following No or just Yes
an urge to void barely
Nocturnal incontinence (presence of wet Yes Rare
pads or undergarments in bed)
Nocturia (waking to pass urine at night) Usually Seldom
Pharmacotherapy , A Phatopysiologic Approach 7Ed, 2008 The McGraw-Hill
Treatment of UI
The goal of therapy is to minimize the signs and symptoms of most
bother to the patient.
Nonpharmacologic
• Life style modification.
Associated with incontinence include obesity, smoking, level of
physical activity and diet.
Smoke cessation for patient with cough-induced stress incontinence.
• Bladder training
Timed and habit voiding are recommended to patients who can void
independently. Bladder training can be offered to any patient with any
form of UI, as a first-line therapy for at least a short period of time.
Treatment of UI
Nonpharmacologic
• Physical exercise
Regular physical activity may strengthen the pelvic floor musculature
and possibly decrease the risk of developing UI, especially SUI.
• Fluid intake
Advice on fluid intake given by healthcare professionals should be
based on 24-hour fluid intake and urine output measurements.
• Surgical Treatment
Bladder denervation
Bladder augmentation
– Bladder becomes enlarged with an extension made out of bowel
– Larger reservoir with lower bladder pressures
Treatment of UI
Pharmacologic
• Antimuscarinic drugs
Antimuscarinic (anticholinergic) drugs are currently the
mainstay of treatment for UUI.
They differ in their pharmacological profiles, e.g. muscarinic
receptor affinity and other modes of action, in their
pharmacokinetic properties, e.g. lipid solubility and half-life,
and in their formulation.
Treatment of UI
Pharmacologic
• Oestrogen
Oestrogen treatment for UI has been tested using oral,
transdermal and vaginal routes of administration.
Available evidence suggests that vaginal oestrogen treatment
with oestradiol and oestriol is not associated with the
increased risk of thromboembolism, endometrial
hypertrophy, and breast cancer seen with systemic.
Vaginal (local) treatment is primarily used to treat symptoms
of vaginal atrophy in postmenopausal women
Treatment of UI
Pharmacologic
• Desmopressin
Desmopressin is a synthetic analogue of vasopressin (also
known as antidiuretic hormone).
It can be taken orally, nasally or by injection.
Desmopressin is most commonly used to treat diabetes
insipidus and, when used at night, to treat nocturnal enuresis.
Treatment of UI
• Pharmacologic
EVALUATION THERAPETIC OUTCOME
In the long-term management of UI, the clinical symptoms of
most distress to the individual patient need to be monitored.
Therapies for UI frequently have nuisance adverse effects,
which need to be carefully elicited.
Adverse effects can necessitate
• Drug dosage adjustments,
• Use of alternative strategies (e.g., chewing sugarless gum,
sucking on hard sugarless candy, or use of saliva substitutes
for xerostomia), or
• Drug discontinuation.
