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04.11.2014
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UrinaryUrinary IncontinenceIncontinence
Tevfik Tevfik YoldemirYoldemir, , MD, BBAMD, BBA
Marmara Marmara UniversityUniversityDepartmentDepartment of of ObstetricsObstetrics andand GynecologyGynecology
DivisionDivision of of ReproductiveReproductive EndocrinologyEndocrinology andand InfertilityInfertility
DefinitionDefinition
•• ““InvoluntaryInvoluntary lossloss of of urine or stool in urine or stool in sufficient amount orsufficient amount or frequency to frequency to constitute a social and/orconstitute a social and/or healthhealth problem.problem.
•• A A heterogeneousheterogeneous condition that ranges in condition that ranges in severity fromseverity from dribbling small amounts of dribbling small amounts of urine tourine to continuouscontinuous urinaryurinaryincontinenceincontinence…”…”
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PrevalencePrevalence
•• AAffectsffects up 20% of communityup 20% of community--dwelling dwelling olderolder individualsindividuals
•• Affects up to 50 % of nursing home Affects up to 50 % of nursing home residentsresidents
•• IncreasesIncreases graduallygradually duringduring youthyouth
•• PeaksPeaks aroundaround middlemiddle ageage
•• Steadily increases in the elderlySteadily increases in the elderly
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Prevalance of UI among womenEPINCONT Study [n=27.936]
Hannestad et al, J Clin Epidemiol 2003;53:1150-1157
Curr Med Res Opin 2004;20;(6):791-801
Risk Risk factorsfactors
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ReversibleReversible CausesCauses
• • DeleriumDelerium;;dementiadementia
• • InfectionsInfections::urinaryurinary,,respiratoryrespiratory, skin, skin
• • AtrophicAtrophic vaginitisvaginitis, , urethritisurethritis; ; alcoholalcohol ingestioningestion; ; acuteacute illnessillness
• • PharmacologicalPharmacological agentsagents : : diureticsdiuretics, , sedativesedative//hypnoticshypnotics
antianti--cholinergicscholinergics, , calciumcalcium channelchannel blockersblockers antidepressantsantidepressants,,etcetc
• • PsychologicalPsychological causescauses: : depressiondepression, , griefgrief//lossloss
• Endocrine disorders: Hyperglycemia ;excess urine• Endocrine disorders: Hyperglycemia ;excess urine outputoutput; ; excessexcess fluidfluid intakeintake
• Restricted mobility :physical restraints, musculoskeletal• Restricted mobility :physical restraints, musculoskeletaldisordersdisorders
• • StoolStool impactionimpaction; ; chronicchronic constipationconstipationtevfik@yoldemir.comtevfik@yoldemir.com
ClassificationsClassifications of of UrinaryUrinaryIncontinenceIncontinence
• • StressStress
• • UrgeUrge
• • OverflowOverflow
• • FunctionalFunctional
• • MixedMixed componentcomponent ((detrusordetrusor hypercontractabilityhypercontractability andandimpairedimpaired contractioncontraction))
• • ReflexReflex ((spinalspinal cordcord damagedamage))
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StressStress
• Leakage with increase in intra• Leakage with increase in intra--abdominalabdominal
pressurepressure
• • UrethralUrethral sphinctersphincter malfunctionmalfunction ((intrinsicintrinsic weaknessweakness) / ) / bladderbladder neckneck hypermobilityhypermobility
• Associated with weakening of pelvic floor• Associated with weakening of pelvic floor musclemuscle
• Loss of small to moderate amount of urine• Loss of small to moderate amount of urine
• No evidence of urgency or • No evidence of urgency or nocturianocturia
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UrgeUrge
• • VoidingVoiding dysfunctiondysfunction associatedassociated withwith involuntaryinvoluntary lossloss of of urineurine
• • DetrusorDetrusor overactivityoveractivity
• • UrgencyUrgency
• • FrequencyFrequency
• • NightNight time time voidingvoiding
• Most common in older women• Most common in older women
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OverflowOverflow
• Involuntary loss of urine due to distention of the• Involuntary loss of urine due to distention of the
bladderbladder
• Filling occurs to the stretch limit of the bladder• Filling occurs to the stretch limit of the bladder
• Underactive • Underactive detrusordetrusor with/without bladder outletwith/without bladder outlet
obstructionobstruction
• • LargeLarge PVR >400ccPVR >400cc
• • DribblingDribbling, , frequencyfrequency
• • HighHigh ratesrates of of infectionsinfections
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Incontinence AssesmentIncontinence Assesment
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Measurement of Bladder Base Measurement of Bladder Base Descent (The QDescent (The Q--tip Test)tip Test)
TreatmentTreatment
• • BehavioralBehavioral ModificationModification
• • PharmacotherapyPharmacotherapy
• • UrethralUrethral InjectionInjection
• • SurgerySurgery
• • DevicesDevices
• • ReferralReferral
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BehavioralBehavioral TreatmentTreatment
StressStress IncontinenceIncontinence
1. 1. PatientPatient educationeducation
2. 2. KegelKegel exercisesexercises
3. 3. DietDiet modificationmodification
4. 4. WeightedWeighted vaginalvaginal conescones
5. 5. PessaryPessary
6. Pelvic floor electrical stimulation6. Pelvic floor electrical stimulation
7. 7. WeightWeight reductionsreductions
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BehavioralBehavioral TreatmentTreatment
UrgeUrge IncontinenceIncontinence
1. 1. PatientPatient educationeducation
2. 2. TimedTimed voidingvoiding
3. 3. HabitHabit trainingtraining
• • urgeurge inhibitioninhibition
• • bladderbladder trainingtraining
4. Avoid caffeine and alcohol intake4. Avoid caffeine and alcohol intake
5. 5. DietDiet modificationmodification
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BehavioralBehavioral TreatmentTreatment
MixedMixed IncontinenceIncontinence
1. 1. PatientPatient educationeducation
2. Treat the predominant type2. Treat the predominant type
3. 3. KegelKegel exercisesexercises--81% reduction in urinary81% reduction in urinary
leakageleakage
4. 4. DietDiet modificationmodification
5. 5. BladderBladder trainingtraining
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BehavioralBehavioral TreatmentTreatment
OverflowOverflow IncontinenceIncontinence
1. 1. PatientPatient educationeducation
2. “2. “DoubleDouble voidingvoiding techniquetechnique””
3. 3. DietDiet modificationmodification
4. 4. AvoidAvoid caffeinecaffeine//alcoholalcohol
5. Barrier product to prevent skin5. Barrier product to prevent skin
breakdownbreakdown
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BehavioralBehavioral TreatmentTreatment
FunctionalFunctional IncontinenceIncontinence
1. 1. PatientPatient educationeducation
2. 2. EnvironmentEnvironment alterationsalterations
3. 3. GrabGrab barsbars//raisedraised seatsseats
4. 4. CaregiverCaregiver assistanceassistance//educationeducation
5. 5. ScreenScreen forfor depressiondepression//cognitivecognitive impairmentimpairment
6. 6. OccupationalOccupational //PhysicalPhysical therapytherapy
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PharmacologicalPharmacological TreatmentTreatment
• • AnticholinergicsAnticholinergics==detrusordetrusor underactivityunderactivity, , maymay causecauseretentionretention
• • CholinergicsCholinergics==detrusordetrusor overactivityoveractivity, , maymay causecause frequencyfrequency
• • AlphaAlpha agonistsagonists==outletoutlet overactivityoveractivity, , maymay causecause retentionretention
• • AlphaAlpha blockersblockers==outletoutlet underactivityunderactivity, , maymay causecause stressstressincontinenceincontinence
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AnticholinergicsAnticholinergics
• • DarifenacinDarifenacin ((EnablexEnablex))
• • OxybutyninOxybutynin ((UropanUropan XL)XL)
• • SolifenacinSolifenacin ((VesicareVesicare))
• • TolterodineTolterodine ((DetrusitolDetrusitol))
• • TrospiumTrospium ((SancturaSanctura))
• • FlavoxateFlavoxate ((UrispasUrispas))
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AlphaAlpha AgonistsAgonists
• • PhenylpropanolaminePhenylpropanolamine hydrochloridehydrochloride--nono
longer marketed in U.S. (longer marketed in U.S. (IntracerebralIntracerebral
hemorrhagehemorrhage))
• • PseudoephedrinePseudoephedrine ((SudafedSudafed))
• • MidodrineMidodrine ((ProamatineProamatine))
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AlphaAlpha BlockersBlockers
• • AlfuzosinAlfuzosin ((UroxatralUroxatral))
• • DoxazosinDoxazosin ((CarduraCardura))
• • TamsulosinTamsulosin ((FlomaxFlomax))
• • TerazosinTerazosin ((HytrinHytrin))
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PhysiologyPhysiology of of StressStressIncontinenceIncontinence
1. Urethral sphincter fails to protect against1. Urethral sphincter fails to protect against
lossloss of of urineurine
–– IntrinsicIntrinsic weaknessweakness
–– FailureFailure toto contractcontract
2. 2. UrethralUrethral hypermobilityhypermobility
3. 3. CoexistCoexist togethertogether
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PharmacologicalPharmacological TreatmentTreatment ofofStressStress IncontinenceIncontinence1. 1. PhenylpropanolaminePhenylpropanolamine hydrochloridehydrochloride //pseudoephedrinepseudoephedrine
//midodrinemidodrine
• • ReductionReduction in in padpad changeschanges
• • ReductionReduction in in incontinenceincontinence episodesepisodes
• • ImprovementImprovement in in subjectivesubjective symptomssymptoms
2. 2. DuloxetineDuloxetine ((CymbaltaCymbalta))
• • InhibitorInhibitor of of serotoninserotonin//norepinephrinenorepinephrine reuptakereuptake
• Increases serotonin/• Increases serotonin/norepinephrinenorepinephrine levels in the sacrallevels in the sacral
spinalspinal cordcord
• Increased contraction of urethral sphincters during urine• Increased contraction of urethral sphincters during urine
storage phase of storage phase of micturitionmicturition cyclecycletevfik@yoldemir.comtevfik@yoldemir.com
PhysiologyPhysiology & & PharmacologicalPharmacologicalTreatmentTreatment forfor OveractiveOveractive BladderBladder
1. 1. NeurogenicNeurogenic
–– CauseCause--enhancedenhanced bladderbladder CC--fiber fiber sensorysensory inputinput
–– AbnormalAbnormal atropineatropine--resistantresistant parasympatheticparasympathetic transmissiontransmission
–– AcetylcholineAcetylcholine mediatesmediates detrusordetrusor contractioncontraction
2. 2. AnticholinergicAnticholinergic versusversus placeboplacebo controlcontrol
–– 41% experienced a cure or improvement in urinary 41% experienced a cure or improvement in urinary incontinence,incontinence, improvement in leakage episodes/24 hours, improvement in leakage episodes/24 hours, number of voids in 24number of voids in 24 hours, volume at first contractionhours, volume at first contraction
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DistributionDistribution//FunctionFunction of of MuscarinicMuscarinicReceptorsReceptors ThroughoutThroughout thethe BodyBody
• M1:• M1:CerebralCerebral cortexcortex, , hippocampushippocampus, , salivarysalivary glandsglands, , eyeeye--memorymemory//cognitioncognition
• M2:• M2:BladderBladder, , HeartHeart, , eyeeye, , hippocampushippocampus--heartheart rate/rate/teartearsecretionsecretion
• M3:• M3:BladderBladder,,salivarysalivary glandsglands, , eyeeye, , brainbrain--bladderbladder
contractioncontraction/ / bowelbowel motilitymotility
• M4:• M4:BasalBasal forebrainforebrain, , salivarysalivary glandsglands
• M5:• M5:SubstaniaSubstania nigranigra, , eyeeye--visualvisual accommodationaccommodation
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MuscarinicMuscarinic ReceptorsReceptors AntagonistsAntagonists
• • DetrusorDetrusor contraction contraction ––mediated by M3mediated by M3 muscarinicmuscarinicreceptorsreceptors
• • MainstayMainstay of of treatmenttreatment
• Choose an agent that is selective for the• Choose an agent that is selective for the bladderbladder
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SurgicalSurgical TreatmentTreatment
IndicationsIndications::
–– FailedFailed nonsurgicalnonsurgical managementmanagement
–– Unable to tolerate side effects of medicationsUnable to tolerate side effects of medications
–– MoreMore definitivedefinitive therapytherapy
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BurchBurch Burch + PDRBurch + PDR
TVT TVT ––11
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TVT TVT --22
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TVT TVT --33
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TVT TVT --44
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TOT TOT --11
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TOT TOT --22
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PessariesPessaries
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