UP DATE MANAGEMENT OF URINARY INCONTINENCE IN ADULT

Transcription

1 UP DATE MANAGEMENT OF URINARY INCONTINENCE IN ADULT Yunizaf, MD Division of Urogynecology Department of Obstetrics and Gynecology School of Medicine, University of Indonesia/ Dr. Cipto Mangunkusumo Hospital Jakarta, Indonesia

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3 DEFINATION Urinary incontinence is the involuntary loss of urine which is objectively demonstrable and a social or hygiene problem.

4 TYPE OF URINARY INCONTINENCE 1. Stress incontinence 2. Overactive bladder 3. Overflow incontinence 4. Continue incontinence

5 STRESS INCONTINENCE Stress incontinence is the involuntary loss of urine when the intravesical pressure exceeds the maximum urethral closure pressure in the absence of detrusor activity

6 ETIOLOGY STRESS INCONTINENCE Descent of the bladder neck and proximal urethra Loss of the urethral resistance

7 PELVIC FLOOR A B

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10 DETERMINANTS OF STRESS INCONTINENCE Resting urethral closure pressure Stress pressure transmission Intraabdominal pressure increases

11 SYMPTOM STRESS INCONTINENCE Urine loss when. Coughing, laughing, sneezing and other physical activities

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13 2002 ICS TERMINOLOGY: OVERACTIVE BLADDER Overactive bladder (OAB) is a symptom syndrome Urgency, Urgency with or without urge incontinence, usually with frequency and nocturia these symptoms are suggestive of detrusor overactivity (urodynamically demonstrable involuntary bladder contractions) but can be due to other forms of voiding or urinary dysfunction these terms can be used if there is no proven infection or other obvious pathology Abrams P et al. Neurourol Urodyn. 2002;21:

14 2002 ICS DEFINITIONS Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer Increased daytime frequency is the complaint by the patient that he/she voids too often by day (equivalent to polyuria) Nocturia is the complaint that the individual has to wake at night 1 or more times to void Abrams P et al. Neurourol Urodyn. 2002;21:

15 2002 ICS DEFINITIONS: INCONTINENCE Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceding urgency Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing Abrams P et al. Neurourol Urodyn. 2002;21:

16 ETIOLOGY OVERACTIVE BLADDER 1. Detrusor hyperreflexia or Neurogenic detrusor overactivity 1. Detrusor instability or Idiopathic detrusor overactivity

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18 SYMPTOM OVERACTIVE BLADDER Urgency Frequency Overactive bladder Urge incontinence

19 Storage Symptoms and Incontinence In a recent US survey (n = 5204),16.5% of individuals in the general population met the criteria for OAB SUI UUI: Mixed OAB wet SUI/UUI (2.7%) (6.1%) SUI: stress urinary incontinence UUI: urge urinary incontinence OAB dry urgency frequency nocturia (10.3%) Stewart W et al. World J Urol Available at:

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21 DIAGNOSTIC INCONTINENCE URINE 1.History Questions 1. Do you leak urine when you cough, sneeze, or laugh? 2. Do you ever have such an uncomfortable strong need to urinate that if you don,t reach the toilet you will leak? 3. If yes to question 2, do you ever leak before you reach the toilet? 4. How many times during the day do you urinate? 5. How many times do you void during the night after going to bed? 6. Have you wet the bed in the past year? 7. Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry? 8. Do you ever leak during oe aftersexual intercourse? 9. How after do you leak? 10. Do you find it necessary to wear a pad because of your leaking? 11. Have you had bladder, urine, or kidney infection? 12. Are you troubled by pain or discomfort when you urinate? 13. Have you had blood in your urinate? 14. Do you find it hard to begin urinating? 15. Do you have as slow urinary stream or have to strain to pass your urine? 16. After you urinate, do you have dribbling or a feeling that you bladder is still full?

22 1. EXAMINATION Physical examination Gynecology examination Neurologic examination

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24 1. LABORATORY TESTS Urinalysis to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria Blood work as appropriate glucose prostate specific antigen others Fantl JA et al. Agency for Healthcare Policy and Research; 1996; AHCPR Publication No

25 1. POST-VOID RESIDUAL URINE Catherization Ultrasound examination

26 1. URINARY DIARY Your Daily Bladder Diary This diary will help you and your healthcare team. Bladder diaries help show the causes of bladder control trouble. The sample line (below) will show you how to use the diary. Time Sample 6 7 AM 7 8 AM 8 9 AM 9 10 AM AM PM Drinks Urination Accidental Leaks What kind? How much? How many times? How much? (fill in amount: small, medium, large) How much? (fill in amount: small, medium, large) coffee 2 cups 12 large large Your name: J. Doe Date: March 31, 2003 Did you feel a strong urge to go? What were you doing at the time? Sneezing, exercising, having sex, lifting, etc. yes laughing

27 Pad Test

28 1. URODYNAMICS

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30 TREATMENT OPTIONS Conservative Surgical/modulatory therapies

31 STRESS INCONTINENCE TREATMENT Conservative Pelvic floor exercises Weighted vaginal Cones Electrostimulation Positive fedback/perineometri Devices (e.g. pessary) Pharmacotherapy

32 SURGICAL TREATMENT 1. Anterior colporraphy 2. Transvaginal Needle Bladder Neck suspension 3. Retropubic suspension 1. Marshall - Marchetti Krantz 2. Burch colposuspension 3. Sling prosedures (e.g. TVT) 4. Artificial sphincter

33 Burch colposuspension

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35 OVERACTIVE BLADDER TREATMENT Conservative Bladder training Pharmacothrapy

36 PHARMACOLOGIC THERAPY Flavoxate Hydrochloride Oxybutynin Tolterodine Others

37 SURGICAL / MODULATORY THERAPIES Denervation central peripheral and perivesical Acupuncture Electroacupunture Electrical stimulation/neuromodulation Overdistention Augmentation cystoplasty

38 OVERFLOW INCONTINENCE Chronic urinary retention with resultant overflow incontinence is uncommon in women Aetiology Bladder hypothonia / antonia Postoperative trauma Inflammation Pelvic mass Drugs Neuropathic bladder Postoperative for stress incontinence Urethral stenosis/strictura Treatment Catheterisation Drug Urethral dilatation Causal

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40 CONTINUE INCONTINENCE Etiology: Fistula Treatment: repair

41 CONCLUSION Management of urinary incontinence Depent on type and etiology of the incontinence Treatment consist of conservative and surgical The acurity of diagnostic and treatment will given a good out come

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43 CONSERVATIVE TREATMENT Physiotherapy A. Pelvic floor exercises B. Vaginal cones C. Positive feedback (perineometer) D. Faradism E. Interferential therapy F. Maximal electrical stimulation Drugs A. Estrogen B. a-adrenergic agents

44 CONSERVATIVE TREATMENT Mechanical devices A. Bladder neck support prosthesis B. Contraceptive diaphragm C. Hodge pessary D. Vaginal tampon E. Catheter

45 INDICATION OF CONSERVATIVE TREATMENT 1. Stress incontinence is mild 1. The patient wishes to defer surgery for a period of time 2. Detrusor instability and urethral sphincter incompetence coexist 3. Surgery is contraindicated because of patientls poor general health

46 BEHAVIORAL THERAPY Modify symptoms through systematic changes in patient behavior or the environment Behavioral modification therapies dietary modification bladder training pelvic floor muscle exercises adjunct therapies scheduled/assisted voiding

47 PHARMACOLOGIC THERAPY Antimuscarinic agents are the mainstay for treating OAB OAB symptoms are relieved by inhibition of involuntary bladder contractions increased bladder capacity Treatment can be limited by side effects such as dry mouth, GI effects (eg, constipation), and CNS effects

48 COMPONENTS OF URETHRAI SPHINCTER Urethral mucosa The vascular content of the submucosal covernous plexus Elastic and connective tissue of the urethral wall Smoth musele fibers in urethral wall Periurthral striated muscle fibers (sphincter urethra) Muscle of the urogenital diaphragm or perineal membrane : Urogenital sphingter and compressor sphingter

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50 CONTOH DAFTAR HARIAN BERKEMIH KARTU CATATAN BUANG AIR KECIL Hari ke-i Tgl y Interval waktu Tengah malam Buang air kecil y Mengompol y y m m d d Keinginan buang air kecil

51 2002 ICS TERMINOLOGY OUT IN Detrusor hyperreflexia Neurogenic detrusor overactivity Detrusor instability Idiopathic detrusor overactivity Motor urgency None Sensory urgency None Motor urge incontinence Detrusor overactivity incontinence with urgency Reflex incontinence Detrusor overactivity incontinence without sensation Abrams P et al. Neurourol Urodyn. 2002;21:

52 STRESS INCONTINENCE TRIATMENT Surgical treatment Overactive Bulking agents Needle suspension Colposuspension Sling operation

53 THE KIND OF URINARY INCONTINENCE Stress incontinence Overactive bladder Continue incontinence Overflow incontinence