URGENCY INCONTINENCE FLAME LECTURE: 175 BURNS / TABIT

Size: px

Start display at page:

Download "URGENCY INCONTINENCE FLAME LECTURE: 175 BURNS / TABIT"

Jessica Hoover
5 years ago
Views:

1 URGENCY INCONTINENCE FLAME LECTURE: 175 BURNS / TABIT

2 Learning Objectives Discss etiology and risk factors for rge rinary incontinence Describe the workp for rge rinary incontinence Describe management of rge rinary incontinence Prereqisites: NONE See also for closely related topics FLAME LECTURE 174 Urogyn H&P FLAME LECTURE 176 Stress Urinary Incontinence FLAME LECTURE 177 Urinary Retention

3 Etiology Urge Incontinence is the rge to void immediately preceding or accompanying an involntary leakage of rine Most commonly de to detrsor mscle overactivity Overactive Bladder (OAB) syndrome with rgency (with or withot leakage); often accompanied by noctria and increased freqency Bladder overactivity fond in 21% of healthy elderly patients1 Look for other cases contribting to rgency: Bladder infection/inflammation Bladder stones Obstrcted bladder opening Bladder cancer Nerologic isses Often specific etiology is nknown Risk Factors Obesity Smoking Diabetes Caffeine Family history Impaired mental stats History of bladder infections Childhood enresis and bladder dysfnction

4 Physiology - Bladder Mscle Fnction Detrsor Mscle smooth mscle layer of bladder which relaxes to allow bladder filling and contracts to facilitate rination Sphincter control bladder otlet (internal sphincter is nder atonomic control, external sphincter is nder somatic control) Levator ani volnry mscle of pelvic floor that assists in rine retention

5 Physiology Nervos Stimlation Sympathetic stimlation maintains continence Hypogastric n. inhibits detrsor mscle, relaxing bladder Pdendal n. contracts sphincter, preventing bladder otflow Parasympathetic Bladder stimlation assists in rination filling cases stretch receptors to send afferent signals to brain that create parasympathetic otflow via pelvic splanchnic n. s which case detrsor mscle contraction

6 Evalation History Dring the last 3 months, did yo leak rine: when yo were performing some physical activity (coghing, sneezing, lifting, exercise)? when yo had the rge or the feeling that yo needed to empty yor bladder bt yo cold not get to the toilet fast enogh? withot physical activity and withot a sense of rgency? Dring the last 3 months, did yo leak rine most often: when yo were performing some physical activity (coghing, sneezing, lifting, exercise)? = SUI when yo had the rge or the feeling that yo needed to empty yor bladder bt yo cold not get to the toilet fast enogh? = Urgency Incontinence withot physical activity and withot a sense of rgency? = Incontinence of other predominant case Abot eqally as often with physical activity as with a sense of rgency = Mixed incontinence

7 Evalation History Associated Dysria, if symptoms noctria, hematria, pelvic pain, fever present consider UTI as sorce of incontinence Nerologic Impact symptoms and qality of life Which symptoms are most bothersome? How have the symptoms changed since the last visit?

8 Evalation - Physical Exam Speclm Exam Post-void Residal Usefl in evalating for rinary retention PVR <50ml is normal; > 200mL abnormal Bladder Stress Test Shold be done on any woman with rinary incontinence symptoms. Look for vaginal atrophy, pelvic masses, anterior vaginal wall prolapse Used to rle ot stress incontinence. While standing, patient with fll bladder is asked to valsalva or cogh while examiner looks for leakage from rethra UA/UCx Usefl in rling ot UTI

9 Treatment Lifestyle Modifications Diet modifications Decrease nighttime flid Decrease alcohol, caffeine, carbonated drinks Increase fiber - constipation Smoking cessation Bladder training: Timed voids sing voiding diary, identify shortest voiding interval, and schedle reglar voids at this interval Voiding intervals are increased ntil patient is voiding 3-4x/day Pelvic floor exercises (Kegel exercises) 10 second contractions of mscles that are sed to prevent rination

Treatment Topical vaginal estrogen (Premarin, Estrace, Vagifem, Estring) Vaginal atrophy can lead to symptoms of rinary freqency and dysria and can contribte to incontinence Topical vaginal estrogen

10 Treatment Topical vaginal estrogen (Premarin, Estrace, Vagifem, Estring) Vaginal atrophy can lead to symptoms of rinary freqency and dysria and can contribte to incontinence Topical vaginal estrogen has been shown to restore the normal vaginal acidic ph and microflora, thicken the epithelim, and redce the incidence of UTIs and overactive bladder symptoms Systemic absorption is low, bt may be contraindicated in certain women with estrogen-dependent tmors

11 Treatment - Medical Antimscarinics conteract parasympathetic activation of detrsor mscle thereby decreasing bladder contractility Available in immediate and extended release Patients shold receive post-void residal testing to monitor for rinary retention Adverse effects: dry moth, blrred vision, constipation, hyperthermia, flshing, rinary retention, iles Contraindications: gastric retention/paresis, acte angle closre glacoma Mirabegron Beta3 agonist activates sympathetic tone in detrsor bladder leading to increased bladder relaxation Contraindication: hypertension Darifenacin (Enablex) Fesoterodine (Toviaz) Oxybtynin (Ditropan) Tolterodine (Detrol) Solifenacin (Vesicare) Trospim (Sanctra) Hot as a hare Dry as a bone Red as a beet Blind as a bat

12 Treatment Nerve Modlation Sacral nerve modlation (Interstim) Has been shown to be beneficial for OAB symptoms Placement of a wire lead into the S3 foramen to increase sympathetic stimlation of bladder Test phase: lead wire placed, tnneled throgh skin, and connected to a temporary stimlation device Patient is asked to maintain voiding diary for 2 weeks to assess whether there is a 50% redction in rinary rgency, freqency, and leakage Implanation phase: if test phase is sccessfl, a permanent stimlation device is implanted nder the skin of the back

13 Treatment Nerve Modlation Perctaneos tibial nerve stimlation (PTNS) Has been shown to be beneficial for detrsor overactivity Placement of an acpnctre needle medially behind the ankle with electrical stimlation administered for 30 minte sessions weekly for 12 weeks, followed by maintenance therapy monthly Detrsor Office Botlinm Toxin Injections procedre involving injections into the varios locations within the bladder; effects last 3-9 months

14 IMPORTANT LINKS / REFERENCES 1. Pelvic Floor Distress Inventory 2. Pelvic Floor Impact Qestionnaire 3. AUA Gidelines Gideline for the Srgical Management of Female Stress Urinary Incontinence (2009)

Urinary Incontinence for the Primary Care Provider

Urinary Incontinence for the Primary Care Provider Diana J Scott FNP-BC https://youtu.be/gmzaue1ojn4 1 Assessment of Urinary Incontinence Urge Stress Mixed Other overflow, postural, continuous, insensible,