INCONTINENCE and… DESCENT INTO THE VAGINA Leila Van Gelder RNP/CNM Overview • Demographics of Urinary Incontinence • Morbidity • Costs • Physiology...
Author: Jeremy Davis
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Leila Van Gelder RNP/CNM

Overview • Demographics of Urinary Incontinence • Morbidity • Costs • Physiology of Incontinence • Treatment Options

DEMOGRAPHICS UI affects 19 million people in the US most are women > 20% of women age 40 or over have UI The incidence increases with age >50% of the 1.5 million residents in nursing homes are incontinent - 50-70% of women with UI fail to seek treatment because of social stigma

MORBIDITY - UI is 2nd leading cause of nursing home -

admissions Prolonged hospital admissions (35%) Urinary Tract Infections (2%) Contact Dermatitis (1.6%) Falls (1%)

COSTS - UI costs range from $16-26 billion/yr -

(AHCPR) Costs incurred for treating incontinence related secondary complications $2.8 billion/yr Depression $44 billion (J Clin Psych) Alzheimers costs $100 billion (NIH)

Urinary Incontinence Background • Definition: “involuntary loss of urine” • Types of Urinary Incontinence: - STRESS UI (30-55%) - URGE UI (20-35%) - MIXED UI (25-35%) - OVERFLOW UI (uncommon)

STRESS Incontinence Pathophysiology • Leakage of urine occurring coincident with • • •

increased intra-abdominal pressure in the absence of uninhibited detrusor contraction Bladder outlet has poor resistance to urinary flow Urethral hypermobility caused by poor anatomic pelvic support Intrinsic Sphincter Deficiency defect in urethra

URGE Incontinence Pathophysiology • Involuntary loss of urine due to

overactivity of the detrusor muscle • Neuropathy or detrusor myopathy • Common neurologic disorders associated with Urge UI include stroke, Parkinson’s, MS, brain tumors and spinal cord injuries

MIXED Incontinence Pathophysiology • Combination of stress and urge

incontinence • Weak bladder outlet combined with overactive detrusor muscle

OVERFLOW Incontinence Pathophysiology • Overdistention of the detrusor muscle and subsequent passive leakage of urine • Bladder outlet obstruction • Detrusor muscle weakness • Neurologic impairment of the bladder • Herniated lumbar disc, Diabetes,enlarged prostate, Peripheral neuropathy, sacral cord injury, use of muscle relaxants

Clinical History – Stress UI • Leaks occur with coughing sneezing bending lifting exercising laughing

Clinical History – Urge UI • Leaks occur suddenly

- with strong urge to void but can’t hold it - loose large volume - frequent voiding pattern - nocturia • Perimenopausal • Caffeine • Dietary triggers • History of sexual abuse

Clinical History – Mixed UI • Symptoms of Stress and Urge coexist • Mild to moderate urine loss with physical activities • Sometimes acute urine loss without warning

Clinical History – Overflow UI • Urine overflows from the bladder when it is overdistended and has stretched to its limit • Sense of incomplete emptying • Slow flowing urine • Dribbling

Fecal Incontinence • More common than you think • Medical provider MUST ask • Inability to control bowel

Coping Behaviors • Reorganize daily life • “Just in case” behaviors • Toilet mapping • Avoid travel and trips • Reduce fluid intake • Avoid exercise • Wear dark clothing

History – Reversible Causes of UI •D •I •A •P •E •R •S


delirium urinary tract infection atrophic urethritis pharmaceutical drug side effects excessive urine output:Diabetes, CHF restricted mobility stool impaction

Medications that can cause UI • Diuretics • Caffeine • Anticholinergics: psychotropics • • • • • •

antispasmodics anti Parkinson drugs

Benzodiazepines Alcohol Decongestants (alpha adrenergics) Alpha blockers Beta blockers Ca++ channel blockers

Workup for UI • Ask every patient about leakage at every visit.

(Denial, shame, embarassment) • Urinalysis and urine culture - UTI can cause urgency, incontinence too - Persistant UTI may be upper tract anatomic abnormalities or renal stones so Ultrasound may be appropriate - Persistant Hematuria needs Urology referral to r/o neoplasm

Risk Factors - Prolapse • Childbirth • Repetitive Bearing Down • Heavy Lifting or Coughing • Family History of Prolapse • Hysterectomy • Pelvic Surgery or Trauma • Menopause- Endopelvic Fascia Failure • Obesity

Voiding Diary • Written record by the patient 24 hours

- fluid intake - urine output - incontinece episodes and circumstances Evaluate volumes voided day vs night time intervals between voids largest and smallest volumes timing of leaks in relation to caffeine behavior patterns

Clinical Exam • Vagina

Evaluate descent of bladder = cystocele of rectum = rectocele of cervix = uterine descensus of vault = vault descensus of intestine = enterocele Pelvic Floor Muscle Strength


Clinical Exam • Urethra Q Tip test to measure urethral mobility Strain Test Cough Test • Perineal Sensation • PVR Post Void Residual

Multi-channel Urodynamics • Gold standard for diagnosis of UI measures storage phase: bladder sensation bladder capacity urethral sphincter pressures emptying phase: uroflow, PVR

Treatment Options Pelvic Floor Therapy Pessary Surgery Collagen Injection for ISD only

Treatment Options • Pelvic Floor Therapy:

Exercise PF Muscle- 100 Kegels/day EMG Biofeedback to learn how to isolate, contract and sustain pelvic floor muscle contraction Electric Stimulation Outcome: Increase PFM strength Decrease urgency symptoms Increase bladder holding capacity Decrease loss of urine with exertion

Treatment Options - Behavioral • Behavioral Therapy: Timed Voiding Bladder Diary Urge Suppression Techniques

Treatment Options - Food • Dietary Changes: Caffeine Alcohol Fluid Intake High Oxalate Foods Acidic Foods Artificial Sweeteners Weight Loss Program

Treatment Options - Drugs • Medications: anticholinergics side effects: dry mouth, nausea

Treatment Options- Estrogen • Vaginal Estrogen atrophic vagina Premarin, Estrace, Estradiol creams Estring

Treatment Options - Pessary • Pessary fitting short vs long term use self care regimen risks benefits

Treatment Options - Operative • Surgery TVT Sling Multiple prolapse repair

• Collagen Injection

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