Urinary IncontinenceUrinary Incontinence

Aliza BenAliza Ben--Zacharia, ANP, MSNZacharia, ANP, MSN

The Corinne Goldsmith DickinsonThe Corinne Goldsmith Dickinson

Center for Multiple SclerosisCenter for Multiple Sclerosis

The Mount Sinai Medical CenterThe Mount Sinai Medical Center

aliza.benaliza.ben--zacharia@mssm.eduzacharia@mssm.edu

Anatomy of MicturitionAnatomy of Micturition

Detrusor muscleDetrusor muscleExternal and Internal External and Internal sphinctersphincterNormal capacity 300Normal capacity 300--600cc600ccFirst urge to void 150First urge to void 150--300cc300ccCNS controlCNS control

Pons Pons -- facilitatesfacilitatesCerebral cortex Cerebral cortex -- inhibitsinhibits

Parasympathetic Parasympathetic --Bladder contractionBladder contractionSympathetic Sympathetic -- Bladder Bladder RelaxationRelaxationSympathetic Sympathetic -- Bladder Bladder neck and urethral neck and urethral contraction contraction Somatic (Pudendal Somatic (Pudendal nerve) nerve) -- contraction contraction pelvic floor musculaturepelvic floor musculature

Nerves & MicturitionNerves & Micturition

Prevalence of Urinary IncontinencePrevalence of Urinary IncontinenceUrinary incontinence Urinary incontinence –– involuntary loss of urine involuntary loss of urine sufficient to be a problemsufficient to be a problem

Affects 13 million Americans Affects 13 million Americans 33% of women >65 have some degree of UI33% of women >65 have some degree of UI26% of women>18 experience various degree of SI26% of women>18 experience various degree of SI15% to 30% of noninstitutionalized older adults 15% to 30% of noninstitutionalized older adults (19% men; 39% women)(19% men; 39% women)Prevalence increases with age (not normal aging) Prevalence increases with age (not normal aging) 50% of those in nursing facilities50% of those in nursing facilities

Nygaard et al., Obstet Gyneco 2003; 101: 149Nygaard et al., Obstet Gyneco 2003; 101: 149--56. 56. Thom D. J Am Geriat Society 1998; 46:473Thom D. J Am Geriat Society 1998; 46:473--80.80.

Urinary Incontinence is Common Urinary Incontinence is Common Among Older AdultsAmong Older Adults

MenWomen

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5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85Age (years)

This is an example of one woman's idea of This is an example of one woman's idea of another great use for duct tape.another great use for duct tape.

(She lives in a household with five guys!)(She lives in a household with five guys!)

Economic CostsEconomic Costs

10 Billion Dollars 10 Billion Dollars –– 1987 1987 30 Billion Dollars 30 Billion Dollars –– 19951995Cost of UI in 1995 : $24.3 billion or $3,565 per Cost of UI in 1995 : $24.3 billion or $3,565 per incontinent personincontinent personCost of UI > Coronary artery bypass surgery + renal Cost of UI > Coronary artery bypass surgery + renal dialysisdialysisCost : Physical, Psychosocial & economicCost : Physical, Psychosocial & economicWagner, Urology 1998; 51:355Wagner, Urology 1998; 51:355--61.61.Resnick, JAMA 1998; 280:2034Resnick, JAMA 1998; 280:2034--5.5.Hendrix, DiseaseHendrix, Disease--AA--Month, 2002; 48:622Month, 2002; 48:622--636.636.

Direct Cost of UrinaryDirect Cost of Urinary Incontinence in the USAIncontinence in the USA

US $

billio

n

20

16

12

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01984 1987 1993

Factors Associated with Factors Associated with Bladder Control ProblemsBladder Control Problems

• Age• Childbirth• Gender• Menopausal Status• Surgery• Prostate enlargement• Lifestyle • Medications• Concomitant illnesses

Urinary IncontinenceUrinary IncontinenceUI is not a normal part UI is not a normal part of agingof agingLoss of urine due to a Loss of urine due to a combination ofcombination ofGenitourinary pathologyGenitourinary pathologyAgeAge--related changesrelated changesComorbid conditionsComorbid conditionsEnvironmental obstaclesEnvironmental obstacles

Age related changes (BPH, Age related changes (BPH, atrophic vaginitis)atrophic vaginitis)Dementia, depression, stroke, Dementia, depression, stroke, PD, MSPD, MSConstipation/Fecal Constipation/Fecal incontinenceincontinenceCOPD, or chronic coughCOPD, or chronic coughDetrusor overactivity & Detrusor overactivity & uninhibited contractionsuninhibited contractionsIncreased PVR or decreased Increased PVR or decreased capacitycapacityImpaired ADLsImpaired ADLsObesityObesity

Types of IncontinenceTypes of IncontinenceUrge incontinenceUrge incontinence –– strong urge to void strong urge to void ImmediatelyImmediately

preceded by a sensation of urgent need to urinate, with or withopreceded by a sensation of urgent need to urinate, with or without ut increased frequencyincreased frequency

Stress incontinenceStress incontinence –– increased intraincreased intra--abdominal abdominal pressure that lead to incontinence pressure that lead to incontinence

On exertion, or sneezing or coughingOn exertion, or sneezing or coughing

Overflow incontinenceOverflow incontinence –– overover--distended bladderdistended bladderleading to UI / dribblingleading to UI / dribblingFunctional incontinenceFunctional incontinence –– physical / psychological physical / psychological impairment impairment UI due to inability getting to BRUI due to inability getting to BRMixed incontinenceMixed incontinence –– combination of 2 or more combination of 2 or more typestypes

Urge IncontinenceUrge Incontinence

Most common cause of UI >75 years of ageMost common cause of UI >75 years of ageAbrupt desire to void cannot be suppressedAbrupt desire to void cannot be suppressedUsually idiopathicUsually idiopathicCauses: infection, tumor, stones, atrophic Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Multiple vaginitis or urethritis, stroke, Multiple sclerosis, Parkinsonsclerosis, Parkinson’’s Disease, dementias Disease, dementia

Other Names: OAB, detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder

Overactive BladderOveractive Bladder

Frequency

OVERACTIVE BLADDER

Urgency

Urgeincontinence

When you got to go, you got to go!When you got to go, you got to go!

Stress IncontinenceStress IncontinenceMost common type in women < 75 years oldMost common type in women < 75 years oldOccurs with increase in abdominal pressure; Occurs with increase in abdominal pressure; cough, sneeze, etc.cough, sneeze, etc.HypermotilityHypermotility of bladder neck and urethraof bladder neck and urethra; ; associated with aging, hormonal changes, trauma of childbirth associated with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases)or pelvic surgery (85% of cases)

Intrinsic sphincterIntrinsic sphincter problems; problems; due to due to pelvic/incontinence surgery, pelvic radiation, trauma, pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)neurogenic causes (15% of cases)

Stress IncontinenceStress Incontinence

(a) Continent woman (b) Woman with stress incontinence

Externalurethral

sphincter

Sudden increase in intra-abdominal pressure

Overflow IncontinenceOverflow IncontinenceOver distention of Over distention of bladderbladderBladder outlet Bladder outlet obstruction; obstruction; stricture, stricture, BPH, cystocele, fecal BPH, cystocele, fecal impactionimpactionNonNon--contractile bladder contractile bladder (hypoactive detrusor or (hypoactive detrusor or atonic bladder); atonic bladder); Diabetes, Diabetes, MS, Spinal Injury, MS, Spinal Injury, MedicationsMedications

Functional IncontinenceFunctional IncontinenceDoes not involve lower urinary tractDoes not involve lower urinary tractResult of psychological, cognitive or physical Result of psychological, cognitive or physical impairmentimpairment

Mixed Incontinence (older women)Mixed Incontinence (older women) Stress & Urge IncontinenceStress & Urge Incontinence

Sudden increase in intra-abdominalpressure

Uninhibited detrusorcontractions

Potentially Reversible CausesPotentially Reversible Causes

DD --

DeliriumDelirium

II

--

InfectionInfection

AA

--

Atrophic vaginitis or urethritisAtrophic vaginitis or urethritis

PP

--

PharmaceuticalsPharmaceuticals

PP

--

Psychological disordersPsychological disorders

EE --

Endocrine disordersEndocrine disorders

RR --

Restricted mobilityRestricted mobility

SS

--

Stool impactionStool impaction

Reversible causes of incontinence Reversible causes of incontinence (DRIP Mnemonic)(DRIP Mnemonic)

DeliriumDeliriumRestricted mobilityRestricted mobility(illness, injury, gait (illness, injury, gait disorder, restraint)disorder, restraint)Infection; Infection; InflammationInflammation (atrophic (atrophic vaginitis); vaginitis); ImpactionImpaction of of stoolstoolPolyuriaPolyuria (diabetes (diabetes mellitus, caffeine intake, mellitus, caffeine intake, volume overload); volume overload); PharmaceuticalsPharmaceuticals

Other factors causing IncontinenceOther factors causing IncontinenceAntidepressants, sedatives, Antidepressants, sedatives, antipsychoticantipsychotic

Sedation, retention (overflow)Sedation, retention (overflow)

DiureticsDiuretics Frequency, urgencyFrequency, urgency--OABOABCaffeineCaffeine Frequency, urgencyFrequency, urgency--OABOABAnticholinergicsAnticholinergics Retention (overflow)Retention (overflow)AlcoholAlcohol Sedation,frequencySedation,frequency--OABOABNarcoticsNarcotics Retention, constipation, sedation Retention, constipation, sedation

(overflow/OAB)(overflow/OAB)

ααAdrenergic blockersAdrenergic blockers Decreased urethral toneDecreased urethral toneααAdrenergic agonistsAdrenergic agonists--ClonidineClonidine Increased urethral toneIncreased urethral tone

Calcium Channel BlockersCalcium Channel Blockers Retention (overflow)Retention (overflow)ACE inhibitorsACE inhibitors Cough (Stress Incontinence)Cough (Stress Incontinence)

Why is Treatment of Incontinence Important?Why is Treatment of Incontinence Important?

Medical complicationsMedical complications -- skin breakdown, skin breakdown, increased risk of fractures, increased urinary increased risk of fractures, increased urinary tract infectionstract infectionsSocial stigmaSocial stigma -- leads to social isolation, decline leads to social isolation, decline in function, restricted activities and depressionin function, restricted activities and depressionInstitutionalizationInstitutionalization -- UI is the second leading UI is the second leading cause of nursing home placementcause of nursing home placement

Urinary Incontinence is OftenUrinary Incontinence is Often UnderUnder--Diagnosed and UnderDiagnosed and Under--TreatedTreated

Only 32% of primary care physicians routinely Only 32% of primary care physicians routinely ask about incontinenceask about incontinenceOften not mentioned to physiciansOften not mentioned to physicians5050--75% of patients never describe symptoms 75% of patients never describe symptoms to physiciansto physicians80% of urinary incontinence can be cured 80% of urinary incontinence can be cured or improvedor improved

Taking the HistoryTaking the History

Duration, severity, Duration, severity, symptoms, previous symptoms, previous treatment, medications, treatment, medications, GU surgeryGU surgery3 P3 P’’ss

Position of leakage Position of leakage (supine, sitting, standing)(supine, sitting, standing)Protection (pads per day, Protection (pads per day, wetness of pads)wetness of pads)Problem (quality of life)Problem (quality of life)

Voiding DiaryVoiding DiaryDocument number of Document number of voids per dayvoids per dayVolumesVolumesNumber of incontinent Number of incontinent episodesepisodesSeverity of the problemSeverity of the problemTime of day with Time of day with increased incontinenceincreased incontinence

Morning incontinence may Morning incontinence may be associated with diuretic be associated with diuretic useuse

Bladder DiaryBladder Diary

Date: Monday 19 MarchTime Drinks

(types andamount)

Amountof urinepassed

(ml)

Did you feel astrong and

sudden desire tourinate ( if yes)

If leakage occurs,amount of urine

leaked

SSmmaallll MMeeddiiuumm LLaarrggee8:00 am Tea, 2 cups

8:30 am 150 ml

10:00 am Coffee, 1 mug

11:15 am 200 ml

12:00 pm 100 ml

1:00 pm 100 ml

2:00 pm Cola, 1 can

2:30 pm

Urinary AssessmentUrinary Assessment

Four questions (Caroline Sampselle, PhD)Four questions (Caroline Sampselle, PhD)Are you leaking urine?Are you leaking urine?Do you have trouble making it to the BR or Do you have trouble making it to the BR or Do you urinate very frequently?Do you urinate very frequently?Do you leak urine when you cough, stand, Do you leak urine when you cough, stand, sneeze?sneeze?Do you wear a pad for urine leakage? Do you wear a pad for urine leakage?

Evaluation of IncontinenceEvaluation of Incontinence

Medical historyMedical history: : Symptoms Symptoms associated with associated with incontinenceincontinenceSurgical historySurgical history

Social history Social history

Obstetric & Obstetric &

MedicationsMedications

Physical Physical examinationexamination: Neuro, : Neuro, abdominal & pelvic & abdominal & pelvic & rectal examinationrectal examination

Examination Examination proceduresprocedures: PVR, : PVR, UrodynamicsUrodynamics

LaboratoriesLaboratories: UA, : UA, urine culture, blood testurine culture, blood test

Interpretation of PostInterpretation of Post--Void ResidualVoid Residual

PVR < 50cc PVR < 50cc --

Adequate bladder emptyingAdequate bladder emptying

PVR > 100cc PVR > 100cc --

Detrusor weakness, Detrusor weakness, neuropathy or outlet obstructionneuropathy or outlet obstruction

PVR > 150cc PVR > 150cc --

Avoid bladder relaxing Avoid bladder relaxing drugsdrugs

PVR > 200cc PVR > 200cc --

Refer to UrologyRefer to Urology

PVR > 400cc PVR > 400cc --

Overflow Urinary Overflow Urinary Incontinence likelyIncontinence likely

Bladder PressureBladder Pressure--Volume Volume RelationshipRelationship

Urinary IncontinenceUrinary Incontinence When to referWhen to refer

Failure of initial conservative methodsFailure of initial conservative methods

Significant stress urinary incontinenceSignificant stress urinary incontinence

Recurrent urinary tract infections; Hematuria Recurrent urinary tract infections; Hematuria

Recent onset of overactive bladderRecent onset of overactive bladder

Significant pelvic prolapse Significant pelvic prolapse

Prior incontinence surgeryPrior incontinence surgery

Prior radical pelvic surgery or radiationPrior radical pelvic surgery or radiation

Bladder IrritantsBladder IrritantsAlcoholic beveragesAlcoholic beverages

Carbonated Carbonated beveragesbeverages

Medications with Medications with caffeinecaffeine

Highly spicy foodHighly spicy food

HoneyHoney

Tomatoes and Tomatoes and tomato paste tomato paste productsproducts

Milk or milk Milk or milk productsproducts

Coffee or tea Coffee or tea (including decaf)(including decaf)

Citrus juice and fruitsCitrus juice and fruits

SugarSugar

ChocolateChocolate

Corn syrupCorn syrup

Artificial sweetenersArtificial sweeteners

Treatment pathwayTreatment pathway

Lifestyle interventions Refer

Mixed UI OAB with or without urge UIStress UI

OAB with or without urge UIStress UI

Urodynamics if appropriate, not routinely for pure stress UI

Assess and categorise

Behavioral management, Medical approaches, Behavioral management, Medical approaches, Medications, Surgical proceduresMedications, Surgical procedures

Behavioral Therapy TechniquesBehavioral Therapy TechniquesLifestyle Lifestyle InterventionsInterventions

Fluid & Dietary Fluid & Dietary modificationsmodifications

Eliminating bladder Eliminating bladder irritantsirritants

Constipation Constipation preventionprevention

Weight reductionWeight reduction

Smoking cessationSmoking cessation

Bladder TrainingBladder TrainingPatient educationPatient education

Scheduled voiding Scheduled voiding regimenregimen

Urge control Urge control strategies strategies

Self monitoring Self monitoring

Pelvic Floor Muscle Pelvic Floor Muscle ContractionsContractions

Good Bladder HabitsGood Bladder Habits

Step 1Step 1: Maintain appropriate fluid intake

Step 2Step 2: Practice good toilet habits

Step 3Step 3: Maintain good bowel habits

Step 4Step 4: Exercise of pelvic floor muscles

Pelvic Floor Muscle ExercisesPelvic Floor Muscle ExercisesContracting the muscles Contracting the muscles for at least 10 secondsfor at least 10 seconds3030--40 contractions/day 40 contractions/day can prevent & treat UIcan prevent & treat UIUsing vaginal cones or Using vaginal cones or balls to do pelvic muscle balls to do pelvic muscle contractionscontractionsWomen using devices are Women using devices are less likely to continue less likely to continue PFMT PFMT

Women will see results Women will see results from PFMT after 12from PFMT after 12--16 16 weeksweeksMay increase sexual May increase sexual pleasure while doing pleasure while doing them during intercoursethem during intercourseDo them prior to cough Do them prior to cough or sneeze if has stress or sneeze if has stress incontinenceincontinence

Pelvic Floor ExercisesPelvic Floor Exercises

Locate pelvic floor muscles

Squeeze pelvicfloor musclesas tightly aspossible for afew seconds(maximum of10 seconds)

Relax completely for atleast 10 seconds

Repeat, asrecommendedby physician/

continenceadvisor

Physical therapy & Body Physical therapy & Body MechanicsMechanics

Physical therapy Physical therapy programprogram

Strengthening pelvic Strengthening pelvic floor musclesfloor muscles

Controlling spasticityControlling spasticity

Maintaining posture Maintaining posture & body mechanics & body mechanics while doing ADLswhile doing ADLs

Other interventions Pessaries

Incontinence Pads and Incontinence Pads and Protective EquipmentProtective Equipment

Absorbent pads

Dribble pouch

Reusable underpantsdesigned to carrydisposable absorbent pads

All-in-one briefs

Chair and bed pads

Bladder Catheterization VS Bladder Catheterization VS Indwelling CatheterIndwelling Catheter

Stress Incontinence Stress Incontinence ManagementManagement

Behavioral therapyBehavioral therapyPelvic floor muscle exercisesPelvic floor muscle exercises (Kegel)(Kegel)Exercises with biofeedbackExercises with biofeedback

MedicationsMedicationsAlphaAlpha--adrenergic stimulantsadrenergic stimulants (urethral closure; (urethral closure; pseudoephedrine)pseudoephedrine)Oral EstrogenOral Estrogen -- sensitize adrenergic receptors in the sensitize adrenergic receptors in the bladder neckbladder neckTransvaginal EstrogenTransvaginal Estrogen may be used for atrophic vaginitismay be used for atrophic vaginitisDuloxetine Duloxetine (Cymbalta(Cymbalta®®--SSRI & Norepinephrine reuptake SSRI & Norepinephrine reuptake inhibitor) Increases urethral sphincter contraction inhibitor) Increases urethral sphincter contraction

Stress Incontinence Stress Incontinence ManagementManagement

DevicesDevicesExtracorporeal magnetic innervation (ExMI) chairExtracorporeal magnetic innervation (ExMI) chair ––a chair that stimulates pelvic muscles via a low intensity a chair that stimulates pelvic muscles via a low intensity magnetic field (twice weekly in 20 minutes sessions for 8 magnetic field (twice weekly in 20 minutes sessions for 8 weeks) weeks) Intravaginal support devicesIntravaginal support devices –– used in patients with used in patients with exercise induced incontinence exercise induced incontinence PessariesPessaries ––Used to treat prolapse Used to treat prolapse –– support to bladder support to bladder neck (long term use requires monitoring for vaginal neck (long term use requires monitoring for vaginal infection and ulceration)infection and ulceration)Pessaries may worsen urge incontinencePessaries may worsen urge incontinence by reducing by reducing obstruction as a result of the prolapseobstruction as a result of the prolapse

Urge Incontinence Urge Incontinence ManagementManagement

Behavioral therapyBehavioral therapyBladder trainingBladder training –– more effective than oxybutinin & more effective than oxybutinin & improves incontinence in more than 50% of patientsimproves incontinence in more than 50% of patientsDietary manipulationsDietary manipulations (Fluid intake: 30mL/kg of body (Fluid intake: 30mL/kg of body weight, 0.5oz/lb)weight, 0.5oz/lb)Kegel exercisesKegel exercises –– RCT: Patients doing Kegel exercises RCT: Patients doing Kegel exercises had an 81% reduction in incontinence episodes compared had an 81% reduction in incontinence episodes compared with 69% decrease in oxybutinin patients (statistical with 69% decrease in oxybutinin patients (statistical significant)significant)Biofeedback trainingBiofeedback training for learning effective Kegel for learning effective Kegel technique (does not show increase efficacy)technique (does not show increase efficacy)

Medications for treatment of Urge Medications for treatment of Urge Incontinence Incontinence

AnticholinergicsAnticholinergics

Inhibit involuntary Inhibit involuntary bladder contractionsbladder contractions

Increase in bladder Increase in bladder capacitycapacity

Oral agentsOral agentsOxybutinin (DitropanOxybutinin (Ditropan®®))

Tolterodine (DetrolTolterodine (Detrol®®))

Short & Long actingShort & Long acting

Side effectsSide effects: : Dry mouth, Dry mouth, Constipation, Blurred vision, Constipation, Blurred vision, Nausea, Dizziness, Nausea, Dizziness, Headache, Altered cognitive Headache, Altered cognitive functionfunctionTransdermal agentTransdermal agent

Oxybutinin (OxytrolOxybutinin (Oxytrol®®))One patch twice weeklyOne patch twice weekly

Botox Botox –– off label off label Refractory to oral meds Refractory to oral meds & neurogenic bladder& neurogenic bladder

Urge Incontinence Urge Incontinence ManagementManagement

Electrical TherapyElectrical TherapyIndicated in patients with severe Indicated in patients with severe refractory urge incontinencerefractory urge incontinenceA generator device that is A generator device that is inserted into the sq tissue of the inserted into the sq tissue of the lower back or buttockslower back or buttocksThe generator powers a lead that The generator powers a lead that is placed through the sacral is placed through the sacral foramen to stimulate the foramen to stimulate the S3 S3 sacral nerve to decrease sacral nerve to decrease detrusor muscle contractionsdetrusor muscle contractionsEffective treatmentEffective treatment

Cost of deviceCost of device--$10,000$10,000(covered by Medicare)(covered by Medicare)

Overflow Incontinence Overflow Incontinence ManagementManagement

Urinary retention Urinary retention –– ? Bladder emptying? Bladder emptyingIdentify the etiology of retentionIdentify the etiology of retentionPoor detrusor contractionPoor detrusor contraction

A trial of betanechol (cholinergic agent)A trial of betanechol (cholinergic agent)Multiple side effects: flushing, N/V/D, bronchospasm, H/A, Multiple side effects: flushing, N/V/D, bronchospasm, H/A, salivation, sweating, & visual changessalivation, sweating, & visual changesIntermittent catheterization or a chronic indwelling catheter inIntermittent catheterization or a chronic indwelling catheter insevere detrusor hyposevere detrusor hypo--contractilitycontractility

Bladder outflow obstructionBladder outflow obstructionUsually associated with pelvic organ prolapseUsually associated with pelvic organ prolapseReferral to a urologistReferral to a urologist

Mixed Incontinence Mixed Incontinence ManagementManagement

Initial treatment of Initial treatment of symptomssymptomsNonNon--invasive behavioral & invasive behavioral & rehabilitative therapyrehabilitative therapyBladder trainingBladder trainingEliminating irritants Eliminating irritants Pelvic muscle exercisesPelvic muscle exercisesMedical treatment optionsMedical treatment optionsNo drugs for SINo drugs for SISurgical therapy for SUISurgical therapy for SUIReferral to a urologistReferral to a urologist

Functional Incontinence Functional Incontinence ManagementManagement

Physical or cognitive Physical or cognitive impairmentsimpairmentsTimed voidingTimed voidingMobility assist devicesMobility assist devicesBedside commodesBedside commodesRoutine nursing careRoutine nursing care

Transient & Continuous Transient & Continuous Incontinence ManagementIncontinence Management

Transient IncontinenceTransient Incontinence

Identification of the Identification of the inciting factors for inciting factors for transient incontinencetransient incontinenceTreat the reversible causes Treat the reversible causes as outlined by the as outlined by the mnemonic mnemonic DIAPPERS/DRIPDIAPPERS/DRIPTransient incontinence can Transient incontinence can persist if left untreatedpersist if left untreated

Continuous IncontinenceContinuous Incontinence --urinary leakage or dribblingurinary leakage or dribblingUnrelated to stress or Unrelated to stress or urgencyurgencyRelated to an anatomic Related to an anatomic abnormalityabnormality

Urethral diverticulumUrethral diverticulum

Urinary fistulaUrinary fistula

Referral to a specialistReferral to a specialistFurther diagnostic evaluationFurther diagnostic evaluationSurgical correctionSurgical correction

Key Clinical recommendationsKey Clinical recommendations

Patients with urge incontinence should be Patients with urge incontinence should be taught Kegel exercises. Biofeedback does not taught Kegel exercises. Biofeedback does not improve the efficacy of the exercisesimprove the efficacy of the exercisesSelection of an anticholinergic agent for Selection of an anticholinergic agent for treatment of urge incontinence should be treatment of urge incontinence should be based on a discussion with the patient about based on a discussion with the patient about efficacy & side effectsefficacy & side effectsElectrical therapy can be considered in Electrical therapy can be considered in patients with severe refractory urge patients with severe refractory urge incontinence who do not respond to incontinence who do not respond to behavior therapy & medicationsbehavior therapy & medications

Case StudyCase StudyCC: CC: ““I have been having problems over I have been having problems over the past 3 months with losing my urine. I the past 3 months with losing my urine. I have leaked a small amount of urine when have leaked a small amount of urine when I laugh or sneeze. But it is getting worse. I laugh or sneeze. But it is getting worse. Sometimes when I sit I feel the urge to Sometimes when I sit I feel the urge to urinate. When I urinate at that time I have urinate. When I urinate at that time I have large amounts of urine. I have been using large amounts of urine. I have been using pads to keep myself dry.pads to keep myself dry.””

Case studyCase studyHistory (medical, family, History (medical, family, social, meds, ROS)social, meds, ROS)Physical examPhysical examDiagnostic testsDiagnostic tests

UA, C&SUA, C&SPVRPVRUrinary diaryUrinary diaryLabs;chemistryLabs;chemistryPE; stress testPE; stress test

Stress incontinenceStress incontinenceUrge incontinenceUrge incontinenceMixed; stress+urgeMixed; stress+urgeOverflow incontinenceOverflow incontinence

Case Study Case Study --

TreatmentTreatment

If UTIIf UTI –– A course of A course of antibioticsantibioticsEducation & NonEducation & Non--pharmacological Txpharmacological TxFluid intake issuesFluid intake issuesHygiene and sexual Hygiene and sexual Avoiding bladder Avoiding bladder irritantsirritantsUrge control by using Urge control by using breathing exercisesbreathing exercisesKegelKegel’’s/PFME can s/PFME can be effectivebe effective

Stress IStress I –– a sympathetic a sympathetic agonist acts by increasing agonist acts by increasing sphincter tone sphincter tone (pseudoephedrine)(pseudoephedrine)Overflow IOverflow I with obstruction with obstruction –– a med to increase bladder a med to increase bladder tone tone –– bethanecholbethanecholOveractive detrusorOveractive detrusor –– a a med to decrease bladder tone med to decrease bladder tone –– anticholinergic anticholinergic * * Anticholinergic Anticholinergic medications may cause medications may cause urinary retentionurinary retention

To All Employees: To maximize productivity and make us more

efficient, we are going to modify all work areas: It is expected that this change will increase

productivity by approximately 4.58%