Urogenital Damage/dysfunction:

• Vaginal delivery
• Aging
• Estrogen deficiency

• Neurological disease

• Psychological disease

Myths:

• Urinary incontinence/prolapse is a natural part of aging

• Nothing can be done about it

• Surgery is the only solution

Urogenital Aging:

• Urogenital aging is a symptom complex with associated physical findings

• Involves the lower urinary and genital tracts and the pelvic floor

Symptoms:

• Frequency
• Nocturia
• Dysuria
• Incomplete emptying
• Incontinence
• Urgency
• Recurrent infections

• Dyspareunia

• Prolapse

Quality of Life Impact:

• Impact on lifestyle and avoidance of activities
• Fear of losing bladder control
• Embarrassment
• Impact on relationships

• Increased dependence on caregivers

• Discomfort and skin irritation

Types of Urinary Incontinence:

• Genuine stress incontinence
• Urge incontinence
• Mixed
• Chronic urinary retention and overflow incontinence
• Functional incontinence
• Miscellaneous (UTI, dementia)
• Genuine stress incontinence
• Urge incontinence
• Mixed
• Chronic urinary retention and overflow incontinence

• Functional incontinence

• Miscellaneous (UTI, dementia)

Genuine Stress Incontinence:

• Loss of urine with increases in abdominal pressure
• Caused by pelvic floor damage/weakness or weak sphincter(s)
• Symptoms include loss of urine with cough, laugh, sneeze, running, lifting, walking

Urge Incontinence:

• Loss of urine due to an involuntary bladder spasm (contraction)
• Complaints of urgency, frequency, inability to reach the toilet in time, up a lot at night to use the toilet
• Multiple triggers

Mixed Incontinence:

• Combination of stress and urge incontinence
• Common presentation of mixed symptoms
• Urodynamics necessary to confirm

Chronic Urinary Retention:

• Outlet obstruction or bladder under activity
• May be related to previous surgery, aging, development of bad bladder habits, or neurologic disorders
• Medication, such as antidepressants
• May present with symptoms of stress or urge incontinence, continuous leakage, or urinary tract infection

Functional and Transient Incontinence:

• Mostly in the elderly
• Urinary tract infection
• Restricted mobility
• Severe constipation
• Medication - diuretics, antipsychotics
• Psychological/cognitive deficiency

Unusual Causes of Urinary Incontinence:

• Urethral diverticulum
• Genitourinary fistula
• Congenital abnormalities (bladder extrophy, ectopic ureter)
• Detrusor hyperreflexia with impaired contractility

Causes of Incontinence:

Inherited or genetic factors

• Race
• Anatomic differences
• Connective tissue
• Neurologic abnormalities

External factors:

• Pregnancy and childbirth
• Aging
• Hormone effects
• Nonobstetric pelvic trauma and radical surgery
• Increased intra-abdominal pressure
• Drug effects

Pregnancy and Childbirth:

• Hormonal effects in pregnancy
• Pressure of uterus and contents
• Denervation (stretch or crush injury to pudendal nerve)
• Connective tissue changes or injury (fascia)
• Mechanical disruption of muscles and sphincters

Aging:

• Gravity
• Neurologic changes with aging
• Loss of estrogen
• Changes in connective tissue cross linking and reduced elasticity

Hormone Effects:

• Common embryonic origin of bladder urethra and vagina from urogenital sinus
• High concentration of estrogen receptors in tissues of pelvic support
• General collagen deficiency state in postmenopausal women due to the lack of estrogen (falconer et al., 1994)
• Urethral coaptation affected by loss of estrogen

Increased Intra-abdominal Pressure:

• Pulmonary disease
• Constipation/straining
• Lifting
• Exercise
• Ascites/hepatomegaly
• Obesity

Drug Effects:

• Alpha-blocking agents
• Terazosin
• Prazosin
• Phenoxybenzamine
• Phenothiazines
• Methyldopa
• Benzodiazepines

Fecal Incontinence:

• Approximately 10% women with urinary incontinence have incontinence of flatus or stool

Diagnosis:

Urinalysis:

Conditions associated with overactive bladder

• Hematuria
• Pyuria
• Bacteriuria
• Glucosuria
• Proteinuria
• Urine culture

Post void Residual Volume (PVR):

• If clinically indicated accurate PVR can be done by

1.           Catheterization
2.           Ultrasound

• PVR of <50 ml is considered adequate, repetitive PVR >200 ml is considered inadequate
• Use clinical judgment when interpreting PVR results in the intermediate range (50-199 ml)

Treatment:

Non-surgical

• Fluid management
• Reduce caffeine, alcohol, and smoking
• Bladder retraining
• Pelvic floor exercises
• Pessaries
• Continence devices
• Hormone replacement therapy
• Medication to help strengthen the urethra
• Medication to help relax the bladder

Bladder retraining:

• Regular voiding by the clock
• Gradual increase in time between voids
• Double voiding

Fluid management:

• Avoid caffeine and alcohol
• Avoid drinking a lot of fluids in the evening

Physiotherapy:

• Pelvic floor exercises
• Vaginal cones
• Devices for reinforcement

Pessaries :

• Support devices to correct the prolapse
• Pessaries to hold up the bladder

Hormone replacement:

• Systemic  hormone replacement
• Local hormone application
• Vaginal cream
• Vaginal estrogen ring

Medication to strengthen the urethra:

• Cold medication  - Ornade

Medication to relax the bladder:

• Oxybutynin (ditropan)
• Toteridine (detrol)
• Flavoxate (urispas)
• Imipramine (elavil)

Surgery:

• Burch repair
• Marshall-marchetti-krantz repair
• Sling
• Needle suspension
• Injections
• Tension free vaginal tape