_of urinary incontinence in adults成人尿失禁概述课件

Overview of Urinary Overview of Urinary Incontinence in AdultsIncontinence in Adults Christina M. Bordeau, D.O. Christina M. Bordeau, D.O. Internal Medicine, PGY-3Internal Medicine, PGY-3 October 28, 2012October 28, 2012 Goals and ObjectivesGoals and Objectives Provide the clinician with a basic, yet Provide the clinician with a basic, yet comprehensive, overview of urinary incontinence comprehensive, overview of urinary incontinence pathophysiology pathophysiology Equip the physician with a basic understanding Equip the physician with a basic understanding of proper evaluation and assessment of patients of proper evaluation and assessment of patients with urinary complaints within the adult with urinary complaints within the adult populationpopulation Establish the indications for and procedures Establish the indications for and procedures involved in urodynamic testinginvolved in urodynamic testing No commercial investments, endorsements, nor No commercial investments, endorsements, nor biasbias Urinary Incontinence: DefinitionUrinary Incontinence: Definition International Continence SocietyInternational Continence Society The “involuntary leakage of urine”The “involuntary leakage of urine” Stress Urinary Incontinence Stress Urinary Incontinence is “involuntary leakage on is “involuntary leakage on effort or exertion, or on sneezing or coughing”effort or exertion, or on sneezing or coughing” Urinary UrgencyUrinary Urgency is “the complaint of a sudden compelling is “the complaint of a sudden compelling desire to pass urine which is difficult to defer”desire to pass urine which is difficult to defer” Urgency Incontinence Urgency Incontinence is “the complaint of involuntary is “the complaint of involuntary leakage accompanied by or immediately preceded by urgency”leakage accompanied by or immediately preceded by urgency” Overactive Bladder Syndrome Overactive Bladder Syndrome is “urgency with or without is “urgency with or without urgency incontinence, usually increased daytime frequency urgency incontinence, usually increased daytime frequency and nocturia”.and nocturia”. Urinary DisordersUrinary Disorders Three categories:Three categories: StorageStorage VoidingVoiding PostmicturitionPostmicturition Voiding SymptomsVoiding Symptoms Slow urinary streamSlow urinary stream Splitting or sprayingSplitting or spraying Intermittency or hesitancy with flowIntermittency or hesitancy with flow Straining to voidStraining to void Incomplete emptyingIncomplete emptying Postmicturition dribblePostmicturition dribble Case ReportCase Report Mrs. M.A. is an 84-year-old female Mrs. M.A. is an 84-year-old female Alzheimers DementiaAlzheimers Dementia 87-year-old husband reports her urinary incontinence 87-year-old husband reports her urinary incontinence is worsening and is causing increased caregiver stressis worsening and is causing increased caregiver stress Occasional incontinence Occasional incontinence 5yrs 5yrs Past 6 months has had at least 3 episodes of urine Past 6 months has had at least 3 episodes of urine loss daily, at least 1 of these during the night loss daily, at least 1 of these during the night Doing more laundry and restricting social activities to Doing more laundry and restricting social activities to minimize embarrassmentminimize embarrassment Case Report 2Case Report 2 She minimizes the concernShe minimizes the concern Reports only occasional urine lossReports only occasional urine loss Independent in self-care but needs assistance with Independent in self-care but needs assistance with shopping and complex meal preparationshopping and complex meal preparation Medications:Medications: Donepezil 10mg daily, 7 months agoDonepezil 10mg daily, 7 months ago Nifedipine XR 30mg daily Nifedipine XR 30mg daily HCTZ 25mg daily for HTNHCTZ 25mg daily for HTN ASA 81mg daily ASA 81mg daily Oxazepam 30mg QHS PRN sleepOxazepam 30mg QHS PRN sleep Case Report 3Case Report 3 Describes small-volume urine loss with coughing Describes small-volume urine loss with coughing or laughingor laughing Loss of moderate volumes of urine (enough to drip Loss of moderate volumes of urine (enough to drip down her leg) if she “doesnt get to the bathroom down her leg) if she “doesnt get to the bathroom right away” (within two minutes) upon urgeright away” (within two minutes) upon urge Occasionally wakes up wet and needs to go to the Occasionally wakes up wet and needs to go to the toilet immediately upon awakeningtoilet immediately upon awakening Coffee in the AM Coffee in the AM 3 cups of tea between lunch and bedtime3 cups of tea between lunch and bedtime Denies EtOH and tobacco use Denies EtOH and tobacco use Restricted fluid intake Restricted fluid intake UI / Fast FactsUI / Fast Facts 25 million US/predominantly 25 million US/predominantly 15-20 Billion US $ 15-20 Billion US $ diagnosisdiagnosis 25%-35% of adults and 50% of the 1.5 million NH 25%-35% of adults and 50% of the 1.5 million NH residentsresidents Up to 60% of NH patients are incontinent vs. 30% of Up to 60% of NH patients are incontinent vs. 30% of elderly people living at home are incontinentelderly people living at home are incontinent Underdiagnosed and underreported : Great MythUnderdiagnosed and underreported : Great Myth 50%-70% of women fail to seek medical evaluation and 50%-70% of women fail to seek medical evaluation and treatment treatment SI affects 15%-60% of women of all agesSI affects 15%-60% of women of all ages 1/4 of nulliparous, young, college athletes experience 1/4 of nulliparous, young, college athletes experience SI in sportsSI in sports Bladder Physiology Bladder Physiology Urine storage Urine storage Sympathetic (T/L) Sympathetic (T/L) Detrusor relaxationDetrusor relaxation Smooth also when pelvic urethra to help maintain continence; also when pelvic floor muscles are contractedfloor muscles are contracted Pelvic FloorPelvic Floor Supportive Fxn: Muscular and CT (Endopelvic Fascia)Supportive Fxn: Muscular and CT (Endopelvic Fascia) Levator Ani (Puborectalis, pubococcgeus and Levator Ani (Puborectalis, pubococcgeus and iliococcygeus) and coccygeus musclesiliococcygeus) and coccygeus muscles Pelvic Floor 2Pelvic Floor 2 Somatic NS:Somatic NS: Controls striated external urethral sphincter Controls striated external urethral sphincter and levator ani muscle via pudendal nerve and levator ani muscle via pudendal nerve and S2-S4.and S2-S4. InhibitionInhibitionrelaxation of bladder outlet and relaxation of bladder outlet and pelvic floor in voiding.pelvic floor in voiding. CNS:CNS: Voluntary control and modification of Voluntary control and modification of micturition reflexesmicturition reflexes UrethraUrethra Funnels at the urethrovaginal junctionFunnels at the urethrovaginal junction The urethra becomes more patent and has reduced The urethra becomes more patent and has reduced closing pressure and continence is lostclosing pressure and continence is lost Mechanical closure/integrity of the urethra is Mechanical closure/integrity of the urethra is necessary to prevent SUInecessary to prevent SUI Closure/integrity requires mucosal surface coaptation Closure/integrity requires mucosal surface coaptation intact viscoelastic properties of urethral epithelium, intact viscoelastic properties of urethral epithelium, healthy vascular plexus and contraction of healthy vascular plexus and contraction of surrounding musculaturesurrounding musculature Regional Defects of Micturition Regional Defects of Micturition CentralCentral PeripheralPeripheral NeurologicalNeurological MusculoskeletalMusculoskeletal CongenitalCongenital Voluntary Control of MicturitionVoluntary Control of Micturition Disruption of Central Control = dysfunctional Disruption of Central Control = dysfunctional storage and voiding patternsstorage and voiding patterns Lesions in cortical centers result in urge Lesions in cortical centers result in urge incontinence, enuresis and urethral spasmincontinence, enuresis and urethral spasm StrokeStroke Alzheimers Disease, Multi-infarct Dementia, Parkinson Alzheimers Disease, Multi-infarct Dementia, Parkinson Disease Disease MS with suprapontine lesions MS with suprapontine lesions involuntary detrusor involuntary detrusor contractions in synchrony with urethral relaxation contractions in synchrony with urethral relaxation neurogenic detrusor overactivity with neurogenic detrusor overactivity with urgency/frequency and urgency incontinenceurgency/frequency and urgency incontinence Voluntary Control of Micturition 2Voluntary Control of Micturition 2 High spinal cord or UMN lesions High spinal cord or UMN lesions neurogenic detrusor overactivity neurogenic detrusor overactivity Detrusor contractions are not synchronized Detrusor contractions are not synchronized with urethral relaxation detrusor-sphincter with urethral relaxation detrusor-sphincter dyssynergia (urinary retention)dyssynergia (urinary retention) Seen in acute spinal cord trauma, cervical or Seen in acute spinal cord trauma, cervical or lumbar stenosis, disc herniation or chronic SC lumbar stenosis, disc herniation or chronic SC conditions, ie: MS conditions, ie: MS Voluntary Control of Micturition 3Voluntary Control of Micturition 3 LMN lesionsLMN lesions Injury to peripheral nervous system Injury to peripheral nervous system contraction of detrusor muscle overflow contraction of detrusor muscle overflow incontinenceincontinence Peripheral neuropathy : DiabetesPeripheral neuropathy : Diabetes Injury to Pelvic Plexus : Resection surgery : Injury to Pelvic Plexus : Resection surgery : Radical Hysterectomy or rectal surgery Radical Hysterectomy or rectal surgery Parasympathetic innervation is mainly affectedParasympathetic innervation is mainly affected Muscular Causes of Urine Storage Muscular Causes of Urine Storage and Evacuation Dysfunctionand Evacuation Dysfunction Detrusor muscles functional ability to contract Detrusor muscles functional ability to contract appropriately is altered by:appropriately is altered by: Age, atrophy, trauma or Age, atrophy, trauma or muscular innervation muscular innervation Overactive bladder tissue demonstrates increases in Overactive bladder tissue demonstrates increases in elastin, collagen and segments of denervated muscleelastin, collagen and segments of denervated muscle Raised intracellular calcium levels: ATP phosphorylation, protein Raised intracellular calcium levels: ATP phosphorylation, protein kinases, and potassium and calcium channels kinases, and potassium and calcium channels Abnormal number of intercellular connections used for Abnormal number of intercellular connections used for communication between smooth muscle cells communication between smooth muscle cells inappropriate inappropriate detrusor contractionsdetrusor contractions Transient IncontinenceTransient Incontinence “Transient Incontinence”“Transient Incontinence” UI that develops due to temporary underlying UI that develops due to temporary underlying condition: UTIs, atrophic vaginitis, urethritis condition: UTIs, atrophic vaginitis, urethritis or prostatitisor prostatitis Dysuria and urinary urgency Dysuria and urinary urgency Physiologic conditions may lead to polyuria Physiologic conditions may lead to polyuria and UI: Diabetes insipidus, psychogenic and UI: Diabetes insipidus, psychogenic polydipsia, hyperglycemia, hypercalcemia, polydipsia, hyperglycemia, hypercalcemia, fluid overload (CHF), delirium, fecal impactionfluid overload (CHF), delirium, fecal impaction Chronic IncontinenceChronic Incontinence Persistent Persistent StressStress UrgeUrge OverflowOverflow FunctionalFunctional MixedMixed Conditions and Factors Affecting Conditions and Factors Affecting Urine Storage and EvacuationUrine Storage and Evacuation UI reflects multiple impairmentsUI reflects multiple impairments Intact functional ability to toilet oneselfIntact functional ability to toilet oneself Potentially reversible contributors to UI: Potentially reversible contributors to UI: DIAPPERSDIAPPERS: : D Dementia/delirium ementia/delirium I Infectionnfection A Atrophic Vaginitistrophic Vaginitis P Psychological sychological P Pharmacologic harmacologic E Endocrinendocrine R Restricted mobilityestricted mobility S Stool impactiontool impaction Stress Urinary IncontinenceStress Urinary Incontinence Concepts of pressure transmission, anatomic Concepts of pressure transmission, anatomic support and urethral integritysupport and urethral integrity Continence during physical stress requires Continence during physical stress requires anatomic urethral support and integrityanatomic urethral support and integrity Ideal support: Ideal support: 1. Ligaments along the lateral aspects of urethra : 1. Ligaments along the lateral aspects of urethra : pubourethral ligamentspubourethral ligaments 2. Anterior vaginal wall and its lateral fascial condensation2. Anterior vaginal wall and its lateral fascial condensation 3. Arcus tendinous fascia pelvis3. Arcus tendinous fascia pelvis 4. Levator ani muscles4. Levator ani muscles SUI 2SUI 2 Genuine Stress IncontinenceGenuine Stress Incontinence Leakage that occurs with an increase in Leakage that occurs with an increase in abdominal pressure without a rise in true abdominal pressure without a rise in true detrusor pressure (pDet)detrusor pressure (pDet) SUI 3SUI 3 Lift, laugh, cough, sneezeLift, laugh, cough, sneeze Due to inadequate closure of the external Due to inadequate closure of the external urethral sphincterurethral sphincter Urethral hypermobility with loss of support Urethral hypermobility with loss of support of the urethraof the urethra Urge IncontinenceUrge Incontinence Detrusor overactivity Detrusor overactivity Overactive Bladder: dry vs. wetOveractive Bladder: dry vs. wet Dx Urgency or leakage with a contraction that patient Dx Urgency or leakage with a contraction that patient cannot suppresscannot suppress Involuntary ctx in filling phase: spontaneous vs. Involuntary ctx in filling phase: spontaneous vs. provokedprovoked Leak large volumes of urineLeak large volumes of urine Neurogenic detrusor overactivity: MS, Parkinson Neurogenic detrusor overactivity: MS, Parkinson Disease, stroke, spinal cord injuries, spinal stenosis, Disease, stroke, spinal cord injuries, spinal stenosis, DementiaDementia Urethra DefectsUrethra Defects Prior etiologies of such defects: Prior etiologies of such defects: Retropubic surgery with denervation or Retropubic surgery with denervation or scarring of the urethra and supporting tissuescarring of the urethra and supporting tissue Prior pelvic radiotherapyPrior pelvic radiotherapy HypoestrogenismHypoestrogenism Diabetic neuropathyDiabetic neuropathy Childbirth associated traumaChildbirth associated trauma Pharmacological CausesPharmacological Causes Use of diureticsUse of diuretics Anticholinergic medicationsAnticholinergic medications AlcoholAlcohol Psychotropic medicationsPsychotropic medications NarcoticsNarcotics Alpha agonists or antagonistsAlpha agonists or antagonists Beta mimetics Beta mimetics Calcium channel blockersCalcium channel blockers Overflow IncontinenceOverflow Incontinence Outlet obstruction or poor detrusor Outlet obstruction or poor detrusor contractility and incomplete bladder contractility and incomplete bladder emptyingemptying Men: BPHMen: BPH Urethral stricturesUrethral strictures Frequent loss of small volumes of urineFrequent loss of small volumes of urine Functional IncontinenceFunctional Incontinence Urinary leakage that occurs as a result of Urinary leakage that occurs as a result of factors not directly associated with bladderfactors not directly associated with bladder Cognition and mobility limitationsCognition and mobility limitations Transient: ie: hip fxTransient: ie: hip fx Dementia and vascular disorder: cannot Dementia and vascular disorder: cannot recognize sensation of full bladderrecognize sensation of full bladder Cannot manipulate clothing or use toiletCannot manipulate clothing or use toilet Mixed IncontinenceMixed Incontinence More than one type of UI at a timeMore than one type of UI at a time Most common: stress and urgeMost common: stress and urge Detrusor Hyperactivity with Impaired Detrusor Hyperactivity with Impaired Contractility Contractility Urinary urgency and frequency caused by Urinary urgency and frequency caused by uninhibited detrusor contractionsuninhibited detrusor contractions Bladder does not contract adequately nor Bladder does not contract adequately nor empty completelyempty completely Fecal Incontinence Fecal Incontinence Distal colon and rectum: SDistal colon and rectum: S 2 2 -S-S 4 4 reflex arc reflex arc Patients with UI, particularly urge Patients with UI, particularly urge incontinence, may also experience incontinence, may also experience problems with fecal incontinenceproblems with fecal incontinence Chronic constipation exacerbates UI Chronic constipation exacerbates UI symptomssymptoms Evaluation and TreatmentEvaluation and Treatment History and Physical ExaminationHistory and Physical Examination Diagnostic ModalitiesDiagnostic Modalities Pharmacologic and Non-pharmacologic Pharmacologic and Non-pharmacologic RegimensRegimens PediatricsPediatrics EvaluationEvaluation History and Physical E