URINARY INCONTINENCE

Dr. MOCH. RIDWAN,Sp.KFR

Lab. Ilmu Kedokteran Fisik dan Rehabilitasi FKUB/RSUD Dr. Saiful Anwar Malang

Urinary Incontinence
Definition
Urinary incontinence is unintentional loss of urine

that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. Urinary retention is the inability to empty the bladder. With chronic urinary retention, you may be able to urinate, but you have trouble starting a stream or emptying your bladder completely

1. Stress incontinence 2. Urge incontinence 3. Overflow incontinence 4. Mixed incontinence 5. Anatomic or developmental abnormalities 6. Temporary incontinence 7. Bed-wetting

Stress incontinence
People with stress incontinence involuntarily leak

urine while exercising, coughing, sneezing, laughing or lifting. During these activities, sudden pressure to the bladder causes urine to leak. Stress incontinence is the most common type of incontinence among women. It may be due to weakened pelvic muscles, weakening in the wall between the bladder and vagina, or a change in the position of the bladder.

Other causes of stress incontinence include:

Weakening of muscles that hold the bladder in place, or

weakening of the bladder itself Weakening of the urethral sphincter muscles Damage to the nerves controlling the bladder from diseases such as diabetes, stroke, Parkinson's disease and/or multiple sclerosis, or from treatment of gynecologic or pelvic cancers with surgery, radiation or chemotherapy In women, a hormone imbalance or a decrease in estrogen following menopause, which can weaken the sphincter muscle In men, benign prostatic hyperplasia (a noncancerous overgrowth of the prostate gland), prostate cancer or prostate surgery

Urge incontinence
A frequent, sudden urge to urinate along with little

control of the bladder (especially when sleeping, drinking, or listening to running water) is known as urge incontinence. This condition is also known as spastic bladder, overactive bladder or reflex incontinence. Urge incontinence is marked by a need to urinate more than seven times daily or more than twice nightly. It is most common in older adults. It also may be a symptom of a urinary infection in the bladder or kidneys, or may result from injury, illness or surgery

Problems caused by oversensitive bladder.

Among the possible causes are:

Stroke
Diseases of the nervous system, such as multiple

sclerosis, Alzheimer's or Parkinson's Tumors or cancer in the uterus, bladder or prostate Interstitial cystitis (inflamed bladder wall) Prostatitis (inflamed prostate) Prostate removal, cesarean section, hysterectomy, or surgery involving the lower intestine or rectum

Overflow incontinence
People with overflow incontinence cannot completely

empty their bladders. A constantly full bladder triggers frequent urination or a constant dribbling of urine, or both. This type of incontinence is often caused by bladder muscles weakened as a result of nerve damage from diabetes or other diseases. It can also occur when the urethra is blocked due to kidney or urinary stones, tumors, an enlarged prostate in men, female bladder surgery that is too tight, or a birth defect.

 Bladder doesn't empty completely, leading to frequent

urination or dribbling.

Functional incontinence
Functional incontinence is the most common type among

older adults with arthritis, Parkinson's disease or Alzheimer's disease. These people are often unable to control their bladder before reaching the bathroom due to limitations in moving,thinking or communicating.

Mixed incontinence
Some people experience two types of incontinence

simultaneously, typically stress incontinence and urge incontinence. Mixed incontinence is most commonly found in women. What causes the two forms may or may not be related.

Anatomic or developmental abnormalities

Incontinence is sometimes caused by an anatomic

(physical) or neurologic abnormality. An abnormal opening between the bladder and another structure (called a fistula) can cause incontinence, as can a leak in the urinary system. Loss of normal bladder function may also result from damage to part of the nervous system due to trauma, disease or injury. This dysfunction, called neurogenic bladder, can cause the bladder to be underactive (unable to contract and empty completely) or overactive (contracting too quickly or frequently).

Temporary incontinence
Sometimes incontinence comes and goes with specific

conditions or as a side effect of a treatment for other chronic or acute diseases. Temporary incontinence may be caused by: Severe constipation Infections in the urinary tract or vagina Certain medications such as diuretics (water pills); sleeping pills or muscle relaxants; narcotics, such as morphine; antihistamines; antidepressants; antipsychotic drugs; or calcium channel blockers

Bed-wetting
In addition, some children have nocturnal enuresis

(wetting the bed at night). Bed-wetting is normal until the age of 5 years. It is often an inherited disorder with a delay in neurological control of the bladder. Treatment is usually delayed to age 6 and may involve either medication or an alarm device that will awaken the child at the first sign of wetness.

Diagnosis
To make a diagnosis, your doctor may order one or more of the following tests : Blood tests Urinalysis or urine culture to rule out urinary tract infection or other abnormalities Pad test. After placement of a pre-weighed sanitary pad, the patient is asked to exercise. Following exercise, the pad is re-weighed to determine the amount of urine loss. Cystoscopy (inspection of the inside of the bladder) Urodynamic studies, to measure pressure and urine flow

Risk factors for urinary incontinency

Urinary incontinence is a disorder with multiple factors, wherein

some of them are transient and others are permanent. Various risk factors have been associated with increased incidence of UI. Some these are: Immobility/chronic degenerative diseases Medications Morbid obesity Smoking Diabetes Stroke Pelvic muscle weakness Childhood nocturnal enuresis Pregnancy / vaginal delivery

Treatment of urinary incontinency

The management of UI depends on various factors such as Age of the individual Type of incontinence Underlying cause and Severity of the condition It may range from minor modification in the medications being consumed to surgery for the correction of muscle actions. The correction of the underlying disorder relieves the condition in majority of the cases. In general, the treatment modalities can be categorized as behavior management (include lifestyle changes, physical therapy, bladder retraining and use of vaginal and urethral devices), administration of medications and surgical management.

Treatment is keyed to the type of incontinence. The usual approaches are as follows:
Treatment is keyed to the type of incontinence. The usual

approaches are as follows: Stress incontinence - Surgery, pelvic floor physiotherapy, anti-incontinence devices, and medication Urge incontinence - Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention Mixed incontinence - Anticholinergic drugs and surgery Overflow incontinence - Catheterization regimen or diversion Functional incontinence - Treatment of the underlying cause

 In general, the first choice for treatment is the least

invasive one, with the least number of potential complications for the patient. Examples of noninvasive treatments include medications or exercises. However, the least invasive treatment may not afford the best outcome in certain situations. In specific situations, minimally invasive surgery may be the most effective form of managing urinary incontinence.

 Kegel exercises have been shown to improve the

strength and tone of the muscles of the pelvic floor (ie, the levator ani, and particularly the pubococcygeus). During times of increased intra-abdominal pressure, tensing of these muscles tightens the connective tissue that supports the urethra. Thus, pressure transmission to the urethra may increase, and the urethra compresses shut during times of increased stress.

 The exercises consist of voluntary contractions of the

muscles of the pelvic floor. Because both fast-twitch and slow-twitch muscle fibers are found in the levator ani complex, both rapid contractions and slow contractions held for maximal duration should be performed to achieve the best possible results. Patients can perform pelvic floor muscle exercises by drawing in or lifting up the levator ani muscles, as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner-thigh muscles. The patient can confirm that she is using the correct muscles at home by periodically performing the contractions during voiding with the goal of interrupting the urinary stream.

 Initially, patients are instructed to perform the

squeezing exercise 5 times, holding each contraction for a count of 5. Five contractions equal 1 set. Patients should do 1 set every hour while they are awake, during such activities as driving, reading, or watching television. An alternate program requires 1 set of exercises every time the patient uses a bathroom. Soon after starting the exercises, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation.

 Another regimen is to perform the exercises for 10

minutes twice a day using an audiocassette tape. The audiocassette coaches the patient to contract the levator ani muscles for a count of 10 seconds and then to relax for a count of 10 seconds, performing 25 repetitions in a row. Twenty-five contractions equal 1 set. Perform the first set slowly, followed by a second set performed rapidly.

 Approximately 6-12 weeks of exercises are required

before improvement is noted, and 3-6 months are needed before maximal benefit is reached. The key to success with pelvic floor exercises is a commitment on the patients part to performing them for a long period of time. Patients who do not tend to revert back to pretherapy levels of incontinence.

 Individuals who benefit most tend to be young healthy

women who can identify the levator ani muscles (specifically, the pubococcygeus portion) accurately. Older adults with weak pelvic muscle tone or women who have difficulty recognizing the correct muscles need adjunctive therapy such as biofeedback or electrical stimulation. Patients with severe neuromuscular damage to the pelvic floor may not be able to perform Kegel exercises, even with proper instruction.

Biofeedback
Biofeedback therapy is a form of pelvic floor muscle

rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles. Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to relay auditory or visual information to the patient about the status of pelvic muscle activity. These devices allow the patient to receive immediate visual feedback on the activity of the pelvic floor muscles, thereby providing incentive and confirmation of proper performance of the muscle contractions.

 Studies on biofeedback combined with pelvic floor

exercises show a 54-87% improvement with incontinence. The best biofeedback protocol is the one that reinforces levator ani muscle contraction with inhibition of abdominal and bladder contraction. Reports using this method show a 76-82% reduction in urinary incontinence. Biofeedback also has been used successfully in the treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery.

Electrical stimulation
Electrical stimulation of pelvic floor muscles produces

a contraction of the levator ani muscles and external urethral sphincter while inhibiting bladder contraction. This therapy depends on a preserved reflex arc through the intact sacral micturition center. Similar to biofeedback, electrical stimulation can be performed at the office or at home. Electrical stimulation can be used in conjunction with biofeedback or pelvic floor muscle exercises.

 Electrical stimulation therapy requires a similar type of

probe and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to the biofeedback therapy, except small electric currents are used. Nonimplantable pelvic floor electrical stimulation uses vaginal sensors, anal sensors, or surface electrodes. Adverse reactions are minimal. Like biofeedback, pelvic floor muscle electrical stimulation has proved effective in treating female stress incontinence. It may be effective in men and women with urge or mixed incontinence. Urge incontinence secondary to neurologic diseases may be decreased with this therapy. Unfortunately, this treatment does not appear to benefit patients who are cognitively impaired.

 Electrical stimulation may be the most beneficial

when stress incontinence and very weak or damaged pelvic floor muscles coexist. A regimented program of electrical stimulation helps these weakened pelvic muscles contract so they can become stronger. For women with urge incontinence, electrical stimulation may help the bladder relax and prevent it from contracting involuntarily.

Behavioral Approaches
Bladder training involves relearning how to urinate.

This method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms; however, it also may be used for stress and mixed incontinence. Often, these patients find that when they respond to symptoms of urge and return to the bathroom soon after they have voided, they do not urinate much. In other words, although their bladder is not full, it is signaling for them to void.

 Bladder training generally consists of self-education,

scheduled voiding with conscious delay of voiding, and positive reinforcement. Bladder training requires the patient to resist or inhibit the sensation of urgency and postpone voiding. Patients urinate according to a scheduled timetable rather than the symptoms of urge. Bladder training also uses dietary tactics such as adjustment in fluid intake and avoidance of dietary stimulants. In addition, distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder. By using these strategies, patients can induce the bladder to accommodate progressively larger voiding volumes.

 Initially, the interval goal is determined by the patient's

current voiding habits and is not enforced at night. The interval goal between each void usually is set at 2-3 hours, but may be set further apart if desired. As the bladder becomes accustomed to this delay in voiding, the interval between mandatory voids is increased progressively, in 15- to 30-minute increments, with simultaneous distraction or relaxation techniques and dietary modification. Typically, the interval is increased by 15 minutes per week until the patient reaches a voiding interval of approximately 3-4 hours.

COMPLICATIONS
Complications of urinary incontinency
Specific complications such as social inhibition,

frequent urinary tract infections, and formation of kidney stones may be associated with UI. Some other complications may be associated with the type of underlying disorder.

PREVENTION
Prevention of urinary incontinency
The lifestyle changes advised before may help in

reducing the incidence to a certain extent. Performing exercises such as Kegels exercise to strengthen the pelvic muscles during pregnancy and after delivery can prevent incontinence associated with pregnancy.

 The lifestyle changes include weight loss in obese

patients, postural changes and decreasing the intake of caffeine. Physical exercises such as Kegels exercises are advised to strengthen the pelvic muscles. Medications specific for UI include drugs such as pseudoephedrine and imipramine. Surgical correction of the muscles to aid in urine retention may be advised in selected cases.1,24

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