Urinary Incontinence Karla Reinhart DNP, FNP-C, ARNP October, 2015 - - PDF document

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Urinary Incontinence

Karla Reinhart DNP, FNP-C, ARNP October, 2015

Conflict of Interest

• None

Objectives

• Acquire knowledge of A & P of micturition, as well as pertinent pathologies

for male and female incontinence

• Identify urinary incontinence risk factors including irritants
• Discuss types and causes of urinary incontinence
• Identify components of an incontinence assessment
• Identify interventions to treat urinary incontinence

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Statistics

• More than 13 million people in the United States- male and female, young

and old- experience incontinence

• Women experience incontinence twice as often as men, pregnancy and

childbirth, menopause, and the structure of the female urinary tract account for the difference

• Underdiagnosed and underreported problem that increases with age with 50-

84% of elderly affected

Anatomy

• Relevant lower urinary tract
• Urethra
• Bladder

Pathophysiology

• Micturition requires coordination of several physiological processes
• Somatic and autonomic nerves carry bladder volume input to the spinal cord
• Motor output innervating the detrusor, sphincter, and bladder musculature is

adjusted accordingly

• Cerebral cortex exerts a inhibitory influence
• Brainstem facilitates urination by coordinating urethral sphincter relaxation and

detrusor muscle contraction

• As bladder fills, sympathetic tone contributes to closure of the bladder neck and

relaxation of the dome of the bladder, inhibiting parasympathetic tone.

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Pathophysiology Continued

• With urination sympathetic and somatic tones in the bladder and periurethral

muscles diminish resulting in decreased urethral resistance.

• Cholinergic parasympathetic tone increases, resulting in bladder contraction.
• Urine flow results when bladder pressure exceeds urethral resistance.
• Bladder capacity is 300-500 ml, and the first urge to urinate generally occurs

between bladder volumes of 150-300 ml.

• Incontinence occurs when micturition physiology, functional toileting ability, or

both have been disrupted.

Pathologies

• Urinary incontinence (UI) is a multifactorial syndrome produced by a

combination of genitourinary pathology, age-related changes, and comorbid conditions that impair normal micturition or the functional ability to toilet

• neself, or both.

Risk Factors

• Age
• Gender
• Race
• Obesity
• Surgery
• Diet

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Bladder Irritants

• Too much or too little water intake
• Alcoholic beverages
• Caffeine containing drinks and foods
• Acidic foods and drinks
• Carbonated drinks
• Spicy foods
• Sugar, honey and artificial sweeteners

Types and Causes

• Stress Incontinence
• Urge Incontinence
• Mixed Incontinence
• Overflow Incontinence
• Functional Incontinence

Urinary Incontinence: the accidental leakage of urine

Stress Incontinence

Can happen when there is an increase in abdominal pressure, urine leaks due to weakened pelvic floor muscles and tissue. Increased intra-abdominal pressure raises pressure within the bladder to the point it exceeds the urethra’s resistance to urinary flow.

• Exercise
• Laugh
• Sneeze
• Cough

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Causes

• Major cause is urethral hypermobility due to impaired support from pelvic floor.
• Less common cause is an intrinsic sphincter deficiency, usually secondary to pelvic

surgeries.

• Pregnancy & Childbirth
• Overweight or obese
• Prostate surgery
• Certain medications: anti-hypertensive, anti-depressant, diuretics, sleeping pills,

muscle relaxants

Urge Incontinence

• Often referred to as overactive bladder. Urgent need to urinate but may leak if

unable to get to bathroom in time.

• Gotta go Gotta go
• Involuntary urine loss associated with the feeling of urgency (detrusor over activity)
• Urinary urgency, usually accompanied by frequency and nocturia, with or without

urgency urinary incontinence, in the absence of UTI or other obvious pathology.

• Unclear etiology and incompletely understood pathophysiology.

Causes

• Damage to bladder nerves
• Damage to nervous system
• Damage to muscles
• Interstitial cystitis
• MS, Parkinson’s, DM, stroke
• Bladder infection
• Bladder stones
• Medications: decongestants, estrogen, NSAIDs plus previous discussed

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Mixed Incontinence

• A combination of stress incontinence and urge incontinence
• Approximately 40-60% of females with incontinence have this condition
• Generally defined as detrusor over activity and impaired urethral function,

the actual pathophysiology of mixed urinary incontinence is still unknown.

• Bladder outlet is weak and the detrusor is overactive

Overflow Incontinence

• Insufficient emptying of bladder causing leakage when bladder is full
• More common in men causing symptoms of dribbling of urine

Causes

• Weak bladder muscles
• Blockage of urethra by prostate enlargement
• Tumors that cause obstruction of urine flow
• Constipation

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Functional Incontinence

• Physical problems or cognitive problems prevent successful access to

bathroom in time.

• DIAPPERS- delirium, infection, atrophic urethritis or vaginitis,

pharmacologic agents, psychiatric illness, endocrine disorders, reduced mobility or dexterity, stool impaction

• Arthritis
• Dementia

Incontinence Assessment

• Basic evaluation including history, physical exam, and urinalysis
• Voiding diary
• Cotton swab test
• Cough stress test
• Post void residual measurement
• Cystoscopy
• Urodynamic studies

History

• Severity and quantity of urine lost and frequency of incontinence episodes
• Duration of complaint and if worsening
• Triggering factors or events
• Constant versus intermittent urine loss
• Associated frequency, urgency, dysuria, pain with full bladder
• History of UTIs
• Concomitant fecal incontinence or pelvic organ prolapse
• Coexistent complicating or exacerbating medical problems
• OB history
• History of pelvic surgery
• Other urological conditions
• Spinal and CNS surgery
• Lifestyle Issues
• BPH

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Additional Diagnosis

• Patients with urinary incontinence should undergo a basic evaluation that includes a history,

physical examination, and urinalysis. In selected patients, the following may also be needed:

• Voiding diary
• Cotton swab test
• Cough stress test
• Measurement of postvoid residual (PVR) urine volume
• Cystoscopy
• Urodynamic studies

Treatment Interventions

• Estrogen- transvaginal
• Antimuscarinics
• B2 Adrenoceptor Agonist
• Anticholinergic agents
• Antispasmodic drugs
• Tricyclic antidepressants
• Botulinum toxin

ACP Guideline

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Non-Pharmaceutical Interventions

• Removal bladder irritants
• Bladder retraining
• Pelvic floor exercises- Kegel
• Biofeedback
• Devices- pessary, electrical stimulation
• Injections & Surgery
• Herbs/supplements

Herbs/Supplements

Most of the herbal preparations contain several herbs combined rather than a single herb. This allows a synergistic effect, addressing the urinary problem from several different angles at once. * Gosha-jinki-gan: improves urinary urgency, frequency, and nocturnal enuresis ( increases bladder capacity and reduces bladder contractions via effects on the nervous system).

• Bucha: used for bladder and kidney infections. Has anti-inflammatory, antibacterial, and diuretic properties (nourishes the

bladder tissue).

• Cleavers: diuretic effects, coats along bladder wall that protects against irritation (irritation is a cause of overactive bladder).
• Horsetail: acts as a diuretic, anti-inflammatory, and antioxidant. (used to treat kidney and bladder stones, UTIs, and

incontinence)

• Saw palmetto: may have anti-inflammatory properties, and testosterone effects (enlarged prostate)

(caution with herbal usage is recommended- drug interactions, ingredient list not always accurate)

References

Luber, K. (2004). The definition, prevalence, and risk factors for stress urinary

• incontinence. Reviews in Urology, 6(3), 53-59.

Merkelj, I. (2002). Basic assessment of urinary incontinence. South Med J, 95(2), 1-6. Minassian, V., Stewart, W., & Wood, G. (2008). Urinary incontinence in women. Obstetrics & Gynecology, 111(2), 324-331. Qaseem, A., Dallas, P., Forclea, M., Starkey, M., Denberg, T., & Shekelle, P. (2014). Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American college of physicians. American College of Physicians, 161(6), 429-446.

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References

Peyrat, L., Haillot, O., Bruyere, F., Boutin, J.M., Bertrand, P., & Lanson, Y. (2002). Prevalence and risk factors of urinary incontinence in young and middle-aged women. BJU International, 89, 61-66. Sacco, E., Prayer-Galetti, T., Pinto, F., Fracalanza, S., Betto, G., Pagano, F., & Artibani, W. (2006). Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU International, 97, 1234- 1241. Vasavada, S. & Kim, E. (2014). Urinary Incontinence retrieved from http://emedicine.medscape.com/article/452289-overview Watson, S. (2011). Herbal Remedies for Overactive Bladder retrieved from http://www.webmd.com/urinary-incontinence-oab-13/herbal-remedies