Urinary incontinence

Defined as the involuntary loss of urine that is objectively demonstrable.

Categorized as stress, urge or mixed types of incontinence.

Stress urinary incontinence affects approximately one in three women older than age 18 at some point in their lives.

Costs approximately $20 billion annually.

One in six women in the US report symptoms of moderate to severe urinary incontinence.

In primary stress urinary incontinence, involuntary loss of urine occurs with effort or physical exertion.

In urgency urinary incontinence, leakage is associated with a sensation of urgency.

Reported in 35% of women and 4% of men in the U.S.

Reported to affect up to 58% of women with a negative effect on quality-of-life.

Approximately 25% of premenopausal and 40% postmenopausal women report incontinence.

10% of middle aged women report daily incontinence and one third report weekly events of incontinence.

One in five women undergo surgery for either stress or mixed incontinence by age 80 years.

Affects more than 11 million women in the U.S.

Risk factors in women include cognitive impairment which has consistent relationship to presence and increased severity of dementia in acute care and nursing home settings, and a weaker associations in community dwellers.

Increased risk in women with impaired mobility, arthritis, history of falls, and inability to walk.

Increased risk in women with diabetes that is present for at least 1 year.

Urinary incontinence in women increased in women with a history of having incontinence in the last year.

Affects 30-60% of middle aged and older women (Hunskaar S).

More than 25% of all the women in the United States experience urinary incontinence with 5-15% experiencing daily episodes.

More than 200 million people suffer from incontinence worldwide.

Associated with increased risk of falls, fractures and nursing home admissions.

It is estimated that 5-10% nursing home admissions are attributable to this process.

Most women manage incontinence on their own, with only 30-45% seeking medical care.

In community-dwelling women aged 65 or older estimated to be 30%-50%.

In community-dwelling elderly men 22%.

In community-dwelling nonelderly women 10%.

In community-dwelling nonelderly men 1.5%.

Occurs frequently from middle age on.

Prevalence increases with age to approximately 50 years and stabilizes until approximately 65 years of age, and then increases with age.

Increased risk with vaginal delivery, maternal age at pregnancy, and fetal weight.

Parity is a signficant risk in younger women, but is less or absent in middle aged or older women, as other factors are more important.

Increased risk or worsening incontinence with use of conjugated estrogens alone or with medroxyprogesterone with effect by 4 months and sustained for 4 years (Grady D, Hendrix SL).

One third of women experience, 10% have urinary incontinence at least weekly and 5% have incontinence daily.

Prevalence 9-19% for all community-dwelling elderly and 2% for nonelderly.

Significant incontinence increases with age from approximately 6% the second decade to 16% in the eighth decade of life.

Affects over half of the residents of nursing homes.

More severe during the night than during the day.

25-40% of incontinent nursing home patients respond to daytime prompted voiding.

Most common type are stress, urgency and mixed (stress and urgency)types of urinary incontinence.

Of women with urinary incontinence 1/3 have mixed incontinence, that is symptoms of both stress and urinary incontinence.

Stress incontinence is the involuntary loss of urine on effort, exertion or with cough or sneezing.

Stress incontinence is the most common type and occurs during physical activities as a result of loss of vesicourethral support or deficiency of the urethral sphincter, or both.

Stress incontinence occurs when increased intra-abdominal pressure forces urine to leak from the urethra.

Stress incontinence associated with negative effects on quality-of-life.

Balance between urethral and bladder pressures is influenced by intrinsic factors like urethral musculature, blood flow and innervation, and extrinsic factors such as degree of urethral support, weight and patient physical activity.

Stress Incontinence associated with coughing or sneezing.

Stress incontinence related to vaginal delivery.

Stress incontinence that develops during pregnancy usually resolves.

Stress incontinence develops in up to one third of pregnant women.

Lower prevalence of stress incontinence in African american and Asian groups compared with whites (Milsom I).

In pregnant women with persistence of incontinence at 3 months after delivery, 92% will continue to have stress incontinence at 5 years postpartum.

Stress incontinence in women peaks between 45-49 years of age.

Stress incontinence risk factors include obesity, pregnancy, childbirth, especially vaginal, and white race.

Each 5 unit increase in body mass index increases the risk of daily incontinence by approximately 60% (Brown JS, Jackson RA).

Stress incontinence twice the risk for obese women with BMI equal or greater than 30 compared to thin women, independent of age and parity.

Detrusor instability occurs in 0.5% of nonpregnant women.

Urge incontinence refers to involuntary leakage of urine accompanied by or preceded by urgency.

Urge incontinence a function of uncontrolled detrusor contractions that overcome urethral resistance.

Patients may have a combination of stress and urge incontinence and distinguishing between them is important to focus on appropriate therapy.

Mixed urinary incontinence is the complaint of voluntary leakage associated with urgency and also with effort, exertion, sneezing, and coughing.

Next urinary incontinence includes both stress and urgency urinary incontinence and is often considered more severe because it is more challenging to manage than either urinary condition alone and responds poorly to treatment.

Most common type in older women is mixed incontinence, and accounts for approximately one half of all cases, with urge incontinency being the most common type and stress incontinence the least common (Minassian VA).

The prevalence of female urinary incontinence is approximately 25-45% for urinary incontinence and 20-36% for mixed urinary incontinence.

Mixed urinary incontinence is the most bothersome and has the largest effect on quality of life than other types of incontinence.

Treatment for mixed urinary incontinence include behavioral and pelvic floor muscle training, followed by overactive bladder medication, but many women eventually undergo surgery.

Women with large volume incontinence or frequent leakage are more likely have mixed urinary incontinence than urge urinary incontinence or stress urinary incontinence symptoms.

Other types of urinary incontinence includes continuous urinary leakage, insensible urinary incontinence, and coital incontinence.

Number of episodes of incontinence peaks during the third trimester of pregnancy and decreases after delivery but not to prepregnancy rates.

Primiparous patients studied revealed urinary incontinence before, during and after pregnancy at 4, 32, and 7% , respectively.

Stress incontinence that develops during pregnancy usually resolves while incontinence that develops after delivery is more likely to persist suggesting nerve damage as a cause.

Pelvic muscles contribute to continence with levator ani contractions pulling the vagina forward toward the pubic symphysis creating a backstop of the urinary tract by compressing the two walls of the urethra preventing urinary leakage during cough or other similar intraabdominal increases in pressure.

In women, association with low libido, vagina dryness, dyspareunia, and possible loss of urine during intercourse.

0AB-dry (obstructive sleep apnea) sometimes used to refer to women with urgency-frequency without urge incontinence.

OAB-wet refers to women with urging incontinence associated with wetting accidents.

Specific cause for OAB is not known, but is thought to result from an inappropriate contraction of the detrusor muscle.

In the majority of women the syndrome is idiopathic.

Only 30 to 45% of women with incontinence seek care.

Incontinence questioning should be included in the review systems for all older women.

Evaluation requires history and physical examination, a voiding diary, urinalysis, assessment of post void residual and a cough stress test.

Female patients may have fecal incontinence and pelvic organ prolapse.

In women assessment of pelvic musculature by testing pelvic muscle contraction strength by noting the ability of the patient to voluntarily contract pelvic floor muscles.

Cough stress test should be performed in women and involves cough with a full bladder and observe the urethra for leakage, which, if present, supports the diagnosis.

Moderate weight loss associated with improvement in urinary continence in the obese (Subak).

Reduced urinary incontinence noted in morbidly obese women who have weight loss after bariatric surgery.

Weight loss of more than 5% associated with a 50% reduction in the frequency of incontinence in the obese (Subak).

A comprehensive weight loss program results in a reduction in the frequency of self-reported urinary incontinence episodes at 6 months (Subak).

Behavioral intervention is effective in preventing increased incontinence or in reducing the progression of infrequent episodes of incontinence.

Behavioral interventions include scheduled voiding, delayed avoiding, pelvic floor exercising, stress strategies, urge-suppression strategies, biofeedback, reduction in caffeine intake, fluid management, weight loss, and electrical stimulation.

Kegel exercises provide pelvic floor muscle training and it is effective to reduce stress, urgency, and mixed incontinence in most patients.

Kegel exercises can reduce urinary incontinence episodes by 54-75% compared with 6-16% with no treatment in randomized trials.

Behavioral training for stress incontinence includes pelvic floor muscle strengthening, improving structural support, and educating patients to utilize pelvic muscles consciously to clue the value read through to prevent leakage.

Conscious pelvic floor muscle contractions can be used to suppress the truce or contractions and reduce urinary urgency.

With urgency incontinence teaching patients not to rush to the toilet, but to remain in place and use pelvic muscles to suppress urgency and wait But for the urge to pass.

Physiotherapy, pelvic floor muscle training, has variation in the rates of subjective success from 53-97% and objective success 5-49%, and patients with more severe symptoms have worst outcomes.

25 to 50% of women initially treated with physiotherapy (after 3 to 15 years) proceed to surgery.

Midurethral sling surgery has subjective cure rates between 75-94%, and objective cure rates 57-92%.

Midurethral sling surgery is a minimally invasive surgical procedure for stress urinary incontinence.

In a randomized study initial midurethral sling surgery as compared to initial physiotherapy for stress urinary incontinence resulted in higher rates of subjective improvement and subjective and objective cure at one year (Labree J and al).

Physical examination of female patients with incontinence include gynecological and neurologic testing.

Pelvic examination evaluation focuses on assessment of vulvovaginal atrophy or genito urinary syndrome of menopause, palpation of the urethra to rule out diverticulum, and a evaluation for vaginal discharge and bimanual examination to evaluate for other GYN pathology Including fibroids and adnexal masses.

A cough stress test is simple way to diagnose stress incontinence by observing the loss urine loss during cough or Valsalva.

Neurologic examination assesses lower extremity strength, reflexes, and and pelvic floor muscle strength.

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