Diagnosis & Management of

Urinary Incontinence

G.M. PUNARBAWA
G. M. Punarbawa RSUD Prov NTB/FK UNRAM
UROGINECOLOGY

1. Pelvic floor disfunction

2. Urinary incontinence
3. Fecal incontinence
4. Reconstruction:
a. Congenital anomaly
b. Trauma
5. Female Sexual Dysfunction (FSD)
 Introduction
Urinary incontinence (UI)
ICS: as the complaint of any involuntary leakage of urine.1
Common in the community
Impact significantly on QOL (physically & psychosocially)
Has major economic ramifications
There are many treatment options for UI
Only 1/3 seek medical attention (social stigma or ignorance
regarding available treatments)
It is essential that general practitioners understand the
manifestations of this condition and its treatments2

1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation
Sub-committee of the International Continence Society. Am J Obstet Gynecol 2002;187:116–26.
2. O’Donnell M, Viktrup L, Hunskaar S. The role of general practitioners in the initial
management of women with urinary incontinence in France, Germany, Spain and the UK. Eur J Gen Pract 2007;13:20–6.
 Continence mechanisms in women
• Continence is maintained by a coordinated
effort between bladder, urethra, pelvic
muscles & surrounding connective tissue.
• Lower urinary tract: to store (storage phase) or
expel (voiding phase) urine.
• Bladder (able to expand, maintaining low
pressure, absence of involuntary contractions).
• Bladder innervated by parasympathetic;
bladder neck by sympathetic innervation
• Urine storage: closed outlet & relaxed bladder3
• Outlet closure: dependent on the bladder neck
& urethral smooth muscle with a skeletal
muscle rhabdosphincter, voluntary control
(somatic).
• The outlet remains closed during urine storage
and the rhabdosphincter and pelvic floor
respond to rises in intra-abdominal pressure.
• Intact urethral mucosal is also important for a
watertight seal.
• Continence is maintained while the urethral
pressure exceeds intravesical pressure.

3. Morrison A, Levy R. Fraction of nursing home admissions attributable to urinary incontinence. Value in Health 2006;9:272–4.
Continence mechanisms in women…

• The voiding phase starts with relaxation of the

outlet with a sustained detrusor contraction.
• The micturition reflex is normally under
voluntary control and coordinated by the
pontine micturition centre with various relays
in the spinal cord.
Functions of the autonomic
& somatic nervous systems
Pathophysiology and terminology

• UI: dysfunction in storage or in emptying function

• Urethral sphincter dysfunction & bladder dysfunction
can co-exist & various components of the continence
mechanism may compensate one another.
• For example, women may experience anatomical or
neuromuscular injury during childbirth but remain
asymptomatic until there is a loss of urethral
sphincter function due to aging.
• ICS: nomenclature for UI as: stress (SUI), urge
(UUI)/OAB and mixed (MUI)
• Overflow incontinence
Pathophysiology and terminology…
UUI (Urge Urinary Incontinence)
UUI
• ICS (2002): Urgency, with or without urge
incontinence, usually with frequency and
nocturia, can be described as the overactive
bladder syndrome
– Wet OAB: urge incontinence
– Dry OAB: without urge
• Detrusor overactivity (DO) – a ‘urodynamic
observation characterized by involuntary detru-
sor contractions during the filling phase which
may be spontaneous or provoked’.
UUI/OAB…

ClInIcal PresentatIon:
• Frequency: void too often (> 8x/day)
• Nocturia: wake at night >1 times to void;
• Urgency: a sudden compelling desire to pass
urine that is difficult to defer;
• Urge: involuntary leakage accompanied by, or
immediately preceded by, a strong desire to
void.
 History:
• 2/3 of UI sufferers not seek medical treatment
• Frequency, nocturia, urgency
• Voiding symptoms: hesitancy, poor or interrupted stream,
straining & terminal dribbling.
• Frequency of incontinent episodes, pad usage, degree of
bother, time of day (or night), relationship to drug
treatments (eg. diuretics, alpha blockers), voiding habits,
fluid intake
• Urinary tract infection, diabetes, constipation
• Haematuria (microscopic or macroscopic): malignancy?
• Bladder diary or frequency and volume chart: simple &
useful for initial assessment and QOL evaluation.4,5
4. van der Vaart CH, de Leeuw JR, Roovers JP, Heintz AP. The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. BJU Int 2002;90:544–9.
5. Coyne KS, Zhou Z, Thompson C, Versi E. The impact on health-related quality of life of stress, urge and mixed urinary incontinence. BJU Int 2003;92:731–5.
 D I A P P ER S

Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985; 313:800-805
Examination:
• Focused on organ systems that could be implicated.
• Abdominal examination for pelvic masses
• Neurological examination for upper motor neuron lesions (eg.
multiple sclerosis, Parkinson disease) or lower motor neuron lesions
(eg. sacral nerve root lesion).
• Vaginal examination: oestrogen status, pelvic organ prolapse,
urethral meatal abnormality, pelvic floor muscle tone, leakage
during coughing or Valsalva manoeuvre.
• The strength of the pelvic floor muscles: bimanual examination
• Pad test
 Labolatory, cystometry, urodynamic:
• Urine microscopy & culture: infection?
• Ultrasound: postvoid residual volume?
• Cystometry or urodynamic:6, 7
- Patients with suspected voiding difficulties or neuropathy
- Previous failed treatment
- When considering surgical treatment
In cases where central nervous system pathology is suspected: require
opinion of a neurologist.

6. Artibani W, Cerruto MA. The role of imaging in urinary incontinence. BJU Int 2005;95:699–703.
7. Homma Y. The clinical significance of the urodynamic investigation in incontinence. BJU Int 2002;90:489–97.
BLADDER DIARY
Daftar harian berkemih
 OAB Treatment
Nonsurgical therapy
Lifestyle intervention
• Weight loss and exercise (morbidly obese)
reduces SUI, and some UUI.6,7
• Fluid & caffeine restriction may also reduce UI.8

6. Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. Weight loss: a novel and effective treatment for urinary incontinence.
J Urol 2005;174:190–5.
7. Bo K, Borgen JS. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc 2001;33:1797–802.
8. Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol 2005;174:187–9.
OAB Treatment…

Many drugs affect bladder function

OAB Treatment…
Bladder training
• Initial treatment for UUI, noninvasive, inexpensive &
easy
• Includes PFMT, a scheduled voiding program (with
gradual increases in the duration between voids)
• WHO: a voiding interval of 1 hour during waking hours
with a gradual increase by 15–30 minutes per week
until a 2–3 hour voiding interval is reached.9
• Pelvic floor muscle training and bladder training are
best undertaken with the assistance of a continence
therapist (physiotherapist)
9. Wilson P. Incontinence. Plymbridge Distributors; 1999, p. 579–634.
OAB Treatment…

Drug therapy:
Most OAB require drug therapy
Anticholinergic
• Anticholinergic for UUI: by reducing involuntary detrusor
contractions mediated by acetylcholine.
• A Cochrane review: anticholinergic effective in reducing
urgency, improve QOL & symptoms during treatment when
compared with, or combined with, bladder training alone.10,11

10. Nabi G, Cody JD, Ellis G, Herbison P, Hay-Smith J. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults.
Cochrane Database Syst Rev 2006; Issue 4. Art. No.: CD003781.
11. Alhasso AA, McKinlay J, Patrick K, Stewart L. Anticholinergic drugs versus non-drug active therapies for overactive bladder
syndrome in adults. Cochrane Database Syst Rev 2006; Issue 4. Art. No.: CD003193.
OAB Treatment…

Drug Therapy…
β3-adrenoceptor agonist
. Mirabegron

Other medications
• Imipramine (tricyclic antidepressant)
- reduce detrusor contractility & increases outlet resistance
- can be used in conjunction with anticholinergics.

• There is little evidence to support the use of oestrogen

replacement for UI.12

12. Grady D, Brown JS, Vittinghoff E, et al. Postmenopausal hormones and incon-tinence: the Heart and Estrogen/Progestin
Replacement Study. Obstet Gynecol 2001;97:116–20.
OAB Treatment…

Surgical therapy
Detrusor overactivity refractory to oral medications:
- intravesical botulinum toxin A injections
- Neuromodulation: stimulation S3 nerve root
(implanted electrical pulse generator) can provide
effective relief from frequency‐urgency symptoms.
- Detrusor myomectomy or bladder augmentation ,
which reduce the efficacy of detrusor contraction and
thus improve continence.
- Ileal conduit urinary diversion: to create an abdominal
stoma for urinary diversion, drained using
self‐catheterisation
OAB Treatment…
OAB Treatment…
 Stress Urinary Incontinence (SUI)
• SUI: vesical pressure > urethral pressure (sudden
increases in intra- abdominal pressure).
• Due to weakness of the pelvic floor or sphincter.
• Loss of bladder neck support  bladder neck
hypermobility (R/ restoration of that support).
• Sphincter dysfunction (intrinsic sphincter deficiency).
Risk factors for SUI: childbirth, postmenopausal
involution of the urethra, complication of pelvic surgery
or trauma.
Stress Urinary Incontinence (SUI)
 Stress Urinary Incontinence (SUI)…
Clinical Presentation
- The complaint of involuntary leakage on effort or
exertion, or on sneezing or coughing
Diagnosis
• Medical history
• Physical exam (abdomen & genitals)
• Urine sample to test for infection, traces of blood or other
abnormalities
• Brief neurological exam to identify any pelvic nerve problems
• Urinary stress test, observes urine loss cough, laugh or bear
down
 SUI TREATMENT
Behavior therapies
Pelvic floor exercise
• Pelvic floor muscle training (PFMT): 3–4 months
• Three sets of 8–12 slow maximal contractions
sustained for 6–8 seconds and repeated 3–4 times per
week.
• A 2001 Cochrane review: women undergoing PFMT: 7x
more likely to be cured & 23x more likely to show
improvement.13
• Can be combined with biofeedback equipment,
weighted vaginal cones.

13. Hay-Smith EJ, Bo Berghmans LC, Hendriks HJ, de Bie RA, van Waalwijk van Doorn ES. Pelvic floor muscle training for urinary
incontinence in women. Cochrane Database Syst Rev 2001;(1):CD001407.
SUI TREATMENT…

Healthy lifestyle changes

- Quitting smoking
- Losing excess weight
- Treating a chronic cough
Medications
Vaginal pessary:
- Specialized UI pessary
- Support bladder base to prevent urine leakage during
activity (cystocele)

Mayo Clinic
SUI TREATMENT…

Surgical interventions:
- To improve closure of the sphincter or support
the bladder neck.
Injectable bulking agents
- Synthetic polysaccharides or gels
- Bulk the area around the urethra, improving the
closing ability of the sphincter.
- Multiple injections are required for most people.

Mayo Clinic
SUI TREATMENT…

Retropubic colposuspension.
• Laparoscopically or by abdominal incision:
sutures attached either to ligaments or to bone
to lift and support tissues near the bladder neck
and upper portion of the urethra.
Sling procedure.
• Most common procedure
• Create a sling or hammock that supports the
urethra.

Mayo Clinic
SUI TREATMENT…
Abdominal approach
1. Marshal-Marchetti-Krantz
2. Burch
3. Laparoscopic Burch suspensi
Vaginal approach
1. Anterior Colporaphy
2. Needle suspension
3. Periuretral Bulking agent
4. Sling
5. Standard: midurethral slings
a. TVT (Tension Free Vaginal Tape)  retro pubic
b. TVT-O (Tension Free Vaginal Tape Obturator)
6. Single incision mini slings (mini-sling)
a. TVT secure
b. Mini Arc
Conclusion
• UI: common in women but under-reported and undertreated.
• Generally UI is caused by aging, childbirth pelvic surgery or neurological
disorders.
• Most UI can be evaluated and treated in the primary care setting after careful
history and simple clinical assessment.
- Include lifestyle modification, PFMT, bladder training and/or
pharmacotherapy.
Complex symptomatology or primary management fails referral to a specialist is
suggested.
UI can be very distressing both physically and psychologically and impacts on
quality of life and health.
As primary care providers, it is essential that GPs evaluate, treat and refer high risk
patients.
T E R I M A K A S IH