​Kembara Xtra - Medicine - Female Urinary Incontinence

​Kembara Xtra - Medicine - Female Urinary  Incontinence 
A sudden, uncontrollable loss of urine that is preceded or accompanied by urgency, or a sudden, intense urge to urinate that is challenging to delay, is known as urge incontinence. Stress incontinence is connected with increased intra abdominal pressure, such as coughing, laughing, sneezing, or effort. Overactive detrusors or an overactive bladder may both contribute to urge incontinence.
Mixed incontinence is the loss of urine brought on by both stress incontinence and urge incontinence.
Functional incontinence is the loss of urine as a result of cognitive and/or mobility limitations. Continuous incontinence is the continuous leaking of urine; leakage without awareness. Overflow incontinence is high residual or chronic urinary retention resulting to urinary spilling from an overdistended bladder.

Epidemiology 
Overall prevalence: Research has revealed that middle-aged and postmenopausal women had prevalence rates as high as 44-57%. Women described one-third of these as moderate to severe cases, and one-fourth of these women said the symptoms interfered with their everyday life.
Female underreporting is probably a thing. Only around 45% of women in a poll of American women who had these symptoms reported them to their doctor, underlining the significance of screening for these illnesses.


Pathophysiology and Etiology 

Incontinence under stress happens when the intraabdominal pressure rises. There are two types of stress incontinence: intrinsic sphincter deficiency (ISD), which is the defective closure of the urethra as a result of surgical scarring, radiation, hormonal, and aging-related changes, and anatomic, which is caused by urethral hypermobility from a lack of pelvic support.
Detrusor overactivity, neurological conditions (such as spinal cord injury), or idiopathic causes of urge incontinence
Detrusor underactivity ("neurogenic bladder") or bladder outlet obstruction can cause overflow incontinence.
Fibroids, pelvic organ prolapse, and less frequently masses/tumors can all result in obstruction of the bladder outlet.
Mixed incontinence combines the symptoms of stress and urgency incontinence.
Continuous incontinence is the involuntary loss of pee on a regular basis. Female ectopic ureters frequently cause persistent leakage by opening in the urethra distal to the sphincter or in the vagina. They can also be caused by fistulous connections between the bladder, ureters, or urethra and the vagina or uterus.

Age, menopause/vaginal atrophy, impaired functional status, obesity (BMI >30), diabetes mellitus, parity, vaginal childbirth, pelvic surgery or radiation, urethral diverticula, pelvic organ prolapse, neurologic illness such as stroke, smoking, chronic obstructive pulmonary disease (COPD), cognitive impairment, constipation, caffeine, high impact exercises, and pelvic floor dysfunction are risk factors.

Prevention 

Avoiding excess weight and coffee, quitting smoking, and eating a high-fiber diet can ease constipation

History Age: Stress incontinence is more prevalent in women between the ages of 19 and 64, whereas mixed incontinence is more prevalent in women beyond the age of 65. Childhood onset suggests congenital reasons (such as an ectopic ureter). Leakage volume and frequency; pad use. Dysuria and suprapubic discomfort are symptoms of interstitial cystitis or a urinary infection.
● Stress incontinence: brief bursts of incontinence; patients normally sleep dry at night. pelvic floor symptoms that occur simultaneously, such as bulging, dyspareunia, or pressure.
Urge incontinence is a rapid urge followed by significant leakage, typically accompanied by frequency and nocturia. Triggering sensory sensations like cold may occur.
Ectopic ureter or urinary fistula are indicated by persistent slow leakage between routine voiding.
Surgical history: Gynecologic and bowel surgery on the pelvis can harm the pelvic floor musculature and impair neurologic function.
Drugs: Sympatholytic -blockers, such as terazosin, prazosin, doxazosin, tamsulosin, alfuzosin, and silodosin, can either cause or exacerbate incontinence. Tricyclic antidepressants, anticholinergics, opioids, and sympathomimetic drugs can all lead to retention with overflow incontinence.
The International Consultation on Incontinence Questionnaire (ICIQ) is strongly advised for evaluating the patient's perception of incontinence symptoms and how they affect quality of life. To assess fluid intake, caffeine intake, time of leakage, and patient habits, think about keeping a 3-day voiding journal.

clinical assessment 
A general neurologic examination, checking for sensory impairment in the perineal-sacral region and general status, including BMI A urologic examination paying attention to: lumps and surgical incision scars on the abdomen; A palpable, swollen bladder is a sign of chronic urine retention, and suprapubic pain could be a sign of cystitis.
A pelvic examination that includes feeling and looking at the quality of the tissue in the perineum and external genitalia. Check for prolapse with a vaginal (half-speculum) examination. For pelvic masses, fecal impaction, and pelvic floor function, perform a bimanual pelvic and anorectal examination.
Evaluation of pelvic floor muscles' ability to contract and isolate them at rest; strength can be rated using the Oxford scale. Cystocele: stage if present (grade 0 to 4). Rectocele: stage (stage 0 to 4) if present.
When combined with urodynamics, urethral mobility (the cotton swab test) has limited diagnostic value, but it may be able to predict how well midurethral sling surgery would work. 
Stress test: positive with coughing or the Valsalva maneuver accompanied by an involuntary leak of urine from the urethral meatus. Make sure the patient's bladder is sufficiently filled. The test's positive predictive value ranges from 78% to 97%.

Differential diagnoses include idiopathic, detrusor overactivity, neurogenic, cardiogenic, or sleep apnea for nocturnal enuresis and ectopic ureter or urinary fistulas for continuous leakage and post-void dribbling, respectively.

Hematuria/recurrent UTI/pelvic mass: malignancy; pelvic pain/dyspareunia: interstitial cystitis, STI; Pelvic organ prolapse; Functional: neurologic, cognitive, psychological, physical impairment


Laboratory Results 

Initial examinations (lab, imaging)
Urine testing and culture
If renal impairment is suspected, a renal function assessment is advised. Imaging is not indicated for people with uncomplicated cases of TSH if constipation is present.
Upper tract imaging, such as renal ultrasound or CT urogram, if upper tract involvement is suspected, such as the presence of microscopic hematuria. Bladder scan to evaluate postvoid residual (PVR) if overflow is suspected (>150 mL).
Tests in the Future & Special Considerations
Initial therapy is feasible in the presence of a positive urine culture.
However, treating asymptomatic bacteriuria won't help the elderly's UI.
Other/Diagnostic Procedures
Urodynamic examinations, such as pressure flow studies that examine bladder emptying and cystometric tests of detrusor function, should only be carried out when conservative treatment has failed. These tests should not be carried out during the initial workup. Women who have microscopic hematuria should have a cystoscopy, which can also be used to assess recurring UTIs. For uncomplicated patients with known SUI, the results of urodynamic testing are not predictive of treatment outcome (1)[A] and are not required prior to surgery.


Management Start with conservative measures as a first line of defense; Treat correctable causes, such as infections and/or constipation.
Women with moderate to severe stress incontinence may be given surgical alternatives sooner.
Pharmacologic therapies, which can include anticholinergics, -agonists, topical estrogens, and onabotulinumtoxinA, should only be used for urge or mixed urine incontinence.


First Line of Medicine
Modest weight loss can reduce the symptoms of urine incontinence in overweight or obese females (1)[B]. Reduce daily fluid intake by 2 L before going to bed. Limit caffeine intake to one cup of coffee each day.
aggressive constipation treatment. Quitting smoking is highly advised.

Kegel exercises can be performed alone or in conjunction with bladder training, biofeedback, or electrical stimulation to strengthen the muscles in the pelvic floor.

For women looking for nonsurgical treatments, incontinence pessaries or vaginal inserts for stress and mixed urine incontinence are available, albeit there is minimal research on their efficacy.

Bladder training includes scheduled voiding and controlling urges in between voids. When training is overseen by a healthcare professional, benefits are enhanced.

Next Line

Anticholinergics are effective treatment options for urge urinary incontinence and overactive bladder, resulting in statistically significant improvement in symptoms and is associated with a modest increase in quality of life. Medication treatment for stress incontinence is not effective and not recommended; there are no FDA approved medications for stress incontinence.
Studies showing comparable effectiveness in terms of effectiveness and tolerability between tolterodine and oxybutynin
– Narrow angle glaucoma and extended QT intervals are contraindications to the use of anticholinergic medicines. Recent research raises the issue of dementia risk from prolonged exposure.

Weak evidence exists to support the use of -adrenergic medications to treat stress incontinence. Patients with uncontrolled high blood pressure, end-stage renal or hepatic illness should not take this medication.

You might think about combining mirabegron and low-dose anticholinergics for dual therapy.
The 40 mg of duloxetine (Cymbalta) is beneficial for treating stress and mixed incontinence.
In postmenopausal women with vaginal atrophy, topical estrogen may be helpful for symptoms of urgency and frequency, while transdermal or oral estrogen may exacerbate symptoms.
OnabotulinumtoxinA for urge incontinence reduces incontinence episodes in a manner comparable to that of antimuscarinic (anticholinergic) medications, while more patients report complete symptom relief. Urinary retention, insufficient bladder emptying, and urinary tract infections are risks.
- Anticholinergic medications (inhibit involuntary detrusor contractions) for urge incontinence. It has not been demonstrated that any one agent is better overall. Less negative effects are associated with transdermal and extended-release medicines. Anticholinergic side effects such as dry mouth, dry eyes, diarrhea, decreased cognitive function, and others can limit use. Avoid if you have narrow-angle glaucoma, urine retention (PVR > 250 mL), reduced stomach emptying, or you are an elderly person who is frail since it could make your cardiac arrhythmias worse.
Higher doses have a higher risk of side effects but are more effective.
(mirabegron [Myrbetriq ER] 25–50 mg/day) is a class 3 agonist.
Patients with liver or kidney illness in the final stages should not take this medication.
A few weeks after starting, think about rechecking blood pressure in people with uncontrolled hypertension.
Not linked to a higher risk of cognitive aging.

Third-line surgical alternatives (Can be used as a first or second line treatment for mild to moderate stress incontinence as described below)

Stress incontinence: Mesh midurethral sling (most popular, most researched surgical technique), autologous fascia PVS, Burch colposuspension, and bulking agents. The choice should be made specifically for each patient depending on their symptoms, objectives, and expectations.
– Midurethral slings provide greater results after a year for women with moderate to severe stress incontinence than pelvic floor muscle exercises.
– Up to 40% of women may have incontinence hidden by pelvic organ prolapse; consider treating both during the same surgery.
- In women who experience recurrent discomfort after surgery or who are unable to endure surgery yet frequently need further injections, periurethral bulking agents (silicone polymers, collagen) may increase periurethral resistance.
Urge incontinence - Sacral nerve stimulation is invasive and fraught with issues, although it is not more effective than posterior tibial nerve stimulation or onabotulinumtoxinA.
When a patient has exhausted all other therapeutic options, bladder augmentation should be an alternative.

Aspects of Geriatrics
In the elderly population, anticholinergics should be used with caution. Anticholinergics, especially oxybutynin, can aggravate cognition and delirium; the effects build up over time and become more pronounced. The hazards of long-term dementia are being examined in the evidence.
Following a thorough review and a consensus-based decision-making process, doctors may recommend synthetic MUS in addition to alternative slings to the elderly population.
Surgery for incontinence produces comparable results in people over 65.
Consider polypharmacy or the patient's current drugs as a possible contributing reason to LUTS or urine incontinence. Despite the fact that 25–50 mg/day can raise blood pressure and shouldn't be taken in individuals with end-stage renal or hepatic illness, studies show that dementia and cognition in the senior population are not a problem.


Patient Follow-Up Monitoring
periodic long-term monitoring using questionnaires with results

Prognosis 

The majority of patients often experience significant improvements.


Complications 
The breakdown of skin and dermatitis brought on by prolonged exposure to urine can result in ulceration and subsequent infections.
The primary reason for many nursing home admissions is the inability to take care of oneself, including using the restroom.
Depression and social exclusion
Weight increase (as a result of exercising less out of fear of leakage) as well as decreased quality of life and sexual function.