​Kembara Xtra - Medicine - Male Urinary Incontinence

​Kembara Xtra - Medicine - Male  Urinary  Incontinence 
Urinary incontinence (UI) is a pathologic condition that can be acute or chronic and refers to the unintentional leakage of urine that causes issues with one's health, finances, social life, or personal hygiene. There are five primary classifications of UI: stress, urge, mixed, overflow (retention of urine), and functional UI.

Sneezing, laughing, coughing, or effort can cause involuntary urine leaks due to increased intra-abdominal pressure that is larger than the sphincter can control.
Urge incontinence: It is thought that uncontrolled contraction of the urinary bladder is the secondary cause of involuntary pee leaking accompanied by urgency. Overactive detrusor is another name for it.
Involuntary urine leakage accompanied by urgency and stress, such as sneezing, laughing, coughing, or physical activity, is known as mixed incontinence.
Overflow incontinence, sometimes referred to as urinary retention, is a condition in which the bladder overswells as a result of a detrusor weakness or a blocked bladder outlet (caused by benign prostatic hyperplasia [BPH], bladder stones, bladder tumors, pelvic tumors, urethral strictures, or spasms).
Functional UI: Urine leakage is variable and frequently brought on by physical or environmental obstacles to using the restroom (e.g., limited mobility). 
Polyuria is characterized by high urine production (2.5 to 3.0 L/24 hours).
When more than 33% of a person's daily pee output happens while they sleep, it's called nocturnal polyuria.

Reported rates of incontinence range from 1% after transurethral resection to 2-66% after radical prostatectomy and 1-15% after transvesical prostatectomy, although rates decline over time. Epidemiology Stress incontinence in men is uncommon and frequently related to prostate surgery, neurologic disease, or trauma.

According to the National Health and Nutrition Examination Survey (NHANES) report from 2010, the prevalence of UI in community-dwelling adult men in the United States was 12.4%; 4.5% of these men reported moderate to severe UI, of which 48.6% had urge incontinence, 23.5% had other UI, 15.4% had mixed incontinence, and 12.5% had stress incontinence.


Pathophysiology and Etiology 

Incontinence owing to bladder abnormalities: Urge incontinence is caused by detrusor overactivity.
- Detrusor overactivity is frequently linked to BPH-induced bladder outlet blockage.
- Drugs that intensify obstructive effects or boost bladder contractility 
Incontinence brought on by anomalies in the outflow - Commonly associated with BPH due to constriction of the urethra, which affects urine flow; - Sphincteric dysfunction secondary to neurologic disease; - Sphincteric damage secondary to pelvic surgery or radiation;
Stress incontinence is caused by impaired urethral sphincter and/or pelvic floor weakness. Mixed incontinence is produced by anomalies of both the bladder and the outlet overflow or by enlarged prostate/bladder neck contracture from prostate surgery.


Diabetes, BPH, hypertension (HTN), significant depression, and neurologic disease are risk factors for aging-related diseases.
Prostate surgery and pelvic trauma, particularly a history of urinary tract infections (UTIs)
Drug addiction

Prevention 

Incontinence issues later in life may be avoided with proper therapy of diseases, such as symptomatic bladder outlet obstruction brought on by BPH early in the course.


3 Incontinence Questions Tool Questionnaire for Presenting History: - Have you ever urinated (even a little bit) during the last three months? Quiz over if not.
– Did you leak pee over the past three months (tick all that apply):  When you engaged in physical action like lifting, exercising, coughing, or sneezing?
When could you not get to the bathroom quickly enough despite having the need or feeling that you needed to void your bladder?
Without both physical exercise and a sense of urgency?
- Did you leak urine most frequently over the past three months (check one):  When you engaged in physical action like lifting, exercising, or coughing and sneezing?
When could you not get to the bathroom quickly enough despite having the need or feeling that you needed to void your bladder?
Without both physical exercise and a sense of urgency?
 About equally commonly when there is a sense of urgency as when there is physical activity?
Voiding symptoms - Incontinence features and duration - Precipitants, timing, severity, and related symptoms (BPH, fluid intake, etc.) Use of pads, briefs, and diapers; changes in bowel habits; the impact of previous therapies on incontinence
Temporary causes include UTI, delirium, drugs, constipation, and immobility.
Geriatric patients should have their cognitive abilities (including dementia and delirium), psychiatric disorders, and mobility issues evaluated. Medication use should include diuretics, medications for BPH, opioids, muscle relaxants, anticholinergics, and antidepressants. Alcohol and other substance use, including caffeine, should also be evaluated.
Surgery includes prostatectomy (radical for cancer, open/transurethral for benign illness), colon, back, genitourinary operations, and pelvic surgery or radiation.
Pain, hematuria, recurrent UTIs, history of prostate radiation, history of radical pelvic surgery (i.e., prostate surgery), persistent leaking pointing to a fistula, difficulty voiding, and suspected neurologic disease are red flag symptoms that need prompt referral to specialist therapy.

clinical assessment 

During an abdominal exam, discomfort above the pubis may indicate a UTI.
Indications of previous pelvic surgery include: - Surgical scars - Suprapubic lump, which may be a palpable bladder and indicate retention.
- A suprapubic mass could potentially be an abdominal mass pressing against a healthy bladder.
- Wider abdominal circumference
Genitourinary examination: DRE (prostate), external genitalia 
Musculoskeletal (Check for functional or neurogenic reasons.) - Skeletal abnormalities, scars from prior spinal surgery, and the extremities and spine - Neurogenic bladder dysfunction may be correlated with sacral anomalies.
Neurologic - Reflexes, motor, and sensory


Transient differential diagnosis (infections, medications, constipation, etc.) 
Chronic incontinence of the voiding tract, stress incontinence, mixed incontinence, overflow incontinence, and functional UI

Laboratory Results 
Initial examinations (lab, imaging)
Urinalysis and urine culture to look for blood, pyuria, proteinuria, or glucose in the urine - If UTI is present, treat it before reevaluating whether more testing is necessary because this commonly results in UI.
The Three Incontinence Questions, a voiding diary
Pad test (low sensitivity) if the amount of leakage or an objective result measure is sought.
Using ultrasonography (US) to evaluate postvoid residual (PVR) volume in cases with lower urinary tract symptoms or difficulty voiding
PVR consistently below 100 mL is a sign of voiding dysfunction.

PVR greater than 200 mL indicates overflow incontinence. A patient does not have overflow incontinence if their PVR is less than 200 mL.
Only if prostate cancer diagnosis would affect therapy or if levels can assist people at risk for BPH in making decisions

 Renal operation
Voiding cystogram in some circumstances

Other/Diagnostic Procedures
Urethrocystoscopy to rule out potential bladder or urethral pathology or before invasive therapies, if indicated by a physical examination or PSA level

 Upper and lower urinary tract imaging is not typically recommended as part of UI examination.


Management 

Prior to beginning any pharmacologic therapy, conservative, non-drug measures such as behavioral modification, timed voiding, bladder training, and pelvic floor muscle exercise should be prioritized.

General Actions 
Bladder diaries are useful, as are bladder training and timed urination.
Weight loss may lessen the symptoms of UI. Pelvic floor muscle training improves the recovery of continence after radical prostatectomy.
UI and constipation are related, however therapy may not help UI.
While reducing caffeine intake could increase urgency and frequency, UI is not improved.

Pads and external sheaths can both be used to confine urine in UI; however, external sheaths may have lower rates of UTIs and higher quality of life. Men with UI should be advised that leaking is not an inevitable feature of getting older and that one of the treatment's objectives is to do away with the necessity for them.

First Line of Medicine
There is inconsistent evidence that pharmacological therapy is superior to behavioral therapy in treating urge incontinence (UIU), and behavioral therapy yields higher patient satisfaction.
Antimuscarinic medications are the first line of treatment for UUI, and there is no evidence that any particular medication is better than another.
Trospium chloride (Sanctura XR) 60 mg PO daily; Oxybutynin (Ditropan XL) 5 to 15 mg PO daily; Tolterodine (Detrol LA) 2 to 4 mg PO daily; Darifenacin (Enablex) 7.5 to 15.0 mg PO daily; Solifenacin (VESIcare) 5 to 10 mg PO daily; and Transdermal oxybutynin (Gelnique) 10%
Mirabegron, a 3-agonist, has been demonstrated in some trials and systematic reviews to be equally effective as antimuscarinics. Fesoterodine (Toviaz) 4 to 8 mg PO every day.
25 to 50 mg orally daily of mirabegron (Myrbetriq). caution: HTN
Review the effectiveness and side effects 4 to 6 weeks after the start of the treatment.
The majority of patients discontinue antimuscarinic therapy after 3 months due to side effects, ineffectiveness, or expense.

Those who have a bladder outlet obstruction and a PVR of 250 to 300 mL should use caution. Consider using -blockers (such as tamsulosin, alfuzosin, or silodosin) as a monotherapy or in conjunction with antimuscarinics for persistent overactive bladder in males with BPH-related urgency.
Stress incontinence: There is no universally recognized medication therapy for this condition. ER formulations are preferable since they have less negative effects.

Next Line

 Urge incontinence Tricyclic antidepressants - Imipramine 10 to 25 mg PO BID/TID Desmopressin (DDAVP) for sporadic short-term relief of UI - 25 to 50 g PO or intranasal at bedtime Intradetrusor botulinum toxin injections - 100 U intravesical injections (not FDA-approved) Duloxetine for Aspects of Geriatrics
Tricyclics and anticholinergics can seriously impair cognitive function in older persons.

Referral criteria include: PVR >300 mL; Neurologic disease; recurrent bladder or prostate infections; pelvic pain; severe incontinence needing numerous heavy pads or diapers each day; prior pelvic surgery; invasive treatment; or radiation of the prostate or urethra.

Further Treatments 

The initial care of stress UI should include pelvic floor rehabilitation (Kegel exercises), which may considerably reduce both stress and urge incontinence in male patients.
Overflow incontinence is typically brought on by a weak bladder's ability to contract and urinary retention.
- Evaluate for outlet obstruction using intermittent or indwelling catheterization.


Urge incontinence, sacral nerve stimulation with behavioral treatment, augmentative cystoplasty and urine diversion, cystoscopy-assisted Botulinum toxin injection, stress incontinence, and urethral bulking agents are surgical procedures with modest success rates and low cure rates.
Male sling operations have promising short- and intermediate-term outcomes, but there are no long-term studies available. The artificial urinary sphincter implant is the gold standard and has great long-term continence rates.
○ Success rates—defined as the usage of less than one pad per day—have ranged from 59% to 90% during follow-up intervals of between one and eight years. The success rate of surgical operation is relatively high, but revision is frequently necessary because of urethral erosion, infection, or atrophy. Late urethral erosion is frequently caused by trauma to the Foley catheter.


Follow-Up - The Michigan Incontinence Symptom Index (M-ISI) can be used to evaluate the associated symptoms, severity, and inconveniences of incontinence.

Short Form of the International Consultation on Incontinence Questionnaire 
There are a few ways to gauge UI severity: - Sandvik questionnaire, which measures how often and how much leaking occurs. - Weight of a 24-hour pad
- Bladder journal


Complications include dermatitis, candidiasis, and skin deterioration as well as social isolation, sex avoidance, and weight gain.