Incontinentia Urine Kuliah Uniba 6-11-12. a Ppt

8/13/2019 Incontinentia Urine Kuliah Uniba 6-11-12. a Ppt

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Lower Urinary TractSymptoms (LUTS)

dr. Putra Hendra SpPD

UNIBABATAM


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Definition:

LUTS, or lower urinary tract symptoms , is a

common term used to describe the range ofurinary symptoms as frequency, urgencyetc ,which was previously called prostatism but thishas been replaced by LUTS because the

prostate is most often not the cause.


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LUTS had been categorized into:

1. Storage (irritative ) symptoms

2. Voiding( obstructive) symptoms

3. Post voiding symptoms


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Understanding Lower Urinary

Tract Symptoms(after Abrams, Bristol, UK)

Storage Symptoms Frequency Nocturia Urgency Urge incontinence Bladder Pain

Detrusor Instability Bladder Hypersensitivity Bladder Outlet Obstruction Detrusor Failure

Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining

Terminal dribble


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Causes of LUTS:

In males: Outflow obstruction

BPHMeatal stenosis

Impaired detrusor function

NM dysfunctionDetrusor instabilityImpaired detrusor contractilityPsychogenic voiding dysfunction


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CONT

InfectionCystitis, prostatitis, prostatic abcess andurethral diverticulum.

neoplasticProstatic cancer, bladder cancer

Others:Bladder diverticulum, stone andinterstitial cystitis.


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In females :

Mostly storage symptomsUTIPregnancyAnxietyOveractive bladderInterstitial cystitisPostmenopausal urogenital atrophyBladder tumor or stoneGenital prolapses or pelvic mass

Mostly voiding symptomsAge related detrusor muscle weaknessObstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis)UrethritisDrugs ( diuretics, alcohol, lithium, anticholinergics)


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What happens with aging?

Smaller bladder capacity increased bladder irritability

decreased bladder emptying genitourinary atrophy concurrent conditions

stroke, dementia, PD, BPH, DM


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Incidence of Subtypes ofUrinary Incontinence in Women

Stress Incontinence 50%

Urge Incontinence 20%

Mixed 30%


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Storage symptoms:

Daytime frequency

Urgency:sudden desire for urination that isdifficult to postponed. Nocturia :urinary urgency that awakens the

pt. from sleep.

Urge incontinence Enuresis:incontinence during sleep.


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Voiding symptoms

hesitancy:delay in starting micturation. Intermittent folw Weak stream:diminished force and caliber with

prolonged voiding time.

Double voiding

Straining to void Terminal dribbling


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Post void symptoms

Post void dribbling Feeling of incomplete emptying


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GOTTA GO, GOTTA GO!!!!!!!!


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Urge Incontinence

Most common cause of UI >75 years ofage

Abrupt desire to void cannot besuppressed

Usually idiopathic Causes: infection, tumor, stones,

atrophic vaginitis or urethritis, stroke,

Parkinsons Disease, dementia

Other Names: detrusor hyperactivity, detrusor instability,irritable bladder, spastic bladder


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Potentially Reversible Causes

D - Delirium

I - Infection

A - Atrophic vaginitis or urethritisP - Pharmaceuticals

P - Psychological disorders

E - Endocrine disorders

R - Restricted mobility

S - Stool impaction2


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Medications That May Cause

Incontinence DiureticsAnticholinergics - antihistamines,

antipsychotics, antidepressants Seditives/hypnoticsAlcohol

Narcotics -adrenergic agonists/antagnists Calcium channel blockers


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Diagnostic Tests

Stress test (diagnostic for stress incontinence; specificity>90%)

Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture

Simple (bedside) Cystometrics


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Cont. Investigation

*Assessment ot upper tract:Only for pt with hematuria , recurrent UTI

or history of urinary stones is present.

# U/S of the kidneys and bladder

#CT urography

# (IVU) intravenous urogram


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US


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Ascending Urethrogram


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Cont. Investigation

2- voiding cystourethrogram(VCUG):Is performed by filling the bladder with radiographic

contrast agent through a urethral catheter or suprapubic

tube

. The process is monitoring by fluoroscopy .static film areobtained with the bladder full, during micturation and

after voiding.

. VCUG is excellent method of diagnosing vesical neckobstruction and vesicoureteral reflux.


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Cont. Investigation

*Uroflowmetry:an electronic flowmeter can provide a recording of urinary

flow rate

*CystourethroscopyEndoscopy permits direct visualization of the entire urinary

tract .

* Cystometry:is continuous recording of bladder pressure duringgradual filling and during contraction .indication in anyneuralgic disease is suspect


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Treatment Options

Bladder training Patient education

Scheduled voiding

Positive reinforcement

Pelvic floor exercises (Kegel Exercises) Biofeedback

Caregiver interventions Scheduled toileting

Habit training

Prompted voiding2


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Pharmacological Interventions

Urge Incontinence Oxybutynin (Ditropan)

Propantheline (Pro-Banthine) Imipramine (Tofranil)

Stress Incontinence

Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed)

Estrogen (orally, transdermally or transvaginally)


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Surgical Interventions

Urethral Hypermotility Marshall-Marchetti-Kantz procedure

Needle neck suspension

Intrinsic sphincterdeficiency

Sling procedure

Surgery is reported to cure 4 out of 5cases, but success rate drops to 50% after10 years.


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Other Interventions

Pessaries Periurethral bulking agents (periurethral

injection of collagen, fat or silicone) Diapers or pads Chronic catheterization

Periurethral or suprapubic

Indwelling or intermittant


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Pessarie

s


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TREATMENT

*Obstructive ureter:

- Suprapubic cystostomy

- Ureteric catheter drainage

- Uretheral catheter drainage


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Cont TREATMENT

A. Distal urethra:*Urethral strictures:-Dilation

- - Visual urethrotomy -transurethral balloon dilation catheter- Urethroplasty

*Meatal stenosis:-Dilation-surgical meatotomy


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BENIGN PROST TEHYPERTROPHY


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What causes BPH?

BPH is part of the naturalaging process, like getting

gray hair or wearing glasses

BPH cannotbe prevented

BPH canbe treated


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The size of prostate enlarged microscopically since theage of 40.Half of all men over the age of 60 willdevelop an enlarged prostate

By the time men reach their 70s and 80s, 80% willexperience urinary symptoms

But only 25% of men aged 80 will be receiving BPHtreatment

BPH


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Top 10 Diagnosed Diseasesin Men Age 50 Years

Rank Disease

1-year prevalence (%)

(n = 963,452 person-

years)

1Coronary Artery

Disease/Hyperlipidemia

51.3

2 Hypertension 45.2

3 Diabetes Mellitus Type 2 17.5

4 Enlarged Prostate 13.5

5 Osteoarthritis 13.3

6 Arrhythmias 8.87 Cataract 8.6

8 Gastroesophogeal reflux disease 8.4

9 Bursitis 8.0

10 Prostate Cancer 7.8

Issa MM et al. Am J Manag Care. 2006;12(suppl):S83S89.


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Anatomy of BPHNormal BPH

Hypertrophieddetrusormuscle

Obstructedurinary flow

PROSTATE

BLADDER

URETHRA

Roehrborn CG, McConnell JD. In: Walsh PC et al, eds. Campbells Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:1297-1336.


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Clinical Presentation of BPHObstructive

Symptoms

Incomplete emptying Intermittency Weak stream Hesitancy

Irritative Symptoms

Nocturia Frequency

Urgency


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Prevalence of BPH

Source: J Urol 1984;132:474

Around 25% inmen aged 40-49yearsAround 50% in

men aged 70 andolder


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Risk factors

-Age: at late 40s only 3.5% of menat 80s it raise to 35%

-Ethnic groups: African American at high riskAsian at low risk

-Family history

-Medical condition :Obesity

Heart and circulatory disease

Type 2 DM


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The initial evaluation of all patient presentingwith LUTS suggestive of BPH should include:

-Medical history

-Digital rectal exam DRE

-Neurological exam

-Urinalysis

The DRE :-A benign prostate:

Feels smooth

Symmetric-Prostate cancer

Palpable nodule

Feel hard

Asymmetric gland


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Protocol for the management ofBPH

Severe

IPSS > 20

Flow rate < 10 mls/s

Resid vol > 200 mls

Moderate

IPSS 7-20

Flow rate < 15mls/sResid vol


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Treatment Modalities for BPH

Watchful waiting Medical therapy

Phytotherapy

-adrenergic blockers

5-reductase inhibitors Combination therapy

Office-based treatment TUMT

TUNA

WIT

Surgicenter/Hospital-basedtreatment

TURP (gold standard)

TUIP

Open surgery (prostatectomy) TUVP

ILC

VLAP

Prostatic stents

Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health

Publication Ltd; 2001;519-534. McConnell JD et al. Benign Prostatic Hyperplasia: Diagnosis and

Treatment. Clinical Practice Guideline, Number 8.


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Drugs for Medical ManagementAlpha Blockers:Alfuzosin

DoxazosinTamsulosinTerazosin

Hormonal: Finasteride

Dutasteride

Combination: Alfuzosin/finasterideDoxazosin/finasteride

Terazosin/finasteride


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Cumulative Incidence of Progression of Benign Prostatic Hyperplasia

McConnell, J. et al. N Engl J Med 2003;349:2387-2398


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Combination Therapy: AUnique Approach

Alpha blockers 5-Alpha reductase inhibitors

Improve symptomsand increase urinaryflow rate by relaxingprostatic and bladder-

neck smooth musclethrough sympatheticactivity blockade

Improve symptoms,increase urinary flow rate,and prevent BPH outcomesby reducing prostate

enlargement throughhormonal mechanisms

Source: Roehrborn CG Curr Opin Urol2001;11:17-25

National Cancer Institute. NIH Publication No. 99-4303, 1999.

Combination Activates Two Distinct and Complementary Mechanisms of Action


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ibution of 1-Adrenergic Receptors

li ti f Ad i


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ocalization of 1-Adrenergiceceptors (1-ARs)


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TURP

Gold Standardof care for BPH

Uses an electrical knife to surgically cutand remove excess prostate tissue

Effective in relieving symptoms and

restoring urine flow

(transurethral resection of the prostate)


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Transurethral Microwave Therapy

Microwave energycauses tissue necrosis

Cooling channels in

catheter cool urethra


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Trans-Urethral Resection ofProstate


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Incontinentia Urine Kuliah Uniba 6-11-12. a Ppt

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