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URINARY INCONTINENCE IN WOMEN Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang.

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Presentasi berjudul: "URINARY INCONTINENCE IN WOMEN Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang."— Transcript presentasi:

1 URINARY INCONTINENCE IN WOMEN Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang

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3 DEFINISI  adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial

4 Inkontinensia urin Kondisi lazim, merugikan  kesehatan, fungsi, kualitas hidup Prevalensi: 11,3 - 62,7% Paling umum: SIU; 14,7-52% Tx: farmako, nonfarmako, bedah 1 st choice: Non invasif LODP; kuno tp efektif Arnold Kegel ; 84% sembuh

5 Klasifikasi 1.Stress incontinence 2.Overactive bladder 3.Overflow incontinence 4.Continue incontinence

6 STRESS INCONTINENCE Stress incontinence is the involuntary loss of urine when the intravesical pressure exceeds the maximum urethral closure pressure in the absence of detrusor activity

7 Incompetence of urethral closure mechanism ETIOLOGY STRESS URINARY INCONTINENCE

8 Sphincter urethra eksterna (rhabdosphincter) Otot peri-urethra dari dasar panggul Muara urethra eksterna Jaringan kolagen UrethraKandung kemih Otot detrusor Otot polos urethra dan jaringan ikat

9 1.Anatomic support of urethral and the urethrovesical junction damage (Urethral hypermobility)  Descent of the bladder neck and proximal urethra  Pressure transmission Decreases  stress incontinence 2.Components of the internal mechanism damage (ISD)  Loss of the urethral resistance  Urethral closure pressure Decreases  stress incontinence CAUSES STRESS INCONTINENCE PELVIC FLOOR SI ISD

10 PELVIC FLOOR A B DESCENT OF THE BLADDER NECK AND PROXIMAL URETHRA

11 RISK FACTORS URETHRAL HYPERMOBILITY  Child birth  Age  Menopause  Chronic intra abdominal pressure (chronic cough, constipation, obesity)  Pelvic denervation

12 Risk Factors: INTRINSIC SPHINCTER DYSFUNCTION (ISD 10%)  Multiple prior operations  Trauma  Radiation  Neurogenic disorders including diabetes mellitus  Atrophic changes lack of estrogen  Mielodysplacia

13 DETERMINANTS OF STRESS INCONTINENCE Resting urethral closure pressure Stress pressure transmission Intraabdominal pressure increases

14  SYMPTOM  Patient complaint of involuntary urine loss with physical exercise, coughing, sneezing, laughing  SIGN  Urine is loss from urethra immediately upon increasing intraabdominal pressure (e.g. Coughing sneezing, laughing) SYMPTOM AND SIGN

15 Diagnosis :  Anamnesis tentang simptom stres inkontinensia  Residu urin < 50 cc  Kapasitas kandung kemih > 400 cc  Tes batuk positif atau valsava positif

16 Pemeriksaan penunjang :  Daftar harian berkemih  Urinalisis  Tes Batuk  tes PAD  Urodinamik

17 1 hour Pad test (ICS) Ti me in minutes InvestigatorPatiënt 0 Apply pad with known weight Drinks 500 ml saltfree liquid (water) Sits and rests 30 Walk around and take some stairs 45 Sit / stand x 10 Cough x 10 Run x 1 minute Pick-up things from floor Wash hands x 1 minuut 60 Take away pad and weight Patiënt voids: Measure the volume

18 Classification Weight increase of pad (in gram) Dry< 2 Moderate Severe10 – 50 Very severe> 50

19 TREATMENT OPTIONS Conservative Surgical/ modulatory therapies

20 STRESS INCONTINENCE TREATMENT Conservative Pelvic floor exercises Weighted vaginal Cones Electrostimulation Positive fedback/perineometri Devices (e.g. pessary) Pharmacotherapy

21 SURGICAL TREATMENT 1.Anterior colporraphy 2.Transvaginal Needle Bladder Neck suspension 3.Retropubic suspension 1.Marshall - Marchetti – Krantz 2.Burch colposuspension 3.Sling procedures (e.g. TVT-TVT-O) 4.Artificial sphincter STRESS INCONTINENCE TREATMENT

22 Burch colposuspension

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25 2002 ICS TERMINOLOGY: OVERACTIVE BLADDER Overactive bladder (OAB) is a symptom syndrome Urgency Urgency, with or without urge incontinence, usually with frequency and nocturia  these symptoms are suggestive of detrusor overactivity (urodynamically demonstrable involuntary bladder contractions) but can be due to other forms of voiding or urinary dysfunction  these terms can be used if there is no proven infection or other obvious pathology Abrams P et al. Neurourol Urodyn. 2002;21:

26 2002 ICS DEFINITIONS Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer Increased daytime frequency is the complaint by the patient that he/she voids too often by day (equivalent to polyuria) Nocturia is the complaint that the individual has to wake at night 1 or more times to void Abrams P et al. Neurourol Urodyn. 2002;21:

27 1.Detrusor hyperreflexia or Neurogenic detrusor overactivity 2.Detrusor instability or Idiopathic detrusor overactivity ETIOLOGY OVERACTIVE BLADDER

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30 Patofisiologi  fase pengisian, tekanan normal vesica urinaria  <10cm H2O - 15cm H2O.  otot detrussor vesica urinaria selalu berkontraksi pada tekanan <15cm H2O, sehingga pasien akan merasa ingin berkemih, dan sulit ditahan  Overactive Detrussor.

31 History Questions 1.Do you leak urine when you cough, sneeze, or laugh? 2.Do you ever have such an uncomfortable strong need to urinate that if you don,t reach the toilet you will leak? 3.If “yes” to question 2, do you ever leak before you reach the toilet? 4.How many times during the day do you urinate? 5.How many times do you void during the night after going to bed? 6.Have you wet the bed in the past year? 7.Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry? 8.Do you ever leak during oe after sexual intercourse? 9.Do you find it necessary to wear a pad because of leaking ? 10.How after do you leak? 11.Have you had bladder, urine, or kidney infection? 12.Are you troubled by pain or discomfort when you urinate? 13.Have you had blood in your urinate? 14.Do you find it necessary to wear a pad because of your leaking? 15.Do you find it hard to begin urinating? 16.Do you have as slow urinary stream or have to strain to pass your urine? 17.After you urinate, do you have dribbling or a feeling that you bladder is still full? DIAGNOSTIC INCONTINENCE URINE

32 Evaluation urological history 1 Elicit stress incontinence 2 – 8 elicit detrusor instability (overactive bladder) 3 urge frequncy 6 bed wetting 8 leaking with intercourse 2 and 7 urgency 9 and 10 severity 11 – 13 infection and neoplasm 14 – 17 elicit voiding disfunction symptom

33 EXAMINATION  Physical examination  Gynecologic examination  Neurologic examination

34 Fantl JA et al. Agency for Healthcare Policy and Research; 1996; AHCPR Publication No LABORATORY TESTS Urinalysis to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria

35 URINARY DIARY Time DrinksUrinationAccidental Leaks Did you feel a strong urge to go? What were you doing at the time? What kind? How much? How many times? How much? (fill in amount: small, medium, large) Sneezing, exercising, having sex, lifting, etc. Samplecoffee2 cups12large yeslaughing 6–7 AM 7–8 AM 8–9 AM 9–10 AM 10–11 AM 11–12 PM 12–1 PM 1–2 PM 2–3 PM 3–4 PM 4–5 PM Your Daily Bladder Diary This diary will help you and your healthcare team. Bladder diaries help show the causes of bladder control trouble. The “sample” line (below) will show you how to use the diary. Your name: J. Doe Date: March 31, 2003

36 URODYNAMICS

37 OVERACTIVE BLADDER TREATMENT Conservative Behavioral modification therapies dietary modification bladder training No Stress.. pelvic floor muscle exercises adjunct therapies scheduled/assisted voiding

38 Tertiary AminesQuaternary Amines TolterodinePropantheline OxybutyninTrospium Propiverine DarifenacinNot Well Absorbed SolifenacinLow Lipophilicity Well AbsorbedHigher Molecular Size High LipophilicityHigh Charge Small Molecular Size Low Charge OVERACTIVE BLADDER TREATMENT Conservative Antimuscarinics

39 MUSCARINIC RECEPTOR DISTRIBUTION

40 SURGICAL / MODULATORY THERAPIES Denervation  central  peripheral and perivesical Acupuncture Electroacupunture Electrical stimulation/neuromodulation Overdistention Augmentation cystoplasty

41 OVERFLOW INCONTINENCE Chronic urinary retention with resultant overflow incontinence is uncommon in women Aetiology Bladder hypothonia / antonia Postoperative trauma Inflammation Pelvic mass Drugs Neuropathic bladder Postoperative for stress incontinence Urethral stenosis/strictura Treatment Catheterisation Drug Urethral dilatation Causal

42 DEFINISI : Retensio urin : tidak adanya proses berkemih spontan 6 jam setelah kateter menetap dilepaskan, atau dapat berkemih spontan dengan urin sisa > 200ml (kasus Obstetri) dan urin sisa > 100ml (kasus Ginekologi) RETENSIO URIN

43 DISEBABKAN OLEH : 1.Anestesia 2.Rasa nyeri luka insisi dinding perut reflek menginduksi spasme otot levator pasien enggan untuk mengkontraksikan dinding perut guna memulai pengeluaran urin 3. Manipulasi kandung kemih 4. Jika SC akibat distosia PK II (iritasi, edema) RETENSIO URIN PASCA SEKSIO SESAREA

44 BIASANYA DISEBABKAN OLEH : 1.Anestesia 2.Rasa nyeri 3.Edema 4.Spasme otot-otot pubokoksigeus RETENSIO URIN PASCA BEDAH GINEKOLOGI

45 1.Kencing tidak lampias 2.Waktu BAK lama 3.Frekuensi BAK lebih sering 4.Tidak bisa BAK 5.Kandung kemih merasa penuh 6.Distensi abdomen GEJALA RETENSIO URIN

46 1.Anamnesis : Gejala retensio urin 2.Pemeriksaan fisik Teraba massa diatas simpisis pemeriksaan bimanual DIAGNOSIS

47 3. PEMERIKSAAN URIN SISA (dengan kateter) Setelah 6 jam kateter dilepas diukur urin sisa RETENSIO URIN JIKA : Pasca bedah Ginekologi : urin sisa >100 ml Pasca bedah Obstetri : urin sisa >200 ml DIAGNOSIS

48 4. USG Dapat memeriksa secara non invasif 5. Pemeriksaan uroflowmetri normal jika flow rate > ml/detik Gangguan berkemih : penurunan flow rate perpanjangan waktu berkemih DIAGNOSIS

49 I.Kateterisasi II.Obat-obatan : 1.Obat-obat yang meningkatkan kontraksi kandung kemih dan menurunkan resistensi uretra : a.Yang bekerja pada sistem saraf parasimpatis obat koligernik ~ asetik kolik bekerja di “end organ”  efek muskarinik contoh : betanekhol, karbakhol, metakholin b.Yang bekerja pada sistem saraf simpatis contoh : fenoksibenzamin Penatalaksanaan

50 c. Obat yang bekerja pada otot polos Mempengaruhi kerja otot otot detrusor. contoh : Prostaglandin E2 III Pemberian cairan Banyak minum 3 liter/24 jam Gunanya mencegah kolonisasi bakteri IV Antibiotika: sesuai kultur Penatalaksanaan

51 Penatalaksanaan retensio urin Retensio Urin Pasca Bedah Keteterisasi urinalisa, kultur urin Antibiotika, banyak minum (3 liter/24 jam), prostaglandin Urin <500mlUrin mlUrin mlUrin > 2000ml IntermittenDauer kateter 1 x 24 jam Dauer kateter 2 x 24 jam Dauer kateter 3 x 24 jam Buka-tutup kateter/6 jam Selama 24 jam (kecuali dapat BAK dapat dibuka segera Kateter dilepas pagi hari Dapat BAK SpontanTidak dapat BAK Spontan Urin residu > 200 ml (obstetri) Urin residu > 100 ml (ginekologi) Urin residu < 200 ml (obsstetri) Urin residu < 100 ml (ginekologi) Pulang Keterangan : Intermiten adalah kateterisasi tiap 6 jam selama 24 jam

52 CONTINUE INCONTINENCE Etiology: Fistula Treatment: repair

53 DIFINITION Fecal incontinence is the inability to control the passage of gas, liquid or solid through the anus.

54 ANATOMY ANORECTAL ANATOMY: Anal Sphincter: internal sphincter external sphincter Puborectalis muscle

55 FUNCTION OF ANAL SPHINCTER AND PUBORECTALIS Puborectalis: control continence over solid stool Internal sphincter: control of liquid faeces External sphincter provide internal sphincter in times of sudden need, such as raised intra abdominal presures Anal cushion  the amount of blood flowing through its arteriovenous channels provide control over flatus

56 Etiologi inkontinensia ani Multifaktorial Proses persalinan Miopati Neuropati Usia Trauma operasi Kelainan medis DM Stroke Trauma medula spinalis Proses degeneratif dan kelainan saraf Mobilitias berkurang Konstipasi kronis

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58 Trauma akibat proses persalinan

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60 Penanganan inkontinensia ani Non surgikal Modifikasi diet Farmakoterapi Enema dan irigasi rektum Terapi biofeedback Surgikal Spingteroplasti anal Postanal pelvic floor repair Muscle transposition procedure Artificial anal sphincter Kolostomi atau illeostomi

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