URINARY INCONTINENCE IN WOMEN 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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1 DEFINISI adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial

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

Overflow incontinence Continue incontinence 1 Klasifikasi Stress incontinence Overactive bladder Overflow incontinence Continue incontinence

1 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

Incompetence of urethral closure mechanism 1 ETIOLOGY STRESS URINARY INCONTINENCE Incompetence of urethral closure mechanism

Sphincter urethra eksterna (rhabdosphincter) 1 Sphincter urethra eksterna (rhabdosphincter) Otot peri-urethra dari dasar panggul Muara urethra eksterna Jaringan kolagen Urethra Kandung kemih Otot detrusor Otot polos urethra dan jaringan ikat

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

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

RISK FACTORS URETHRAL HYPERMOBILITY 1 RISK FACTORS URETHRAL HYPERMOBILITY Child birth Age Menopause Chronic intra abdominal pressure (chronic cough, constipation, obesity) Pelvic denervation

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

DETERMINANTS OF STRESS INCONTINENCE 1 DETERMINANTS OF STRESS INCONTINENCE Resting urethral closure pressure Stress pressure transmission Intraabdominal pressure increases

SYMPTOM AND SIGN SYMPTOM SIGN 1 SYMPTOM AND SIGN 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)

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

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

1 hour Pad test (ICS) Time in minutes Investigator Patiënt 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

Classification Weight increase of pad (in gram) Dry < 2 Moderate 2 - 10 Severe 10 – 50 Very severe > 50 De gewichtstoename bepaalt de ernst van het urine verlies

TREATMENT OPTIONS Conservative Surgical/ modulatory therapies 1 TREATMENT OPTIONS Conservative Surgical/ modulatory therapies Treatment Options Initial management of overactive bladder should include behavioral therapy, drug therapy, or a combination of the two. Combination therapy has been shown to be more effective than either therapy alone Patients who are refractory to noninvasive therapies should be considered for minimally invasive therapy, such as neuromodulation. In extreme cases, patients may be considered for surgery

STRESS INCONTINENCE TREATMENT 1 STRESS INCONTINENCE TREATMENT Conservative Pelvic floor exercises Weighted vaginal Cones Electrostimulation Positive fedback/perineometri Devices (e.g. pessary) Pharmacotherapy Treatment Options Initial management of overactive bladder should include behavioral therapy, drug therapy, or a combination of the two. Combination therapy has been shown to be more effective than either therapy alone Patients who are refractory to noninvasive therapies should be considered for minimally invasive therapy, such as neuromodulation. In extreme cases, patients may be considered for surgery

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

Burch colposuspension 1 Burch colposuspension

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2002 ICS TERMINOLOGY: OVERACTIVE BLADDER 1 2002 ICS TERMINOLOGY: OVERACTIVE BLADDER Overactive bladder (OAB) is a symptom syndrome 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 The diagnosis of OAB can now be made on symptomatic grounds. Although still controversial, there is no need to perform urodynamic studies on a routine basis. Abrams P et al. Neurourol Urodyn. 2002;21:167-178.

1 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 In a recent article by Abrams and colleagues, a number of standardised definitions were suggested to help to codify the terms used in the diagnosis and treatment of disorders relating to lower urinary tract function. This slide shows the proposed definitions for urgency, increased daytime frequency, and nocturia. Abrams P et al. Neurourol Urodyn. 2002;21:167-178.

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

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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.

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

Evaluation urological history 1 Evaluation urological history 1 Elicit stress incontinence 2 – 8 elicit detrusor instability (overactive bladder) 3 urge 4 - 5 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

EXAMINATION Physical examination Gynecologic examination 1 EXAMINATION Physical examination Gynecologic examination Neurologic examination Laboratory Tests Urinalysis is an essential component of the patient workup and is used to rule out conditions that may be responsible for such urinary symptoms as urinary tract infection, cancer, diabetes, and renal disease Blood work is also essential. A PSA test should be administered to adequately informed men over 50 years of age in accordance with the AUA guidelines

LABORATORY TESTS Urinalysis 1 LABORATORY TESTS Urinalysis to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria Laboratory Tests Urinalysis is an essential component of the patient workup and is used to rule out conditions that may be responsible for such urinary symptoms as urinary tract infection, cancer, diabetes, and renal disease Blood work is also essential. A PSA test should be administered to adequately informed men over 50 years of age in accordance with the AUA guidelines Fantl JA et al. Agency for Healthcare Policy and Research; 1996; AHCPR Publication No. 96-0686.

URINARY DIARY Your Daily Bladder Diary 1 URINARY DIARY 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 Time Drinks Urination Accidental 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. Sample coffee 2 cups 12 large yes laughing 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 Daily Bladder Diary The bladder diary has been referred to as “the last free test” in medicine. It provides valuable information that can be used to determine the exact nature of the bladder symptoms being described by the patient This slide shows a typical daily bladder diary. Patients should be instructed on its proper use and importance for evaluating their condition

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OVERACTIVE BLADDER TREATMENT Conservative 1 OVERACTIVE BLADDER TREATMENT Conservative Behavioral modification therapies dietary modification bladder training No Stress .. pelvic floor muscle exercises adjunct therapies scheduled/assisted voiding Behavioral Therapy The goal of behavioral therapy is to modify symptoms through systematic changes in the patient’s behavior or their environment Various therapies can be used in the behavioral modification regimen, including: dietary modification bladder training pelvic floor muscle exercises and other adjunct therapies scheduled/assisted voiding Primary care physicians should be encouraged to seek the assistance of, and work closely with, a specialist trained in behavioral modification techniques

OVERACTIVE BLADDER TREATMENT Conservative Antimuscarinics 1 OVERACTIVE BLADDER TREATMENT Conservative Antimuscarinics Tertiary Amines Quaternary Amines Tolterodine Propantheline Oxybutynin Trospium Propiverine Darifenacin Not Well Absorbed Solifenacin Low Lipophilicity Well Absorbed Higher Molecular Size High Lipophilicity High Charge Small Molecular Size Low Charge

MUSCARINIC RECEPTOR DISTRIBUTION 1 MUSCARINIC RECEPTOR DISTRIBUTION

SURGICAL / MODULATORY THERAPIES 1 SURGICAL / MODULATORY THERAPIES Denervation central peripheral and perivesical Acupuncture Electroacupunture Electrical stimulation/neuromodulation Overdistention Augmentation cystoplasty There are a number of surgical and or modulatory therapies available to treat OAB. Theses include: Denervation central peripheral and perivesical Acupuncture Electroacupunture Electrical stimulation/neuromodulation Overdistention Augmentation cystoplasty

OVERFLOW INCONTINENCE 1 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 Treatment Options Initial management of overactive bladder should include behavioral therapy, drug therapy, or a combination of the two. Combination therapy has been shown to be more effective than either therapy alone Patients who are refractory to noninvasive therapies should be considered for minimally invasive therapy, such as neuromodulation. In extreme cases, patients may be considered for surgery

RETENSIO URIN 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 PASCA SEKSIO SESAREA DISEBABKAN OLEH : Anestesia 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)

PASCA BEDAH GINEKOLOGI RETENSIO URIN PASCA BEDAH GINEKOLOGI BIASANYA DISEBABKAN OLEH : Anestesia Rasa nyeri Edema Spasme otot-otot pubokoksigeus

GEJALA RETENSIO URIN Kencing tidak lampias Waktu BAK lama Frekuensi BAK lebih sering Tidak bisa BAK Kandung kemih merasa penuh Distensi abdomen

DIAGNOSIS Anamnesis : Gejala retensio urin Pemeriksaan fisik Teraba massa diatas simpisis pemeriksaan bimanual

DIAGNOSIS 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 USG Dapat memeriksa secara non invasif Pemeriksaan uroflowmetri normal jika flow rate > 15-20 ml/detik Gangguan berkemih : penurunan flow rate perpanjangan waktu berkemih

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

Penatalaksanaan III Pemberian cairan 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 retensio urin Retensio Urin Pasca Bedah Keteterisasi urinalisa, kultur urin Antibiotika, banyak minum (3 liter/24 jam), prostaglandin Urin <500ml Urin 500-1000ml Urin 1000-2000ml Urin > 2000ml Intermitten Dauer kateter 1 x 24 jam 2 x 24 jam 3 x 24 jam Buka-tutup kateter/6 jam Selama 24 jam (kecuali dapat BAK dapat dibuka segera Kateter dilepas pagi hari Dapat BAK Spontan Tidak 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

CONTINUE INCONTINENCE 1 CONTINUE INCONTINENCE Etiology : Fistula Treatment : repair Treatment Options Initial management of overactive bladder should include behavioral therapy, drug therapy, or a combination of the two. Combination therapy has been shown to be more effective than either therapy alone Patients who are refractory to noninvasive therapies should be considered for minimally invasive therapy, such as neuromodulation. In extreme cases, patients may be considered for surgery

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

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

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

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

Trauma akibat proses persalinan

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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