URINARY INCONTINENCE AND URINARY RETENTION

Dr. MOCH. RIDWAN, Sp. KFR

DEPARTEMENT OF PHYSICAL MEDICINE AND REHABILITATION FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY/ Dr. SAIFUL ANWAR GENERAL HOSPITAL MALANG

Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. The unintentional loss of urine. Inability to hold urine in the bladder due to loss of voluntary control over the urinary sphincters resulting in the involuntary passage of urine.

Urinary retention is the inability to empty the bladder

Types of Incontinence
Stress incontinence Urge incontinence Overflow incontinence Functional incontinence Mixed incontinence

In stress incontinence the pelvic floor may be weakened because of excessive body weight (> 20 % overweight), pregnancy, deliveries, and heavy work. Stress incontinence may also be caused by connective tissue weakness, asthma, or muscle-relaxant drug such as prazozine

Stress incontinence is an involuntary loss of control of urine that occurs at the same time abdominal pressure is increased as in coughing or sneezing. It develops when the muscles of the pelvic floor have become weak.

 Urge incontinence is a consequence of chronic bladder irritation. It can be related to : O Recurring urinary tract infections O Past surgery for incontinence O Oestrogen deficiency after menopause O Diabetes or multiple sclerosis O Use of medicines, such as neuroleptics and diuretics

Overactive bladder

In the majority of cases the cause of OAB symptoms is unknown. Patients with underlying neurologic disease may manifest with urinary incontinence. Although neurologic disease is not a common cause of OAB, multiple sclerosis, cerebrovascular disease, Parkinson's disease, and Alzheimer's disease are most often associated with involuntary bladder contractions.

Overflow Incontinence
Overflow incontinence is defined as the involuntary loss of urine associated with bladder overdistention in the absence of detrusor contraction. Overflow incontinence most often occurs due to postoperative obstruction if the bladder neck is overcorrected, or with a hyporeflexic bladder due to neurologic disease or spinal cord injury.

Functional Incontinence

Rarely, structural problems can cause incontinence, usually diagnosed in childhood, for example an ectopic ureter. Fistulas caused by obstetric and gynecologic trauma or injury can also lead to incontinence. These types of vaginal fistulas include most commonly, vesicovaginal fistula, but more rarely ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media

Functional incontinence [2] Functional incontinence is seen in patients with normal voiding systems but who have difficulty reaching the toilet because of physical or psychological impediments.

Mix Incontinence

not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.[4]

Mixed incontinence occurs when both stress incontinence and detrusor instability occur simultaneously.

Aetiology

Urinary incontinence is the loss of bladder control. This means that you can't always control when you urinate. Urinary incontinence is caused by weak pelvic muscles, certain medicines and build-up of stool in the bowels. It can also be caused by conditions such as diabetes and congestive heart failure.

Causes urinary retention

Some of the most common causes are vaginal childbirth infections of the brain or spinal cord diabetes stroke accidents that injure the brain or spinal cord multiple sclerosis heavy metal poisoning pelvic injury or trauma

BPH Infection After surgery Medication Bladder stone Cystocele and Rectocele Constipation Urethral stricture

DEFINITION, ETIOLOGY & CLINICAL CORRELTES

TREATMENT

 The

aim of pelvic floor muscle exercises in the treatment of overactive bladder is to inhibit involuntary detrusor contraction

Three bladder training methods

Kegel exercises: These are exercises that help strengthen the muscles you use to stop the flow of urine.

Pelvic Floor Exercise

the

use of pelvic floor muscle exercises to inhibit detrusor contractions has not been well studied.

The goal of pelvic muscle training

The goal of pelvic muscle training is to isolate the pelvic floor muscle, specifically the levator ani. The PFMs comprise a striated, skeletal muscle group, that is under voluntary control and is important in maintaining urinary and fecal continence as well as in providing support to the pelvic organs (bladder, rectum and, in women, the uterus

Four Phases of Pelvic Muscle Exercise

1. Awareness of the function and co-ordination of the PFM muscle 2. Gains over muscle identification, control and strength 3. Firming, thickening, broadening and bulking of the muscles to increase muscle endurance. 4. Improvements of the symptoms indicate that the muscles are strengthening, especially as the ability to feel the muscle contract and relax increases

Kegel's Figures 17 and 18. Firm pressure on the posterior segment of the puboccygeus (or the levator ani plate) may produce an antagonistic contraction. When repeated several times, the patient will become aware of the function of this muscle.

PMEs consist of repeated, high intensity pelvic floor muscle contractions. The PFM has two types of muscle fibers -- Type I or slow twitch muscle fibers and Type II, fast twitch muscle fibers The functional demands on the fibers of the pelvic muscle include sustaining force over time especially during increases in intraabdominal pressure, developing force quickly, and contracting and relaxing voluntarily

Perfect your technique. Once you've identified your pelvic floor muscles, empty your bladder and sit or lie down. Contract your pelvic floor muscles, hold the contraction for five seconds, then relax for five seconds. Try it four or five times in a row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.

Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles. Patients should be instructed to squeeze their pelvic floor muscles by performing one of the following techniques: (1) stop the flow of urine during micturition, (2) squeeze the anal sphincter as if to prevent passing gas, (3) tighten perivaginal muscles by squeezing a penis during sexual relations or squeezing a finger inserted into the vagina

How Often to Do the Pelvic Muscle Exercise

Individuals

are instructed to do the pelvic muscle exercises three times daily and, optimally, to perform the exercises in 3 positions -- lying, sitting and standing

Specifically, women should "draw in" and "lift up" the perivaginal and rectal/anal sphincter muscles . Men should just draw in or tighten the rectal sphincter 2-second contractions followed by sustained (endurance contractions) contractions of 5 seconds and longer as part of a daily exercise regimen least 10 seconds of relaxation is recommended between contractions

. A minimum of 50-60 PMEs per day is recommended . A gradual increase in number of contractions over a period of PME practice has been shown to increase muscle strength significantly and decrease urine loss The person should be instructed to contract the muscle at the time of the UI episode.

The muscle also can be contracted when he or she feels a strong urge to void . Results may not occur until after 6-8 weeks of exercise, and optimal results usually take longer

Benefits of Pelvic Floor Muscle Exercises

Strengthen pelvic floor muscles Improve bladder and bowel control and prevent bladder control problems Support the spine and prevent low back pain Increase the support of pelvic and abdominal organs and prevent organ prolapse Improve sexual response and orgasm Prevent or reduce constipation Prevent hemorrhoids Prevent injuries of the perineum during childbirth Prevent incontinence after childbirth Increase blood flow to the vagina, rectum and perineum, to aid in healing.

BLADDER TRAINING
Means you urinate only when you want to. For good bladder control, all parts of your system must work together. Pelvic muscles must hold up the bladder and urethra. Sphincter muscles must open and shut the urethra. Nerves must control the muscles of the bladder and pelvic floor

Bladder Training

Delay urination: Some people who have urge incontinence can learn to put off urination when they feel the urge. You start by trying to hold your urine for 5 minutes every time you feel an urge to urinate. When it's easy to wait 5 minutes, you try to increase the time to 10 minutes until you're urinating every 3 to 4 hours. When you feel the urge to urinate before your time is up, you can try relaxation techniques. Breathe slowly and deeply. Concentrate on your breathing until the urge goes away. Kegel exercises may also help control urges.

Scheduled bathroom trips: Some people control their incontinence by going to the bathroom on a schedule. This means that you go to the bathroom at set times, whether you feel the urge or not. For example, you might start by going to the bathroom every hour. Then gradually you increase the time until you find a schedule that works for you.

Bladder training generally consists of self-education, scheduled voiding with conscious delay of voiding, and positive reinforcement.

Bladder training uses dietary tactics such as adjustment in fluid intake and avoidance of dietary stimulants

Frequency for Bladder Control Exercises In order to strengthen the muscles, do your bladder control exercises at least three times a day. Every day, use three positions: Lying down Sitting Standing.

Arnold Kegel's Figure 2: The Three Lower Diaphragms of the Pelvic Floor. The most superficial muscles are shown in green, the muscles of the urogenital diaphragm are in yellow, and the puboccygeus is colored red.

Kegel's Figures 17 and 18. Firm pressure on the posterior segment of the puboccygeus (or the levator ani plate) may produce an antagonistic contraction. When repeated several times, the patient will become aware of the function of this muscle.

Although bladder training is used primarily for urge incontinence, this program may be used for simple stress incontinence and mixed incontinence.

BIOFEEDBACK

Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to relay auditory or visual information to the patient about the status of pelvic muscle activity

During biofeedback therapy, a special tampon-shaped sensor is inserted in the patient's vagina or rectum and a second sensor is placed on her abdomen. These sensors detect electrical signals from the pelvic floor muscles. The patient then is instructed to contract and relax the pelvic floor muscles upon command.

When performed properly, the electric signals from the pelvic floor muscles are registered on a computer screen. Biofeedback, using multimeasurement recording, displays the simultaneous measurement of pelvic and abdominal muscle activity on

The benefit of biofeedback therapy is that it provides the patient with minute-byminute feedback on the quality and intensity of her pelvic floor contraction

Biofeedback is best used in conjunction with pelvic floor muscle exercises and bladder training. Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence.

Vaginal weights

Vaginal weight training is an effective form of pelvic floor muscle rehabilitation for stress incontinence in women who are premenopausal. Vaginal weights are tamponlike special help aids used to enhance pelvic floor muscle exercises. Shaped like a small cone, vaginal weights (identical shape and volume) are available in a set of 5, with increasing weights (ie, 20 g, 32.5 g, 45 g, 60 g, 75 g).

As part of a progressive resistive exercise program, a single weight is inserted into the vagina and held in place by tightening the perivaginal muscles (ie, levator ani muscles) for as long as 15 minutes. As the levator ani muscles become stronger, the exercise duration may be increased to 30 minutes.

ELECTRICAL STIMULATION

Electrical stimulation therapy requires a similar type of probe and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to the biofeedback therapy, except small electric currents are used. Nonimplantable pelvic floor electrical stimulation uses vaginal sensors, anal sensors, or surface electrodes. Adverse reactions are minimal

Electrical stimulation of pelvic floor muscles produces a contraction of the levator ani muscles and external urethral sphincter while inhibiting bladder contraction.

This therapy depends on a preserved reflex arc through the intact sacral micturition center

Electrical stimulation therapy requires a similar type of probe and equipment as those used for biofeedback. As in biofeedback, pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence, as well as urge and mixed incontinence

A regimented program of electrical stimulation helps these weakened pelvic muscles contract so they can become stronger. Electrical stimulation may be the most beneficial when stress incontinence and very weak or damaged pelvic floor muscles coexist.

Long-term data report that the rate of patients cured or improved from electrical stimulation ranged from 5477%; however, in order to derive significant benefit, stimulation must be performed for a minimum of 4 weeks, and patients must continue pelvic floor exercises after the treatment.

With acute urinary retention, treatment begins with the insertion of a catheter through the urethra to drain the bladder. This initial treatment relieves the immediate distress of a full bladder and prevents permanent bladder damage. Long-term treatment for any case of urinary retention depends on the cause.

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