INCONTINENCE

Presented
By
MD. Monsur Rahman
MPT in Musculoskeletal Disorders
MMIPR,Mullana,Ambala
 Introduction
Continence
 The word continence comes from the Latin word ”continentia” which means holding back.
 Continence could appear as a poor urinary stream or an intermittent flow.
 It could also be used delay between trying to urinate and the flow actually beginning, or inability to
completely empty the bladder
Incontinence
 The complaint of any involuntary loss of urine (Abrams et al. 2010).
 It means a person urinates when they do not want to
 Cont…

 Many Women do not discuss their Urinary Incontinence

 Clinically Relevant Anatomy: Pelvic Floor
 The pelvic floor is made up of the muscles(levator ani, striated urogenital sphincter, external
anal sphincter, ischiocavernosus, and bulbospongiosus), ligaments, and fascial structures
 The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic
floor muscles.
 Cont…

 Pelvic floor act together to support the pelvic organs and to provide compressive forces to the
urethra during increased intra-abdominal pressure.

 When the pelvic floor muscles contract the urethra, anus, and vagina close.

 The contraction is important in preventing involuntary loss of urine or rectal contents.

 Incidence and Prevalence

 According to the U.S. Department of Health and Human Services, approximately 13

million people in the United States suffer from urinary incontinence & 400 million people
around the world
 From a survey of disability in Bangladesh village residents(2006) aged ≥60 years.UI was
reported as troublesome by 28% of villagers (particularly women)
(Cherry et al. BMC Public Health 2012)
 Types of Incontinence

1. Acute Incontinence:
Comes on suddenly and is usually caused by a new illness or condition.
2. Chronic Incontinence
– Develops gradually over time or remains after other illness or conditions have been
treated.
 Types of Chronic Incontinence
I. Stress (urinary) incontinence
II. Urgency (urinary) incontinence
III. Mixed (urinary) incontinence
 Incidence of chronic incontinence in
women
 Stress Incontinence 50%
 Urge Incontinence 20%
 Mixed 30%
(European Association of Urology guidelines on urinary incontinence-July 2017)
 Stress Incontinence
It is involuntary escape of few drops of urine with increased intra-abdominal
pressure as during- straining, sneezing, coughing, laughing & Sporting activities...
etc.
 Degrees of Stress Incontinence
 Grade I:
Incontinence occurs only with severe stress, such as coughing, sneezing, etc …
 Grade II:
Incontinence with moderate stress, such as rapid movement or walking up and
down stairs
 Grade III:
Incontinence with mild stress, such as standing.
 Causes of Stress Incontinence(SI)
 Most common causes:
– Aging
– Nerve and vascular injury
– Lack of oestrogen hormones (menopause)
– Trauma and stretching of vaginal delivery
– Congenital weakness of the internal urethral sphincter.
– Hysterectomy
– Pelvic denervation
– Genital prolapse
 Cont..

 Congenital defects as:

• Short urethra (less than 1 cm)
• Wide bladder neck
• Separation of symphysis pubis.
 Risk Factors For SI

 Increasing number of vaginal deliveries, probably due to nerve or muscular trauma

• Risk increased by multiple pregnancies, prolonged labour or difficult deliveries.
 Pelvic floor trauma and nerve injury
• Obstetric trauma
• Pelvic fractures and radical surgery
 Hormonal status and estrogen deficiency
 Increasing intra-abdominal pressure
 Medical factors
• chronic bronchitis or pulmonary problems
• Constipation with chronic straining at stool
• Obesity
 Urgency (urinary) incontinence

• Complaint of involuntary loss of urine associated with urgency (a sudden,

strong desire to pass urine) and an inability to get to the bathroom in time.
Causes
• Infection /inflammation
• Neurological disease
• Obstruction
• Unknown
 Mixed Incontinence
 A combination of both stress and urge incontinence .
 Complaint of involuntary loss of urine associated with urgency and also effort
or physical exertion or on sneezing or coughing.
 Diagnostic Procedures

A large portion of women with urinary stress incontinence can be diagnosed from clinical
history alone.
Clinical history
 A detailed history differentiates between the different types of incontinence.
 Stress incontinence and detrusor instability frequently occur together.
 Gradual onset after menopause suggests oestrogen deficiency.
 History of vaginal repair or operation in the region of the bladder neck and history of any
neurologic disease.
 Physical Symptoms

 Limited fluids → Constipation → Straining → Increased incontinence due to pelvic

floor muscle damage
 Limited activity → Weight gain → Decreased cardio-vascular fitness
 Disturbed sleep patterns
 Frequent bathroom visits
 Psychological Symptoms

• Insecurity
• Anger
• Dependence
• Guilt
• Indignity
• Shame
• Embarrassment
• Depression
 Sense of Self
• Loss of self-confidence
• Sexual difficulties
• Lack of attention to personal hygiene, skin breakdown
• Person felt older than they were
 Social Interaction

• Reduction in social activities

• Socially isolated
• Psychological and functional decline
 STRESS TEST
 The patient in the standing position, the two labia are separated, and the patient is asked to
cough.If urine escapes, the patient is incontinent.
 If no urine escapes, the test is repeated while the index and middle fingers in the vagina press
on the perineum to abolish reflex contraction of the levator ani muscles during straining.
 If still no urine escapes, the test is repeated while the patient is standing with the legs
separated
 Bonney Test
• If incontinence is due to descent of bladder neck or weakness of the
sphincter.
• The index and middle fingers are placed on both sides of the urethra to
elevate the bladder neck upwards.
• If no urine escapes on stress it means that the incontinence is due to
descent of the bladder neck, but if urine still escapes it means weakness of
the sphincter.
 The Cotton-tip Applicator (Q-tip) Test
 A sterile applicator with a small piece of cotton at its tip is introduced to reach the bladder
neck.
 The patient then strains maximally using the Valsalvamanoeuvre.
 The angle between the applicator and the horizontal is measured.
 In stress incontinence the change is more than 30 degrees indicating poor support and
abnormal descent of bladder neck
 Cystourethroscopy

 To exclude lesions in the urethra and bladder.

 The bladder neck is examined.
 It should close in response to straining.
 However, it opens in case of stress incontinence.
 Cystourethrography
 Radio-opaque dye is injected by a catheter into the bladder.
 On straining, the lateral view will show absence of the posterior urethrovesical angle in more
than 90% of cases.
 Funneling of the bladder neck in the antero-posterior view may be seen in some cases.
 The procedure is recorded on video tape (video Cystourethrography) to facilitate diagnosis
and for education purposes.
 Kegel Perineometer

 A Kegel perineometer or vaginal manometer is an instrument for measuring the strength

of voluntary contractions of the pelvic floor muscles.
 Arnold Kegel (1894–1981) was the gynecologist who invented the Kegel Perineometer
(used for measuring vaginal air pressure) and Kegel exercises (squeezing of the muscles of
the pelvic floor).
 Pelvic Floor Muscle Strength

 Modified Oxford grading system:

Palpation of the pelvic floor muscles per the vagina in females and per the
rectum in male patients.
0 - no contraction
1 – flicker Contraction
2 - weak squeeze, no lift
3 - fair squeeze, definite lift
4 - good squeeze with lift
5 - strong squeeze with a lift
 PERFECT Assessment

P - power, may use the Modified Oxford grading scale

E - endurance, the time (in seconds) that a maximum contraction can be sustained
R - repetition, the number of repetitions of a maximum voluntary contraction
F - fast contractions, the number of fast (one second) maximum contractions
ECT - every contraction timed, reminds the therapist to continually overload the muscle activity
for strengthening

Described by Jo Laycock
 MANAGEMENTS

 Conservative Management
o Counseling
o Medication
o Physiotherapy
o Behavioral techniques
 Surgical Management
 Medications

 Anticholinergics. These medications can calm an overactive bladder and may be helpful for
urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol)

 Mirabegron .Used to treat urge incontinence, this medication relaxes the bladder muscle
and can increase the amount of urine your bladder can hold.

 Alpha blockers. In men with urge or overflow incontinence, these medications relax bladder
neck muscles and muscle fibers in the prostate and make it easier to empty the bladder.

 Topical estrogen. For women, applying low-dose, topical estrogen in the form of a vaginal
cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas.
 Behavioral techniques

 Bladder training: start by trying to hold off for 10 minutes every time you feel an urge to urinate.
The goal is to lengthen the time between trips to the toilet until the urinating only every 2.5 to 3.5
hours.
 Double voiding: Double voiding means urinating, then waiting a few minutes and trying again.

 Scheduled toilet trips: to urinate every two to four hours rather than waiting for the need to go.

 Fluid and diet management: avoid alcohol, caffeine or acidic foods. Reducing liquid consumption,
losing weight or increasing physical activity also can ease the problem.
 Physiotherapy Management
 Kegel exercise, also known as pelvic floor exercise, consists of repeatedly contracting and
relaxing the muscles that form part of the pelvic floor.

Recommendations for Effective Strength Training

 8 – 12 slow velocity close to max. contractions
 Starting
 3 sets per day
 2-4 days a week
 Intensity is more important than frequency
 Medical devices

Vaginal cone
 A vaginal cone (or vaginal weight) is a medical device specifically designed and shaped
to exercise pelvic floor muscles in order to strengthen them and restore proper bladder
functions in women with urinary stress incontinence.
 These exercises are known as vaginal weightlifting.
 Uses
Generally around 15 minutes, twice a day (Jorge Milhem Haddad et all,May-2011)
 Nerve stimulators
 The device may be implanted under the skin in the buttock and connected to wires on the
lower back, above the pubic area or with the use of a special device, inserted into the vagina.
 Stimulating the sacral nerves can control urge incontinence if other therapies haven't worked.
 SURGICAL TREATMENT

 Urehroplasty (Kelly,kennedy,etc….)
 Urethropexy (Retropubic Urethropexy E.G. Marchall-marchitti-krantz, Etc….)
 Colposuspension ( Burch Operation,preyera , Etc….)
 Urethral Slings (Aldridge Operation,etc…..)
 Tension Free Vaginal Tape (TVT)
 Kelly operation 1914
 It consists of repair of cystocele and/or urethrocele.
 Vertical mattress sutures are then placed to plicate the whole urethra and bladder neck.
 This gives support to the urethra and restores the normal posterior urethrovesical angle.
 Operation is done for mild and moderate cases of stress incontinence.
 Long term success rate is 55-65%.
 Vaginal tape operation (TVT)
 The cystoscopies is used by the assistant to make sure that the bladder is not pierced by the
needle.
 The tape is adjusted by pulling on its ends, and continence is confirmed by asking the patient to
cough.
 The ends of the tape are cut off and left free and not fixed to the tissues, Finally the vaginal and
suprapubic incisions are closed.
 When stress occurs ,the recti will contract and pull on the tape to support the urethra and prevent
escape of urine
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Thank You