Professional Documents
Culture Documents
Incontinentia Urine Kuliah Uniba 6-11-12. A
Incontinentia Urine Kuliah Uniba 6-11-12. A
Definition:
LUTS, or lower urinary tract symptoms , is a
common term used to describe the range of urinary symptoms as frequency, urgencyetc , which was previously called prostatism but this has been replaced by LUTS because the prostate is most often not the cause.
Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining Terminal dribble
Causes of LUTS:
In males: Outflow obstruction
BPH Meatal stenosis
CONT
Infection
neoplastic Others:
Prostatic cancer, bladder cancer Bladder diverticulum, stone and interstitial cystitis.
In females :
Mostly storage symptoms
UTI Pregnancy Anxiety Overactive bladder Interstitial cystitis Postmenopausal urogenital atrophy Bladder tumor or stone Genital prolapses or pelvic mass
Age related detrusor muscle weakness Obstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis) Urethritis Drugs ( diuretics, alcohol, lithium, anticholinergics)
Storage symptoms:
Daytime frequency Urgency: sudden desire for urination that is
difficult to postponed. Nocturia : urinary urgency that awakens the pt. from sleep. Urge incontinence Enuresis: incontinence during sleep.
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
Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder
Medications That May Cause Incontinence Diuretics Anticholinergics - antihistamines, antipsychotics, antidepressants Seditives/hypnotics Alcohol Narcotics -adrenergic agonists/antagnists Calcium channel blockers
Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity
>90%)
Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture Simple (bedside) Cystometrics
Cont.
Investigation
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
US
Ascending Urethrogram
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 are obtained with the bladder full, during micturation and after voiding. . VCUG is excellent method of diagnosing vesical neck obstruction and vesicoureteral reflux.
Cont.
Investigation
*Uroflowmetry:
*Cystourethroscopy * Cystometry:
Treatment Options
Bladder training
Patient education Scheduled voiding Positive reinforcement
Pharmacological Interventions
Urge Incontinence
Oxybutynin (Ditropan) Propantheline (Pro-Banthine) Imipramine (Tofranil)
Stress Incontinence
Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed) Estrogen (orally, transdermally or transvaginally)
Surgical Interventions
Surgery is reported to cure 4 out of 5 cases, but success rate drops to 50% after 10 years.
Urethral Hypermotility
Intrinsic sphincter
deficiency
Sling procedure
Other Interventions
Pessaries Periurethral bulking agents (periurethral
injection of collagen, fat or silicone) Diapers or pads Chronic catheterization
Periurethral or suprapubic Indwelling or intermittant
Pessarie s
TREATMENT
*Obstructive ureter:
- Suprapubic cystostomy - Ureteric catheter drainage
Cont
TREATMENT
A. Distal urethra:
*Urethral strictures: -Dilation - - Visual urethrotomy transurethral balloon dilation catheter - Urethroplasty *Meatal stenosis: -Dilation -surgical meatotomy
BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated
BPH
The size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostate By the time men reach their 70s and 80s, 80% will experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment
Anatomy of BPH
Normal BPH
BLADDER
PROSTATE URETHRA
Roehrborn CG, McConnell JD. In: Walsh PC et al, eds. Campbells Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:1297-1336.
Prevalence of BPH
Around 25% in men aged 40-49 years Around 50% in men aged 70 and older
Source: J Urol 1984;132:474
Risk factors
-Age : at late 40s only 3.5% of men at 80s it raise to 35% -Ethnic
The initial evaluation of all patient presenting with 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
Moderate IPSS 7-20 Flow rate < 15mls/s Resid vol <200 mls
Severe IPSS > 20 Flow rate < 10 mls/s Resid vol > 200 mls
Surgicenter/Hospital-based
treatment
TURP (gold standard) TUIP Open surgery (prostatectomy) TUVP ILC VLAP Prostatic stents
Office-based treatment
TUMT TUNA WIT
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.
Alpha blockers
Improve symptoms and increase urinary flow rate by relaxing prostatic and bladderneck smooth muscle through sympathetic activity blockade
Source: Roehrborn CG Curr Opin Urol 2001;11:17-25 National Cancer Institute. NIH Publication No. 99-4303, 1999.
TURP
Uses an electrical knife to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow
Microwave energy