1

Urinary
Incontinence
CICE TRESNASARI
PHYSICAL MEDICINE AND REHABILITATION
FACULTY OF MEDICINE
UNISBA
2017
 2
Objectives

1. Neurogenic bladder
2. Urinary incontinence
3. Rehabilitation aproach
3
 4

Neurogenic bladder (dysfunction)

Bladder or voiding dysfunction

resulting from a lesion or disease in the
CNS or PNS
 5

The classification of
neurogenic bladder

Based on the location of the neurologic

lesion or disease

(PMR Mayo College of Medicine USA)

6
 7
The location of disease
or lesion

1. Above the Pons Micturition Center (PMC)

2. Between the PMC and sacral spinal cord
3. Sacral cord lesions that damage the
detrusor nucleus
4. Sacral lesions that damage the pudendal
nucleus
5. Sacral cord or sacral nerve root
8
 9
1. Above the PMC

• Stroke, TBI, brain tumor, Parkinson’s disease

• Uninhibited bladder
• Reduction or loss of inhibition of PMC by cortical and
subcortical structure damage  reduce awareness of
bladder fullness
• Low bladder capacity
• PMC is intact  detrusor-sphincter coordination spare
 no high bladder pressure
• Incontinence (especially bilateral lesions)
 10
2. Below the PMC and
at suprasacral spinal cord

• Stroke, SCI, multiple sclerosis, transverse myelitis

• Detrusor-sphincter dyssynergia (DSD) 
simultaneous detrusor and sphincter contractions 
high pressure bladder  vesicoureteral reflux  renal
damage
• High detrusor tonus (detrusor overactivity or
hyperreflexia)  reduce bladder capacity
• If detrusor pressure exceeds sphincter pressure in the
proximal urethra  overflow incontinence
 11
3. Sacral cord lesions that damage
the detrusor nucleus

• The mixed type A neurogenic bladder

• The more common of the mixed type bladders
• Detrusor nucleus damage  the detrusor flacid
(detrusor areflexia)
• Intact pudendal nucleus  spastic external urinary
sphincter
• The bladder is large, low pressure
• Urinary retention, upper urinary tract damage from
vesicoureteral reflux does not occur  Incontinence is
uncommon
 12
4. Sacral cord lesions that damage
the pudendal nucleus

• The mixed type B neurogenic bladder

• The pudendal nucleus lesion  flaccid
external urinary sphincter
• The disinhibited detrusor nucleus  spastic
bladder
• The bladder capacity is low, but bladder
pressure are usually not elevated since there
is little outflow resistance  Incontinence
 13
5. Sacral cord or sacral nerve root
injuries

• Lower motor neuron bladder

• The Sacral Micturition Center (SMC) or related
peripheral nerves are damaged
• The thoracic sympathetic nervous system outflow to
the lower urinary tract is intact
• Detrusor tone is low, internal urinary sphincter
innervation is intact  bladder capacity is large
• Despite the low detrusor pressure, overflow urinary
incontinence and urinary tract infections are common
Urinary incontinence
URINARY INCONTINENCE

Inability to hold leakage of urine

from the bladder
• Common

• The basic work up :

determine the cause and
the type
Classification of urinary
incontinence

• Transient UI

• Chronic UI
 Transient urinary
incontinence
Causes : DIAPPERS
 Delirium
 Infection (acute UTI)
 Atrophic vaginitis
 Pharmaceutical
 Psychological disorder, especially
depression
 Excessive urine output (e.g
hyperglicaemia)
 Reduced mobility (functional
incontinence) or reversible (e.g drug
induced) urinary retention
 Stool impaction
Pharmaceuticals
• Antihypertensives
• Pain relievers
• Psychotherapeutics
• Others (alcohol, antihistamin, etc)
Chronic urinary incontinence

Types :
 Stress incontinence
 Urge incontinence
 Mixed incontinence
 Overflow incontinence
 Functional incontinence
 Evaluation of
urinary incontinence patient

• Transient or chronic UI

Transient UI
Find the cause: DIAPPERS
Chronic UI
• History & 3 incontinence questions
questionnaire
• Review voiding diary
• Physical examination
• Include cough stress test (if stress incontinence is
suspected)
• Measure post-void residual (PVR) urine
• Laboratory evaluation
 Management of
neurogenic bladder
The goals of management of neurogenic
bladder :

 Achieve continence to avoid the psychological and

physical consequences of incontinence

 Prevent development of a high pressure detrusor

that can lead to upper urinary tract damage

 Minimize risk of symptomatic urinary tract infections

 Prevent over-distention of the bladder

 Behavioral management
• Timed voiding
• Bladder (re)training and fluid schedule
• Bladder stimulation (relaxation, suprapubic
tapping, valsava maneuver, crede maneuver)
• Pelvic floor exercise
 BLADDER (RE)TRAINING

• A way of teaching the bladder increasing

the amount of urine the bladder can hold
by gradually ‘stretching’ it  increase
bladder capacity  decrease frequencies
of voiding

• To stop urine leaking

• Avoid alcohol, caffeine, soft drink, tea
• Drinks 1.5 – 2 litres of fluid a day
• Avoid drinks anything within 2 hours going
to bed
 Urine Collection Devices
• External condom catheter
• Indwelling catheter
• Adult diapers
• Intermitten catheterization
 Medication
• Anticholinergic
• Cholinergic
• Adrenergic antagonist
• Adrenergic agonist
• Estrogen
• Muscle relaxan
• Botulinum A toxin

 Surgery
Intermitten catheterization
• Intermittent catheterization :
the insertion and removal of a catheter several
times a day to empty the bladder

• An effective bladder management strategy

for patients with incomplete bladder
emptying due to idiopathic or neurogenic
bladder dysfunction
IC equipments
Intermitten catheterization
 The advantages of Intermitten
catheterization over indwelling catheter

• Improve self-care and independence

• Reduced risk of common indwelling catheter-
associated complications
• Reduced need for equipment (such as drainage
bags)
• Less barriers to intimacy and sexual activities
• Potential for reduced lower urinary tract
symptoms (frequency, urgency, incontinence)
between catheterizations
Catheterization techniques:
• Clean re-used
• Clean, single-used
• Sterile or aseptic
The catheterization schedule should be
based on:
• Frequency-volume records
• Post-Void Residual volume
• Bladder capacity (from urodynamic)
 Review

1.Neurogenic bladder

2.Urinary incontinence

3.Rehabilitation aproach
 Refferences

• Neurogenic Bladder, Peter T. Dorsher and Peter M.

McIntosh, Hindawi Pusblishing Coorporation, 2012
• Diagnosis of Urinary Incontinence, Christine Khandelwal,
Christine Kistler, University of North Carolina, 2013
• Management of bladder dysfunction, Randall L.
Braddom, Physical Medicine and Rehabilitation, 2011
• Neurogenic bladder and bowel, Delisa’s, Physical
Medicine and Rehabilitation, 2010
43