urinary incontinence in women
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URINARY INCONTINENCE IN WOMEN
Bobby Indra Utama
Divisi Uroginekologi & Bedah Rekonstruksi
Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang
DEFINISI
adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial
Inkontinensia urinKondisi lazim, merugikan kesehatan, fungsi, kualitas hidup Prevalensi: 11,3 - 62,7%Paling umum: SIU; 14,7-52%
Tx: farmako, nonfarmako, bedah1st choice: Non invasifLODP; kuno tp efektif
Arnold Kegel; 84% sembuh
Klasifikasi
1. Stress incontinence
2. Overactive bladder
3. Overflow incontinence
4. Continue incontinence
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
ETIOLOGY STRESS URINARY INCONTINENCE
Sphincter urethra eksterna(rhabdosphincter)
Otot peri-urethra dari dasar panggul
Muara urethra eksterna
Jaringan kolagen
Urethra Kandung kemih
Otot detrusorOtot polos urethra dan
jaringan ikat
1. Anatomic support of urethral and the urethrovesical junction
damage (Urethral hypermobility)
Descent of the bladder neck and proximal urethra Pressure
transmission Decreases
stress incontinence
2. Components of the internal mechanism damage (ISD)
Loss of the urethral resistance
Urethral closure pressure Decreases
stress incontinence
CAUSES STRESS INCONTINENCE
PELVIC FLOOR
SI
ISD
PELVIC FLOOR
A
B
DESCENT OF THE BLADDER NECK AND
PROXIMAL URETHRA
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 operationsTraumaRadiationNeurogenic disorders including
diabetes mellitusAtrophic changes lack of estrogenMielodysplacia
DETERMINANTSOF
STRESS INCONTINENCE
Restingurethralclosure
pressure
Stresspressure
transmission
Intraabdominalpressureincreases
SYMPTOMPatient complaint of involuntary urine loss
with physical exercise, coughing, sneezing, laughing
SIGNUrine is loss from urethra immediately upon
increasing intraabdominal pressure (e.g. Coughing sneezing, laughing)
SYMPTOM AND SIGN
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
0 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 10Cough x 10Run x 1 minutePick-up things from floorWash 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
TREATMENT OPTIONS
Conservative
Surgical/ modulatory
therapies
STRESS INCONTINENCE TREATMENT
ConservativePelvic floor exercises
Weighted vaginal Cones
Electrostimulation
Positive fedback/perineometri
Devices (e.g. pessary)
Pharmacotherapy
SURGICAL TREATMENT1. Anterior colporraphy
2. Transvaginal Needle Bladder Neck suspension
3. Retropubic suspension
1. Marshall - Marchetti – Krantz
2. Burch colposuspension
3. Sling procedures (e.g. TVT-TVT-O)
4. Artificial sphincter
STRESS INCONTINENCE TREATMENT
Burch colposuspension
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
Abrams P et al. Neurourol Urodyn. 2002;21:167-178.
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
Abrams P et al. Neurourol Urodyn. 2002;21:167-178.
1. Detrusor hyperreflexia or Neurogenic detrusor overactivity
2. Detrusor instability or Idiopathic detrusor overactivity
ETIOLOGY OVERACTIVE BLADDER
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.
History Questions
1. Do you leak urine when you cough, sneeze, or laugh?
2. Do you ever have such an uncomfortable strong need to urinate that if you don,t reach the toilet you will leak?
3. If “yes” to question 2, do you ever leak before you reach the toilet?
4. How many times during the day do you urinate?
5. How many times do you void during the night after going to bed?
6. Have you wet the bed in the past year?
7. Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry?
8. Do you ever leak during oe after sexual intercourse?
9. Do you find it necessary to wear a pad because of leaking ?
10. How after do you leak?
11. Have you had bladder, urine, or kidney infection?
12. Are you troubled by pain or discomfort when you urinate?
13. Have you had blood in your urinate?
14. Do you find it necessary to wear a pad because of your leaking?
15. Do you find it hard to begin urinating?
16. Do you have as slow urinary stream or have to strain to pass your urine?
17. After you urinate, do you have dribbling or a feeling that you bladder is still full?
DIAGNOSTIC INCONTINENCE URINE
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
Neurologic examination
Fantl JA et al. Agency for Healthcare Policy and Research;1996; AHCPR Publication No. 96-0686.
LABORATORY TESTS
Urinalysisto rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria
URINARY DIARY
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)
How much? (fill in amount: small, medium,
large)
Sneezing, exercising,
having sex, lifting, etc.
Sample coffee 2 cups 12 large 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
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
URODYNAMICS
OVERACTIVE BLADDER TREATMENT
Conservative
Behavioral modification therapiesdietary modification
bladder training
No Stress ..
pelvic floor muscle exercises adjunct therapies
scheduled/assisted voiding
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
OVERACTIVE BLADDER TREATMENT Conservative
Antimuscarinics
MUSCARINIC RECEPTOR DISTRIBUTION
SURGICAL / MODULATORY THERAPIES
Denervation central peripheral and perivesical
Acupuncture
Electroacupunture
Electrical stimulation/neuromodulation
Overdistention
Augmentation cystoplasty
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
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
DISEBABKAN OLEH :
1. Anestesia2. Rasa nyeri luka insisi dinding perut
reflek menginduksi spasme otot levator pasien enggan untuk mengkontraksikan
dinding perut guna memulai pengeluaran urin
3. Manipulasi kandung kemih4. Jika SC akibat distosia PK II (iritasi, edema)
RETENSIO URIN PASCA SEKSIO SESAREA
BIASANYA DISEBABKAN OLEH :
1. Anestesia2. Rasa nyeri3. Edema4. Spasme otot-otot pubokoksigeus
RETENSIO URIN PASCA BEDAH GINEKOLOGI
1. Kencing tidak lampias 2. Waktu BAK lama3. Frekuensi BAK lebih sering4. Tidak bisa BAK 5. Kandung kemih merasa penuh6. Distensi abdomen
GEJALA RETENSIO URIN
1. Anamnesis : Gejala retensio urin
2. Pemeriksaan fisik Teraba massa diatas simpisis pemeriksaan bimanual
DIAGNOSIS
3. PEMERIKSAAN URIN SISA (dengan kateter) Setelah 6 jam kateter dilepas diukur urin sisa
RETENSIO URIN JIKA :Pasca bedah Ginekologi : urin sisa >100 mlPasca bedah Obstetri : urin sisa >200 ml
DIAGNOSIS
4. USG
Dapat memeriksa secara non invasif
5. Pemeriksaan uroflowmetri normal jika flow rate > 15-20 ml/detik Gangguan berkemih :
penurunan flow rateperpanjangan waktu berkemih
DIAGNOSIS
I. Kateterisasi
II. Obat-obatan :
1. Obat-obat yang meningkatkan kontraksi kandung kemih dan menurunkan resistensi uretra :a. Yang bekerja pada sistem saraf parasimpatis
obat koligernik ~ asetik kolik bekerja di “end organ” efek muskarinik
contoh : betanekhol, karbakhol, metakholin
b. Yang bekerja pada sistem saraf simpatis
contoh : fenoksibenzamin
Penatalaksanaan
c. Obat yang bekerja pada otot polos
Mempengaruhi kerja otot otot detrusor.
contoh : Prostaglandin E2
III Pemberian cairanBanyak minum 3 liter/24 jam
Gunanya mencegah kolonisasi bakteri
IV Antibiotika: sesuai kultur
Penatalaksanaan
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 kateter1 x 24 jam
Dauer kateter2 x 24 jam
Dauer kateter3 x 24 jam
Buka-tutup kateter/6 jamSelama 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)
PulangKeterangan : Intermiten adalah kateterisasi tiap 6 jam selama 24 jam
CONTINUE INCONTINENCE
Etiology : Fistula
Treatment: repair
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 surgikalModifikasi diet
Farmakoterapi
Enema dan irigasi rektum
Terapi biofeedback
SurgikalSpingteroplasti anal
Postanal pelvic floor repair
Muscle transposition procedure
Artificial anal sphincter
Kolostomi atau illeostomi
Terima Kasih
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