1. Incontinencia UrinariaIncontinencia Urinaria

2. Anatomía de la Micción
 Músculo Detrusor
 Esfínter Externo e Interno
 Capacidad Normal 300-600cc
 Primera sensación 150-300cc
 Control SNC
 Puente - facilita
 Corteza Cerebral - inhibe
 Efectos Hormonales - estrógenos

3. Nervios Periféricos en la Micción
 Parasimpático (colinérgico) – contracción vesical
 Simpático - Relajación vesical
 Simpático - Relajación vesical (β adrenérgico)
 Simpático – Contracción del Cuello vesical y
uretral (α adrenérgico)
 Somático (nervio pudendo) - contracción de la
musculatura del piso pélvico

4. Control de la micción
Cuello vesical
Uretra proximal
Músculo detrusor
Vejiga
Esfínter uretral externo
Suelo de la pelvis
Nervio pudendo
S2 – S4
Simpático
D11 – L2
Parasimpático
S2 – S4
Cortex
Àrea motora del detrusor
(+)
(+)
(+)
(-)
(-)
Núcleo pontino
(+)
(-)

5. Nervios Periféricos en la Micción

6. Incontinencia urinaria
“Pérdida involuntaria de orina,
demostrable objetivamente,
que ocasiona un problema de
salud o social”.
(International Continence Society)

7. Incontinencia: Epidemiología
1. Comunidad: 15-30%
Hospital de agudos: 30-40%
Instituciones: 50-80%
2. Estudio de Madrid: Varones 14,5 %
Mujeres 16%
Por grupos de edad: 65-74 13%
75-84 16%
>84 26%

8. Prevalence of Urinary Incontinence
 Estimated 10% to 35% of adults
 > 50% of 1.5 million nursing home residents
 A conservative estimated cost of $5.2 billion
per year for urinary incontinence in nursing
homes
Fant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy and
Research. 1996. AHCPR Publication No. 90-06 National Center for Health Statistics. Vital Health Statistics Series.
13(No. 102). 1989e in

9. ¿Cuán Común es la Incontinencia?
 Prevalencia se incrementa con la edad (pero no
es parte del envejecimiento normal)
 25-30% de la comunidad de ancianas
 10-15% de la comunidad de ancianos
 50% residentes de hogares; frecuentemente
asociado con demencia, incontinencia fecal,
pérdida de la habilidad para caminar y
trasladarse independientemente

10. La Incontinencia Urinaria es Frecuentemente
Sub-diagnósticada y Sub-tratada
 Sólo el 32% de los médicos generales
preguntan rutinariamente acerca de la
incontinencia
 50-75% de los pacientes nunca describen
síntomas a los médicos
 80% de las incontinencias urinarias
pueden ser curadas o mejoradas

11. Incontinencia urinaria: repercusiones
Físicas:
Infecciones, sepsis, úlceras, caídas
Psíquicas:
Ansiedad, depresión, pérdida autoestima,
Interferencias sexuales
Sociales:
Aislamiento, mayor necesidad de recursos,
institucionalización
Económicas:
Costes de complicaciones y de medidas paliativas

12. Impact on Quality of Life
 Loss of self-esteem
 Decreased ability to maintain independent
lifestyle
 Increased dependence on caregivers for
activities of daily life
 Avoidance of social activity and interaction
 Restricted sexual activity
Grimby et al. Age Aging. 1993; 22:82-89.
Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. Washington
DC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988.
Noelker L. Gerontologist. 1987; 27:194-200.

13. Consequences of UI
 An increased propensity for falls
 Most hip fractures in elders can be traced to
nocturia especially if combined with urgency
 Risk of hip fracture increases with
 physical decline from reduced activity
 cognitive impairments that may accompany a UTI
 medications often used to treat incontinence
 loss of sleep related to nocturia

14. Risk Factors
 Aging
 Medication side effects
 High impact exercise
 Menopause
 Childbirth

15. Factors Contributing to
Urinary Incontinence
 Medications
 Diuretics
 Antidepressants
 Antihypertensives
 Hypnotics
 Analgesics
 Narcotics
 Sedatives
 Diet
 Caffeine
 Alcohol
 Bowel Irregularities
 Constipation
 Fecal Impaction

16. Age Related Changes in the
Genitourinary Tract
 Majority of urine production occurs at rest
 Bladder capacity is diminished
 Quantity of residual urine is increased
 Bladder contractions become uninhibited
(detrusor instability)
 Desire to void is delayed

17. Cambios del tracto urinario inferior con
el envejecimiento
Disminución de:
Capacidad vesical
Longitud de la uretra funcional
Contractilidad vesical
Presión de cierre uretral
Habilidad para posponer la micción
Aumento de:
Residuo vesical postmiccional
Contracciones no inhibidas del detrusor

18. Causas de Incontinencia Urinaria aguda
-Infecciones
-Síndrome confusional agudo
-Inmovilidad
-Impactación fecal
-Vaginitis atrófica
-Medicamentos:
Diuréticos, anticolinérgicos, antidepresivos,
Neurolépticos, hipnóticos, sedantes,
Mórficos, bloqueantes del calcio,
Antiparkinsonianos, antihistamínicos,
Antidiarreicos, agonistas alfa y beta adrenérgicos

19. Causas Potencialmente Reversibles
D - Delirio
I - Infección
A - Atrofia vaginal o uretritis
F - Fármacos
P - Psycológicos
E - Endocrinos
M - Mobilidad restringida
I - Impactación fecal
2

20. Cause of Stress Urinary
Incontinence
 Failure to store secondary to urethral
sphincter incompetence

21. Causes of Urge Urinary
Incontinence
 Failure to store, secondary to bladder
dysfunction
 Involuntary bladder contractions
 Decreased bladder compliance
 Severe bladder hypersensitivity

22. Stress Incontinence vs. Urge
Incontinence: System Check List
Symptoms Stress
Incontinence
Urge
Incontinence
Urgency accompanies incontinence
(strong, sudden desire to void)
NO YES
Leaking during physical activity (e.g.
coughing, sneezing, lifting, etc.)
YES NO
Ability to reach the toilet in time,
following an urge to void
YES NO
Waking to pass urine at night SELDOM OFTEN

23. Causes of Mixed Urinary
Incontinence
 Combination of bladder overactivity and stress
incontinence
 One type of symptom (e.g., urge or stress
incontinence) often predominates

24. Symptoms of Overactive Bladder
 Urgency
 Frequency
 Nocturia, and/or urge incontinence
 ANY COMBINATION - in the absence of any
local pathological or metabolic disorder

25. Causes of Overflow Urinary
Incontinence
 Loss of urine
associated with over
distention of the
bladder
 Failure to empty
 Underactive bladder
 Vitamin B12
deficiency
 Outlet obstruction
 Enlarged Prostate
 Urethral Stricture
 Fecal Impaction
 Neurological Conditions
 Diabetic Neuropathy
 Low Spinal Cord Injury
 Radical Pelvic Surgery

26. Neurogenic Bladder
What is a neurogenic bladder?
 A medical term for overflow incontinence,
secondary to a neurologic problem
 However, this is NOT a type of urinary
incontinence

27. Basic Types and Underlying Causes of
Incontinence
Type Definition Causes
Stress Loss of urine with increase in intra-
abdominal pressure (coughing,
laughing, exercise, standing, etc.)
Weakness and laxity of
pelvic floor musculature,
bladder outlet or urethral
sphincter weakness
Urge Leakage of urine because of
inability to delay voiding after
sensation of bladder fullness is
perceived
Detrusor muscle instability,
hypersensivity associated
with local genitourinary
conditions or central
nervous system disorders
Overflow Leakage of urine resulting from
mechanical forces on an over
distended bladder, or from other
effects of urinary retention on
bladder and sphincter function
Anatomic obstruction by
prostate, stricture,
cystocele, acontractile
bladder, detrusor-sphincter
dyssynergy
Mixed Urinary leakage associated with
inability to toilet because of
impairment of cognitive and/or
physical functioning, unwillingness,
or environmental barriers
Severe dementia, other
conditions that cause
severe immobility, and
psychological factors

28. Reversible or Transient Conditions That
May Contribute to UI
“D” Delirium
Dehydration*
“R” Restricted mobility
Retention
“I” Infection
Inflammation
Impaction
“P” Polyuria
Pharmaceuticals

29. *Dehydration
 Dehydration due to decreased fluid intake;
increased output from diuretics, diabetes, or
caffeinated beverages; or increased fluid
volume due to congestive heart failure can
concentrate the urine (increased specific
gravity) and also lead to fecal impaction
 The specific gravity of the urine can be tested to
determine whether or not the resident is
dehydrated

30. Medications That May Cause Incontinence
 Diuréticos
 Anticolinérgicos - antihistaminas,
antipsicóticos, antidepresivos
 Sedantes/hipnóticos
 Alcohol
 Narcoticos
 Agonistas/antagonistas α-adrenérgicos
 Bloqueadores de los canales de Calcio

31. Tipos clínicos de Incontinencia Urinaria
1. AGUDA
2. PERSISTENTE
a) de urgencia
b) de estrés
c) por rebosamiento
d) funcional

32. Types of Urinary Incontinence
 Stress
 Urge
 Mixed
 Overflow
 Total

33. Types of Urinary Incontinence
 Stress: Leakage of small amounts of urine as
a result of increased pressure on the
abdominal muscles (coughing, laughing,
sneezing, lifting)
 Urge: Strong desire to void but the inability to
wait long enough to get to a bathroom

34. Types of Urinary Incontinence
(continued)
 Mixed: A combination of two types, stress
and urge
 Overflow: Occurs when the bladder overfills
and small amounts of urine spill out (bladder
never empties completely, so it is constantly
filling)
 Total: Complete loss of bladder control

35. History
Obtaining an accurate and
comprehensive UI History

36. Taking the History
 Duration, severity, symptoms, previous
treatment, medications, GU surgery
 3 P’s
 Position of leakage (supine, sitting, standing)
 Protection (pads per day, wetness of pads)
 Problem (quality of life)
 Bladder record or diary
1

37. Evaluation is the Key!
Identification of the type of
urinary incontinence is the key
to effective treatment.

38. Basic Evaluation
 Physical Exam
 Female genitalia abnormalities
 Rectocele
 Urethral Prolapse
 Cystocele
 Atrophic Vaginitis

39. Physical Examination
 Mental status
 Mobility
 Fluid overload
 Abdominal exam
 Neurologic exam
 Pelvic
 Rectal

40. Basic Evaluation for Differential
Diagnosis
 Patient History
 Focus on medical, neurological, genitourinary
 Review voiding patterns and medications
 Voiding diary
 Administer mental status exam, if appropriate
 Physical Exam
 General, abdominal and rectal exam
 Pelvic exam in women, genital exam in men
 Observe urine loss by having patient cough vigorously

41. Basic Evaluation for Differential
Diagnosis (continued)
 Urinalysis
 Detect hematuria, pyuria, bacterimia,
glucosuria, proteinuria
 Post void residual volume measurement by
catheterization or pelvic ultrasound

42. Lab Results
 Lab results from approximately the last 30
days:
 Calcium level normal 8.6 - 10.4 mg/dl
 Glucose level normal fasting 65 - 110 mg/dl
 BUN normal 10 - 29 mg/100 ml (OR)
 Creatinine normal 0.5 - 1.3 mg/dl
 B12 level (within the last 3 years) normal 200 -
1100pg/ml
*Normal lab values may vary depending on laboratory used.

43. Three Day Voiding Diary
 Three day voiding diary should be completed
on the resident
 Assessment should be completed 24 hours a
day for 3 days
 Make sure CNA’s are charting when the
resident is dry or not, the amount of
incontinence, if the voiding was requested or
prompted

44. Basic Continence Evaluation
Focused Physical Exam, including:
 Pelvic exam to assess pelvic floor & vaginal wall
relaxation and anatomic abnormalities including digital
palpation of vaginal sphincter
 Rectal exam to rule out fecal impaction & masses
including digital palpation of anal sphincter.
 Neurological exam focusing on cognition & innervation
of sacral roots 2-4 (Perineal Sensation)
 Post Void Residual to rule out urinary retention
 Mental Status exam when indicated

45. Simple Urologic Tests
 Provocative Stress Testing
 Key components
 Bladder must be full
 Obtain in standing or lithotomy position
 Sudden leakage at cough, laughing, sneezing,
lifting, or other maneuvers

46. The Bulbocavernous Reflex Test
 When the nurse is inserting a finger into the
anus to check for fecal impaction, the anal
sphincter should contract
 When the nurse is applying the litmus paper
to check the vaginal pH, the vaginal muscle
should contract
(When both these muscles contract this indicates
intact reflexes)

47. Post Void Residual
 A post void residual should be obtained after
voiding via a straight catheterization or via the
the bladder scan
 If the resident has > 200 cc residual the test is
positive
(Document the exact results on the assessment
form)

48. Mini Mental Exam (MMSE)
 Complete a mini mental exam on the resident
 Chart the score on the assessment form
 Score the resident on the number of
questions they answered correctly to the total
number of questions reviewed

49. Diagnostic Tests
 Stress test (diagnostic for stress incontinence; specificity >90%)
 Post-void residual
 Blood Tests (calcium, glucose, BUN, Cr)
 Urine Culture
 Simple (bedside) Cystometrics

50. Bladder Pressure-Volume
Relationship

51. Interpretation of Post-Void Residual
PVR < 50cc - Adequate bladder
emptying
PVR > 150cc - Avoid bladder relaxing
drugs
PVR > 200cc - Refer to Urology
PVR > 400cc - Overflow UI likely

52. Incontinencia Urinaria Persistente-
tipos (I)
Tipo Concepto Causas
De urgencia
Pérdidas de gran
volumen
Incapacidad para
diferir la micción
Residuo postmiccional
pequeño
Inestabilidad del detrusor,
aislada o asociada a:
- alteraciones locales: cistitis,
cálculos, tumores,
divertículos, obstrucción.
- lesiones SNC: demencia,
ACV, Parkinson, lesiones
medulares.

53. Urge Incontinence
 Most common cause of UI >75 years of age
 Abrupt desire to void cannot be suppressed
 Usually idiopathic
 Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s
Disease, dementia
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder

54. Incontinencia Urinaria Persistente-
tipos (II)
Tipo Concepto Causas
De estrés
Pérdidas de pequeño
volumen
Al aumentar la presión
abdominal
Residuo postmiccional
pequeño
Debilidad y laxitud
muscular del suelo de la
pelvis
Incompetencia del esfínter
uretral

55. Stress Incontinence
 Most common type in women < 75 years old
 Occurs with increase in abdomenal pressure;
cough, sneeze, etc.
 Hypermotility of bladder neck and urethra;
associated with aging, hormonal changes, trauma of childbirth or
pelvic surgery (85% of cases)
 Intrinsic sphinctor problems; due to
pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic
causes (15% of cases)

56. Incontinencia Urinaria Persistente-
tipos (III)
Tipo Concepto Causas
Por
rebosamiento
Pérdidas
continuadas de
pequeño volumen
Residuo
postmiccional
> 100 cc
Obstrucción anatómica:
próstata, cistocele, uretra
Vejiga acontráctil: diabetes,
lesión medular,
anticolinérgicos
Disinergia vesico-
esfinteriana (lesiones
medulares suprasacras)

57. Overflow Incontinence
 Over distention of bladder
 Bladder outlet obstruction; stricture, BPH,
cystocele, fecal impaction
 Non-contractile baldder (hypoactive
detrusor or atonic bladder); diabetes, MS, spinal
injury, medications

58. Incontinencia Urinaria Persistente-
tipos (IV)
Tipo Concepto Causas
Funcional
Pérdidas de orina
asociadas con
incapacidad para ir al
retrete o usar
sustitutivos, con falta
de motivación o
existencia de barreras
arquitectónicas
Demencia severa u otros
trastornos neurológicos
Factores psicológicos
(depresión, regresión,
hostilidad)
Falta o ineficacia de los
cuidadores

59. Functional Incontinence
 Does not involve lower urinary tract
 Result of psychological, cognitive or
physical impairment

60. Incontinencia urinaria: orientación diagnó
1. Historia clínica:
Comienzo, cantidad, desencadenante, ficha de
incontinencia
2. Historia farmacológica
3. Exploración física:
general, ginecológica, urológica, rectal
3. Pruebas complementarias:
Analítica de sangre y orina, urocultivo
4. Pruebas urodinámicas:
(Si dificultad diagnóstica ó falta de respuesta)

61. Tratamiento de la incontinencia urinaria
Medidas generales
1. Adaptación del entorno
2. Medidas higiénico-dietéticas
3. Modificación de fármacos
4. Modificación de conducta:
- dependiente del paciente: Reentrenamiento vesical
Ejercicios de Kegel
- dependiente del cuidador: Ficha de incontinencia
Micción programada
5. Medidas paliativas

62. Treatment Options
 Reduce amount and timing of fluid intake
 Avoid bladder stimulants (caffeine)
 Use diuretics judiciously (not before bed)
 Reduce physical barriers to toilet (use
bedside commode)
1

63. Treatment Options
 Bladder training
 Patient education
 Scheduled voiding
 Positive reinforcement
 Pelvic floor exercises (Kegel Exercises)
 Biofeedback
 Caregiver interventions
 Scheduled toileting
 Habit training
 Prompted voiding
2

64. Pharmacological Interventions
 Urge Incontinence
 Oxybutynin (Ditropan)
 Propantheline (Pro-Banthine)
 Imipramine (Tofranil)
 Stress Incontinence
 Phenylpropanolamine (Ornade)
 Pseudo-Ephedrine (Sudafed)
 Estrogen (orally, transdermally or transvaginally)

65. Surgical Interventions
 Urethral Hypermotility
 Marshall-Marchetti-Kantz
procedure
 Needle neck suspension
 Intrinsic sphincter
deficiency
 Sling procedure
Surgery is reported to “cure” 4 out of 5 cases,
but success rate drops to 50% after 10 years.

66. Other Interventions
 Pessaries
 Periurethral bulking agents (periurethral
injection of collagen, fat or silicone)
 Diapers or pads
 Chronic catheterization
 Periurethral or suprapubic
 Indwelling or intermittant

67. Inserts
 Pessary
 Urethral inserts
 Vaginal weights

68. Pessaries

69. Pessary

70. Indwelling Catheters
 Indwelling catheters (urethral or suprapubic)
may be necessary for certain residents with
incontinence:
 Urinary retention that cannot be corrected medically or
surgically, cannot be managed by intermittent
catherization and is causing persistent overflow
incontinence, symptomatic UTIs
 Pressure ulcers or skin lesions that are being
contaminated by incontinent urine
 Terminally ill severely impaired residents

71. Indwelling Catheter

72. ratamiento de la incontinencia de urgencia
(inestabilidad del detrusor)
1. Medidas generales
2. Fármacos
Anticolinérgicos puros: cloruro de trospio
Anticolinérgicos mixtos: Oxibutinina
Tolterodina
Otros: Bloqueantes del calcio
Antidepresivos tricíclicos
3. Estimulación eléctrica

73. Tratamiento de la incontinencia de estrés
1. Medidas generales
2. Conos vaginales
3. Fármacos: estrógenos locales
4. Pesario
5. Cirugía: colporrafia, colposuspensión, etc.
6. Otros: Estimulación eléctrica
Inyección de expansores de volumen
Esfínter urinario artificial

74. amiento de la incontinencia por rebosamiento
1. Obstrucción: tratamiento de la obstrucción
2. Arreflexia vesical: - cateterismo intermitente
- agonistas colinérgicos (betanecol)
Tratamiento de la incontinencia funcional
1. Evaluación integral del paciente y de su entorno
2. Evaluación de la formación y capacidad de los
cuidadores
3. Aplicación de medidas generales

75. Remember...
Urinary Incontinence can
be treated even if the resident
has dementia!!

76. Treatment
Guidelines recommend least
invasive evaluation and
treatment as baseline!!

77. Treat Transient Causes First
Such as:
 Atrophic vaginitis
 Symptomatic urinary tract infections (UTI)

78. Hypoestrogenation Causes
(Loss of Estrogen)
 Decreased glycogen
 Decreased lactic acid
 Increased vaginal pH
 Increased risk of UTI’s

79. Urinary Tract Infections (UTI)
The vaginas of postmenopausal women
not being treated with estrogen have
been found to be predominately
colonized by E. coli

80. Circulating Estrogen Inhibits
Uropathogen Growth by:
 Colonization of the vagina with lactobacilli
 Maintenance of acidic pH (<5)

81. Positive Effects of Estrogen
Replacement
 A decrease in vaginal pH
 Reemergence of lactobacilli
 Colonization of the vagina rarely occurs when
the pH is below 4.5

82. Symptoms tend to re-appear
when estrogen treatment ends!

83. Other Treatments of Urinary
Incontinence
 Behavioral therapy
 Pharmacotherapy
 Electrical Stimulation
 Denervation/decentralization
 Augmentation cystoplasty
 Catheterization
 Urinary diversion

84. Behavioral Treatments
 Fluid management
 Voiding frequency
 Toileting assistance
 Scheduled toileting
 Prompted voiding
 Bladder training
 Pelvic floor muscle exercise

85. Bladder Training & Urgency
Inhibition Training
 Bladder Training - techniques for postponing
voiding
 Urge Inhibition Training - techniques for
resisting or inhibiting the sensation of
urgency
 Bladder training & urge inhibition training is
strongly recommended for urge & mixed
incontinence & is recommended for
management of stress incontinence

86. Behavior Treatments
 Pelvic muscle exercises
 Effects of exercises
 Support, lengthen and compress the Urethra
 Elevate the urethrovesical junction
 Increase pelvic/muscle tone

87. Behavior Treatments
 Pelvic muscle (Kegel) exercises
 Goal: to improve urethral resistance and
urinary control through the active exercise of
the pubococcygenus muscle
 Components:
 Proper identification of muscle (if able to stop urine
mid-stream)
 Planned active exercise (hold for 10 seconds then
relax) 30-80 times per day for a minimum of 8
weeks

88. Biofeedback
 Very helpful in assisting patients in identifying
and strengthening pelvic muscles
 Give positive feedback for bladder training,
habit training and/or Kegels

89. Pharmacotherapy
 Medications
 To relax or augment bladder or urethral activity

90. Surgical Treatment
(Last Choice)
 More than 100 techniques
 Repair hypermobility
 Repair urethral support
 Contigen ™ implants (ISD)

91. When do you Refer to a Specialist?
 Uncertain diagnosis/no clear treatment plan
 Unsuccessful therapy/resident requests further
therapy
 Surgical intervention considered/ previous
surgery failed
 Hematuria without infection

92. Referral to Specialist (continued)
 Existence of other comorbid conditions:
 Recurrent symptomatic urinary tract infection
 Persistent symptoms of difficulty with bladder emptying
 Symptomatic pelvic prolapse
 Prostate nodule enlargement, asymmetry, suspicion of
cancer
 Abnormal post void residual urine
 Neurological condition: multiple sclerosis, spinal cord
lesion/injury
 History of previous radical pelvic or anti-incontinence
surgery