urinary incontinence in women

61
URINARY INCONTINENCE IN WOMEN Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang

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URINARY INCONTINENCE IN WOMEN. Bobby Indra Utama Divisi Uroginekologi & Bedah Rekonstruksi Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang. adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial. DEFIN ISI. - PowerPoint PPT Presentation

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Page 1: URINARY INCONTINENCE IN WOMEN

URINARY INCONTINENCE IN WOMEN

Bobby Indra Utama

Divisi Uroginekologi & Bedah Rekonstruksi

Bagian/SMF OBGIN FK UNAND/dr.M.Djamil Padang

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DEFINISI

adalah keluarnya urin yang tidak dapat dikontrol/dikendalikan, yang dapat dibuktikan secara obyektif, merupakan masalah higiene dan sosial

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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

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Klasifikasi

1. Stress incontinence

2. Overactive bladder

3. Overflow incontinence

4. Continue incontinence

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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

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Incompetence of urethral closure

mechanism

ETIOLOGY STRESS URINARY INCONTINENCE

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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

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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

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PELVIC FLOOR

A

B

DESCENT OF THE BLADDER NECK AND

PROXIMAL URETHRA

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RISK FACTORS URETHRAL HYPERMOBILITY

Child birth Age Menopause Chronic intra abdominal pressure (chronic

cough, constipation, obesity) Pelvic denervation

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Risk Factors: INTRINSIC SPHINCTER DYSFUNCTION (ISD 10%)

Multiple prior operationsTraumaRadiationNeurogenic disorders including

diabetes mellitusAtrophic changes lack of estrogenMielodysplacia

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DETERMINANTSOF

STRESS INCONTINENCE

Restingurethralclosure

pressure

Stresspressure

transmission

Intraabdominalpressureincreases

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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

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Diagnosis : Anamnesis tentang simptom stres inkontinensia

Residu urin < 50 cc

Kapasitas kandung kemih > 400 cc

Tes batuk positif atau valsava positif

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Pemeriksaan penunjang : Daftar harian berkemih

Urinalisis

Tes Batuk

tes PAD

Urodinamik

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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

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Classification

Weight increase of pad

(in gram)Dry < 2

Moderate 2 - 10

Severe 10 – 50

Very severe > 50

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TREATMENT OPTIONS

Conservative

Surgical/ modulatory

therapies

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STRESS INCONTINENCE TREATMENT

ConservativePelvic floor exercises

Weighted vaginal Cones

Electrostimulation

Positive fedback/perineometri

Devices (e.g. pessary)

Pharmacotherapy

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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

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Burch colposuspension

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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.

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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.

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1. Detrusor hyperreflexia or Neurogenic detrusor overactivity

2. Detrusor instability or Idiopathic detrusor overactivity

ETIOLOGY OVERACTIVE BLADDER

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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.

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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

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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

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EXAMINATION

Physical examination

Gynecologic examination

Neurologic examination

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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

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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

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URODYNAMICS

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OVERACTIVE BLADDER TREATMENT

Conservative

Behavioral modification therapiesdietary modification

bladder training

No Stress ..

pelvic floor muscle exercises adjunct therapies

scheduled/assisted voiding

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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

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MUSCARINIC RECEPTOR DISTRIBUTION

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SURGICAL / MODULATORY THERAPIES

Denervation central peripheral and perivesical

Acupuncture

Electroacupunture

Electrical stimulation/neuromodulation

Overdistention

Augmentation cystoplasty

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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

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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

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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

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BIASANYA DISEBABKAN OLEH :

1. Anestesia2. Rasa nyeri3. Edema4. Spasme otot-otot pubokoksigeus

RETENSIO URIN PASCA BEDAH GINEKOLOGI

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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

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1. Anamnesis : Gejala retensio urin

2. Pemeriksaan fisik Teraba massa diatas simpisis pemeriksaan bimanual

DIAGNOSIS

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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

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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

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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

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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

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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

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CONTINUE INCONTINENCE

Etiology : Fistula

Treatment: repair

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DIFINITION

Fecal incontinence is the inability to

control the passage of gas, liquid or

solid through the anus.

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ANATOMY ANORECTAL

ANATOMY:

Anal Sphincter: internal sphincter

external sphincter

Puborectalis muscle

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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

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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

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Trauma akibat proses persalinan

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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

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Terima Kasih