Urinary Incontinence, Pelvic Prolapse & Cancer Screening

Urinary Incontinence
& Pelvic Prolapse

Dr Israa Heleli, Family Medicine Specialist & Trainer in the
Egyptian Fellowship Board
• Introduction
AGENDA • Epidemiology
• Types
• Management
• Summary
Presentation title 2
• Involuntary urine leakage
• Common in the elderly population
Urinary Incontinence especially females (30%)
• Causes physical issues and disrupts
quality of life
• May lead to depression, social
embarassement, falls and fractures
3
Types
• Stress incontinence
• Urge incontinence
• Functional
incontinence
• Overflow
incontinence
• Mixed incontinence
Urge Incontinence
• Most common type in older adults

• Sudden urge irrepresible need to void
• Moderate to large amount of urine
• Nocturia and nocturnal incontinence are common
• Associated with diuretic use and atrophic vaginitis
Stress Incontinence
• Abrupt urine leakage after increase of intraabdominal

pressure (e.g coughing, sneezing)
• Main reasons: childbirth, surgery
• Second most common cause
• Low to moderate amount of urine
• Obesity exacerbates the condition
Functional Incontinence
• Inability to get to the bathroom

• Mainly due to cognitive or physical impairments
• Secondary to dementia, fractures, environmental barriers
Overflow Incontinence
• Second most common type in men

• Constant dribbling of small amounts of urine
• Full bladder
Urinary Incontinence 8
Transient Incontinence
Established incontinence:
Etiology of Causes:
Delirium
persistent problem of the
nerves or muscles caused by:
Incontinence Infection
Outlet obstruction
Atrophic urethritis
Outlet incompetence
Pharmaceuticals
Detrusor overactivity
Psychiatric
Detrusor underactivity
Excess urine output
Detrusor sphinter
Restricted mobility
dyssynergia
Stool impaction
Established Incontinence
• Bladder obstruction: spinal cord lesion, urethral stricture, urethral diverticulae,

urethral stones, benign prostatic hyperplasia, prostate cancer, cystocele, surgery
• Bladder incompetence: multiple vaginal deliveries, lower motor neuron lesion,
surgery
• Detrusor overactivity: Alzheimer's disease, stroke, multiple sclerosis, bladder
carcinoma, cystitis
• Detrusor underactivity: autonomic neuropathy (diabetes, vit b12 def), disk
compression, chronic outlet obstruction
• Detrusor-sphincter dyssnergia: voiding dysfunction of childhood, spinal cord
dysfuntion, brain lesion
Evaluation of Urinary Incontinence
• History: includes voiding diary

• Physical examination: includes cotton swab test, cough stress test,
perineal sensation and anal wink
• Investigations: Urinalysis, urine culture, BUN, Cr, postvoid residual
urine, renal ultrasound or urodynamic testing
Management
• General measures: educate patients that incontinence is not an inevitable condition of aging, limit fluid
intake 3-4 hours before sleep, drink 1.5 -2 L of fluid daily, limit caffeine intake, absorpent pads
• Behavioral bladder training
• Kegel's exercise
• Medications:
• Urge incontinence: oxybutynin 5 mg PO 2-3 times daily or tolterodine 2mg PO bid (CI: urinary retention,
prostatic hypertrophy, narrow angle-closure glaucome, blockage in the digestive tract , liver diseaseor
allergy)
• Stress incontinence: pseudoephedrine 60 mg PO q4-6 hours (CI: MI, bronchitis, angle-closure
glaucoma, renal failure), imipramine (70 mg PO OD)
• Surgery
• Occlusive devices
• Overflow incontinence: indwelling catheterization, double-voiding, valsalva manoeuvre, application of
suprapubic pressure while voiding
13
Presentation title
Kegel's
Exercises
Case 1
A 55-year-old man presents with an inability to void and intermittent leakage of

urine. The patient denies any known triggers that cause urinary leakage. His history
is significant for benign prostatic hyperplasia. The patient is on a maximum dose of
tamsulosin. He denies any medication allergies, other medical conditions, history
of surgeries, or traumas. Vital signs are normal. Physical examination reveals a
distended bladder and suprapubic tenderness. Which of the following is the best
next step in management?
• Obtain a urine culture
• Urethral catheterization
• Prescribe an alpha-adrenergic agonist
• Suprapubic catheterization
Case 2
A clinician is seeing an 84-year-old man with dementia from a nursing home.

He is a poor historian. The nurse caring for him states that he is often found
wet with urine. The nurse states that he has no other medical conditions or
symptoms. His vital signs are within normal limits. Physical examination
reveals a pleasantly demented, frail older male who smells of urine. There is
no suprapubic tenderness. What is the next best step in the management of
this patient?
• Insertion of an indwelling Foley catheter

• Empiric treatment with antibiotics for 3 days
• Bladder scan
• Start the patient on oxybutynin Presentation title 16
Pelvic prolapse
• Laxities in the ligaments, fascia and muscles supporting the pelvic organs causing them to
sag or drop
• Prolapse or sagging of the vaginal walls allows the surrounding organs to protrude into
the vaginal space
Risk factors:
• Vaginal delivery
• Obesity
• Aging
• Surgery
• Chronic straining
18
Types of Prolapse
Clinical Presentation
• Pelvic fullness, pressure

• Sensation that organs are falling out
• Bulging organs on coughing or straining
• Urinary incontinence
• Urinary retention
• Constipation
• Dyspareunia
• Lower back pain (enteroceles)
Management
• Clinical diagnosis : pelvic
examination
• Treatment:
• Rule out vaginal cancer (if
ulcerations present)
• Kegel's exercises
• Pessary: need to be of correct
size and cleansed monthly
• Surgical repair
Pelvic Mass
Cervical cancer screening
Ovarian cancer screening
• Not recommended
• If high suspicion: Lesar-Trélat sign, genetic
susceptibility, family history of breast cancer, sister Mary
Joseph nodes: Transvaginal US
Endometrial Carcinoma screening
• Not routinely recommended

• Annual endometrial sampling starting at age 30-35 only for women at high-
risk (HNPCC (Hereditary Non-Polyposis Colorectal Cancer)/ Lynch II
syndrome)

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Urinary Incontinence

& Pelvic Prolapse

• Most common type in older adults

• Abrupt urine leakage after increase of intraabdominal

• Inability to get to the bathroom

• Second most common type in men

• Bladder obstruction: spinal cord lesion, urethral stricture, urethral diverticulae,

• History: includes voiding diary

A 55-year-old man presents with an inability to void and intermittent leakage of

A clinician is seeing an 84-year-old man with dementia from a nursing home.

• Insertion of an indwelling Foley catheter

• Pelvic fullness, pressure

• Not routinely recommended

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