Inkontinensia Uri ; Bahasannya dengan Skenario DUniversitas SriwijayaFakultas kedokteran

Pendidikan dokter UmumFerdi Stefiyan

Definisi Inkontinensia uri didefinisikan oleh International Continence Society sebagai keluarnya urin secara involunter.

Klasifikasi inkontinensia urin1. Transient inkontinensia uri2. Persisten inkontinensia uri

Stress incontinence Urge incontinence Mixed incontinence Overflow incontinence Functional incontinence

Etiologi1. Transient causes

1. D: Delirium or acute confusion

2. I: Infection (symptomatic UTI)

3. A: Atrophic vaginitis or urethritis

4. P: Pharmaceutical agents

5. P: Psychological disorders (depression, behavioral disturbances)

6. E: Excess urine output (due to excess fluid intake, alcoholic or caffeinated beverages, diuretics, peripheral edema, congestive heart failure, or metabolic disorders such as hyperglycemia or hypercalcemia)

7. R: Restricted mobility (limits ability to reach a bathroom in time)

8. S: Stool impaction

2. Neurological causes Cortical lesions (eg, from strokes, tumors, aneurysms, or hemorrhages) can lead to

inappropriate voiding secondary to depressed social awareness, decreased sensation, and/or inappropriate urethral sphincter relaxation.[22]

Spinal cord lesions can alter sympathetic and parasympathetic tone, resulting in urinary incontinence. Peripheral nerve disease such as diabetic peripheral neuropathy can cause urinary incontinence through a contractile dysfunction of the bladder.

Metastatic carcinoma can cause epidural spinal cord compression. S2-S5 nerve root injury (herniation) can cause bladder dysfunction. Cauda equina syndrome can develop in patients with a large centrally protruding disk. Hemi–cauda equina syndrome (from a herniated lumbar disk) can also manifest as urinary

incontinence. Multiple sclerosis should be considered in any patient without evidence of urinary tract

infection who has episodic or rapid onset of urinary symptoms. Urinary incontinence may occur by itself or may be accompanied by other vague neurological symptoms.

myelomeningocele may cause open bladder neck that results in severe intrinsic sphincter deficiency and urinary loss.

3. Pharmacologic causes

Medication may result in incontinence through the following mechanisms:

Drugs with anticholinergic properties or side effects (eg, antipsychotics, antidepressants) - Urinary retention and thus overflow incontinence

Alpha-adrenergic agonists - Urinary retention and thus overflow urinary incontinence Alpha-antagonist - Urethral relaxation Diuretics – Overwhelming of bladder capacity in elderly persons Calcium channel blockers - Decreased smooth muscle contractility in the bladder, causing urinary

retention with overflow incontinence Sedative-hypnotics - Immobility secondary to sedation, leading to functional incontinence Angiotensin-converting enzyme (ACE) inhibitors – Diuretic effect, as well as side effect of cough

with relaxation of pelvic floor musculature, can exacerbate incontinence Antiparkinson medications - Urinary urgency and constipation

Patofisiologi

Stress incontinence pathophysiology

During episodes of stress incontinence, peningkatan tekanan intra-abdominal (eg, from laughing, sneezing, coughing, climbing stairs) meningkatkan tekanan pada bladder. Penyebab utama inkontinensia tipe stress adalah karena impaired support from pelvic floor.penyebab paling sedikit intrinsic sphincter deficiency, usually secondary to pelvic surgeries. In either case, urethral sphincter function is impaired

Urge incontinence pathophysiology

Urge incontinence is involuntary urine loss associated with a feeling of urgency. The corresponding urodynamic term is detrusor overactivity. Urge incontinence may be a result of detrusor myopathy, neuropathy, or a combination of both.

Mixed incontinence pathophysiology

Mixed incontinence is urinary incontinence resulting from a combination of stress and urge incontinence. Although it is generally defined as detrusor overactivity and impaired urethral function, the actual pathophysiology of mixed urinary incontinence is still being investigated. While generally thought of as separate etiologies for incontinence, some indirect evidence may link these disorders in some instances. In mixed incontinence, the bladder outlet is weak and the detrusor is overactive.

Overflow incontinence pathophysiology

The major contributing factor to overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction.[2, 4] Impaired detrusor contractility is typically neurogenic in nature; causes include diabetes mellitus, lumbosacral nerve disease from tumors, meningomyelocele, MS, prolapsed intravertebral disks, and high spinal cord injuries. Less common causes of overflow incontinence include AIDS, genital herpes affecting the perineal area, and neurosyphilis.

Common causes of bladder outlet obstruction in men include benign prostatic hyperplasia (BPH), vesical neck contracture, and urethral strictures. In women, urethral obstruction after anti-incontinence surgery such as a sling or bladder neck suspension can result in iatrogenically induced overflow incontinence.

Functional incontinence

Functional incontinence is seen in patients with normal voiding systems but who have difficulty reaching the toilet because of physical or psychological impediments. The etiology of the incontinence may be iatrogenic, environmental, situational, or disease related.

How to diagnosis

1. Anamnesis

Severity and quantity of urine lost and frequency of incontinence episodes Duration of the complaint and whether problems have been worsening Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency,

sound of running water, sexual activity/orgasm) Constant versus intermittent urine loss and provocation by minimal increases in intra-

abdominal pressure, such as movement, changes in position, and incontinence with an empty bladder

Associated frequency, urgency, dysuria, pain with a full bladder, and history of urinary tract infections (UTIs)

Concomitant symptoms of fecal incontinence or pelvic organ prolapsed Coexistent complicating or exacerbating medical problems Obstetrical history, including difficult deliveries, grand multiparity, forceps use,

obstetrical lacerations, and large babies

History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures

Other urologic procedures Spinal and CNS surgery Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and

recreational factors causing severe or repetitive increases in intra-abdominal pressure Medications

2. Pemeriksaan fisik

height, weight, blood pressure, and pulse recorded measure the volume voided, and then catheterize the patient to obtain a postvoid

residual measurement Cardiac and pulmonary evaluation The abdomen should be examined for surgical scars, hernias, masses, organomegaly,

and distended bladder after voiding. The back should be inspected for deformity, dimpling, or hair tuft and the flank and

costovertebral angles should be palpated Neuorological examination

- Sensation of the perineum and perianal area should be tested with a soft touch and light prick

- Using a cotton swab, the anal wink pelvic floor reflex can be elicited by stroking laterally to the anal canal

- The bulbocavernosus reflex can be elicited by gently tapping the clitoris with a cotton swab in the female patient.

Pelvic floor examination inspection of the external genitalia and urethral meatus Evidence of atrophy, such as pallor and thinness of tissue, may indicate estrogen

deficiency A red, fleshy lesion of the posterior urethra, a caruncle, may be another indicator of

urogenital hypoestrogenism

3. Pemeriksaan urinalisisUrinary tract infection (UTI) can cause irritative voiding symptoms and urge incontinence. UTI can cause or contribute to urinary incontinence disorders in several ways. Local inflammation can serve as a bladder irritant, causing uninhibited bladder contractions.

4. Urine cytologyPatients with carcinoma in situ of the urinary bladder experience urinary frequency and urgency and show evidence of microscopic hematuria

5. Pemeriksaan fungsi ginjalBUN and creatinine levels should be checked when poor renal function, obstructed ureters, or urinary retention is suggested. This is especially important in the case of a stage III or stage IV cystocele.

6. Pad test A pad test is a useful adjunct to the patient's history and physical examination. The pad test is

an objective test that determines whether the fluid loss the patient is experiencing is in fact urine

7. Paper towel test A paper towel test provides a quick estimate of the degree of stress urine loss.[45] The patient

is asked to cough repetitively and forcefully with a paper towel held a short distance from the urethra.

8. Stress testing his test evaluates stress-induced leakage when the bladder is full.

9. PVR (postvoid residual volume)Measurement of postvoid residual urine volume, using either a bladder ultrasonography or urethral catheter, may be a part of the evaluation for urinary incontinence of patients with apparent failure to empty the bladder completely. If the PVR urine volume is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions cause urinary retention from overflow incontinence

Differential Diagnoses

Multiple Sclerosis Prostatitis Spinal Cord Neoplasms Spinal Cord Trauma and Related Diseases Spinal Epidural Abscess Urinary Obstruction Urinary Tract Infection in Females Urinary Tract Infection in Males Uterine Prolapse in Emergency Medicine Vaginitis in Emergency Medicine

Treatment

Treatment is keyed to the type of incontinence. The usual approaches are as follows:

Stress incontinence - Surgery, pelvic floor physiotherapy, anti-incontinence devices, and medication

Urge incontinence - Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention

Mixed incontinence - Anticholinergic drugs and surgery Overflow incontinence - Catheterization regimen or diversion Functional incontinence - Treatment of the underlying cause

Pharmacologic Therapy

Medication may have some benefit in stress and urge urinary incontinence. These agents are not uniformly effective, and adverse effects may limit their long-term use. Medications used for treatment of urinary incontinence include the following:

Alpha-adrenergic agonists : such as midodrine or pseudoephedrine , may improve symptoms of mild stress incontinence by increasing intrinsic urethral tone due to these agents’ effects on the urethral sphincter. pseudoephedrine dosing is 60 mg qid, or 120 mg bid with the extended-release form.

Anticholinergic agents : The clinical and urodynamic effects of blocking cholinergic receptors in the bladder. Propantheline bromide is an anticholinergic agent that has been used to treat detrusor overactivity. Propantheline commonly is prescribed in dosages of 15-30 mg every 4-6 hours

Antispasmodic drugs : Oxybutynin is the prototype drug in this class. The typical dosage is 5 mg 2-4 times per day

Tricyclic antidepressants : used in the treatment of stress incontinence. Imipramine (Tofranil) is the most widely used tricyclic for urologic indications. It facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. Adult dosing is 10-50 mg 1 to 3 times daily, with a range of 25-100 mg qd.

Estrogen : Estrogen therapy may have several positive effects in patients with stress incontinence who are estrogen deficien

Alpha-adrenergic blockers Botulinum toxin

HUBUNGAN DENGAN SKENARIO D

Penyakit yang diderita oleh mrs.X adalah Inkontinensia Uri, obesitas, hipertensi sistolik, osteoporosis dan atrial fibrilasi

Faktor yang mendukung penegakkan diagnosis Inkontinensia uri dalam skenario :- she was unable to reach a bathroom in time to prevent loss of urine- usia tua (faktor risiko )- menopause (menyebabkan penurunan kadar estrogen)- obesitas (meningkatkan tekanan intra abdominal)- pemakaian kaptopril (obat2an yg dapat mengakibatkan inkontinensia uri)

faktor yang mendukung penegakkan diagnosis obesitas :- BMI : BB(kg)/TB(m)2

Faktor yang mendukung penegakkan hipertensi sistolik :- Tekanan darah sistolik yang melebihi 140 dan tekanan diastolic yang kurang dari 90

Faktor yang mendukung penegakkan osteoporosis :- Lumbal densitometry = -3- Femoral densitometry = -2,7

Faktor yang mendukung penegakkan diagnosis atrial fibrilasi :- Pulse deficit antara apex kordis-a.radialis

Tipe inkontinensia uri didalam skenario :

-TIPE CAMPURAN

Faktor yang mendukung penentuan tipe campuran

- Adanya tipe urgensi :

1. Ketidakmampuan menahan pengeluaran urin

2. Usia lanjut ( bladder overactivity)

- Adanya tipe stress :

1. Menopause (hypoestrogen)

2. Pemakaian kaptopril (memicu tipe stress dengan batuk)

Tata laksana kasus :

- Tatalaksana inkontinensia

(lihat treatment dan pharmacologic theraphy diatas)

- Tatalaksana obesitas :

1. diet dan olahraga

- tatalaksana osteoporosis :

1. increasing weight-bearing and muscle-strengthening exercise

2. calcium : 1200-1500 mg of calcium

3. vitamin D : 800 IU

4. anti-osteoporotic medication :

bisphosphonates ,

parathyroid hormone (PTH): 20 mcg SC qDay into thigh or abdominal wall

raloxifene

estrogen.

5. Physical dan ocupatinal theraphy

6. Aerobic low-impact exercises, such as walking and bicycling

- Tatalaksana atrial fibrilasi :

1. CCB (calcium chanel blocker) :

diltiazem : 0.25 mg/kg (adult dose is usually 20 mg) direct IV over 2 minutes, THEN After 15 minutes: 0.35 mg/kg (adult dose is usually 25 mg) direct IV if 1st dose tolerated but response inadequate

verapamil : Maintenance Dose:  80-320 mg PO q12hr  2. Anticoagulation : ex. Aspirin, warfarin

3. Antithrombotic

4. Antiarrhythmic

- Tatalaksana hipertensi :

5. Penggantian obat ACE-I menjadi ARB (angiotensin2 reseptor blocker) contoh

Valsartan : dosis 80-160mg tablet sekali sehari, namu perhatikan tekanan darah pasien

jika telah diberikan CCB untuk aritmia, karena keduanya merupakan obat

antihipertensive.

“SORY YE TELAT NGUMPULNYO, KALO ADA KEKURANGAN ATO KESALAHAN DALAM PENULISAN HARAP DIKASIH TAU YE NANTI DIBENERI LAGI, SEMOGA BERMANFAAT DUNIA AKHIRAT”.