Urinary Incontinence Naturopathic Treatment

Reclaim Bladder Control

Urinary Incontinence affects people world wide, and can cause people to avoid social contact and not want to deal with others. This ebook by Alice Benton gives you the best way to avoid the embarrassment and discomfort that is associated with urinary incontinence. Why would you want to deal with annoyance of being unable to control your own bladder when you could find a far better way to help heal yourself? This ebook gives you natural methods of taking back control of your bladder, without having to worry about the dangers associated with surgery or medications that can cause harm to your kidneys. You can learn the best natural way to heal yourself from urinary incontinence and give yourself the life that you deserve; start living the way that you deserve to live, without all of the problems that come with urinary incontinence. Take your life back now!

Reclaim Bladder Control Overview

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Incidence Of Urinary Incontinence

The incidence of early poststroke urinary incontinence varies from 57-83 (11,26,31,32). These studies suggest that incontinence may be transitory and related to the patient's immobility and altered mental status. In a study of 151 patients, Borrie et al. (26) reported an initial incontinence rate of 60 . After 1 mo, this incidence was reduced to 29 at 1 mo. Additionally, 66 of patients with mild incontinence at 1 mo regained continence at 3 mo. Brocklehurst et al. (32) found an initial incontinence rate of 39 . They demonstrated that by 2 mo 55 were continent and at 6 mo this increased to 80 . However, the 2 and 3 yr follow-up data demonstrate an incidence higher than the general population. Improvement with time is impressive and should be relayed to the patient and family. Communicating this information could improve the patient's self-image and be an encouraging factor for the future.

Clinical experience with intravesical TRPV1 agonists in idiopathic forms of overactive bladder

Idiopathic overactive bladder is a chronic condition which is probably the leading cause of high urinary frequency, urge sensation to urinate and urge incontinence among the adult population 30 . At urodynamic testing, the bladder of many of these patients will display involuntary contractions during filling 30 . In spite of the considerable efforts to clarify the origin of such abnormal smooth muscle activity, the pathologic mechanisms underlying idiopathic overactive bladder remain unknown. In a recent study we applied intravesically RTX to a small group of these patients 31 . The objectives were to clarify the role of C-fiber input in the emergence of urinary symptoms and, at the same time, investigate the potential therapeutic role of TRPV1 agonists in idiopathic overactive bladder. Eleven females and two males with a mean age of 50 years and urinary symptoms for more than 1 year, all presenting involuntary bladder smooth muscle contractions during urodynamic testing, were treated...

Abnormalities Of Fillingstorage And Emptying Overview

This may occur with neurologic disease or injury, surgical or other mechanical trauma, or aging. Assuming the bladder neck and proximal urethra are competent at rest, lack of a stable suburethral supportive layer (see ref. 5) seems a plausible explanation of the primary factor responsible for genuine stress urinary incontinence in the female. Vesicourethral suspension (Stress urinary incontinence) Nonsurgical mechanical compression Periurethral polytef injection Periurethral collagen injection Occlusive and supportive devices urethral plugs Surgical mechanical compression Sling procedures Closure of the bladder outlet Artificial urinary sphincter Bladder outlet reconstruction Circumventing the problem Antidiuretic hormone-like agents Diuretics

Treatment of Early Localized Prostate Cancer

Patients are significantly more likely than radiotherapy patients to experience urinary incontinence (39 to 49 vs. 6 to 7 ) and erectile dysfunction (80 to 91 vs. 41 to 55 ), whereas radiotherapy patients are more likely to experience bowel urgency (30 to 35 vs. 6 to 7 ) 6 . Late side effects are generally more dose- limiting than acute effects because they can have a significant impact on quality of life and are often permanent. They may appear between 6 months and 2 years after radiotherapy, although sometimes acute effects do not settle and can continue as late effects. Late urogenital toxicity manifests as chronic cystitis, urinary incontinence (2 to 11 ) and erectile dysfunction (10 to 40 ). Late damage to the rectum results in late radiation proctitis, rectal ulceration, or stricture severe damage occasionally necessitates a defunctioning colos-tomy (risk < 1 ). Permanent implants may be used alone as monotherapy for localized prostate cancer or, less commonly, as a boost in...

Classification Of Voiding Dysfunction

These two concepts can be combined so that one can imagine that a patient could present with urinary incontinence (failure to store) secondary to bladder overactivity or bladder outlet underactivity. Similarly a patient with urinary retention (failure to empty) might have an underactive or hypocontractile bladder or an overactive or obstructing outlet. Failure to empty and failure to store as well as bladder and outlet dysfunction are not mutually exclusive conditions and can exist in multiple combinations. These very simple concepts can be applied to all types of voiding dysfunction. Therefore when evaluating voiding dysfunction, from history and physical examination to simple and comprehensive testing, keeping these concepts in mind can greatly facilitate the process.

Pathophysiology Of Incontinence

Frontal cortical lesions from a CVA may affect a patient's higher cognitive functions. This may be reflected by the patient's inability to suppress a reflex detrusor contraction resulting in urinary incontinence. This incontinence can be owing to to urinary incontinence. However, it must be emphasized that incontinence in the CYA patient merits evaluation to determine its etiology.

Hemispheric Dominance And Voiding Dysfunction

Hemispheric dominance has been well-established for language, whereas the temporal lobe has been linked to musical aptitude. Patients who have experienced a right hemispheric CVA have been known to incur more sexual dysfunction (38). In 1980, Khan et al. (14) postulated that patients after nondominant CVAs were less likely to have urinary incontinence. If so, what effects would a dominant hemispheric stroke have on voiding

The Role of Radical Radiotherapy

Patients should be counseled appropriately. Prostatectomy patients are significantly more likely than radiotherapy patients to experience urinary incontinence (39 to 49 vs. 6 to 7 ) and erectile dysfunction (80 to 91 vs. 41 to 55 ), whereas radiotherapy patients are more likely to experience bowel urgency (30 to 35 vs. 6 to 7 ) 6 .

Prostate Brachytherapy

Permanent implants may be used alone as monotherapy for localized prostate cancer or, less commonly, as a boost in combination with EBRT. Patient selection is extremely important for two reasons (1) to identify patients who are likely to have a good outcome in terms of biochemical disease free survival, and (2) to identify patients who will have a good functional outcome. Patients who are likely to have a good outcome from brachytherapy alone have an initial PSA level < 10ng mL, Gleason score < 6, and low-volume disease with a low risk of extracapsular spread (stage T1 T2). If the prostate is large (> 50cm3), the pubic rami may shield part of the gland that cannot be adequately implanted these patients also need a large number of seeds and are at increased risk of morbidity. If otherwise suitable, neoadju-vant hormone treatment with a luteinizing hormone-releasing hormone (LHRH) analogue for 3 months can lead to a reduction in prostate volume of > 30 . Brachytherapy should be...

Specific Therapies Aimed at the Underlying Pathophysiology

Although the underlying pathophysiology of lower urinary tract symptoms is best determined by urodynamic studies, many patients have other contributing factors and or comorbidities that should be addressed to effect successful treatment. For example, urodynamic study in a women with urinary incontinence may disclose detrusor-external sphincter dyssynergia which could be managed with anticholinergics and intermittent self catheterization, but spasticity of the hip adductors and poor hand function prevent her from catheterizing through the urethra. A practical solution is to create a continent abdominal stoma that the patient can catheterize without even having to transfer.

Detrusor Hyperreflexia with Vesical Neck Prostatic Urethral Obstruction

Hyperreflexia (owing to multiple sclerosis) from detrusor instability (owing to prostatic obstruction). Logic dictates that detrusor overactivity is more likely to be because of multiple sclerosis if the patient is unaware of the involuntary detrusor contractions, cannot abort them, and is incontinent. Our experience defies this logic, and we do not believe that we can reliably make the necessary. The practical consequence of this is that we are unable to predict whether or not a man will be incontinent after transurethral incision or resection. Accordingly, if this form of therapy is chosen, it must be done so with informed consent and contingency plans for managing postoperative urinary incontinence because of persistent detrusor overactivity.

The choice to use hormoneestrogen therapy

If, after appropriate counseling of risks and benefits, a woman still wishes EPT ET, many experts, such as the NAMS panel, recommend the lowest dose of hormone sufficient to control symptoms for the briefest duration possible.56 HT is not an effective treatment for major depression in menopausal women. Clinical trials do not support the benefit of estrogen on urinary incontinence, although anecdotally some women report benefit. Although there are no data to support this recommendation, some experts suggest that women use a different estrogen progestin formulation, a lower dosage, or another route of administration from that used in the WHI trial. However, no studies confirm that there is less risk with this approach. Table 10.7 presents the

Differential Diagnostic Import of the Characteristic Clinical Course of AD

Some entities characterized by dementia, or in which dementia may occur, differ strikingly from the characteristic FAST progression of AD 57,86 . A few examples, which are familiar to all clinicians with a knowledge of brain disease, are stroke and normal pressure hydrocephalus (NPH). For example, a patient may have a stroke and the stroke may result in urinary incontinence. This urinary incontinence may be the only clinically manifest sequela of the cerebrovascular accident (CVA). Alternatively, the CVA with resultant urinary incontinence may also be accompanied by dementia. When this dementia occurs, it may be of any magnitude. For example, the dementia may be of sufficient magnitude to interfere with executive functions, such as organizational skills, and the ability to manage instrumental activities, such as management of personal finances, but not interfere with the ability to choose proper clothing, to put on clothing independently, to bathe without assistance, to toilet without...

Anatomy and Pathogenesis of the Urethral Injury

Tion injury of the rectum is critical to identify but rarely seen with pelvic fracture trauma 17 . The life-threatening injuries take precedence in diagnosis and management over the urethral injury, but in those patients who survive, the urethral injury will be the source of chronic complex disability and morbidity. Urinary incontinence in the male depends on the bladder neck proximally and the external sphincter distally. The distal external sphincter mechanism may be destroyed by this posterior urethral injury or during subsequent reconstruction and continence will, therefore, be dependent on bladder neck function alone. Most men, however, are continent following repair of this injury and will reveal a closed bladder neck on preope-rative cystography and cystoscopy. A few patients will be noted to have a persistently open, funneled bladder neck or a bladder neck quadrant scar seen on transvesical cystoscopy, which support the potential of a concomitant bladder neck injury.

Pharmacological Management Estrogens

Since the majority of women with stress incontinence are perimeno-pausal or postmenopausal, restoring the tissue integrity of the urethral, bladder neck, and vaginal epithelium with the use of estrogen therapy serves as a fundamental adjuvant to the other management options available for urinary incontinence. Clinical studies have revealed its subjective usefulness especially in conjunction with behavioral interventions and pharmacologic agents (22). By promoting upregulation of neurotransmitter receptor function, estrogen therapy may augment the effect of anticholinergics and alpha-adrenergic agonist (23). Therefore, it is recommended as baseline therapy for all forms of urinary incontinence and is usually initiated as a first-line intervention following the detection of estrogen deficiency on the pelvic examination performed on the initial physician visit. For patients with long-standing estrogen deficiency, symptoms of stress incontinence may not change with replacement therapy,...

Neuropsychological And Instrumental Characteristics Of Vascular Dementia Vd

VD may be the consequence of a large brain infarction resulting from the occlusion of a major cerebral artery, which may occur suddenly and be followed by gross changes in behaviour (e.g. aphasia, apraxia, agnosia) as well as impairment of sensory and motor performance. The type of impairment may vary due to the specific vessel affected. In other cases VD may be due to multiple minor infarctions or haemorrhages, mainly in subcortical areas, affecting a variety of cognitive functions involving mental tempo, attention, memory and mood, and possibly producing gait disturbance, urinary incontinence and pyramidal signs. Third, VD can be caused by thickening of blood vessel walls associated with cerebral amyloid angiopathy, hyalinosis and sclerotic factors. These processes are found in small arteries and arterioles consequently, this type of VD is a small-vessel disease. Long penetrating vessels supplying deep white matter and located in watershed areas are thought to be especially...

Incidence Of Incontinence After Prostatectomy

The incidence of urinary incontinence is approximately 1-3 in patients undergoing transurethral resection of the prostate or open prostatectomy for benign disease (3,4). The incidence of incontinence following radical prostatectomy has been reported to range from 2.5 (5) to 87 (6). This wide discrepancy is a result of several factors. The definition of incontinence varies widely among series, ranging from any degree of wetting or restricted to total incontinence. In addition, the method of data acquisition has a significant effect on reported rates of incontinence. Studies that involve patient questionnaires and or direct patient input generally have higher rates of incontinence than data obtained by chart review or physician interview. In a sample of Medicare patients undergoing radical prostatectomy, 47 had leakage of urine daily, and 6 needed surgical intervention (7). Incontinence after prostatectomy has a significant negative impact on a patient's quality of life. Herr discovered...

Etiology Of Incontinence Following Prostatectomy

When considering the etiology of urinary incontinence, it is essential to identify that leakage may occur as a result of an abnormality of bladder and or sphincteric function. Urodynamic studies provide information concerning the relative contributions of bladder and or sphincteric dysfunction in patients with incontinence after prostatectomy.

Medications to Increase Outlet Resistance

Alpha adrenergic agonists have been used to increase bladder outlet resistance. Their use is based on studies that show an abundance of alpha-adrenergic receptors at the bladder neck and proximal urethra (103,104). Ephedrine is a treatment used for stress urinary incontinence (SUI). It enhances the release of norepinephrine from sympathetic neurons and stimulates directly the alpha and beta-adrenergic receptors (105). The usual dose is 25-50 mg QID and tachyphylaxis has been reported. Pseudophedrine, a steriosomer of ephedrine, can also be used at a dose of 30-60 mg QID. The use of these drugs for severe SUI is limited and may only be of benefit for minimal wetting (106,107). Phenylpropanoamine (PPA) has the same pharmacologic properties as ephedrine and has been used for SUI at a dosage of 50 mg BID. The side effects of these medications include anxiety, headaches, tremor, weakness, palpitations, cardiac arrhythmias, hypertension, and respiratory difficulties. Thus, these medications...

Treatment of Detrusor Instability with Electrical Stimulation

There are an estimated 13 million Americans who suffer from incontinence. Urge incontinence is conservatively estimated to account for 40 of all urinary incontinence patients (1). Of this population, two-thirds suffer from chronic or established incontinence. Yet patients diagnosed with urinary incontinence owing to detrusor instability have had limited treatment options. Nonsurgical interventions, including diet modification, behavioral techniques (pelvic muscle exercises, biofeedback, timed voiding), drug therapies, and containment devices are commonly used to treat the condition. If these therapies are unsuccessful or unsatisfactory to the patient, surgical interventions such as bladder denervation procedures, augmentation cystoplasty, or urinary diversion may be considered. These alternatives have their own set of risks and consequences, making them unattractive to the majority of patients. According to the 1996 National Association for Continence (NAFC) survey of 2,000...

Control of bladder pain and overactivity

Within the sacral spinal cord and initiated by activation of capsaicin-sensitive bladder C-fibers, but this pathway is usually inhibited in adult mammals unless there are pathologies such as inflammation or spinal transection 59 . Thus, under patho-physiological conditions, bladder contractions triggered by capsaicin-sensitive C-fibers and mediated by the sacral reflex are involuntary and can be triggered by small volumes of urine, characteristics that generate an urge to urinate, urinary incontinence and a high urinary frequency. Moreover, these C-fiber-initiated contractions lack coordination with urethral sphincter muscle relaxation and can lead to increased intravesicular pressure and potential harm to the upper urinary tract 58 . Interestingly, TRPV1 expression occurs not only in nociceptive fibers that form close contacts with bladder epithelial (uroepithelial) cells but also in uroepithelial cells themselves 60 this suggests that these cells may work in concert with underlying...

Rationale for intravesical application of TRPV1 agonists

Clinical interest on TRPV1 agonists for the treatment of bladder diseases started with the observation that reflex bladder contractions triggered by bladder filling in intact or spinally transected cats had distinct sensibilities to systemic capsaicin. In spinally transected cats, but not in intact cats, reflex bladder contractions were completely suppressed by the neurotoxin 1 . The identification of two neuronal pathways involved in micturition control offered a solid explanation to this finding. A long pathway passing through the pontine micturition center and initiated in AS-, capsaicin-resistant, bladder sensory fibers controls reflex bladder contractions in mammals with intact spinal cord. A short neuronal pathway entirely lodged in the sacral spinal cord and initiated in type C, capsaicin-sensitive, bladder sensory fibers, usually inactive in adult mammals, is enhanced after spinalization and replaces the supra-spinal reflex 1 . Bladder contractions triggered by the sacral...

Clinical experience with intravesical TRPV1 agonists in neurogenic forms of bladder overactivity

A randomized, controlled study comparing capsaicin with 30 ethanol confirmed the superiority of the TRPV1 agonist against the vehicle solution 17 . Twenty cases were randomized to receive either capsaicin or 30 ethanol. All patients treated with capsaicin reported improvement of urge sensation and urinary incontinence whereas only one ethanol-treated patient noticed some improvement. On cys-tometry, only capsaicin-treated patients had an increase in the bladder volume to micturition 17 . The first non-controlled trials with RTX included 54 patients, most of them with incomplete spinal cord lesions 18-22 in which different RTX concentrations were tested. Vehicle solutions included 10 ethanol 18, 21, 22 or saline 19, 20 . RTX instillation in patients with preserved bladder sensation did not cause severe supra-pubic burning pain. In addition, also in contrast with capsaicin did RTX not exacerbate the urinary symptoms transiently. In most studies 18-21 , 50-100 nM RTX brought an immediate...

Chapter Summary continued

Neural tube defects (risk factor folate deficiency) are the most common developmental CNS abnormalities and can take several forms, including anencephaly (no cranial vault, death in infancy), spina bifida occulta (bony defect of the vertebral arch), meningocele (bony defect with outpouching of meninges), meningomyelocele (with outpouching meninges, spinal cord, and spinal roots), and myelocele (complete exposure of spinal cord). Paraplegia and urinary incontinence may complicate the more severe spinal cord defects.

Indications of upper tract disease and need for hospitalization

C., Valkenburg, H. and Riphagen, F. Urinary incontinence in women from 35 to 79 years of age prevalence and consequences. Eur. J. Obstet. Gynecol. Reprod. Biol. 1992 43 229-34. 21 Burgio, K. L., Matthews, K.A. and Engel, B. T. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J. Urol. 1991 146 1255-9. 22 Grimby, A., Milsom, I., Molander, U., Wiklund, I. and Ekelund, P. The influence of urinary incontinence on the quality of life of elderly women. Age Ageing 1993 22 82-9. 23 Simeonova, Z., Milsom, I., Kullendorff, A. M., Molander, U. and Bengtsson, C. The prevalence of urinary incontinence and its influence on the quality of life in women from an urban Swedish population. Acta Obstet. Gynecol. Scand. 1999 78 546-51. 24 Seim, A., Sandvik, H., Hermstad, R. and Hunskaar, S. Female urinary incontinence - consultation behaviour and patient experiences an epidemiological survey in a Norwegian community. Fam. Pract. 1995...

Acute Management of Posterior Urethral Trauma

Membranous Urethra

Strictures, erectile dysfunction, and (in some cases) urinary incontinence may be problems with lifelong ramifications for these patients. Additional traction obtained by applying additional weight to the transurethral catheter has been shown to produce pressure damage to the bladder neck and subsequently increase the risk of urinary incontinence. In addition, the traction may pull the prostatic gland into an

Sphincteric Incompetence

Doing Kegels With Catheter

Pelvic-floor muscle exercises called Kegel exercises can speed the recovery of continence following prostatectomy therefore, patients should be instructed and perform the exercises before prostatectomy (55). There are several studies which suggest the utility of electrical stimulation (56), behavior training (57), and biofeedback (58) in the management of incontinence after prostate surgery. Unfortunately, many of these studies contain only a small number of patients, and many patients still experience wetting requiring pad use even though considered improved. These conservative measures offer little promise in the correction of severe or total urinary incontinence. To date, the most commonly utilized injectable agent is collagen. Glutaraldehyde cross-linked bovine collagen (Contigen, CR Bard Co., Covington, GA) is both biocompatible and biodegradable. No inflammatory reaction or granuloma formation is elicited, and no cases of particle migration are identified (62). Shortliffe et al....

Longterm Urologic Management

Neurostimulation is a promising method currently under investigation using electrical stimulation to control micturition and urinary incontinence. This technique was initially introduced in the 1960s using implantable electrodes in the detrusor muscle (70). Both intradural and

Transurethral Resection of the Prostate and Open Prostatectomy

Prostatectomy

In many cases, prostatic hypertrophy extends beyond the verumonta-num (25,26) (Fig. 2). Thus, the verumontanum remains a critical landmark when performing a transurethral prostatectomy. If the resection is carried past the vera, violation of the distal urethral sphincter will occur, resulting in postoperative incontinence. The distal limit of resection should be at the verumontanum, even if a small rim of adenoma is left behind. This small amount of adenoma may provide some protection against stress urinary incontinence (27). Care should be taken to minimize bleeding to insure adequate visualization, and cautery should be employed judiciously in this area to avoid thermal muscle damage. Most frequently damage to the distal urethral sphincter occurs anteriorly between the 10 and 2 o'clock positions (16).

Inflammatory Dermatoses Eczema

Desquamative Inflammatory Vaginitis

This is the commonest form of vulvar eczema in clinical practice. This is usually seen in the elderly and is often because of urinary incontinence. It is also more likely to occur in fair-skinned individuals who have sensitive skin at other sites as well (Fig. 1). Figure 1 (See color insert) Irritant eczema. Glazed erythema of the most exposed areas in a patient with urinary incontinence. Figure 1 (See color insert) Irritant eczema. Glazed erythema of the most exposed areas in a patient with urinary incontinence.

Obstetrics and Gynecology

The answer is b. (Fauci, 14 e, p 2102.) The patient is presenting with symptoms of normal menopause, which may include hot flashes, urinary frequency, dysuria, urinary incontinence, vaginal dryness, vaginal itchiness, and dyspareunia. Patients also have amenorrhea. Patients may become anxious or depressed during this time, but there is no evidence that personality or mood changes are due to menopause.

Perimenopause and menopause

Estrogen-sensitive tissues in the urogenital tract atrophy, resulting in vaginal dryness, thinning, and decreased elasticity. Subsequently, women often experience dyspareunia and vaginismus. Decreased estrogen levels affect the urethra and bladder, and altered vaginal flora and acidity can cause urethral irritation, urinary tract infections, and urinary incontinence.5,6

Standard External Beam Radiotherapy EBRT

Scan Bladder Cancer

Late side effects are generally more dose-limitingthan acute effects because they can have a significant impact on quality of life and are often permanent. They may appear between 6 months and 2 years after radiotherapy, although sometimes acute effects do not settle and can continue as late effects. Late urogenital toxicity manifests as chronic cystitis, urinary incontinence (2 to 11 ) and erectile dysfunction (10 to 40 ). Late damage to the rectum results in late radiation proctitis, rectal ulceration, or stricture severe damage occasionally necessitates a defunctioning colostomy (risk < 1 ).

Other possible applications of intravesical TRPV1 agonists

Trpv1 The Spinal Cord

Findings of several clinical trials in which TRPV1 agonists have been used intraves-ically show that desensitization of bladder sensory innervation may have a place in the treatment of urge incontinence, high urinary frequency and bladder pain. In addition, the same clinical trials gave an important contribution to the pathophysi-ology of the overactive bladder by confirming the pivotal role of sensory input conveyed in capsaicin-sensitive fibers to this condition. At the moment RTX seems the ideal TRPV1 agonist for clinical use. It is not harmful to the bladder mucosa and its instillation does not evoke significant bladder pain. However, it is probable that future TRPV1 agonists still to be developed will prove even more effective than RTX. degree of bladder filling and urge sensation to urinate looks like an indispensable step. Such studies may, additionally, uncover appropriate receptor antagonists for clinical use. At present the most obvious receptors to be studied are TRPV1 and...

Serge Peter Marinkovic MD and Gopal H Badlani MD

Of the Lower Urinary Tract and the Pontine Micturition Center (PMC) Incidence of Urinary Incontinence Pathophysiology of Incontinence Early Presentation Late Presentation Urodynamics Studies Hemispheric Dominance Technical Difficulties Interpretation of the Study Specific Situations Medical and Surgical Management Urinary Retention in Women Urinary Incontinence in Men

Overflow Incontinence After Lefort Surgery

The answer is b. (Scott, 8 e, pp 768-770.) Stress incontinence is the involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. The most common cause of urinary incontinence is incompetence of the urethral sphincter, termed genuine stress incontinence. The other major cause of incontinence is unstable bladder. An unstable bladder is the occurrence of involuntary, uninhibited detrusor contractions of greater than 15 cmH2O with simultaneous urethral relaxation. Up to approximately 60 of patients presenting with incontinence may have unstable bladder. Other causes of urinary incontinence are less common and include overflow secondary to urinary retention, congenital abnormalities, infections, fistulas, detrusor dyssyner-gia, and urethral diverticula. Detrusor dyssynergia implies that when the patient has an uninhibited detrusor contraction, there is simultaneous contraction of the urethral or periurethral striated...

E Urethral Pressure Profile Overview

Sufficient urethral pressure is mandatory for the maintenance of urinary incontinence. Urethral profile measurement (or urethral profilometry) is a technique used to record the intraluminal pressure changes within the entire length of the urethra. A satisfactory evaluation of urethral function can be made by a standard filling voiding bladder urodynamic study, such that urethral closure mechanism is considered adequate if no incontinence is demonstrated and inadequate if there is obvious stress leakage. Demonstration of urinary stress leakage therefore represents a direct assessment of urinary incontinence, while urethral pressure profilometry (UPP) is a less direct method.

Items 415 through 416

A 61-year-old man develops progressive cramping of his legs and pins and needles sensations in his feet over the course of a year. He consulted a physician when he noticed the paresthesias in his hands and unsteadiness of his gait. The patient's family reports that he has had some urinary incontinence, but was too embarrassed to report it. On examination, the patient has a spastic paraparesis with severe disturbance of position and vibration sense in his legs. Despite obvious spasticity in the legs, the deep tendon reflexes are absent at the knees and ankles. Peripheral blood smear reveals hypersegmented polymor-phonuclear leukocytes. Select the nutritional deficiency that is most likely responsible.

Incising the Bulbocavernosus Muscle

The bulbocavernosus muscle is split down the middle and the urethral bulbus is laid open in the area of the stricture. Although the urethral injury is rarely the main problem of these often multiple and severely traumatized patients, consequences of the urethral trauma such as urethral strictures, erectile dysfunction, and sometimes urinary incontinence are potential problems with lifelong ramifications. The stricture may be localized using a 20-Fr curved metal probe or with a flexible cystoscope (O Fig. 14.5).

Complications

The morbidity of radical prostatectomy today relates principally to erectile dysfunction, but also urinary incontinence. Uncontrolled or unrecognized hemorrhage can be life threatening and can lead to local or systemic complications.Anastomotic stricture can develop in 2 to 20 of patients, and may contribute to difficulties with voiding and urinary control. Rarely, obliteration or distraction at the site of the anastomosis requires more complex procedures and reconstruction. Other significant complications may include infection, lymphatic leak and rarely rectal injury, deep venous thrombosts, and pulmonary embolism.

Urodynamics Studies

Electromyograms performed in the majority of poststroke patients reveal uninhibited relaxation of the external sphincter during or preceding detrusor contractions with resultant urinary incontinence (15). Interestingly, detrusor sphincter dyssynergia (DSD) is uncommon in the poststroke period (13,35). However, pseudodyssynergia, demonstrated by the voluntary contraction of the external sphincter during an involuntary detrusor contraction, may be more commonly observed in the recovery phase and should not be misinterpreted as DSD (36,37). Because of these confounding clinical possibilities, we recommend that there be close supervision of all urodynamic data and clinical symptoms by the urologist during a urodynamic study.

History

Diagnosis largely depends on the history of symptoms. The elderly have been known to underreport their problems, especially when it is related to urinary incontinence. Interviewing the patient may not provide you with sufficient information on which to base a diagnosis. This is often compounded in those patients with dominant hemispheric CYAs with aphasia and those with dementia. Interviewing the caregiver (spouse, relative, or nurse's aide) may be necessary to provide additional information. A questionnaire given to the family, along with a voiding chart that is brought back on the second visit, is very helpful to assess ingested fluid and functional bladder capacity. The first visit is used

Urinary Continence

Urinary incontinence following radical prostatectomy is far less common than erectile dysfunction, but when present may have significant implications for the patient. Its true incidence varies according to its definition. Many patients will be continent when the catheter is removed, and among the remainder it may take up to 2 years for continence to be re-established. Occasional patients suffer persistent, troublesome or severe incontinence. For these individuals placement of an artificial urinary sphincter can restore urinary control and quality of life.

Urologic History

In order to document the nature and severity of urinary incontinence, a micturition diary and pad test are most useful. Conceptually, a pad test will provide a semi-objective measurement of urine loss over a given period of time. A number of pad tests have been described (28,29), but none has met with widespread approval, mainly because of poor test-retest validation (30,31). The simplest pad test can be done by having the patient change his or her pads every 6 h for one representative 24 h period while he or she is taking Pyridium. The amount of staining on the pads is a rough estimate of the severity of the incontinence. Alternatively, the pads can be weighed and the total weight, minus the weight of an unused pad recorded in the patient's record as an estimate of the volume of urine loss (1 gm approximately equals 1 mL of urine). We believe the pad test is very useful and recommend that, once completed, the patient simply be asked to state how representative it was. To this end,...

Agonism

The rationale for agonists as therapeutic agents is that the agonism leads to desen-sitization defunctionalization upon extended exposure. At least one mechanism for the desensitization defunctionalization is calcium toxicity to the nerve terminals, leading to suppression of C-fiber function for a prolonged period. One advantage is thus that limited treatment could have a long-term therapeutic effect. This expectation is realized with RTX treatment of the overactive bladder, where the effect of treatment persists for months 26 . A second advantage of desensitization defunc-tionalization is that it should extend to suppression of all responses mediated by the C-fiber neurons, whereas antagonism would be limited to those responses for which TRPV1 itself is involved.

Conduct Disorder

Discussion Enuresis is defined as urinary incontinence that is not due to a medical condition. It may be voluntary or involuntary and can occur during the day or, more commonly, at night. Differential diagnosis should include neurogenic bladder, medical conditions that cause polyuria or urgency (e.g., juvenile diabetes, spina bifida, seizure disorder), and acute UTI. Most children with the disorder become continent by adolescence.

Summary

The overall emphasis on successful management of female urinary incontinence begins with the combination of a thorough evaluation, selection of individualized behavior modifications, and possibly pharmacologic supplementation. Only for patients who have failed to achieve an acceptable continence status with nonsurgical management and who have maximized their potential for overall pelvic-floor rehabilitation and voiding function should reconstructive surgery then be considered. A recent report (1) of a 10-yr expected cost per elderly patient

Impact

The evidence for effective preventive strategies is very limited, but evidence for valuable and effective therapy is available. Although it affects millions ofwomen, urinary incontinence (UI) is still one of the more invisible complaints. Fewer than half of women with intermittent incontinence mention it to their physicians, and few physicians feel comfortable in methods of helping women manage this problem. Figure 21.1 Percentage of postmenopausal women with urinary incontinence. (Form Brown, J. S., Grad, D., Ouslander, J. G., et al. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet. Gynecol. 1999 94 66-70.) Figure 21.1 Percentage of postmenopausal women with urinary incontinence. (Form Brown, J. S., Grad, D., Ouslander, J. G., et al. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet. Gynecol. 1999 94 66-70.)