גישה למטופלת צעירה עם שלפוחית שתן רגיזה

Case
. מטופלת בשם גיל, בת 23, פרופיל 97. עובדת בעבודה משרדית
אשקנזיה, שוללת תרופות קבוע. שוללת חבלות קשות או היסטוריה .תאונת דרכים
שוללת ניתוחים והריונות
מתלוננת על דחיפות במתן שתן בכמות מספר טיפות בזמן שיעול או אימון גופני במשך שנתיים.
שוללת צריבת במתן שתן
מציינת עליה במתן שתן בזמן שכיס השתן ריק

בדיקה פיזיקלית תקינה
בדיקת שתן כללית תקין, תרבית שתן תקין.
STD תקין
נבדקה אצל רופא נשים – 23.03.19 – בדיקה תקינה

What is it?
URINARY INCONTINENCE
Neurogenic Bladder
ANXIETY
Nicturia
Enuresis

Definitions
Dysuria is a symptom of pain, discomfort, or burning when urinating
Nocturia is “the complaint that the individual has to wake at night one or more times for voiding (i.e. to urinate).”
Enuresis - is a repeated inability to control urination
URINARY INCONTINENCE - any uncontrolled leakage of urine
Neurogenic bladder is a condition that causes problems with bladder control
Guidelines for diagnosis and treatment of urinary incontinence were published in 2012 by the American Urological Association

Epidemiology
Urinary incontinence affects millions of persons, and the prevalence increases with age. Roughly 20 million American women and 6 million American men experience urinary incontinence at some time in their lives.1
Although women report incontinence more often than men,2,3 after 80 years of age, both sexes are affected equally.3 Women commonly experience stress or urge incontinence (i.e., overactive bladder), or a combination of the two, with approximately equal frequency.4 In men, prostate problems, which lead to overflow incontinence, and their treatments, which lead to stress incontinence, are the most common causes.5
1. Fantl AJ. Urinary incontinence in adults: acute and chronic management/urinary incontinence in adults. Guideline Panel Update. Rockville, Md.: U.S. Department of Health and Human Services, 1996; Agency for Health Care Policy and Research; Clinical Practice Guideline Number 2: AHCPR publication no. 96-0682.
2. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA. 2008;299(12):1446–1456.
3. Gibbs CF, Johnson TM II, Ouslander JG. Office management of geriatric urinary incontinence. Am J Med. 2007;120(3):211–220.
4. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46(4):473–480.
5. DuBeau CE, Kuchel GA, Johnson T II, Palmer MH, Wagg A; Fourth International Consultation on Incontinence. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourol Urodyn. 2010;29(1):165–178.

Classification
Incontinence can be classified as
transient - spontaneously reverses after the underlying cause is resolved
chronic - classified into five types:
- stress,
- urge,
- mixed,
- overflow,
- functional
Characteristics of each type are shown in Table 1

Algorithm for the diagnosis of urinary incontinence

Chronic Urinary Incontinence
The 3 Incontinence Questions is a reliable questionnaire available free of charge- It asks three multiple choice questions about if, when, and how often patients experience urine leakage.

ASSESSMENT OF MEDICAL PROBLEMS
The patient history should include an assessment of other medical conditions and symptoms, with their temporal relationship to urinary incontinence.
a history of bowel, back, gynecologic, or bladder surgery could affect the anatomy and innervation of the lower urinary tract, leading to incontinence.
Gynecologic history can assess estrogen status; estrogen deficiency may result in atrophic vaginitis or atrophic urethritis, a potentially reversible cause of urinary incontinence.
about other comorbidities, such as chronic obstructive pulmonary disease (chronic cough can result in stress incontinence); cardiovascular disease (volume status or diuretic therapy can increase urine flow and cause incontinence in patients with an overactive bladder); neurologic conditions (central nervous system dysfunction can impair inhibition of detrusor contractions, or lead to denervation of the detrusor muscle with resultant retention and overflow incontinence); and musculoskeletal conditions (impaired mobility can cause functional incontinence).
ASSESSMENT OF QUALITY OF LIFE
Patients should be asked about the effects of incontinence on work, activities of daily living, sleep, sexual activity, social interactions, interpersonal relationships, and general perception of health and quality of life.
A voiding diary
A voiding diary an also serve as a baseline for comparing the severity of incontinence after treatment, thereby assessing the effectiveness of management. A three-day diary is as informative as a longer-term assessment

PHYSICAL EXAMINATION
The physical examination can identify anatomic abnormalities or transient causes that may not have been considered after applying the DIAPPERS mnemonic. Findings associated with incontinence are listed in Table 4

COUGH STRESS TEST
If stress incontinence is suspected, the cough stress test is the most reliable clinical assessment for confirming the diagnosis.
With a full bladder (although not to the point of abrupt urination), the patient should be in the lithotomy position. Women should separate the labia. The patient should relax the pelvic muscles and forcibly cough once.If the test is initially performed supine and no leakage is observed, the test should be repeated in the standing position. The patient stands while wearing a pad or with his or her legs shoulder-width apart over a cloth or paper sheet on the floor to see the leakage. If urine leaks with the onset of the cough and terminates with its cessation, the test is positive for stress incontinence.
A negative test shows no leak or a delayed leak by five to 15 seconds, and rules out most cases of stress incontinence.36 False-negative results may occur if a patient's bladder is empty, if the cough is not forceful enough, if the pelvic floor muscles contract to override urethral sphincter incompetence, or if severe prolapse masks the leakage.

LABORATORY TESTS
a serum creatinine level - may be elevated if there is urinary retention (overflow bladder) caused by bladder outlet obstruction or denervation of the detrusor.
urinalysis - exclude acute urinary tract infection as a cause of reversible incontinence, a urinalysis should be obtained to rule out hematuria, proteinuria, and glycosuria, any of which require a diagnostic workup.

POSTVOID RESIDUAL URINE
A measurement of postvoid residual (PVR) urine is recommended to diagnose overflow incontinence.Although overflow incontinence is present in only a minority of patients with incontinence, it is important to exclude this diagnosis because chronic failure of bladder emptying can lead to hydronephrosis and irreversibly impaired renal function. Overflow is more common in older persons, but it can also occur in young adults as a manifestation of neurologic disorders, such as multiple sclerosis. Expert opinion recommends that PVR urine always be measured in patients who may have overflow incontinence, and some experts recommend measuring PVR urine when another cause is not obvious.5
To measure PVR urine, the patient empties the bladder, and then the amount of urine remaining in the bladder is measured. This can be performed with a handheld ultrasound unit, which is the preferred method if available. The alternative is in-and-out urethral catheterization.28 In-and-out catheterization requires training to decrease the risk of infection and urethral trauma, which is important in men with significant prostate enlargement. If PVR urine cannot be measured in the office setting and if overflow incontinence is strongly suspected, further urodynamic evaluation is warranted.10,12
A PVR urine measurement less than 50 mL is negative for overflow; 100 to 200 mL is considered indeterminate (and the measurement should be repeated on another occasion); and greater than 200 mL is suggestive of over-flow as a main contributing factor of incontinence.

If the cause of urinary incontinence is unclear after the assessment, referral to a urologist or urogynecologist is recommended!!!
Indications for Urologic Referral
Incontinence associated with relapse or recurrent symptomatic urinary tract infections
Incontinence with new-onset neurologic symptoms, muscle weakness, or both
Marked prostate enlargement
Pelvic organ prolapsed past the introitus
Pelvic pain associated with incontinence
Persistent hematuria
Persistent proteinuria
Postvoid residual volume > 200 mL
Previous pelvic surgery or radiation
Uncertain diagnosis

Routine referral for urodynamic testing is not recommended, even if a patient is a candidate for surgical treatment of stress incontinence. Studies show that routine preoperative urodynamic testing in patients who have uncomplicated stress incontinence does not result in better surgical outcomes.
Nager CW, Brubaker L, Litman HJ, et al.; Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.

Pelvic floor muscle (Kegel) exercises — Consistent with guidelines from the American College of Physicians, we suggest pelvic floor muscle (Kegel) exercises for women with urinary incontinence, particularly stress urinary incontinence [24]. Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to provide a backboard for the urethra to compress on and to reflexively inhibit detrusor contractions.
Initial instructions — These exercises can be effective for both stress and urgency incontinence [25] (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)"). The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds each, performed three times a day. Patients should try to do this every day and continue for at least 15 to 20 weeks

PHARMACOLOGIC THERAPY
Medications can be used to treat urge and mixed incontinence if behavioral therapy is unsuccessful. Cure is rarely achieved solely with drug therapy, however, and in many studies improvement over placebo is modest. Combination therapy with medication and behavioral treatments is more effective than either modality alone.
Anticholinergic Drugs. Anticholinergics are the preferred agents for the treatment of urge incontinence. They reduce detrusor overactivity by antagonizing M2/M3 muscarinic receptors in the bladder

Beta-Adrenergic Agonists. Approved by the FDA in 2012, mirabegron (Myrbetriq) is from a new class of drugs used to treat urge incontinence. Mirabegron acts on beta3-adrenergic receptors to relax the detrusor.27 Studies have shown that use of mirabegron results in one to two fewer incontinence episodes per day, similar to sustained-release tolterodine (Detrol).28 Common adverse effects are nausea, diarrhea, constipation, dizziness, and headache.27 Increased blood pressure can also occur, and mirabegron should not be used in patients with uncontrolled hypertension.27When used with an anticholinergic, the risk of urinary retention increases.27
OnabotulinumtoxinA. Also recently approved by the FDA, injection of onabotulinumtoxinA (Botox) into the detrusor muscle can be considered for treating urge incontinence that has not responded to conservative treatments.7,9,25,29 OnabotulinumtoxinA is superior to placebo in reducing incontinence as well as in improving quality of life.29 Symptom reduction lasts three to six months.9,29 Optimal doses for effectiveness and long-term safety have not yet been determined.14,29
Estrogen. Although intravaginal estrogen is sometimes used to treat urge incontinence, neither intravaginal nor systemic estrogens are FDA-approved for this. Systemic estrogen has been shown to worsen incontinence.10,30

SURGERY
Urge incontinence can be treated with surgically implanted devices that stimulate the sacral, paraurethral, and pudendal nerves. Sacral nerve stimulators are most commonly used, and up to two-thirds of patients experience improvement in symptoms, which is notable because these devices are used only for symptoms that are refractory to all other treatment.