Tuesday, September 27, 2022

Urinary Incontinence Without Sensory Awareness

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Causes Of Overflow Incontinence

Urinary Incontinence – Why Can’t I Hold My Pee: Causes and Treatment

Overflow incontinence, also called chronic urinary retention, is often caused by a blockage or obstruction to your bladder. Your bladder may fill up as usual, but as it is obstructed you will not be able to empty it completely, even when you try.

At the same time, pressure from the urine that is still in your bladder builds up behind the obstruction, causing frequent leaks.

Your bladder can become obstructed as a result of:

Overflow incontinence may also be caused by your detrusor muscle not fully contracting, which means that your bladder does not completely empty when you go to the toilet. As a result, the bladder becomes stretched. Your detrusor muscles may not fully contract if:

  • there is damage to your nerves, for example as a result of surgery to part of your bowel or a spinal cord injury
  • you are taking certain medications

Colposuspension And Sling Procedures

Aetna considers colposuspension and conventional suburethral sling procedures medically necessary for persons with stress UI that is refractory to conservative management .

Aetna considers adjustable retropubic suburethral sling in the treatment of stress urinary incontinence experimental and investigational because its effectiveness has not been established.

Aetna considers the colposuspension and suburethral sling procedures experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

The Icd Code N394 Is Used To Code Overactive Bladder

Overactive bladder , also known as overactive bladder syndrome, is a condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person’s life. The frequent need to urinate may occur during the day, at night, or both. If there is loss of bladder control then it is known as urge incontinence. More than 40% of people with overactive bladder have incontinence. While about 40% to 70% of urinary incontinence is due to overactive bladder, it is not life-threatening. Most people with the condition have problems for years.

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Signs Of Urinary Incontinence

Urinary incontinence is not a disease in itself, but it can be a symptom of an underlying problem. The kind of symptoms you have will help determine the type of urinary incontinence.

Some symptoms may include:

Many people live with urinary incontinence, but it may affect your quality of life. You may feel embarrassed or worried about being too far from a restroom. You may also feel like you cant do normal daily activities or enjoy life. These are common feelings, which may indicate its time to talk to your doctor about how to manage your symptoms.

Causes Of Urge Incontinence

Gale Academic OneFile

The urgent and frequent need to pass urine can be caused by a problem with the detrusor muscle in the wall of the bladder. The detrusor muscles relax to allow the bladder to fill with urine, then contract when you go to the toilet to let the urine out.

Sometimes the detrusor muscle contract too often, creating an urgent need to go to the toilet. This is known as having an ‘overactive bladder’. The reason your detrusor muscle contracts too often may not be clear, but possible causes include:

  • drinking too much alcohol or caffeine
  • poor fluid intake this can cause strong, concentrated urine to collect in your bladder, which can irritate your bladder and cause symptoms of overactivity
  • conditions affecting the lower urinary tract , such as urinary tract infections or tumours in the bladder
  • neurological conditions
  • certain medications

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Causes Of Total Incontinence

Total incontinence occurs when your bladder cannot store any urine at all. It can result in you either passing large amounts of urine constantly, or passing urine occasionally with frequent leaking.

Total incontinence can be caused by:

  • a problem with your bladder from birth
  • injury to your spinal cord, which can disrupt the nerve signals between your brain and your bladder
  • a bladder fistula, which is a small tunnel-like hole that can form between the bladder and a nearby area, such as the vagina, in women

Symptoms Of Urinary Incontinence

Having urinary incontinence means you pass urine unintentionally.

When and how this happens varies depending on the type of urinary incontinence you have.

Although you may feel embarrassed about seeking help, it’s a good idea to see your GP if you have any type of urinary incontinence.

Urinary incontinence is a common problem and seeing your GP can be the first step towards finding a way to effectively manage the problem.

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What Treatment Is Available For Urinary Incontinence

Treatment for urinary incontinence depends on what type it is and whats triggering it, as well as your age, your overall health and medical history, how well you can tolerate medicines or therapies, and other factors. Your physician will take all this into account when prescribing a course of action.

Among the approaches available are special exercises, biofeedback, bladder training, vaginal weight training, pelvic floor electrical stimulation, and surgery.

  • Behavioral therapies
  • Bladder training teaches people to resist the urge to urinate and to gradually extend the intervals between visits to the toilet.
  • Toileting assistance uses routine or scheduled toileting, habit-training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.
  • Pelvic muscle rehabilitation
  • Kegel exercises. Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. To do this exercise, you squeeze the muscles you use to control the flow of urine, hold for up to 10 seconds, then release. It is recommended to do at least three sets of ten repetitions every day for at least eight weeks.
  • Biofeedback. Used in conjunction with Kegel exercises, biofeedback helps people gain awareness and control of their pelvic muscles.
  • Vaginal weight training. Small weights are held within the vagina by tightening the vaginal muscles. Should be performed for 15 minutes twice daily for four to six weeks.
  • Medication
  • Interstim Continence Control Therapy / Sacral Nerve Stimulation

    Axonics Center of Excellence for Overactive Bladder and Urinary Incontinence
  • Bosch J, Groen J. Sacral segmental nerve stimulation as a treatment for urge incontinence in patients with detrusor instability: Results of chronic electrical stimulation using an implantable neural prosthesis. J Urol. 1995 154:504-507.
  • Burrows E, Harris A, Gospodarevskaya E. Sacral nerve stimulation for refractory urinary urge incontinence or urinary retention. MSAC Application 1009. Canberra, ACT: Medicare Services Advisory Committee 2000.
  • Canadian Coordinating Office for Health Technology Assessment . Sacral nerve stimulation device for urinary incontinence. Pre-assessment No. 4. Ottawa, ON: CCOHTA 2002.
  • Dijkema H, Weil EH, Mijs PT, Janknegt RA. Neuromodulation of sacral nerve for incontinence and voiding dysfunction. Eur Urol. 1993 24:72-77.
  • Elabbady AA, Hassouna MM, Elhilali MM. Neural stimulation for chronic voiding dysfunction. J Urol. 1994 152:2076-2080.
  • Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder in adults: AUA/SUFU Guideline. Linthicum, MD: American Urologic Association 2012.
  • Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of overactive bladder in women. Evidence Report/Technology Assessment No. 187. Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I. AHRQ Publication No. 09-E017. Rockville, MD: Agency for Healthcare Research and Quality August 2009.
  • Medtronic, Inc. Medtronic InterStim Therapy. Information for Prescribers. Minneapolis, MN: Medtronic 2008.
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    Stress Urinary Incontinence / Prolapse

  • Clinicians may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments.
  • Clinicians should perform stress testing with reduction of the prolapse in women with high grade pelvic organ prolapse but without the symptom of SUI. Multi-channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated lower urinary tract symptoms .
  • Interstim Continence Control Therapy/sacral Nerve Stimulation

    Aetna considers implantation of the InterStim , a device for unilateral stimulation of the sacral nerve, medically necessary for the treatment of urge UI or symptoms of urge-frequency when all of the following criteria are met:

  • The member has experienced urge UI or symptoms of urge-frequency for at least 6 months and the condition has resulted in significant disability and
  • Pharmacotherapies ) as well as behavioral treatments have failed and
  • Test stimulation provides at least 50 % decrease in symptoms.
  • A test stimulation of the device is considered medically necessary for members who meet selection criteria 1 and 2 above.

    Aetna also considers implantation of the InterStim medically necessary for the treatment of non-obstructive urinary retention when all of the following criteria are met:

  • The member has experienced urinary retention for at least 6 months and the condition has resulted in significant disability and
  • Pharmacotherapies as well as intermittent catheterization have failed or are not well-tolerated and
  • A test stimulation of the device has provided at least 50 % decrease in residual urine volume.
  • Aetna considers removal of an Interstim medically necessary even where the initial implantation of the Interstim was not indicated.

    According to the product labeling, InterStim therapy is contraindicated and has no proven value for individuals who have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator.

    Exclusions

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    Other Experimental And Investigational Interventions For Urinary Incontinence

  • Alsulihem A, Corcos J. The use of vaginal lasers in the treatment of urinary incontinence and overactive bladder, systematic review. Int Urogynecol J. 2021 32:553-572.
  • Angulo JC, Schonburg S, Giamm√≤ A, et al. Systematic review and meta-analysis comparing Adjustable Transobturator Male System and Adjustable Continence Therapy for male stress incontinence. PLoS One. 2019 14:e0225762.
  • Borch L, Rittig S, Kamperis K, et al. No immediate effect on urodynamic parameters during transcutaneous electrical nerve stimulation in children with overactive bladder and daytime incontinence – A randomized, double-blind, placebo-controlled study. Neurourol Urodyn. 2017 36:1788-1795.
  • Burdzinska A, Dybowski B, Zarychta-Winiewska W, et al. Intraurethral co-transplantation of bone marrow mesenchymal stem cells and muscle-derived cells improves the urethral closure. Stem Cell Res Ther. 2018 9:239.
  • Carr LK, Robert M, Kultgen PL, et al. Autologous muscle derived cell therapy for stress urinary incontinence: A prospective, dose ranging study. J Urol. 2013 189:595-601.
  • Clemens JQ. Urinary incontinence in men. UpToDate . Waltham, MA: UpToDate reviewed May 2017.
  • Clemens JQ. Urinary incontinence in men. UpToDate . Waltham, MA: UpToDate reviewed December 2019.
  • Cornu JN, Doucet C, Sebe P, et al. Prospective evaluation of intrasphincteric injections of autologous muscular cells in patients with stress urinary incontinence following radical prostatectomy. Prog Urol. 2011 21:859-865.
  • Pelvic Floor Muscle Training

    Management of dissociate disorders prof. fareed minhas

    Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate. They surround the bladder and urethra .

    Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended.

    Your GP may refer you to a specialist to start a programme of pelvic floor muscle training.

    Your specialist will assess whether you are able to squeeze your pelvic floor muscles and by how much. If you can contract your pelvic floor muscles, you will be given an individual exercise programme based on your assessment.

    Your programme should include doing a minimum of eight muscle contractions at least three times a day and doing the recommended exercises for at least three months. If the exercises are helping after this time, you can keep on doing them.

    Research suggests that women who complete pelvic floor muscle training experience fewer leaking episodes and report a better quality of life.

    In men, some studies have shown that pelvic floor muscle training can reduce urinary incontinence particularly after surgery to remove the prostate gland.

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    Posterior Tibial Nerve Stimulation

    Your posterior tibial nerve runs down your leg to your ankle. It contains nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder symptoms, such as the urge to pass urine.

    During the procedure, a very thin needle is inserted through the skin of your ankle and a mild electric current is sent through it, causing a tingling feeling and causing your foot to move. You may need 12 sessions of stimulation, each lasting around half an hour, one week apart.

    Some studies have shown that this treatment can offer relief from OAB and urge incontinence for some people, although there is not yet enough evidence to recommend tibial nerve stimulation as a routine treatment.

    Tibial nerve stimulation is only recommended in a few cases where urge incontinence has not improved with medication and you don’t want to have botulinum toxin A injections or sacral nerve stimulation.

    Risk Factors & Diagnosis

    Individuals are more likely to experience daytime incontinence if there is a family history. Multiple studies have found a strong heritable link particularly with nocturnal enuresis. This raises the age-old problem of nature versus nurture i.e. is it learnt or genetic? Daytime wetting is also more common in females and in individuals from low socioeconomic backgrounds and/or poor education. School is considered a risk factor due to restricted toilet times. Additionally, potentially embarrassing situations amongst peer groups may have an influence and also bad hygiene on school toilets. Some diseases such as childhood obesity and joint hypermobility are additionally considered to be a risk factor for daytime wetting. Children who have attention deficit hyperactive disorder are more likely to present with daytime incontinence and require more attentive treatment. Previously it was assumed that emotional/behavioural problems were causative of daytime wetting. This long-held belief is now being challenged and any associated behavioural problems in sufferers are more likely a response to incontinence.

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    What Can I Do About Urinary Incontinence

    If you are a woman with stress incontinence, you can help control your condition by doing Kegel exercises to make the muscles around the neck of the bladder stronger. To do this exercise, you squeeze the muscles you use to control the flow of urine, hold for up to 10 seconds, then release. Aim to do three sets of ten each day.

    The best way to handle urge incontinence is to use the bathroom on a regular schedule. This might be a half-hour after a meal, two to three times between meals, and before going to bed.

    Special products and equipment are available. Absorbent underwear, which is no more bulky than normal underwear, can be worn easily under everyday clothing. Incontinence may be managed by routinely inserting a catheter into the urethra and collecting the urine in a container.

    Bladder Structure And Function

    Understanding Urinary Incontinence : A treatable condition

    The bladder, urethra and urinary sphincters work in concert to store urine at low pressure and to void voluntarily at socially convenient or appropriate times. The detrusor muscle and internal urethral sphincter are predominantly smooth muscle, whereas the external urethral sphincter and pelvic floor muscles are predominantly striated muscle. The bladder lumen is lined with epithelial cells and the basement membrane that protect the underlying detrusor muscle from toxins contained in the urine and enable communication with neural cells that coordinate storage and voiding phases .

    Anatomy and histology of the female bladder

    The sympathetic nervous system predominates during the storage phase and maintains continence through the paravertebral ganglia, the hypogastric nerves and hypogastric plexus. The parasympathetic system coordinates the voiding phase, through the sacral plexus and pelvic nerves . Afferent signals from the urothelium and bladder wall are transmitted through to the thalamus the balance between storage and voiding is maintained by the central pontine micturition centre . The neurotransmitters responsible for execution of these commands are acetylcholine and noradrenaline.

    Neurological control of the urinary bladder

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    Gene Testing For Stress Urinary Incontinence

    An UpToDate review on Evaluation of women with urinary incontinence states that The risk of urinary incontinence, particularly urgency incontinence, may be higher in patients with a family history. One study found that the risk of incontinence was increased for both daughters and sisters of women with incontinence. Twin studies attribute a 35 to 55 % genetic contribution to urgency incontinence/overactive bladder but only 1.5 % for stress incontinence.

    Furthermore, an UpToDate review on Urinary incontinence in men does not mention genetic testing as a management option.

    Botulinum Toxin A Injections

    Botulinum toxin A can be injected into the sides of your bladder to treat urge incontinence and overactive bladder syndrome .

    This medication can sometimes help relieve these problems by relaxing your bladder. This effect can last for several months and the injections can be repeated if they help.

    Although the symptoms of incontinence may improve after the injections, you may find it difficult to fully empty your bladder. If this happens, you will need to be taught how to insert a catheter into your urethra to drain the urine from your bladder.

    Botulinum toxin A is not currently licensed to treat urge incontinence or OAB, so you should be made aware of any risks before deciding to have the treatment. The long-term effects of this treatment are not yet known.

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    Care Of Persons With Stroke And Urinary Symptoms

    UI in the setting of an acute stroke is associated with more severe functional limitations than those with acute stroke and no UI. Additionally, the ability to toilet independently is predictive of more positive rehabilitation outcomes such as improved quality of life, functional recovery, and remaining in community-dwelling . Persons with a history of cerebrovascular disease may be predisposed to urgency urinary symptoms or have symptoms of impaired sensory integration of bladder afferent signals. Patients may also report UI without sensory awareness. Patients who describe UI without sensory awareness may benefit from scheduled toileting, which can be personalized based on a bladder diary. Emptying the bladder every 23 h, regardless of the sensation to void, will help to maintain continence. Bladder relaxants may not reduce UI without sensory awareness unless other symptoms of OAB, such as daytime urinary frequency, are also present.

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