Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_32_библиотеки_им_акад_М_И_Перельмана
.pdf
https://t.me/medicina_free
Urinary Incontinence
https://t.me/medicina_free
HENRIK STEINBRECHER
Topics covered
12
Denitions, epidemiology, classication
Neurology and development of continence
Patient assessment
DEFINITIONS, EPIDEMIOLOGY,
CLASSIFICATION
Urinary incontinence can be defined as the
“uncontrollable leakage of urine”. It is one
of the commonest conditions of childhood,
with daytime incontinence (diurnal enuresis)
affecting around 15% of 4-year-old children
and 2% of 9 year olds. Approximately 20% of
4–5-year-old children experience some degree
of bedwetting (nocturnal enuresis). Although
the incidence declines during the course of
childhood, nocturnal enuresis continues to
affect 1–2% of adolescents. Urinary incontinence (both diurnal and nocturnal) is classified as “primary” if the child has never been
reliably dry and “secondary” when the onset
of wetting occurs after a period in which the
child had previously been dry.
Urinar y incontinence may be classied as either
organic or functional in aetiology (Figure 12.1).
Organic causes (anatomical or neurological
abnormalities) are relatively rare and account for
Structural incontinence
Functional daytime incontinence
Night time incontinence
only 1% of cases. ese are described elsewhere in
this book. is chapter deals solely with the functional causes of urinary incontinence.
NEUROLOGY AND NORMAL
DEVELOPMENT OF
CONTINENCE
Normal urinary continence depends on a coordinated relationship between bladder lling
and detrusor contraction and by coordinated
relaxation and contraction of the urethral sphincter. It is also dependent on intact neural pathways
and regulation by higher centres in the brain.
During infancy, voiding is a reex act which
occurs in response to involuntary detrusor contractions. Although bladder function is not under
voluntary control in infancy, higher centres in the
brain have been shown to exhibit arousal activity in response to sensory input prior to voiding.
Aer toilet training, these centres play a far more
153
154 Urinary Incontinence
https://t.me/medicina_free
During the rst year of life, the rate of bladder emptying remains fairly constant at approximately 20 times per day. is decreases to
around ve times a day by the age of 7 years. is
reduction in voiding frequency is due partly to
a growth-related increase in bladder capacity
(which is disproportionately greater than the
volume of urine produced) and partly to the
development of sensory C-bres in the nerves
supplying the bladder.
Once a child has been successfully toilet
trained, the normal bladder cycle is under voluntary control and consists of the following phases.
Figure 12.1 Simple classication of childhood
urinary incontinence.
signicant role in controlling overall bladder
function and continence.
e lower urinary tract is supplied by three
dierent nerve groups:
Sacral parasympathetic (pelvic splanchnic)
nerves (S2, 3, 4). ese comprise both pre and
post ganglionic bres. Acetylcholine is the principal neurotransmitter.
oracolumbar sympathetic (hypogastric)
nerves (T10–L2). Sympathetic bres synapse
in the paravertebral ganglia of the sympathetic
chain before branching out to become the
hypogastric plexus, and nally merging with the
pelvic plexus supplying the bladder base, bladder neck and proximal urethra. Stimulation of
the sympathetic pathways results in relaxation
of the bladder detrusor muscle and contraction of
the bladder neck and posterior urethral sphincter
complex. e main postganglionic neurotransmitter is noradrenaline.
Sacral somatic nerves (S2,3,4). e somatic
nerve supply originates within Oluf’s nucleus
of the anterior horn of S2, 3, 4 spinal segments.
ese nerves, which are richly supplied with
serotonin and noradrenaline receptors, merge to
form the pudendal nerves supplying the pelvic
oor muscles and external urethral sphincter.
e most important factor in successful toilet
training is the development of voluntary inhibition of the voiding reex. is can be aected
by psychological, social and behavioural factors.
1. e bladder lls and the urethra contracts
via modulation from T10 to L2 lumbar
sympathetic nerves and S2, 3, 4 voluntary
somatic innervation.
2. e urethra relaxes under voluntary control
mediated by S2, 3, 4 somatic nerves.
3. e pelvic oor relaxes under voluntary con-
trol mediated via S2, 3, 4 somatic nerves.
4. e detrusor muscle contracts in response
to stimulation via parasympathetic S2, 3,
4 nerves.
5. Voiding occurs to completion.
6. e urethral sphincter contracts under S2, 3,
4 voluntary somatic control.
CLINICAL ASSESSMENT
e initial priority is to exclude an organic (anatomical or neurological) cause of the urinary
incontinence. is can usually be achieved with
the combination of taking a thorough history,
careful physical examination and appropriate
investigations (Table 12.1).
History
ree fundamental questions should be asked:
●
Does the wetting occur principally or entirely
by night or by day?
●
Is the incontinence primary i.e. lifelong
and predating attempts at toilet training or
Clinical assessment / Examination 155
https://t.me/medicina_free
Table 12.1 Organic causes of urinary
incontinence
Urinary infection (intermittent leakage)
Neuropathic (continuous/intermittent leakage)
Bladder outow obstruction (intermittent
leakage)
Structural (continuous leakage)
Exstrophy/epispadias
Ureteric ectopia (girls)
Congenital short urethra (girls)
Urovaginal conuence (girls)
secondary ie developing in a child who was
previously dry and toilet trained (even if only
for a short time)?
●
In the case of daytime wetting, does this occur
continuously or intermittently?
Urinary incontinence which occurs only dur-
ing the day time is usually functional rather than
organic in aetiology. One exception is involuntary
leakage from an ectopic ureter which may sometimes only be apparent when the child is upright –
and not when they are supine and asleep.
ere is virtually never an underlying organic
basis to urinary incontinence which occurs solely
at night and which is not accompanied by day
time daytime symptoms (termed monosymptomatic nocturnal enuresis).
e organic causes of primary daytime uri-
nary incontinence include congenital anatomical abnormalities and certain conditions such
as bladder outow obstruction or neurological
impairment. Although the secondary onset of
daytime incontinence may also have an organic
basis such as late presenting posterior urethral
valves or a neurological condition it is almost
never due to a congenital anatomical anomaly.
Intermittent daytime wetting (in which the
child can remain dry for periods of varying duration) may occasionally have an organic cause
(such as bladder outow obstruction or neurological disease) but it is functional in the overwhelming majority of cases – particularly when
the wetting occurs infrequently.
Despite attempts to obtain an accurate his-
tory from the child and their parents it may not
be possible to form a clear picture of the precise
pattern of symptoms and frequency of wetting at
the time of the initial consultation.
Typical information to be obtained in a his-
tory in a child with wetting is listed in Table 12.2.
A detailed history may sometimes point to a
specic form of urinary incontinence. For example, involuntary dribbling of urine in girls which
occurs immediately or shortly aer voiding is a
characteristic feature of vaginal “reux” – oen
due to the presence of labial adhesions. is is
considered in more detail below.
Giggle incontinence is a distinctive condition
in which urinary leakage occurs only when the
child (usually a girl) is giggling or laughing but at
no other time.
Examination
is should include the abdomen, spine, back,
genitalia and lower limbs. It should also include
observing the child’s gait and performing a limited neurological examination of the lower limbs.
Salient ndings include:
Abdomen – Is the bladder palpably enlarged?
Are the kidneys palpable? A palpable bladder
which can be emptied (“expressed”) by apply-
ing suprapubic pressure is virtually pathogno-
monic of neurological disease – particularly
in the presence of gross constipation.
Genitalia – Examination of the male genitalia
is aimed at identifying conditions such as
primary epispadias, Balanitis xerotica and
meatal stenosis (including cases of hypo-
spadias). In the female, the examination
should look for conditions including primary
epispadias (Figure 12.2), common urogeni-
tal sinus (Figure 12.3) and labial adhesions
(Figure 12.4). e external opening of an
ectopic ureter is very occasionally evident
on gross inspection, although in some girls
urine may be observed leaking from the
introital area. It is usual for examination of
the genitalia of older girls and adolescents
to be performed under sedation or anaes-
thesia. Examination of genitalia should
be performed in the presence of suitable
chaperones.
156 Urinary Incontinence
https://t.me/medicina_free
Table 12.2 Information to be obtained when taking the medical history
Example Comment
Number of episodes of
wetting/day and or
night/week
Frequency of voiding/day
and/night
Presence of urgency/
Vincent’s curtsy sign
Urge incontinence Wets on way to toilet Children may comment they don’t know
Stress incontinence Exercise (running,
Stream – onset, presence
of hesitancy
Stream characteristic Stop/start, continuous This is may represent obstruction or
Fluid intake, last drink
taken, type of drink
taken
Bowel habit Bowels open 1–2x/day,
Use of shampoos, soaps,
etc
Family history of wetting Parents wet until teens,
History of urinary tract
infection
Drug history, other health
history
Social history Sleeping arrangements,
Day = 5/7, 3x/day
Night = 7/7, 1x/night
(early morning)
Day/Night = 7/1 Often children do not visit the toilet
Rushes to toilet, drops
everything to go, car
journeys interrupted,
trampolining, jumping),
Cough, sneezing
ml/day, (often a prop
such as a cup on the
table can be used as a
visual aid to estimate
intake
no pain, no blood,
normal motions
Hair wash in bath, child
sits in soapy water etc
siblings wet.
Asthma, cystic brosis,
ADHD, autism (altered
higher control
mechanisms),
Trisomy 21 (higher risk of
detrusor-sphincter
dyssynergia)
proximity to toilet
An accurate description is essential to
permit a reliable assessment. Words
such as “Occasional”, “often”,
“sometimes” are insufcient.
during the entire school day (a period of
over 6 hours). This should be noted.
In Vincent’s curtsy, the child crouches
down on one heal, pushing upwards on
perineum to prevent leakage.
they are wetting until it has happened.
Giggle incontinence is a specic entity.
Hesitancy may be caused by obstruction.
A seemingly normal stream does not
exclude obstruction.
detrusor instability.
Stimulants drinks such as cola or
blackcurrent juice can exacerbate
detrusor instability.
It is vital to obtain a bowel history in
children with urinary incontinence.
A recent change in perineal bacterial ora
leads to the development of lower tract
infection (cystitis) and bladder
instability.
Recurrent infections can lead to detrusor
instability
Some medical illnesses and their
treatment affects bladder function.
Snoring or inability to wake from sleep
may be implicated in nocturnal enuresis.
Clinical assessment / Examination 157
https://t.me/medicina_free
Figure 12.2 Female epispadias. Bid clitoris
with wide urethral meatus. This anomaly in
females is invariably associated with sphincter
weakness incontinence.
Figure 12.3 Anatomy of common urogenital
sinus anomaly.
Figure 12.4 Extensive occlusion of the introitus
by labial adhesions – resulting in retrograde
lling of the vagina during voiding. Symptoms
cured by separation of labial adhesions.
Neurology – e spine should be carefully
examined for cutaneous lesions denoting pos-
sible occult spinal dysraphism such as hairy
patches, swellings, cutaneous haemangiomata
and sinuses. Blind ending pits overlying the
tip of the coccyx are not usually of neurologi-
cal signicance but if there is any doubt it is
always safer to arrange a neurological referral
and/or spinal imaging. Sacral agenesis is not
accompanied by cutaneous lesions but there
may be a palpable absence of the lowermost
sacral segments and attening of the upper
buttocks. Neurological disease is suggested
by exaggerated lower limb reexes (or frank
clonus) or by wasting of the calves or defor-
mities of the feet, especially if asymmetrical.
e lowermost sacral segments should be
examined for motor and sensory integrity.
An abnormal gait should always raise the
possibility of an underlying neurological
condition.
158 Urinary Incontinence
https://t.me/medicina_free
INVESTIGATIONS
Frequency – Volume Chart
ere are many types but all charts include a
24-hour time column, a uid intake column, urine
output column and some provision for recording when the incontinence occurs (Figure 12.5).
Many charts also record when the child opens
their bowels. Continuous charting over as little as
48 hours is oen sucient to provide a reliable
assessment of intake and output and the extent
of the impact of the incontinence on the life of
the child and their family. It will also provide
the clinician with some indication of the level of
co-operation which might be expected from the
child and their parents when planning treatment.
However, charts tend to be completed at weekends and may not provide an accurate picture
of what happens on school days. A copy of the
Figure 12.5 Example of frequency/volume chart.
Organic causes of incontinence / Labial Adhesions/Vaginal Reux 159
https://t.me/medicina_free
Bristol stool chart may also help the parents to
assess constipation.
Urinalysis or Urine Culture
Reagent strip (Dipstick) testing of the urine should
include glucose because glycosuria and frequency
caused by diabetes can occasionally lead to incontinence. Cultures are usually negative.
Simple non-invasive measurement of ow
rate. is should normally demonstrate a ow
rate of >15 ml/second with non-staccato voiding
pattern. In an older child measurement of ow
rate at the bedside or in the out-patient clinic can
be combined with a post void ultrasound scan of
the bladder to assess bladder emptying.
Urinary tract ultrasound scan. is should
be performed in all children with day time wetting. Relevant upper tract ndings include:
Duplication anomalies – particularly if there
is evidence of dilatation or a congenitally
dysplastic upper pole moiety suggesting
an ectopic ureter
Dilatation – which may indicate organic
outow obstruction or a neuropathic
bladder.
MR urography is the most sensitive investigation for detecting an occult upper pole duplex
system and ectopic ureter as the cause of primary
incontinence in girls. Laparoscopy may also be
helpful.
Cystourethroscopy is occasionally indicated
(mainly in boys) to assess the bladder neck and to
look for anatomical causes of outow obstruction
such as late-presenting posterior urethral valves.
Sleep studies or an ear, nose and throat (ENT)
opinion may be indicated in some children with
nocturnal enuresis.
Invasive Urodynamics/Video
Urodynamics
ese are only performed on a very selective
basis in children with non-neuropathic incontinence because of the need for catheterisation
and exposure to radiation (when combined with
radiological screening). However, urodynamics can sometimes be helpful in distinguishing
between sensory and motor urgency. e video
component is valuable in making the diagnosis
of genuine stress incontinence by demonstrating
leakage induced by increasingly strong valsalva
manoeuvres.
e bladder scan should include measurement
of pre-void bladder volume and post-void blad-
der residual volume – which should not usually exceed 10% of normal age-adjusted bladder
capacity.
Bladder wall thickening is suggestive of either
outow obstruction, neuropathy, idiopathic overactivity or detrusor – sphincter dyssynergia).
Other Investigations
ese are only performed for specic indications.
Although lumbo-sacral spinal X-ray is still
performed in children with possible spinal dysraphism it has been largely superseded by spinal
magnetic resonance imaging (MRI). is is now
regarded as the denitive investigation since it
will visualise tethering, syrinxes and intraspinal
cord lipomas and epidermoid cysts associated
with the spinal cord abnormality.
ORGANIC CAUSES
OF INCONTINENCE
Labial Adhesions/Vaginal Reux
e term “vaginal reux” refers to the phenomenon of retrograde lling of the vagina with
urine during voiding. Urine then leaks from the
vagina aer the girl stands up to leave the toilet.
It is commonly caused by the presence of labial
adhesions but can also occur in girls who sit on
the toilet with their legs closed. Treatment consists of conservative or surgical management of
any labial adhesions or advising the girl to sit
with her legs further apart on the toilet. A gentle
cough or valsalva manoeuvre aer the completion of voiding may help to expel any urine from
the vagina.
160 Urinary Incontinence
https://t.me/medicina_free
Ectopic Ureter
is classically presents with continuous dribbling incontinence. However, there may be a postural element – with the urinary leakage being
absent or much less pronounced at night when
the child is lying supine.
Genuine Stress Incontinence/Wide
Bladder Neck
Strenuous sporting activity in girls (such as gymnastics) is accompanied by a higher incidence of
stress leakage than was previously recognised.
An empirical trial of an alpha-adrenergic agonist
(e.g. ephedrine) may be employed in more severe
cases. If genuine stress incontinence (rather than
simply a wide bladder neck) is conrmed on
video urodynamics it may be necessary to consider a bladder neck sling or similar procedure.
Female Epispadias
Surgical intervention is usually required (see
Chapter 15).
stricture (including post hypospadias repair), syringocele, meatal stenosis and exceptionally, pathological phimosis (Balanitis xerotica obliterans). In girls,
haematocolpos or hydrocolpos due to imperforate
hymen may present with bladder outow obstruction, generally at or aer puberty and with an
accompanying history of primary amenorrhoea.
Pelvic tumours and severe constipation can
interfere with voiding in both sexes but tend to
cause urinary retention rather than incontinence.
Bladder ultrasound typically demonstrates
post void residual urine which is oen (but not
invariably) accompanied by bladder wall thickening. However, the absence of upper tract dilatation
does not exclude outow obstruction. Diagnosis is
by cystoscopy and/or micturating cysto urethrography (MCUG). It is not uncommon for the incontinence to persist (sometimes for years) despite
successful relief of obstruction and the long-term
use of anticholinergic agents may be indicated.
FUNCTIONAL DAY-TIME
INCONTINENCE
Spinal Neurological Disorders
Relevant points in the history include:
Urinary incontinence of unusual severity, espe-
cially if accompanied by constant dribbling
of urine.
Marked disturbance of bowel habit, particu-
larly if associated with fecal soiling.
Almost 90% of cases of occult spinal dysraphism
are accompanied by cutaneous lesions – hence
the crucial importance of a careful examination
of the spine. It is important to note that some
children with neuropathic bladder dysfunction
may nevertheless have virtually (or entirely) normal lower limb locomotor function. Urological
management is the same as for other forms of
neuropathic bladder. (See Chapter 13.)
Bladder Outow Obstruction
is is far more common in boys – in whom the
causes include: posterior urethral valves, urethral
Around 3% of girls and 2% of boys aged 7 years’
experience functional daytime wetting at least once
a week. Many also have nocturnal incontinence.
A number of dierent patterns of functional day
time incontinence can be identied – with detrusor overactivity being an important feature of most
(Table 12.3).
Table 12.3 Functional daytime incontinence
Detrusor instability
Urge syndrome
Uncomplicated
Dysfunctional voiding
Deferred voiding
Lazy bladder
Occult neuropathic bladder
Detrusor instability or central (CNS)
Giggle incontinence
Non-detrusor instability
Diurnal frequency syndrome
Sensory urgency
Overactive bladder / Transcutaneous Electrical Nerve Stimulation (TENS) 161
https://t.me/medicina_free
Simple Treatments
One of the simplest and most rewarding forms of
treatment consists of providing the parents and an
older child with an explanation of the normal micturition cycle and describing the measures needed
to establish a more normal voiding pattern.
ese typically comprise a regimen of regular
voiding (5–6 times a day at 2–3 hourly intervals)
and a regular intake of uid in volumes which are
appropriate for the child’s age. As an approximation this corresponds to a minimum intake of 500
ml at age 5 years, 750 ml at age 7 years, 1000 ml
at age 10, 1250 ml at age 12 and 1500–2000 ml at
age 15+.
Certain drinks should be avoided, especially
in children with symptoms of bladder overactivity. ese include ; tea, coee, hot chocolate, cola
type drinks and any drink containing blackcurrent. In addition to their diuretic eects they may
also provoke detrusor overactivity.
e advice provided to parents and child
should be reinforced with regular follow-up,
encouragement and support – either by face to
face contact or by telephone. Paediatric urology
nurse specialists or specialist continence nurses
can play a particularly valuable role in providing
this service to children and families.
Urinary tract infections (UTIs) are common in
children with functional day time incontinence
and there is oen a causal inter relationship. It is
important that UTIs are eectively treated and
measures are taken to prevent them from recurring. ese may include increasing the child’s
uid intake and voiding frequency (to maintain
diuresis and bladder emptying) and reducing the
use of soap agents such as shampoo and bubble
bath which may signicantly alter the balance of
perineal bacterial ora. Introducing bio-yoghurt
into the diet can also be helpful.
It may sometimes be necessary to prescribe a prophylactic antibiotic such as a single
daily dose of Trimethoprim at 2 mg/kg/day (or
Nitrofurantoin 1 mg/kg/day) until the bladder dysfunction has been adequately treated.
Eective treatment of constipation is also essential because of its role in causing both UTI and
bladder dysfunction. is typically entails the
regular use of laxatives such as Movicol Paediatric
(half – 1 sachet/day), lactulose (2.5–5 ml/day)
and/or Sennakot (2.5–5 ml/day) to try to ensure
the rectum is empty.
OVERACTIVE BLADDER
Medical Treatment
If the symptoms of frequency and urgency do not
respond to the simple measures outlined above
the next line of treatment consists of anticholinergic agents. Oxybutynin is most widely used
agent – with a typical starting dose of 2.5 mg
twice a day, increasing to 2.5 mg three times a
day. e principal alternative is Tolteridine (typi-
cal dose 1–2 mg twice a day).
If the child is able to take tablets these agents
are also available in a slow release form as oxybutynin (5–10 mg, once a day) or slow release
Tolteridine (2–4 mg, once a day). Oxybutynin
and Tolteridine are both associated with a risk of
systemic anti-muscarinic side eects which may
include dry eyes, dry mouth, constipation and
occasionally, personality/behavioural changes.
Solifenacin, a newer anticholinergic agent with
minimal systemic side eects, is being used
increasingly in older children in a typical dose of
5–10 mg once a day. It is not licensed for use in
younger children. Likewise Mirabegron, a beta3
agonist, is used in older children although it is not
yet ocially licensed in the UK for use in patients
under the age of 18.
ese agents should not be used in children
with signicant post void residual volumes
and/or a pattern of infrequent voiding because
inhibition of detrusor activity may lead to further
impairment of bladder emptying and urinary
retention.
Transcutaneous Electrical Nerve
Stimulation (TENS)
is technique has been used in some centres
with a typical regimen consisting of a 20 minutes session performed three to ve times a week
over 6 weeks. Transcutaneous electrical nerve
Соседние файлы в папке Библиотека им академика М.И. Перельмана