TUTORIAL 5 MARIAM ABDUL RASHID

10) How to Diagnose Penegakan Diagnosis; Inkontinensia Urin Physical examination should include cognitive and functional assessments and focus on potential comorbid conditions associated with UI. Rectal exam is used to assess for masses, tone, and prostate nodules or firmness in men (not size). The neurologic evaluation should include evaluation of sacral cord integrity with perineal sensation, anal wink (anal sphincter contraction when the perirectal skin is lightly scratched), and bulbocavernosus reflex (anal sphincter contraction when either the clitoris or glans is lightly touched). Vaginal mucosa should be evaluated for severe atrophy, and the pelvic exam should include evaluation for pelvic organ prolapsed (cystocele, rectocele, uterine prolapse) with straining. Urinalysis is recommended for all patients, primarily to look for hematuria (and glycosuria in diabetics). Pyuria and/or bacteriuria likely represents asymptomatic bacteriurianot cystitisin women without dysuria, fever, or other signs of urinary tract infection, especially if UI is not acute. Anamnesis: ~Riwayat penyakit (kondisi komorbid): DM2, stroke, demensia, cedera medulla spinal, konstipasi, infeksi saluran kemih, vaginitis atrophic dan atrophic urethritis, imobilisasi, delirium) ~Riwayat inkontinensia urin: episode, faktor penyebab (batuk, mengangkat beban berat) ~Kartu catatan berkemih (volume urin 1x miksi, vol rata2 miksi, frek miksi, episode inkontinens) ~Riwayat obat-obatan (diuretik, antikolinergik, psikotropika, analgesik opioid, alfa bloker, penghambat kalsium) Pemeriksaan fisik: ~Pemeriksaan abdomen, rectum (rectal taocher), genital dan evaluasi persyarafan lumbosakral (periksa nyeri tekan, massa) ~Pemeriksaan pelvis perempuan untuk menemukan beberapa kelainan seperti prolaps, inflamasi, keganasan (periksa nyeri tekan, massa) ~Penilaian khusus terhadap mobilitas pasien, status mental, kemampuan mengakses toilet ~Pencatatan aktivitas berkemih (bladder record atau voiding diary) membantu menentukan jenis dan beratnya inkontinensia urin serta evaluasi terapi

Pemeriksaan penunjang: ~Urinalisis (Adanya infeksi, sumbatan akibat batu saluran kemih atau tumor) ~Sistografi ~Urinary tract USG ~Postvoid residual measurement (Jika volume residu urin 50 ml inkontinensia urin tipe stres, jika Volume residu urin > 200 ml kelemahan detrusor atau obstruksi) 6) Effect Psychology (PSIKOGERIATRI DAN SOSIAL) Hilang percaya diri, Aktifitas social menurun, Problem pisikososial,Depresi, Mudah marah, Dan merasa terisolsasi Urinary incontinence impacts 15 to 35% of the adult ambulatory population. Men after the removal of the prostate for cancer can experience incontinence for several weeks to years after the surgery. Women experience incontinence related to many factors including childbirth, menopause and surgery. It is important that incontinence be treated since it impacts not only the physiological, but also the psychological realms of a person's life. Depression and decreed quality of life have been found to co-occur in the person struggling with incontinence. Interventions include pharmacological, surgical as well as behavioral interventions. Effective treatment of incontinence should include the use of clinical guidelines and research to promote treatment efficacy. Although it is not a life-threatening condition, urinary incontinence has a physical and psychological affect on the patients, while at the same time it charges them with an additional financial burden. According to the World Health Organization (WHO), health is defined as the condition of total physical, emotional and social health and prosperity, disproving the previous opinion of the absence, mostly, of disease or disability. ~ Urinary incontinence, in whichever form, sweepingly affects the life of the patients. It is conceived as a lack of health which generates feelings of anger and sadness, as well as embarrassment and depression. Patients avoid social gatherings and lose self-confidence, which has a proportional impact on their social interactions, their sexual life and emotional health. Apart from the emotional repercussions,however, urinary incontinence is a risk factor for other physical conditions and diseases, while simultaneously being a financial burden on the patient and his or her family . ## The ability of skin being a barrier between the internal and the external environment depends on its integrity, the presence of internal and external cellular lipids and its pH. A disorder of its integrity or its histological structure, allows for the development of microbes such as staphylococcus. Secondary infection by Candida albicans is also frequent, which is also favoured by the humidity of the region. The contact of urine with skin also aids in the creation of paratrimma, as well as folliculitis. The perineal dermatitis or incontinence dermatitis refers to the dermatitis caused by urinary or fecal incontinence. It causes severe pain and inflammation in the vagina, the perineum and the buttocks.

~ The increased humidity of the skin ultimately causes a mechanical damage. Erosions by friction are caused by half of the energy on wet skin than on dry skin. Therefore, urinary incontinence is a major risk factor for decubitus ulceration. Frequency, nocturia, urgency, as well as urge incontinence have also been shown to increase the risk of falls, which may lead to fractures and other morbidities. TABLE 1. Physical, psychological and social incidence of urinary incontinence. Physical Incidences Bacterial infections Fungal infections Cellulitis, skin infections Paratrimma Decubitus ulcers Falls and fractions Sexual dysfunction Psychological Effects Stress Depression Loss of self-respect and self-confidence Shame Social incidences Avoid of social events Reduce personal activities Social insularity Loss of independence Cost 4) Pathophysiology of Urinary Incontinence Micturition requires coordination of several physiological processes. Somatic and autonomic nerves carry bladder volume input to the spinal cord and motor output innervating the detrusor, sphincter, and bladder musculature is adjusted accordingly. The cerebral cortex exerts a predominantly inhibitory influence, whereas the brainstem facilitates urination by coordinating urethral sphincter relaxation and detrusor muscle contraction. As the bladder fills, sympathetic tone contributes to closure of the bladder neck and relaxation of the dome of the bladder and inhibits parasympathetic tone. At the same time, somatic innervation maintains tone in the pelvic floor musculature as well as the striated periurethral muscles. When urination occurs, sympathetic and somatic tones in the bladder and periurethral muscles diminish, resulting in decreased urethral resistance. Cholinergic parasympathetic tone increases resulting in bladder contraction. Urine flow results when bladder pressure exceeds urethral resistance. Normal bladder capacity is 300-500 mL, and the first urge to void generally occurs between bladder volumes of 150 and 300 mL. Incontinence occurs when micturition physiology, functional toileting ability, or both have been disrupted.[4] The underlying pathology varies among the different types of incontinence:

Stress incontinence; Stress incontinence is characterized by urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder. Two main causes of stress incontinence exist. The major cause is impaired urethral support from pelvic floor muscle weakness. The less common cause is an intrinsic sphincter deficiency usually secondary to pelvic surgeries. In either case, urethral sphincter function is impaired, resulting in urine loss at lower than usual abdominal pressures. Urge incontinence; Urge incontinence is a result of uninhibited bladder contraction from detrusor hyperactivity. This hyperactivity can be caused by abnormalities of the CNS inhibitory pathway such as strokes or cervical stenosis. Other causes are bladder inflammation from infection, stones, or neoplasms. Urge incontinence is characterized by a sudden strong desire to pass urine that is difficult to suppress leading to involuntary urine loss. It usually entails urgency, frequency, or nocturia. These symptoms are often referred to as the overactive bladder syndrome (OAB). Some individuals may have a pure sensory abnormality where they exhibit urinary frequency and urgency without urine loss. This is often referred to as overactive bladder dry. Elderly persons frequently experience urinary loss without the sensation of urge, but the underlying mechanism of detrusor hyperactivity is still the same. Mixed incontinence; Mixed incontinence is the coexistence of stress and urge incontinence. Although it is generally defined as detrusor overactivity and impaired urethral function, the actual pathophysiology of mixed urinary incontinence is still being investigated. Mixed urinary incontinence is characterized by involuntary loss of urine associated with urgency as well as exertion, cough, sneeze, or any effort that increases intra-abdominal pressure. This is the most common type of incontinence in women. Overflow incontinence; The major contributing factor to overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction. Factors involved in the development of overflow incontinence are physical obstruction such as pelvic organ prolapse and enlarged prostate, and neurological abnormalities, such as spinal cord injuries. It is also commonly associated with bladder neuropathy that occurs in the setting of diabetes mellitus. Patients often complain of continuous small-volume leakage associated with weak urinary stream, dribbling, hesitancy, frequency, and nocturia. Other less frequent causes of urinary incontinence include trauma from pelvic fracture, complications of urologic procedures, and fistulas. In the pediatric population, it includes enuresis and congenital abnormalities of the genitourinary system. Older adults can have transient incontinence from medication, decreased mobility, and fecal impaction. Functional incontinence; Functional incontinence is seen in patients with normal voiding systems but who have difficulty reaching the toilet because of physical or psychological impediments. Patients often present with recent symptom onset and have a good prognosis for cure if the cause is identified and treated. Functional incontinence is often secondary to reversible causes of urinary incontinence, as discussed later.