MODUL 4

URIN INCONTINENCE

GROUP 14
PROBLEM BASE LEARNING

Medical Faculty
Muslim University of Indonesia
Tutor : dr. Marliyanti M. Akib,
Sp.M
110 211 0076 Fadel Maulana
110 211 0122 Abi Rabdi Fadilah
110 212 0031 Al Husna Pratiwi Aksan
110 212 0035 A. Sitti Rahmatullah
110 212 0082 Muh. Awaluddin
110 212 0088 Andi Amalya Permatasari A.
110 212 0100 Muhammad Alif Adhani
110 212 0118 Nurul Hikmah Pratiwi
110 212 0144 Andi Purnamasari Amien
110 212 0147 Dwi Pangestika Kabalmay
SCENARIO 2
A 68 years old woman was taken to the health center by her
family. According to her family, the patient suddenly crashed slipped
close to her bed this morning because of treading her own urine.

The last few days, the patient intermittently to the toilet to

urinate. Patients experienced coughing and shortness of breath, and
her appetite is greatly reduced, but no fever since last week.
Patients had been suffering from diabetes and high blood pressure.
Patients receive treatment from a doctor for the disease. Patients
experienced a stroke attack one year ago.
DIFFICULT WORD
There is no difficult word.
KEYWORDS
Woman, 68 years old

Suddenly falling down because slipped by her urin

Patient intermittent need to go toilet to urinate

Coughing and shortness of breath

Less of appetite

No fever since last week

Suffering of DM and high blood pressure

Receive treatment form doctor about her DM and hypertension

Stroke attack one year ago

PROBLEM TREE
Risk
Etiology
factors
INCONTINEN
CE URIN

Analysis the present Relation

Relation
condition after stroke between other
between
attack complain
Coughing,
Diseases Drugs Is there any nerve
shortness of
history history disorder?
breath

How to assess? Diagnose

Complicatio
Manage Prevent Islamic Point
n
of View
ANALYSIS OF PROBLEM
Coughing

Shortness Suspect
Of Breath Pneumonia
Incontinence
Innancya
Urine

What Type Of DM
Incontinence
Based On Case Hypertension
?
Get Stroke
Attack One
Year Ago
BASED ON SCENARIO
Risk Factor
(Pervaginam Labor,
Pelvic muscle become
A woman, 68 years old menopause
weak
decreasing of
estrogen)

Hipermobility of Intra abdominal The pressure had

Bladder neck & the pressure suddenly transmissionto all
proximal of uretra increasing viscera organ

Bladder pressure >

Stress Incontinence
Bladder neck
Etiology of Urine Incontinence

Acute Persistent/Chronic

Delirium Excessive activity of

Infection detrusor (Over Active
Atrophic vaginitis and Bladder)
atrophic urethritis Decreased of detrusor
Pharmaceuticals activity (overflow type of
Psychologic factors incontinence)
Failure of the urethra
Excess urine output
abdominal pressure
Restricted mobility stress incontinence)
Stool impaction Obstruction of the urethra
Physical & psicology factors
functional type
Risk Factor of Urine
Incontinence
Trauma to the pelvic

Radiation

Deficit of nutrients

Obesity

Smoker, alcoholism

Excessive fluid
intake or lack of
activity
Relation Between Other
Complaint with Incontinence
Less of coughing
apatite
Contaction
IAP abdominal Press vesica
System of urinary
imunity muscles
Pelvic floor
muscle
Inspiration weakness &
Get infection (contarction estrogen
PNEMONIA of Internal &external
diaphragm) sphincter
Shortnes relaxation
s of
breath
Stress
Reference: Intra Abdominal Pressure
http://repository.usu.ac.id/bitstream/123456789/31714/4/Chapter incontinentia
Visited July 5th 2015
 Relation Between Previous
Disease Elderly

Brain Vascularization
Fat Mass Hyperglichemi a(DM)
Disturbance

Vascular plaque Release of trombus Poliols Way Activity

Arterosclerosis Sorbitol accumulation in

Stroke nerve cell

Hypertension Lession in cortical/subcortical Detain mioinositol

Drugs Activity of PKC press the Na- Na intracellular hypertonic

K-ATP-ase
intracellular edema
Intraabdominal pressure,
press the bladder, muscle Urine Incontinence Nerve cell transduction
contraction and fluid output disturbance
1.

Darmojo, R. Boedhy. Buku Ajar Geriatri (Ilmu Kesehatan Usia Lanjut) Edisi ke-3. Jakarta: Balai Penerbit FKUI. 2004
2. Buku ajar ilmu penyakit dalam jilid I edisi V. Jakarta: interna publishing.
Is there any relation between stroke
history and incontinence problem of
patient? Master Control Complete lose of
UI
Destroyed voiding control

Impaired mobility or Difficulty to reach

STROKE communication toilet FI

Brain Injury Dysphagia and Repeated coughing

aspiration or sneezing SI
Centre of senses and
Urine pass without
controls bladder realizing RI
movement destroyed
UI = URGE INCONTINENCE Loss of feeling of
FI = FUNCTIONAL Bladder being too
INCONTINENCE bladder or Urine
full OI
SI = STRESS INCONTINENCE Retention
RI = REFLEX INCONTINENCE
OI= OVERFLOW
INCONTINENCE

Chantale, Dumoulin et all. 2007. Urinary Incontinence after Stroke: Identification, Assessment, and Intervention. American Heart Association
Bradley C Gill, MD, MS. 2014. Neurogenic Bladder. Medscape
Stroke Association. 2012. Continence Problems after Stroke. London
Relation Between Drug History

Increase volume urine

Diuretik (tiazid) Caused poliuria, frecuency and
urgency.

Caused a persistent cough

Increase abdominal and loss bladder
ACE Inhibitors control
Increase flow of urinary

Decreased contraction of M. detrusor

Calcium bloker Caused Urine Retension
How to Assess?
Identitas pasien
Apakah urine yang
keluar disertai rasa
Pemeriksaa
ingin pipis atau tanpa
disasari?
n Fisik Laboratorium
Kapan urin keluar tanpa Urinalisis : hematuri,
disadari Keadaan umum dan pyuri, bakteri kultur
Sering ngompol waktu tanda vital Darah : gula darah,
tidur Abdominal : tumor, buli- fungsi ginjal
Gejala lain yang buli teraba/tidak USG : mengukur urin
berkaitan RT dan VT : kekuatan sisa post miksi
Riwayat penyakit tonus spinchter dan Urethro cystoscopi :
otot dasar panggul melihat keadaan buli-
Operasi sebelumnya
Pem. Neurologis : reflex buli dan urethra
Wanita berapa kali
ani
kehamilan dan Pem. Meatus urethra
melahirkan
sementara
Riwayat pengobatan
batuk/mengedan waktu
Kebiaasaan hidup, buli-buli penuh (Cough
makan dan minum
Kehidupan seksual
stress test
Urine sisa
Pemeriksaa
Bowel habit sering n
Anamnesis
konstipasi, mengedan
Penunjang
 How to manage patient based in this scenario?
Behavioral Training
Urine Incontinence Antibiotic based on
Medication (next causa
slide)
Infection (suspect
Surgery
pneumonia) Treat the complication
Behavioral Training Perform surgery if
Fall Down theres fracture
Medication
Surgery
Anorexia
Diuresis
Control the complication
Blocker system
Hipertention control
adrenergik HT
Vasodilator Hipertention control,
RRA system blocker Stop smooking and not
Antagonis Ca DM to drink alcohol, Life
decrease urine style modification
secretoric (Physical activity
Stroke
management)
Darmojo, Boedhi; Martono, Hadi. Geriatri (Ilmu Kesehatan Usia Lanjut) Edisi ke 5. Jakarta: FK-UI.2012; Vitriana. Evaluasi dan Management
Medis Inkontinensia Urin. 2002. [Visite on : 5th July 2015] Sudoyo, Aru W; Setyohadi, Bambang;dkk. Buk Ajar Ilmu Penyakit Dalam Edisi V
Jilid III. Jakarta : Interna Publishing 2011; Rilantono, Lily. 5 Rahasia Penyakit Kardiovaskular (PKV). Jakarta : FK-UI.2013
 MEDICATION FOR URINE INCONTINENCE
Drugs Type Mecanism Incontinence type Side Effect Drugs name and dossage
Anticholinergic Increase Urgency or stress with Dry mounth, Oksibutinin : 2,5-5 mg tid
and bladder instabilization detrusor Increasing of Telterodine : 2mg bid
antispasmodic capasity and intraocular Propantheline : 15-3- mg tid
decrease of pressure, Dyciclomine : 10-20 mg
bladder constipation, Imipramine 10-50 mg tid
involunter delirium
Alpha Adrenergic Increase Stress type and Headache, Pseudofedrin : 15-30 mg tid
agonis smooth muscle sphincter weakness tacicardi, Phenylpropanolamine : 75 mg
contraction increasing blood bid
pressure Imipramine 10-50 mg tid
Estrogen agonist Increasi blood Stress type and Endometrrium Oral : 0,625 mg/hr
flow in urethra urgencythat has relation cancer, Increase Topical : 0,5-1 mg/application
with vaginitis atropi blood pressure,
renal stone
Cholinergic Bladder For overflow type with Bradichardi Bethanechol : 10-30 mg tid
agonist contraction atonik urinary
stimulation
Darmojo, Boedhi; Martono, Hadi. Geriatri (Ilmu Kesehatan Usia Lanjut) Edisi ke 5. Jakarta: FK-UI.2012; Vitriana. Evaluasi dan Management
Medis Inkontinensia Urin. 2002. [Visite on : 5th July 2015] Sudoyo, Aru W; Setyohadi, Bambang;dkk. Buk Ajar Ilmu Penyakit Dalam Edisi V
Jilid III. Jakarta : Interna Publishing 2011; Rilantono, Lily. 5 Rahasia Penyakit Kardiovaskular (PKV). Jakarta : FK-UI.2013
Impact That We Can Suspect from
Incontinence
Economic
Health Psychological Aspects
Social Aspect
Aspects Aspect (Economic
Losses)
Recurrence of
urinary tract Supplies (diapers
infections etc.)
depression isolated
damage the skin,
ex: decubitus
laundry costs
Falls (mainly due
to incontinence at
night)
Salary nurse /
helper
sleep disorders
dependence with
easy to get angry
family or helper The cost of
dehydration treatment
complications
How to Prevent the Patient?

Healthy weight

Drinking habits (avoid

alcohol&caffeine)

Pelvic floor exercises

Avoid smoking
Islamic Point of View

And your Lord has decreed that you not worship

except Him, and let the mother and your father do well
with the best. If one of the two or both until the age
further in the maintenance of you, then occasionally do
not say to both the word "ah" and do not yell at them
and say to them a noble word. " (Al Isra( chapter 17):
Atsar from Ibnu Abbas radhiyallahu anhuma:

"" It is not a Muslim who had both parents were Muslims

who he is on every day to do good to both of them, but God
will open the door for him 2 (heaven). If the old man lived
alone, then the first door that God opened. If he makes
angry / furious one of them, then God is not going up to the
pleasure of his good pleasure. "Someone said," If both parents
dzalim? "Ibn 'Abbas said," Although parents dzalim! "
THANKS FOR ATTENTION