{"id":9627,"date":"2019-11-26T09:57:06","date_gmt":"2019-11-26T09:57:06","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=9627"},"modified":"2019-11-26T09:57:06","modified_gmt":"2019-11-26T09:57:06","slug":"9627-2","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/9627-2\/","title":{"rendered":"Incontinen\u021ba urinar\u0103"},"content":{"rendered":"

\"\"<\/a>Autori:<\/strong><\/p>\n

Dr. Cornel Petre-Ciudin,<\/strong><\/em><\/p>\n

medic primar medicin\u0103 de familie,\u00a0 atestat \u0219i formator \u00een \u00eengrijiri paliative<\/em><\/p>\n

cornelciudin@yahoo.com<\/strong><\/em><\/p>\n

0745.639.930<\/p>\n

 <\/p>\n

Incontinen\u0163a urinar\u0103 (i.u.) este definit\u0103 ca fiind pierderea involuntar\u0103 de urin\u0103, par\u0163ial\u0103 sau total\u0103, continu\u0103 sau sporadic\u0103, la efort sau la repaus ori manifestat\u0103 prin senza\u0163ie imperioas\u0103 de mic\u0163iune, care se consum\u0103 \u00eenainte ca pacientul s\u0103 ajung\u0103 la toalet\u0103. Poate ap\u0103rea la orice v\u00e2rst\u0103 dar este mai frecvent\u0103 la persoanele v\u00e2rstnice \u015fi la femei. Afecteaz\u0103 1 din 5 adul\u0163i, frecven\u0163a cresc\u00e2nd la 1 din 3 \u00een r\u00e2ndul persoanelor v\u00e2rstnice.<\/p>\n

D<\/strong>e\u0219i i.u. este frecvent\u0103, tratabil\u0103 \u0219i frecvent vindecabil\u0103, aceasta este deseori nediagnosticat\u0103 \u0219i netratat\u0103, afect\u00e2nd semnificativ calitatea vie\u021bii, din cauza jenei, a fricii de a ie\u0219i din cas\u0103, a izol\u0103rii sociale \u00een special la v\u00e2rstnici, a costurilor produselor de \u00eengrijire. I.u. este o cauz\u0103 major\u0103 de spitalizare \u0219i institu\u021bionalizare pe termen lung (al\u0103turi de demen\u021be \u0219i imobilizare) nu at\u00e2t \u00een speran\u021ba unei vindec\u0103ri, c\u00e2t de a elimina din familie o situa\u021bie dezagreabil\u0103 \u0219i de a evita costurile mari de \u00eengrijire, ce nu pot fi ignorate.<\/p>\n

Cauze \u0219i tipuri.<\/u><\/strong> Identificarea paternului clinic este util\u0103 dar duce la suprapuneri, iar tratamentul este acela\u0219i.<\/p>\n

    \n
  1. i.u. tranzitorie, este mult mai probabil\u0103 c\u00e2nd au trecut mai pu\u021bin de \u0219ase s\u0103pt\u0103m\u00e2ni de la debut \u0219i se rezolv\u0103 spontan, c\u00e2nd boala de baz\u0103este tratat\u0103. Pentru reamintirea cauzelor acestui tip de i.u., \u00een practica clinic\u0103 se poate folosi formula mnemotehnica DIAPPERS: D – delir, I – infec\u021bie urinara, A – atrofia tractului genitourinar, P – farmaceutice (ex. diuretice, cafeina, alcool, alfa 1 blocante, benzodiazepine, hipnotice, tranchilizante, antidepresive, laxative), P – patologie psihiatric\u0103 (ex. demente), E – tulbur\u0103ri endocrine (ex. hiperglicemie, D.Z., diabet insipid, hiperparatiroidism, hipecalcemie), R – restric\u021bionarea mobilit\u0103\u021bii (ex.atac vascular cerebral, tulbur\u0103ri de mobilitate, artrite, tulbur\u0103ri de vedere), S – scaun impactat (fecalom);<\/li>\n
  2. i.u. din cauza necesita\u021bii imperioase de a urin\u0103, cea mai frecvent\u0103 cauz\u0103 la persoanele v\u00e2rstnice. Reprezint\u0103 nevoia brusc\u0103 \u0219i intens\u0103 de a urina ce nu poate fi inhibat\u0103 \u0219i este urmat\u0103 de pierderea incontrolabil\u0103 de urin\u0103. Frecvent nu are o cauz\u0103 clar\u0103. Poate fi cauzat\u0103 de asocierea dintre hiperactivitatea mu\u0219chilor vezicii urinare cu sc\u0103derea capacit\u0103\u021bii de contrac\u021bie a acestora.<\/li>\n<\/ol>\n

    Mai este \u00eent\u00e2lnit\u0103 \u00een tumori intrinseci interes\u00e2nd \u00een special trigonul \u0219i colul vezical, modific\u0103ri inflamatorii post-radioterapie, chimioterapia cu ciclofosfamid\u0103, infec\u021bii bacteriene, tulbur\u0103ri neurologice din insuficien\u021ba cerebrovascular\u0103 (scleroz\u0103 multipl\u0103, demen\u021b\u0103 vascular\u0103, encefalite \u0219i meningoencefalite, sindrom de neuron motor) sau neuropsihice (neurastenie, isterie).<\/p>\n

      \n
    1. i.u. de preaplin, reprezint\u0103 sub 5 % din cazurile de i.u. la femei \u0219i de 30-50 % dintre cazurile de i.u. la b\u0103rba\u021bi \u0219i v\u00e2rstnici, din cauza prevalen\u021bei bolilor prostatei. Este cauzat\u0103 de obstruc\u021bia fluxului urinar sau prin afectarea contractilit\u0103\u021bii detrusorului. Constipa\u021bia poate determina i.u. de preaplin dac\u0103 materiile fecale umplu rectul \u00eenc\u00e2t vor comprima colul vezical \u0219i uretra. Anticolinergicele (antihistamine, benztropine, antidepresive) ca \u0219i opioidele (morfina, oxicodona, codeina s.a.), pot afecta contrac\u021biile vezicii urinare \u0219i pot determina i.u.de preaplin ca \u0219i leziunile nervoase care conduc la paralizia vezicii urinare (vezica neurogen\u0103);<\/li>\n
    2. i.u. de efort sau de stres se caracterizeaz\u0103 prin pierderea involuntar\u0103 de urin\u0103 \u00een situa\u021bii de efort fizic sau ca urmare a efortului de str\u0103nut, tuse, r\u00e2s, alergare, ridicat de mari greut\u0103\u021bi sau schimbarea pozi\u021biei din clino \u00een ortostatism, c\u00e2nd cre\u0219te brusc presiunea intra abdominal\u0103. Este legat\u0103 de cre\u0219terea mobilit\u0103\u021bii uretrale \u0219i\/sau func\u021bionarea deficitar\u0103 a sfincterului intrinsec (poate ap\u0103rea \u0219i la femei pospartum sau dup\u0103 unele interven\u021bii chirurgicale cum sunt cele pe prostat\u0103 la b\u0103rba\u021bi). Obezitatea poate cauza sau agrava incontinen\u021ba de stres. Unele persoane cu i.u. de stres sever\u0103, prezint\u0103 pierderi urinare aproape constante, denumite uneori incontinen\u021b\u0103 total\u0103.<\/li>\n
    3. i.u. mixta apare c\u00e2nd sunt prezente simultan dou\u0103 sau mai multe cauze enumerate mai sus, cel mai frecvent, i.u. din cauza necesit\u0103\u021bii imperioase de a urina \u00een combina\u021bie cu o alt\u0103 cauz\u0103. Este foarte frecvent\u0103 \u0219i poate ap\u0103rea la aproximativ la 50 % dintre pacien\u021bii cu i.u. De exemplu, copiii pot avea incontinen\u021b\u0103 determinat\u0103 at\u00e2t de leziuni nervoase c\u00e2t \u0219i de factori psihologici. La b\u0103rba\u021bi pot ap\u0103rea i.u. de preaplin din cauza hipertrofiei de prostat\u0103 \u0219i incontinen\u021ba imperioas\u0103 din cauza unui accident vascular cerebral, iar la femeile v\u00e2rstnice, poate ap\u0103rea acest tip de incontinen\u021b\u0103 mixt\u0103 prin asocierea i.u. imperioase cu incontinen\u021ba de stres;<\/li>\n
    4. i.u func\u021bional\u0103 reprezint\u0103 incapacitatea sau refuzul de a merge la toalet\u0103, din cauza unor factori fizici, cognitivi, psihici sau de mediu (de exemplu un pacient, \u00een special institu\u021bionalizat \u0219i imobilizat fizic sau cu depresie sever\u0103);<\/li>\n
    5. vezica urinar\u0103 hiperactiv\u0103 se refer\u0103 la necesitatea frecvent\u0103 \u0219i urgent\u0103 de a urina f\u0103r\u0103 incontinen\u021b\u0103 urinar\u0103;<\/li>\n
    6. factori de risc. La femei, \u00eenaintarea \u00een v\u00e2rst\u0103, na\u0219terile (pe filiera pelvi-genital\u0103, v\u00e2rsta la na\u0219tere, greutatea f\u0103tului), unele medicamente, diabetul zaharat, obezitatea, irita\u021bia vezicii urinare, tulbur\u0103ri neurologice ca boala Parkinson, scleroza multipl\u0103, contraceptivele orale sau tratamentul hormonal, histerectomia, menopauza, prolapsul de organe pelvine.<\/li>\n<\/ol>\n

      La b\u0103rbat, hipertrofia benign\u0103 de prostat\u0103, prostatectomia, acelea\u0219i afec\u021biuni neurologice \u0219i metabolice men\u021bionate mai sus.<\/p>\n

      Diagnostic.<\/u><\/strong> Evaluarea ini\u021bial\u0103 a pacientului include istoricul medical general \u0219i \u00eentreb\u0103ri specifice legate de simptome de tract urinar, func\u021bia colonic\u0103 \u0219i sexual\u0103 \u0219i prolapsul de organe pelvine. Elementele de baza ale istoricului de tract urinar inferior includ durata, frecven\u021ba \u0219i severitatea pierderii de urin\u0103, factorii precipitan\u021bi \u0219i simptomele asociate. Trebuie evaluate medicamentele pe care le ia pacientul pentru a identifica interac\u021biunile medicamentoase \u0219i efectele secundare, consumul de alcool, cafein\u0103. Trebuie evaluat gradul \u00een care i.u. afecteaz\u0103 via\u021ba pacientului, fapt realizat prin \u00eentreb\u0103ri directe sau folosind diverse chestionare (ca de exemplu Urogenital Distress Inventory Short Form si Incontinence Impact Questionaire Short Form). De asemenea poate fi util un jurnal al mic\u021biunilor \u00een care pacientul este sf\u0103tuit s\u0103 noteze simptomele pe care le prezint\u0103 \u0219i informa\u021bii despre frecven\u021ba \u0219i circumstan\u021bele episoadelor de incontinen\u021b\u0103.<\/p>\n

      Simptome.<\/u><\/strong> 1. <\/strong>nevoia imperioas\u0103 de a urina, primul simptom al contrac\u021biilor vezicale necontrolate; 2.<\/strong> pierderea de urin\u0103 la efortul de tuse, la str\u0103nut sau alte eforturi fizice precum cobor\u00e2tul sc\u0103rilor, alergat; 3. <\/strong>picurarea post urinar\u0103 este un simptom al incontinentei de preaplin, simptom care se accentueaz\u0103 la schimbarea pozi\u021biei corpului sau la manevra Valsalva; 4. <\/strong>disconfortul abdominal, care apare la pacien\u021bii cu incontinen\u021b\u0103 de preaplin din cauza distensiei vezicii urinare, \u00een special dac\u0103 retentia urinar\u0103 a debutat recent; 5. <\/strong>semne de gravitate care includ hematuria macroscopic\u0103, persisten\u021ba, durerea pelvin\u0103 constant\u0103 sau care se agraveaz\u0103 \u0219i debutul brusc. Aceste simptome impun trimiterea de urgen\u021b\u0103 la urologie, pentru interven\u021bii specifice.<\/p>\n

      Examenul fizic trebuie s\u0103 includ\u0103 \u0219i evaluarea statusului cognitiv \u0219i func\u021bional pe l\u00e2ng\u0103 examinarea neurologic\u0103, abdominal\u0103 \u0219i pelvin\u0103. La femei este necesar examenul ginecologic \u0219i tuseul rectal, iar la b\u0103rba\u021bi, trebuie s\u0103 se includ\u0103 obligatoriu examenul prostatei \u0219i tuseul rectal.<\/p>\n

        \n
      1. la toate pacientele cu i.u., se efectueaz\u0103 testul la tuse,<\/li>\n
      2. se evalueaz\u0103 statusul mintal,<\/li>\n
      3. se evalueaz\u0103 func\u021bia reflex\u0103, motorie sau senzorial\u0103,<\/li>\n
      4. distensia abdominal\u0103 sau o vezica urinar\u0103 palpabil\u0103, este sugestiv\u0103 pentru i.u. asociat\u0103 cu i.u de preaplin,<\/li>\n
      5. vaginita atrofic\u0103 indic\u0103 posibilitatea unei incontinen\u021be din cauza vezicii iritabile responsive la extrogeni,<\/li>\n
      6. prolapsul organelor pelviene, asociat\u0103 frecvent cu incontinen\u021b\u0103 de efort,<\/li>\n
      7. hipertrofia \u0219i tumorile de prostat\u0103 sugereaz\u0103 i.u de preaplin prin obstruc\u021bia fluxului urinar,<\/li>\n
      8. fecalomul, care \u0219i el sugereaz\u0103 i.u. de preaplin prin obstruc\u021bie uretral\u0103.<\/li>\n<\/ol>\n

        Examene de laborator. Testele efectuate de rutina sunt: sumarul de urin\u0103 \u0219i urocultur\u0103; m\u0103surarea nivelurilor electrolitilor, glucozei, ureei, creatininei serice; volumul rezidual postgolire (determinat prin cateterism sau ultrasonografie). Volumul rezidual postgolire plus volumul eliminat, estimeaz\u0103 capacitatea total\u0103 a vezicii urinare \u0219i ajut\u0103 la evaluarea propioceptorilor vezicali.<\/p>\n

        Testarea urodinamic\u0103 este indicat\u0103 atunci c\u00e2nd examinarea \u0219i testele de mai sus nu pun diagnosticul \u0219i include:\u00a0 l\u00a0 cistometria care se face pentru a confirma incontinen\u021ba cu senza\u021bia imperativ\u0103 de a urina \u0219i pentru a determina dac\u0103 etiologia este contrac\u021bia inadecvat\u0103a detrusorului; l testarea ratei fluxului urinar se face pentru a confirma sau exclude obstruc\u021bia colului vezical la b\u0103rba\u021bi (cauzat\u0103 de obicei de o boal\u0103 prostatic\u0103); l cistometrografia care poate evalua func\u021bia sfincterian\u0103, se face dac\u0103 toate celelalte evalu\u0103ri nu au ar\u0103tat cauza incontinen\u021bei. \u00cen anumite centre dotate cu echipament specializat, se pot corela contrac\u021bia vezicii urinare cu competen\u021ba colului vezical \u0219i sinergia detrusor-sfincter.<\/p>\n

        Alte teste specializate includ video-cistouretrografia, teste videourodinamice, ecografia, R.M.N.<\/p>\n

        Tratament. Se trateaz\u0103 cauzele specifice iar medicamentele care pot determina sau agrava incontinen\u021ba, sunt stopate sau schema de administrare este modificat\u0103.<\/p>\n

        M\u0103surile generale care sunt de mare ajutor indiferent de tipul sau cauza incontinen\u021bei: l modificarea aportului de lichide. Acesta trebuie limitat \u00een anumite momente (\u00eenainte de culcate sau de a ie\u0219i afar\u0103), se vor evita lichidele care irit\u0103 vezica. Se vor ingera 1500-2000 ml. pe zi; l antrenamentul vezicii urinare care implic\u0103 de obicei goliri la anumite momente (la fiecare 2-3 ore), pacientul fiind treaz. Educarea vezicii reprezint\u0103 tratamentul de elec\u021bie pentru i.u. de urgen\u021b\u0103 \u0219i implic\u0103 \u00eencurajarea pacientului de a am\u00e2na c\u00e2t mai mult posibil, momentul ; l exerci\u021bii pentru musculatura pelvina (Kegel) amelioreaz\u0103 simptomele i.u. de urgen\u021b\u0103 \u0219i pot necesita p\u00e2n\u0103 la \u0219ase luni de antrenament.<\/p>\n

        Terapie farmacologic\u0103.<\/u><\/strong> Anticolinergice (antimuscarinice), oxybutinina oral\u0103 2,5-5 mg. de 2-4 ori pe zi, tolterodina 1-2 mg. de 2ori pe zi, darifenacin 7,5-15 mg. pe zi solifenacin 5-10 mg. pe zi sau trospium 20mg. de 2 ori pe zi, scobutil (hioscinscopolamina) 10 mg. x3 pe zi oral.<\/p>\n

        Antidepresive cu efect antimuscarinic, anticolinergic: imipramina (feniramin) 25-50 mg. x 1 pe zi, amitriptilina 25-50 mg. seara mai ales la pacien\u021bii cu insomnii;<\/p>\n

        Altele \u00een cazul intoleran\u021bei la antimuscarinice \/ anticolinergice: flevoxate 200-400mg. x 3\/zi oral, efect musculotrop, terbutalina 5 mg. p.o. simpatomimetic, AINS – flubriprofen, 50-100mg. x2 \/zi p.o., naproxen 250-500 mg. x3 \/ zi p.o. i.r., fenazopiridina 100-200 mg. x 2 \/zi (analgezic topic).<\/p>\n

        Se afl\u0103 \u00een curs de evaluare introducerea a like- hormonilor HAD, desmopresin, spray intranazal.<\/p>\n

        Interven\u021bie chirurgical\u0103: colposupresie retropubian\u0103 sau proceduri de dislocare suburetral\u0103.<\/p>\n

        Complica\u021bii: <\/u><\/strong><\/p>\n

        l ureterohidronefroza \u00een cazul i.u. prin preaplin secundar\u0103 unei reten\u021bii cronice de urin\u0103 complicat\u0103 mai departe cu insuficien\u021ba renal\u0103 cronic\u0103 reversibil\u0103 sau nereversibil\u0103 dac\u0103 s-a \u00eent\u00e2rziat deblocarea la timp a obstruc\u021biei urinare; l irita\u021bii cauzate de cateterul vezical; l irita\u021bia tegumentelor in cazul fistulelor uro-tegumentare, vaginale, rectale; l decubitus \u0219i agravarea leziunilor preexistente \u00een special la bolnavii imobiliza\u021bi la pat; l tulbur\u0103ri neuro-psihice, anxietate, depresie, insomnii; l\u00a0 tulbur\u0103ri ale activit\u0103\u021bii sexuale consecin\u021be ale polakiuriei, nocturiei \u0219i depresiei secundare. \u00a0\u00a0\u00a0\u00a0\u00a0 (Bibliografia se afl\u0103 la autor) <\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

        Autori: Dr. Cornel Petre-Ciudin, medic primar medicin\u0103 de familie,\u00a0 atestat \u0219i formator \u00een \u00eengrijiri paliative cornelciudin@yahoo.com 0745.639.930   Incontinen\u0163a urinar\u0103 (i.u.) este definit\u0103 ca fiind pierderea involuntar\u0103 de urin\u0103, par\u0163ial\u0103 […]<\/p>\n","protected":false},"author":9,"featured_media":9635,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[33,661],"tags":[],"class_list":["post-9627","post","type-post","status-publish","format-standard","has-post-thumbnail","category-articole","category-nefrologie-articole"],"yoast_head":"\nIncontinen\u021ba urinar\u0103<\/title>\n<meta name=\"description\" content=\"Incontinen\u021ba urinar\u0103Autori: Dr. Cornel Petre-Ciudin, medic primar medicin\u0103 de familie, atestat \u0219i formator \u00een \u00eengrijiri paliative cornelciudin@yahoo.com\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/jurmed.ro\/medici\/9627-2\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Incontinen\u021ba urinar\u0103\" \/>\n<meta property=\"og:description\" content=\"Incontinen\u021ba urinar\u0103Autori: Dr. Cornel Petre-Ciudin, medic primar medicin\u0103 de familie, atestat \u0219i formator \u00een \u00eengrijiri paliative cornelciudin@yahoo.com\" \/>\n<meta property=\"og:url\" content=\"https:\/\/jurmed.ro\/medici\/9627-2\/\" \/>\n<meta property=\"og:site_name\" content=\"Jurmed - 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