GENITAL PROLAPSE

Dr. Liliana Profire PhD, assistant of the Obstetrics and Gynaecology department professor

Pelvic support anatomy

Anatomy
1. ANTERIOR : URETHRA , BLADDER (central
and lateral ).

2. CENTRAL :
VAGINAL VAULT .

UTERUS ,CERVICAL STUMP,

3. POSTERIOR : RECTUM ,LOOPS OF INTESTINE

(low ,mid , high) .

Anatomy
In upright or sitting position
Bladder, upper two-thirds vagina and rectum lie in a horizontal axis; Urethra, distal one-third vagina and anal canal is vertical oriented; Pelvic floor is horizontal and is like a hammock levator plate.

The pelvic floor, closing the outlet of the pelvis is made up of a number of muscular and facial structures the most important of which is the LEVATOR ANI.
The anterior separation between the LEVATOR ANI called LEVATOR HIATUS;

Inferiorly, the LEVATOR HIATUS is coverd by the UROGENITAL DIAPHRAGM;

 These structures (muscular and facial structures the pelvic floor) are pierced by the RECTUM, VAGINA & URETHRA passing through the exterior of the body; These structures are supported in place by: ligaments; condensation of facia.

Pelvic support
Uterus is supported : primarily by the PELVIC DIAFRAGM, PERINEAL BODY AND THE UROGENITAL DIAFRAGM; secondarily by LIGAMENTS and the PERITONEUM (broad ligaments of uterus).

Pelvic support
1. Uterine ligaments are: I.Transverse,Cardinal or Mackenrodts cervical ligaments; II.Uterosacral ligaments; III.Pubocervical ligaments.
N.B: The broad ligaments, round ligaments and the levator ani muscles dont give support to the uterus.

2. Vagina is supported by the pelvic floor muscles

( the levator ani muscles mainly, the superficial and deep transverse perineal muscles) and by the pelvic floor fascia.

 The levator complex is composed of the pubococcygeus, the iliococcygeus, and the coccygeus muscles. The most medial fibers of the pubococcygeus make up the puborectalis. These fibers arounded the posterior aspect of the rectum and create an anterior displacement of the rectum known as the ANORECTAL ANGLE.

Anatomy of levator complex

Anatomy of levator complex

The pelvic surface of the levator complex is innervated by sacral efferent from S2 through S4. The inferior surface is supplied by the perineal and inferior rectal branches of the pudendal nerve. The levator ani musculature is attached to the inner sides of the bony pelvis by a condensation of pelvic fascia called the arcus tendineus.

Nature of pelvic ligaments

They are not true ligaments; Their main function is balance of pelvic organs; They suspend pelvic organs when the levator support fails; Levator is not repairable nor replicable; Ligaments are repairable or replicable; Ligaments are condensations of a continuum called the endopelvic fascia .

Displacement of the uterus

Definition
Displacement indicates a movement from front to back or from side to side, but not a descending as in prolapse. There are two types of displacement: 1) a change in the long axis of the uterus, for example: anteflexion and retroflexion 2) a change in the direction of the long axis of the uterus in relation to the vaginal canal, for example: lateral, retroversion and retrocession.

 Anteversion the angle between the vagina and cervix (normally 90 degree with empty bladder)/ tilted toward bladder. Anteflexion the angle between the cervical canal and the uterine body (normally 170 degree with empty bladder)/ uterus flexed forward on itself.

Normal position
- Uterus is not fixid in pelvis; - Normally the body & uterine fundus tilting anteriorly & cervix more posterior; - The external os is at the level of the ischial spine; - It is anteverted & anteflexed.

NB! The round and uterosacral ligaments hold the uterus in anteversion. * The uterosacral ligament pull the cervix backward and upward. * The round ligament hold the uterine fundus in the anterior position.

REMEMBER!
Deviations from normal anteversion anteflexion can cause the vaginal prolaps. an

Pathological displacement of the uterus

Retroversion it means that the axis of the cervix becomes behind the vertical axis of female body. Retroflexion uterine body ax becomes behind of the female body ax.

Uterine Displacement Retroverted / Retroflexed Uterus

Uterine Displacement Retroverted / Retroflexed Uterus

Etiology: normal in about 20% of women; inadequacy of endopelvic connective tissue; posterior fundal fibroid (uterine myoma); Degrees of severity: First - fundus is above the promontory . Second - the fundus is below the promontory but still above the external os . Third - the fundus is below the external os.

Uterine Displacement Retroverted / Retroflexed Uterus

Causes Acquired during L&D: 1-bearing down; 2- forceps delivery; 3-breach extraction before fully dilatation. During puerperium: No kegles ex; No sims position. Heavy uterus - fibroid, subinvolution. Lax ligament; pregnancy. Adhesion; inflammation.

Uterine Displacement Retroverted / Retroflexed Uterus

Symptomatology: pelvic pain, backache, abnormal menstruation; infertility, dysparunia; urinary retention [with fibroid or pregnancy].

Uterine Displacement Retroverted / Retroflexed Uterus

Objective signs: Cervix is displaced ; Fundus in Douglass pouch; Absent of the uterus anteriorly; Acute anterior angulation of the vagina; The cervix positioned behind the pubic symphysis; A soft, smooth, nontender mass filling the cul-de-sac.

Uterine Displacement Retroverted / Retroflexed Uterus

Investigations: PV examination -----fixed or mobile uterus; Hystrography---- position of the uterus;
Double pessary test.

Uterine Displacement Retroverted / Retroflexed Uterus

Complication Kinking of the uterine vessels (congestion of
utterus) -- dysmenorrhea,abortion, menorrhagia. Congestion of the ovary: polymenorrhrea, anovulation, mid cyclic pain.

Infertility:
anovulation, cervix away from seminal pool.

Uterine prolapse. Prolapse of tube & ovaries.

Uterine Displacement Retroverted / Retroflexed Uterus

Management
1. Prophylaxis: To labor - avoid bearing down, breach extraction before full dilatation of the cervix; In puerperium - sleeping in semis position empty of bladder , Hodge pessary.

Uterine Displacement Retroverted / Retroflexed Uterus

Management

2. Possible therapies for retroversion or incarceration include: bladder drainage by indwelling cathete; patient positioning exercises (eg, intermittent knee-chest or all-fours positioning, sleeping prone); manipulation of the uterus into its usual anatomic position, with or without tocolysis or anesthesia; colonoscopic manipulation of the uterine fundus under anesthesia; surgical exploration and replacement (almost never indicated); specialized and rarely attempted techniques of replacement (eg, employment of a mercury-filled Voorhees bag in the vagina, amniocentesis with manipulation).

Lateral displacement
May signal adnexal disease such as large ovarian tumor on the opposite side, adhesion, cyst. Corrects it by treating the primary disease.

GENITAL PROLAPSE

GENITAL PROLAPSE
Definition
Genital prolapse is the downward descent of the uterus and /or the vagina towards or through the introitus . The bladder , urethra , rectum and bowel may be secondarily involved

Incidence :
Genital prolapse occurred in about 10-30% of multiparous women and in 2% of nulliparous women .

Types
1. Uterine prolapse: (Utero-vaginal- Acquired or
Congenital. ) 3 degrees of uterine prolapse

First degree : is the descent of the cervix within the vagina . Second degree :is the descent of the cervix through the introitus . Third degree (Procidentia ): is the descent of the cervix and the whole uterus through the introitus.

Types
2. Vaginal prolapse: mild , moderate or severe
vaginal prolapse
Cystocele : is the prolapse of the upper 2/3 of the anterior vaginal wall and the bladder. Urethrocele: is the prolapse of the lowest 1/3 of the anterior vaginal wall and the urethra . Rectocele : is the prolapse of the posterior vaginal wall and the rectum. Enterocele : is a true hernia of the pouch of Douglas through the posterior vaginal fornix - which may contain bowel or omentum. Vault prolapse : is an inversion of the vaginal apex which occur after abdominal or vaginal hysterectomy.

Cystocele and uterovaginal prolapse Rectocele

Vaginal vault prolapse

Enterocele

Enterocele and vaginal prolapse

QUANTIFYING AND STAGING PELVIC ORGAN PROLAPSE

The preferred method to describe and document the severity of POP is the Pelvic Organ Prolapse Quantification (POP-Q) system. The extent of prolapse is evaluated and measured relative to the hymen, which is a fixed anatomic landmark. The anatomic position of the six defined points for measurement is denoted in centimeters above the hymen (negative number) or centimeters below the hymen (positive number)

QUANTIFYING AND STAGING PELVIC ORGAN PROLAPSE

Six points two on anterior vaginal wall two on in superior vagina two on posterior vaginal wall

Three measurements

Etiology
Prolapse is due to weakening after damage to the supporting structures of the pelvic organs as a result of : 1. Childbirth :
Childbirth is the most important risk factor in the development of prolapse.

Factors which increase risk of trauma and denervation to the pelvic support include:
increasing parity, prolonged labour , bearing down before full cervical dilatation and difficult

instrumental deliveries.

Etiology
2. Chronic elevation in intra-abdominal pressure:
factors which increase the intra-abdominal pressure include obesity, smoking; Ilness: chronic cough, chronic constipation, heavy lifting at work , abdominal masses and ascites .

3. Menopause :which leads to weakness of the pelvic support

due to the reduction in the amount of collagen and weakness of the connective tissue

4. Pelvic surgery :

Vault prolapse which may occur after abdominal or vaginal hysterectomy; Rectocele and enterocele which may occur after colposuspension.

Etiology
5. Congenital prolapse , due to congenital reduction in
the amount of collagen and weakness of connective tissue of the pelvic support Is responsible for the occurrence of prolapse in 2% of nulliparous women .

6.

Racial variation .
Prolapse is common for Caucasian women, less common for Asians , and rare for Blacks; This racial variation is explained by the variation in the amount of collagen and connective tissue in the pelvic support . Is greater for Blacks and lesser for Caucasian.

Effects of prolapse
NO SYMPTOM- mild & moderate prolapse; Discomfort & disability; Sexual Dysfunction; URINARYFrequency, Dysuria, Stress incontinence, infection; Incomplete emptying of rectum; Discharge; Backache; Ulceration & Infection;.
Management of Genital Prolapse Prof.S.N.Panda 47

2 January, 2014

Diagnosis :
A. History
1. Symptoms: which depends on the site , type & on the degree of the
prolapse:
A feeling of something coming down below or a lump within the vagina or protruding from the introitus, is almost always present in all types of prolapse which is worse at the end of the day , increased on standing and coughing, and relieved by lying down. Other symptoms , depends on the organ which has prolapsed into the vagina: in case of uterine prolapse: low backache, which is central, worse at the end of the day , increased on standing and relieved by lying down; in case of cystocele : urinary symptoms such as stress incontinence, frequency , reccurent UTI , urgency , incomplete emptying of the bladder and the patient may has to reduce the cystocele digitally in order to be able to empty her bladder

Diagnosis :
in case of rectocele : constipation , incomplete rectal evacuation and the patient may has to reduce the rectocele digitally to be able to empty her rectum. in case of procidentia : ulceration, blood stained or purulent vaginal discharge.

Coital problems such as uncomfortable or difficult intercourse occur in

uterine and vaginal prolapse

Diagnosis :
B. Examination (signs)
Inspection of the vulva with cough and straining demonstrate severe prolapse and may demonstrate stress incontinence (provided the bladder is full); Speculum examination either in dorsal position using Bivalve speculum or in left lateral position using Sims speculum; Rectal examination, to differentiate between rectocele (finger goes through it) from enterocele ( finger goes high up).

Diagnosis :
C.Differential diagnosis :
Anterior vaginal wall prolapse to be differentiated from congenital Gartners cyst, dermoid cyst & urethral diverticulum ; Uterine prolapse- to be differentiated from large cervical or endometrial polyp & chronic uterine inversion. MSU for analysis and culture . Renal ultrasound and IVU in cases of procidentia and severe cystocele to exclude hydroureter & hydronephrosis which may occur as a result of kinking of the ureters; Cystometry in cases of incontinence , in order to exclude urge incontinence .

D.Investigations :

Prevention
Genital prolapse is a preventable disease
Prevention and limiting injury to pelvic support during childbirth by : avoiding of: prolonged labour , bearing down before full cervical dilatation and difficult instrumental delivery; encouragment of postnatal pelvic floor exercises ; family planning and smaller family size. Avoiding and treating factors which increase the intraabdominal pressure such as obesity , smoking, chronic cough and chronic constipation Prevention of postmenopausal atrophy of pelvic support by balanced diet, exercise, calcium & by the increased use of HRT.

Treatment
Methods :

Non-surgical methods: - limited role

Pelvic floor rehabilitation (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium); Hormone replacement, both systemic and local; Pessaries.
- Surgical treatment .- Reconstructive surgery is invariably needed and has to be a combination of procedures to correct the multiple defects.

Treatment
Choice of method - depends on the followings:
Age, fitness and wish of the paitent ;
Parity and wish for further pregnancy;

degree of uterine prolapse.

General measures :
Treatment of urinary tract infection; Avoiding and treating factors which increase the intra-abdominal pressure such as smoking, obesity, chronic cough and chronic constipation; Use of HRT in menopausal patients; Reducing the procidentia and treatment of ulceration with oestrogen cream. The ulcer will usually heal within 7 days .

Treatment
Pessaries :
Indications :
Patient unfit for surgery ; Patient refuses surgery ; During pregnancy and after delivery ; During waiting time for surgery; As a therapeutic test to confirm that surgery may help .

Types :
Ring pessary commonly used pessary; Shelf pessary rarely used.

Side effects:
Vaginal infection and discharge ; Vaginal ulceration and bleeding .

Precautions - to minimize side effects:

Use of silicon pessary - rubber pessary should not be used; Change the pessary yearly - or earlier if infection or ulceration occurred ; Use of vaginal ostrogen cream in menopausal patients .

Treatment
Surgical treatment - the definitive treatment of prolapse 1. Preoperative assessment and preparation of the patient:
Choice of operation depends on : 1. Type of prolapse 2. Age and parity of the patient The aims of surgery are : to correct the prolapse , maintain continence and preserve coital function. Success of the surgery depends on: 1. Preoperative preparation of the patient such as reduce weight in obese, stop smoking and treatment of chronic cough .
N.B : The gynecologist cant do his part unless the patient fulfills her

2.

Postoperative care

Preoperative preparation
The following steps are recommended prior to the start of the procedure: Antiseptic vaginal preparation; Shaving or clipping of the pubic or vulvar hair; Bowel preparation or preoperative enema; Cleansing of the entire surgical area with appropriate antiseptic. The following steps are to be considered optional: Placement of an in-dwelling catheter after a urine culture has been performed; Placement of lubricated packing in the rectum; Infiltration of the vaginal wall by saline with a vasoconstrictive solution to ease dissection and reduce bleeding; Administration of antibiotics.

Classisfication of prolapse surgery

Vaginal
Abdominal Laparoscopic
All of the Abdominal procedures +/reinforcement Primary Primary Vaginal hysterectomy Paravaginal repair Anterior/Posterior repair Hysteropexy Secondary Sacrospinous fixation Iliococcygeus fixation Uterosacral fixation

Secondary +- reinforcement Sacrocolpopexy Uterosacral/Sacrospinous fixation

Recurrent+/- reinforcement Synthetic mesh/autologous/ donor/Xenograft

Treatment
2. Operations : A. Uterine prolapse operations : I. Vaginal hysterectomy is the preferred operation in uterine prolapse
Indicated in young patients who complete the family and in menopausal patients .

II. Manchester ( Fothergill ) operation.

Indicated in young patients who not complete the family. Consisted of :
1. Partial amputation of the cervix ; 2. Shortening of the transverse cervical ligaments and suturing them to the front of cervical stump. 3. Anterior and posterior repair.

III. Sacrohysteropexy
Indicated in patients who complete the family and wish to conserve the uterus .

Treatment
2. Operations : B. Vaginal prolapse operations : I. Anterior repair / anterior colporrhaphy, indicated in Cystocele and Urethrocele; II. Posterior repair / posterior colpoperineorrhaphy, indicated in Rectocele; III. Resection of enterocele sac, indicated in Enterocele; IV. Abdominal sacrocolpopexy/ Abdominal Sacral Colpopexy, indicated in Vault prolapse (the procedure is performed by attaching a synthetic mesh material to the vaginal apex (deepest part of the vagina) and suspending it to the sacrum (end of the backbone).

C. Le-Forts operation :
rarely indicated in elderly and frail patients who are unfit for vaginal hysterectomy or pelvic floor repair; rectangular strips of vaginal epithelium are removed from the anterior and posterior vaginal walls in order to obtain a partial closure of the vagina.

Treatment
D. Colpocleisis, indicated to elderly women who suffer from vault prolapse after previous hysterectomy. E. Abdominal Sling Operations - Designed for young women who are suffering from second or third degree prolapse.

Anterior repair / anterior colporrhaphy

Vaginal epithelium should be separeted from underlying fibromuscular tissue; midline plication of the vaginal musculature with interrupted stiches; excision of exess epithelium and closure.

Posterior repair / posterior colpoperineorrhaphy

Vaginal epithelium separeted from the underlying fibromuscular tissue (rectovaginal septum, in between the vaginal muscularis and the rectovaginal adventitia); midline plication of the vaginal musculature with interrupted stiches; excision of exess epithelium and closure.

Resection of enterocele sac

Whether by vaginal, abdominal or laparascopic access; Sharply dissecting the peritoneal sac from the rectum and bladder; A purse string suture can be used to close the peritoneum as high is possible (for preventing the organs trauma).

Treatment
3. Postoperative care Immediate postoperative care :
Vaginal pack which should be removed within 24 hours; Foleys catheter, should be removed after 1- 2 days; Prophylactic antibiotics: Metronidazole and cephalosporin.

Instructions after discharge - to minimize recurrence:

Avoiding intercourse for 6 weeks; Gradual return to normal activities over 2 months; Avoiding smoking,obesity,constipation and lifting of heavy objects; Elective C.S. in the subsequent pregnancy.

Recurrent prolapse
Recurrence occur in about 20-25%; Even with expert surgery and good postoperative care, recurrence can occur, especially in the presence of obesity, smoking and constipation .

Urinary Incontinence

Anatomy of lower urinary tract

Urethra in adult female:
Muscular tube, 3-4 cm in length; Surrounded mainly by smooth muscles; Striated urethral sphincter:
surrounds middle third of urethra. contributes about 50% of the total urethral resistance & serves as a secondary defense against incontinence.

Bladder detrusor muscle:

smooth muscle that appears as a meshwork of fibers; has 3 distinct layers: outer longitudinal, middle circular & inner longitudinal.

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Anatomy
Innervation:
Parasympathetic fibers:
Originate in sacral spinal cord segments S2 through S4. Stimulation / administration of cholinergic drugs: detrusor muscle contraction. Anti-cholinergic drugs vesicle pressure & bladder capacity.

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Anatomy
Sympathetic fibers:
Originate from thoraco-lumbar segments (T10 to L2) of spinal cord. Have & -adrenergic components:
-adrenergic stimulation: contracts bladder neck & urethra + relaxes detrusor. -adrenergic stimulation: relaxes urethra & detrusor muscle.

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Anatomy of Micturition
- CNS control:
Pons facilitates: Cerebral cortex inhibits.

Hormonal effects estrogen; Detrusor muscle; External and Internal sphincter; Normal capacity 400-500 ml; First urge to void 150-200 ml.

Peripheral Nerves in Micturition

Factors influencing bladder behavior

A. Sensory innervation:
Afferent impulses from bladder, trigone, proximal urethra pelvic hypogastric nerve S2 to S4 levels of spinal cord. Sensitivity of these nerve endings may be enhanced by:
a. b. c. d. Acute infection. Interstitial cystitis. Radiation cystitis. Intra-vesical pressure in: standing / bending forward position.; a/w obesity, pregnancy, pelvic tumors.

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Factors influencing bladder behavior

Inhibitory impulses relayed by pudendal nerve also pass thru S2 thru S4 following mechanical stimulation of perineum & anal canal. Their passage may explain why pain in this region can cause urinary retention.

B. CNS: Mental, environmental & sociologic disturbances may profoundly alter micturition patterns.
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Definition of urinary incontinence

Def. Involuntary loss of urine that is objectively

demonstrable & is a social / hygienic problem. Affects 10-25% of women 65, 15-30% of noninstitutionalized women 65 years, >50% of nursing home residents. Pts often rely on absorbent pads / changes in their life style to cope with the condition. They become socially isolated as a result of restricting their interactions with friends & family members.
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Categories of Incontinence
Urge incontinence Stress incontinence Mixed incontinence Overflow incontinence Functional incontinence

Stress incontinence
Definition. Involuntary loss of drops of urine through intact urethra, with sudden in intraabdominal pressure & in absence of bladder contraction.

Causes:
a. Weakness of pelvic floor musculature (due

to child bearing, previous abdominal/pelvic surgery). b. Damage / weakness of urethra or sphincter (e.g. hypo-estrogen of menopause, child bearing).

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Stress incontinence
Mechanism:
a. Proximal urethra drops below pelvic floor because of pelvic relaxation defects intra-abdominal pressure is not transmitted equally to bladder & proximal urethra i.e. bladder pressure > abdo pressure. b. The second possible mechanism is intrinsic sphincter deficiency

Degrees:
Grade I incontinence with severe stress (sneezing, coughing, jogging). Grade II incontinence with moderate stress (rapid movement, waking up & down stairs). 81 Grade III incontinence with mild stress (standing up).

Stress incontinence
Diagnosis:
History: age, PMHx (previous abdo/pelvic surgery), obstetric ( of deliveries). Pelvic exam: Inspection of vaginal walls with Sims speculum allows visualization of anterior vaginal wall & urethro-vesical junction. Scarring, tenderness, rigidity of urethra from previous vaginal surgeries / pelvic trauma may be reflected by scarred anterior vaginal wall. Because distal urethra is estrogen-dependent, pt with 82 atrophic vaginitis also has atrophic urethritis.

Stress incontinence
Investigations:
A. Stress test objective test:

Patient is examined with full bladder in lithotomy position. While physician observes urethral meatus, patient is asked to cough. Stress type is suggested if short spurts of urine escape simultaneously with each cough. Delayed leakage / loss of large volumes of urine suggests uninhibited bladder contractions. If not demonstrated repeat with pt in standing position.
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Stress incontinence
Ultrasound to check: Inclination of urethra; Flatness of bladder base; Mobility & funneling of urethra-vesical junction, both to rest & with Valsalva maneuver; Bladder / urethral diverticula. B.

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Stress incontinence
C. Urethro-cystoscopy performed preoperatively to observe: Amount of residual urine; Bladder capacity (normal = 400-500 ml of water); Appearance of urethral & bladder urothelium, noting any inflammation, diverticula, or trabeculation.
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Stress incontinence
D. Urodynamic studies: Cystometrogram: differentiates

b/w

stress

&

uninhibited detrusor contraction:

Distend bladder with known volumes of H2O / CO2 observe pressure changes in bladder during filling. Pt is asked about sensation of bladder fullness indicates status of sensory innervation of bladder. Check for presence / absence of detrusor reflex a/w strong desire to void. Critical volume (400-500 mL) is capacity that bladder musculature tolerates before pt experiences a strong desire to urinate.
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Stress incontinence
Uroflowmetry:

Records rates of urine flow through urethra when patients is asked to void spontaneously while sitting on uroflow chair.

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Stress incontinence
Voiding cysto-urethro-gram (VCUG): In this radiologic Ix, fluoroscopy is used to observe:
Bladder filling to know bladder size & competency of its neck during coughing. Mobility of urethra & bladder base. Bladder trabeculation, vesico-ureteral reflux during voiding, outflow obstruction.

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Stress incontinence
Treatment:
Non-medical:
Pads. Kegal exercises (pelvic diaphragm exercises):
Improves / cures mild stress incontinence. Require diligence & willingness to practice at home & at work.

Drugs:
Estrogens: (orally, transdermally or transvaginally)
sensory threshold for involuntary detrusor contractions. For atrophic urethritis improve urethral closing pressure, mucosal thickness & possibly reflex urethral functions.

-adrenergic stimulants (Pseudoephedrine, Phenylephrine) enhances urethral closure & improves continence (Sudafed, Ornade).
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Stress incontinence
Most commonly employed. Surgery is reported to cure 4 out of 5 cases, but success rate drops to 50% after 10 years. Aim: to correct pelvic relaxation defect & to stabilize & restore the normal intra-abdominal position of proximal urethra. Approach may be vaginal, abdominal, or combined abdomino -vaginal.
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Surgical:

Urge incontinence
Definition. Urine loss due to uninhibited bladder contractions (detrusor instability).
Causes:
a. b. c.

Unknown in most cases. Local bladder irritation (e.g. cystitis, stone, tumor). CNS disorder.

CFx: urinary urgency, frequency, urge incontinence, nocturia. Dx:

Hx: signs of cystitis (frequency, urgency), PMHx (CNS disorder). Systematic CNS exam. Urine C & S exclude infection. Urodynamics (cystourethrogram): demonstrates uninhibited contractions if unstable bladder, or, small bladder capacity if irritable bladder.
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Urge incontinence
Treatment:
a) Drugs: its reasonable to try several drugs, dose up to max. tolerated, until the most effective drug for a particular pt is found: Anti-cholinergics: most frequently employed agents (Oxybutinin / Pro-pantheline). -Sympathomimetics (Meta-protere-nol). Estrogens: sensory threshold for involuntary detrusor contractions. For atrophic urethritis improve urethral closing pressure, mucosal thickness & possibly reflex urethral functions. Smooth muscle depressant (Flavoxate). Diazepam (Valium): smooth muscle relaxant + anti-cholinergic effect + CNS sedation. TCAs (Imipramine): have anti-cholinergic action + enhances 92 continence by its -adrenergic stimulation of urethra.

Urge incontinence
b) Bladder training: Represents behavior modification designed to repeat process of toilet training. Aim is to bladder capacity day by day & to prolong intervals b/w voiding.

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Mixed Incontinence
Features of both urge and stress incontinence. Common in older women Management: bladder retraining, pelvic muscle exercises, other pelvic muscle rehabilitative options outlined previously, pharmacologic agents.

Overflow incontinence
3. Overflow: Urine loss when intra-vesical pressure exceeds urethral pressure. Causes:
Hypotonic bladder = Detrusor-sphincter dyssynergia due to:
DM, autonomic neuropathy, LMN disease, spinal cord injuries.

Outflow obstruction (e.g. stricture). Ask about: straining to void, poor stream, urinary retention, incomplete emptying.

Best Mx: Self-catheterization.

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Functional incontinence
4. Functional: Urine loss caused by inability to reach toilet in time. Does not involve lower urinary tract Result of psychological, cognitive or physical impairment

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