URINARY INCONTINENCE

BY Professor Dr. Engy Taher

 The pelvis is a basin with 4 walls & floor.

Front wall: back of symphysis pubis. Back wall: sacrum & pyriformis muscle. 2 side walls: obturator internus muscle. Floor.

Bony Pelvis:
bony pelvis consists of 2 hip bones, fused to sacrum posteriorly and to each other anteriorly at symphysis pubis. Each one composed of:
ilium, ischium, pubis.

 Numerous projections and contours provide attachment sites for ligaments, muscles, and fascial layers.

Basic anatomy of lower urinary tract

Bladder Urethra

Anatomy of female pelvic floor support

Basic anatomy of pelvic floor

Pelvic floor Consists of 3 functional layers: I. Muscle: (levator ani + coccygeus = pelvic diaphragm) II. Fascia: as endopelvic fascia III. Perineal membrane (urogenital diaphragm)

I. Levator ani muscle complex

Forms a broad hammock & Consists of 4 parts: 1. Puboperineous 2. Pubococcygeous 3. Puborectalis 4. iliococcygeous

Muscular support of pelvic floor

II- Urogenital diaphragm

Perineal body: Pyramidal fibromuscular structure between anus & vagina 3.5 cm Responsible for closure of vaginal introitus.

Urogenital Diaphragm

Perineal body

III- Fascial components of pelvic floor

Includes parietal & visceral fascia visceral fascia termed endopelvic fascia Uterosacral & cardinal ligaments condensations of endopelvic fascia

are

Endopelvic fascia & connective tissue supports:

3 compartments
Urethral support Bladder support

Anterior Middle
Posterior

Vaginal support Uterine support

Rectal support

Anterior supports:
Urethropelvic ligament: The most important support of proximal urethra and bladder neck. distal half of urethra is supported by pubourethral ligament and levator musculature. pubocervical fascia: the main support of bladder base.

Middle supports:
Cardinal & uterosacral ligaments hold the uterus and upper vagina in their proper place over levator plate.

Posterior supports:
lateral rectal ligaments is the fascial supports for rectum. Additional prerectal and pararectal fascial elements.

Normal Continence In Women

Functions of urinary bladder:

1. Reservoir for urine (resting phase). 2. contractile organ to actively expel the contents (urine) to urethra (active phase)

Micturition cycle :

 Principle of sphincter function is water tight opposition of the urethral lumen, compression of the wall around the lumen, structural support to keep the proximal urethra from moving during increased abdominal pressure and neural control.

 Functions of lower urinary tract:

Storage of urine (accomodation property). Expulsion micturition.

Functions of pelvic floor:

Maintain continence. Prevent P.O.P.

Neural control
I. II. III. IV. Parasympathetic nerves (S2,3,4) Sympathetic nerves (T10-L1) Somatic motor. Central control

Continence
Urethral closure pressure must be greater than bladder pressure both at rest and during increase in intra abdominal pressure.

 During rest:
Tone of urethral muscles maintains a favorable pressure relative to bladder pressure.

During activity:
dynamic process increases urethral pressure to maintain continence closure

Classification of incontinence
A.
1.
2. 3. 4.

Genitourinary causes
Urodynamic stress incontinence
Urge incontinence Mixed incontinence Overflow incontinence

5.
6.

Incontinence caused by fistula

Congenital causes

B.
1.
2. 3.

Non- Genitourinary Causes:Neurological disorders

Medications. Metabolic disorders

Stress Incontinence

Definition:
involuntary escape of urine only with increase in intra abdominal pressure without detrusor muscle contraction.

Incidence & risk factors

Stress urinary incontinence is the most common type of urinary incontinence in women.

Risk factors for stress incontinence:

1. Being female. 2. Childbirth. 3. Coughing over a long period of time (as chronic bronchitis & asthma) 4. Getting older. 5. Obesity. 6. Smoking.

Pathophysiology

a)Urethral hypermobility (80-90%):

Due to loss of normal pelvic support of bladder and urethra due to: 1-Trauma & stretching of vaginal delivery. 2-Hysterectomy. 3-Hormonal changes(menopause). 4-Pelvic denervation. 5-Congenital weakness

B) Intrinsic Sphincter Dysfunction (10 - 20% of patients):

Due to sphincter damage due to:
1-Multiple prior operations. 2-Trauma. 3-Radiation. 4-Neurogenic disorders including Diabetes Mellitus. 5-Atrophic changes: lack of estrogen

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

Diagnosis & Treatment

Diagnosis:

History Examination investigations

History
1. 2. 3. 4. Duration of incontinence. Frequency and intensity of the incontinence. Use of protective pads. Impact of symptoms on lifestyle.

Physical examination
Abdominal examination.

Pelvic examination.

Special tests:
1) Stress test 2) Bonneys test 3) Q-tip test 4) Pad test

Investigations:
1. Urodynamic studies: to quantify bladder & urethral functions while producing patients symptoms 1) Cystometry: measures pressure volume relationship of the bladder, assesses bladder activity & detrusor contraction. 2) Uroflowmetry 3) Urethral pressure profile 2. Urinalysis and urine culture. 3. pelvic or abdominal ultrasound . 4. Cystoscopy. 5. EMG.

Treatment:

Conservative

Surgical

Conservative treatment:
1. Pelvic floor muscle exercises. 2. Biofeedback. 3. Lifestyle changes.

Peri-urethral bulking injections

1. Collagen. 2. Teflon paste.

4) Vaginal cones

Medications
1. Topical estrogen . 2. Alpha adrenergic agonist agents. 3. Imipramine.

Surgical treatment:
Anterior vaginal repair (Kelly's plication)

Abdominal retropubic cystourethropexy

(Marshall-MarchettiKrantz procedure)

(Burch colpo-suspension)

Laparoscopic colpo-suspension:

Recently, Tension-free Vaginal Tape (TVT)

Suburethral sling procedure:

URGE INCONTINENCE

Definition:
Sudden involuntary contractions of muscular wall of bladder, result in urgency and immediate urge to urinate. And involuntary loss of urine.

Incidence
Urge incontinence is the 2nd most common cause of incontinence.
About 3 in 10 cases of incontinence are due to urge incontinence.

It can occur at any age, but commonly first starts in early adult life. Women are more commonly affected than men.

Causes:
In urinary incontinence, patient leaks urine as bladder muscles contract at wrong times. these contractions occur no matter how much urine is in the bladder.

Although there is no definite cause, Urge incontinence may be resulted from: 1. - Nervous system disease (as multiple sclerosis or Parkinsonism). 2. - Nervous system injuries (as spinal cord injury or stroke). 3. - Infection (UTI). 4. - Bladder inflammation (Interstitial cystitis) 5. - Bladder outlet obstruction. 6. - Bladder stones. 7. - Bladder Cancer.

Risk factors:
1. 2. 3. 4. 5. Elderly. Pregnant Women or who just delivered. C-section or other pelvic surgery. Obese. Men had prostate surgery or prostate conditions, as enlarged prostate or prostatitis. 6. Nerve damage from conditions as diabetes, stroke, or injury. 7. Certain cancers, including bladder and prostate. 8. Urinary tract infections.

Clinical Picture:
The main symptom is uncontrolled loss of urine associated with sudden, strong desire to urinate that cannot be postponed. Women may describe sudden loss of urine in a rush to reach the toilet. Often, this occurs with certain triggering events, as:
fumbling with keys to open the door, sound or sensation of running water, drinking much water, coffee or Alcohol exposure to sudden cold.

Treatment of Urge Incontinence

1-Medications:
Most Important is anticholinergic as: Oxybutynin Action: Relax detrusor muscle. Side effects: dry mouth and constipation, blurring of vision ,tachycardia and retention of urine. Contraindications Other medications as estrogen and antibiotics.

THANKS