1. Done by : Yasmin Saidat Mahmoud Ababneh Supervised by : Dr . Lama Al.Muhaisen Jordan university of science and technology .

2. Defintion Involuntary loss of urine that is objectively demonstrable and that is severe enough to constitute a social or hygienic problem. 3. Pharmacology of incontinence a.-Adrenergic receptors. found in urethra. Stimulation cause contraction of urethral smooth muscle, preventing micturition. Drugs: ephedrine, imipramine, and estrogens. a.-Adrenergic blockers or antagonists relaxthe urethra, enhancing micturition. Drugs: phenoxybenzamine . 4. -Adrenergic receptors. Found in detrusor muscle. Stimulation cause relaxation of the bladder wall, preventing micturition. Drugs: flavoxate and progestins. 5. Cholinergic receptors. Found in detrusor muscle Stimulation cause contraction of the bladder wall, enhancing micturition. Chlinergic drugs: bethanecol and neostigmine . Anticholinergic medications block the receptors, inhibiting micturition. Drugs: oxybutynin and propantheline . 6. History P.P: Age, parity . C.C: Duration, frequency and amount of leakage Precipitating factors: 3 Ps - Position of leakage (supine, sitting, standing) - Protection (pads per day, wetness of pads) - Problem (quality of life) Progression is it worsening? 7. Irritative: If Frequency: 10-12 x/day OR urge incont. nocturia: 3-4 x/night. If no freq/nocturia think of stress incont. Dysuria, hematuria, urgencyUTI urge incont. Recurrent Hx of UTI urge Obstructive: Hesitancy, dysuria, straining to void, poor or interrupted stream, retention of urine, incomplete emptying, terminal dribbling. Volume of urine leakage large amounts go with overflow incont. Stones, tumors Lower urinary tract symptoms 8. Past obstetrics Hx: Mode of delivery, Birth Wt of her children . Gyne. Hx: Symptoms of urogenital prolapse: Feeling of mass that goes down while urinating Worse towards the end of the day Dragging backache Medical Hx: DM, HTN, Neurological problems,Disk prolapse Pelvic Surgeries? Trauma to the spine? Drugs: diuretics, psychotropic agents, Ca-channel blockers, alpha- blockers Any alteration in bowel habit? Smoker? Chronic cough? 9. Physical Exam. 1. General look of the pt * 2. Abdominal exam 3. Respiratory exam 4. Neurological exam * 5. Pelvic exam * 6. Asses pelvic floor muscle tone * 7. Rectal exam 8. Stress test * 9. Cotton swab (Q-tip) test urethral mobility * 10. Q-tip (cotton swab) Test 11. Investigation 12. Investigation You MUST rule out UTI first ! Midstream Urinalysis Blood test KFT Bladder diary 13. Example Diary for Urge incontinence Day Time Comments Sunday, 5th of March 7 am Woke up and needed to go to the toilet 7:30 Needed to go to the toilet again 8 am Breakfast 300 ml grapefruit juice and 200 ml tea 8:15 am Passed about 100 ml 8:25 am Passed about 50 ml 9 am Pants a little damp, passed about 50 ml 9:15 am Dribbled a bit, changed pants 9:30 am Passed a few drops, bladder feels very jumpy and so on . 14. Urodynamic studies Parameters measured during urodynamic evaluation 1,2,34 1. Post void residual volume (PVR) 2. Uroflow 3. Pressure flow study 4. Cystometrogram (CMG) 5. Abdominal Leak-Point Pressure (ALPP) 6. Video urodynamics 15. 1. Post void residual urine Distinguish between: true incontinence (Residual urine < 50 mL). overflow incontinence (Residual urine >100 mL). 16. 2. Uroflow Measurement of Urine Speed and Volume 17. 3. Pressure flow study Bladder pressures are measured simultaneously with a urinary flow rate during voiding . This helps to differentiate true urethral obstruction from detrusor failure. Obstruction = detrusor pressure more than 50 cm water and flow < 15 mL/s 18. 4. Cystometrogram The pressure in the bladder and rectum/vagina is measured during bladder filling. Intra-abdominal pressure is subtracted from bladder pressure to give a real indication of detrusorfunction. Residual Volume 30 degrees. Investigative studies. Urinalysis and culture are normal. Cystometric studies are normal with no involuntary detrusor contractions seen. 25. Management of stress incontinence 1. Conservative Stop smoking, cut down on alcohol, caffeine. Pelvic floor muscle exercises (Kegel exercise) Intravaginal device large sized pessaries or cones used to elevate and support bladder neck and urethra. Success rate 70%. 2. Medical Alpha agonists: 1. Pseudoephedrine 2. Phenylpropanolamine Enhance urethral closure and improve continence Do NOT give estrogen replacement unless she has atrophic vaginitis 26. Abdominal approach: aims to elevate the urethral sphincter so that It is again an intraabdominallocation (urethropexy). This is done by attachment of the sphincter to the symphysis pubis, using the Burch procedure as well as the Marshall- Marchetti-Kranz (MMK) procedure. The success rate 85-90% 3. Surgery 27. Vaginal approach: Suburethral sling procedures severe + refractive cases Tension-free Vaginal Tape(TVT) -A modification of the sling procedure uses tension-free synthetic (polypropylene) mesh placed at the level of mid urethra (paraurethral). -Minimally invasive It does not elevate the urethra but forms a resistant platform against intraabdominal pressure. periurethral bulking injections : (ovine collagen- contigen or calcium hydroxylapatite) 28. TVT 29. Urge (Hypertonic) Incontinence Etiology. Involuntary rises in bladder pressure from idiopathic detrusor contrac tions that cannot be voluntarily suppressed. History. Loss of urine occurs in large amounts often without warning. At day and night. The most common symptom is urgency. 30. Examination. Pelvic examination= normal anatomy. Neurologic examination Is normal. Investigative studies. Urinalysis and culture are normal . Cystometric studies show normal residual volume, but involuntary detrusor contractions are present even with small Volumes of urine in the bladder. 31. 1. Behavioral Modification: First line tt. Organize fluid intake habit: fluid intake & avoid liquids during evenings Gradually the interval btw voidings Training Kegel ex. 2. Medical Treatment to inhibit detrusor contractions Anticholinergic medications. NSAIDs to inhibit detrusor contractions. Tricyclic antid-dpressants. Calcium-channel blockers. 3. Functional Electrical Stimulation Management of urge incontinence 32. Sensory Irritative Incontinence Etiology. detrusor contractions stimulated by irritation from conditions: infection, stone, Tumor, or a foreign body. History. Loss of urine occurs with urgency, frequency, & dysuria. At day or night. Examination. Suprapubic tenderness , but otherwise the pelvic examination is unremarkable. 33. Investigative studies. A urinalysis will show the following abnormalities: bacteria and WBCs; suggest an infection, RBCs; suggest a stone, Foreign body, or tumor. A urine culture is positive if an infection is present. Cystometric studies (which are usually unnecessary) would reveal normal residual volume with involuntary detrusor contractions present. Management. Infections are treated with antibiotics. Cytoscopy is used to diagnose and remove stones, foreign bodies, and tumors 34. Overflow (Hypotonic) Incontinence Etiology. Rises in bladder pressure occur gradually from an overdistended, hypotonic bladder. When the bladder pressure exceeds the urethral pressure, involuntary urine loss occurs but only until the bladder pressure equals urethral pressure. The bladder never empties. Then the process begins all over. This may be caused by denervated bladder (e.g., diabetic neuropathy, multiple sclerosis) or systemic medications (e.g.,ganglionic blockers, anticholinergics). 35. History. Loss of urine occurs intermittently in small amounts. This can take place both day and night. The patient may complain of pelvic fullness Exnmination. Pelvic examination may show normal anatomy. The neurologic examination will show decreased pudendal nerve sensation. 36. Investigative studies. Urinalysis and culture are usually normal, but may show an infection. Cystometric studies show markedly increased residual volume, but involuntary detrusor contractions do not occur. Management. Intermittent self-catheterization may be necessary. Discontinue the offending systemic medications. Cholinergic medications to stimulate bladder contractions and a-adrenergic blocker to relax the bladder neck. 37. Bypass Fistula Etiology. The normal urethral-bladder mechanism is intact, but is bypassed by urine Leaking out through a fistula from the urinary tract. History. The patient usually has a history of either radical pelvic surgery or pelvic radiation therapy. Loss of urine occurs continually in small amounts. At day and night. 38. Examination. Pelvic examination may show normal anatomy. normal neurologic findings. Investigative studies. Urinalysis and culture are normal. An intravenous pyelogram (IVP) will demonstrate dye leakage from a urinary tract fistula. Management. Surgical repair of the fistula 39. Prevention 1. Shortening of 2nd stage of labor 2. Reduce traumatic delivery 3. If menopause consider HRT 40. The End