Female Incontinence

8/8/2019 Female Incontinence

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Female Incontinence

Dr Alin CiopecTrust SGO O&G

EDGH

21/10/10


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Clasification of urinary incontinence

Stress Urinary Incontinence involuntary leakage of urine on effort orexertion, or on sneezing, or coughing. It commonly arises as a result ofurethral sphincter weakness

Urge Urinary Incontinence involuntary leakage of urine accompanied by,or immediately preceded by, a strong desire to pass urine (void). Can be asymptom of overactive bladder syndrome

Mixed Urinary Incontinence involuntary leakage of urine associated bothwith urgency and with exertion, effort, sneezing, or coughing. Usually, oneof this is predominant

Overflow Incontinence occurs when the bladder becomes large andflaccid and has little or no detrusor tone or function usually due to injury orinsult after surgery or postpartum. Condition is diagnosed when the urinaryresidual is more than 50% of bladder capacity. The bladder simply leaks

when it becomes full Continuous Urinary Incontinence classically associated with fistula orcongenital abnormality, e.g. ectopic ureter

Other Types of Incontinence arising from UTI, medications, immobilityor cognitive impairment. Situational incontinence e.g giggle incontinence


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Urinary Symptoms

Urinary incontinence stress or urge incontinence

Daytime frequency normal 4-7 voids/day

Nocturia up to the age of 70 years more than a single void is considered abnormal

Nocturnal Enuresis

Urgency sudden compelling desire to pass urine , which is difficult to defer -secondary to detrusor overactivity, or interstitial cystitis

Voiding difficulties hesitancy(difficulty in initiating micturition), straining to void,slow or intermittent urinary stream. All suggestive of urethral obstruction, anunderactive detrusor muscle, or loss of coordination between detrusor contractionand urethral relaxation. Intermittency is seen in neurological disease

Postmicturition feeling of incomplete bladder emptying, terminal dribble (aprolonged final part of micturition), postmicturitional dribble (involuntary lost of urineimmediately after passing urine)

Absent or reduce bladder sensation overflow - caused by spinal cord injuries or

pelvic surgery Bladder pain intravesical pathology

Urethral pain

Dysuria UTI

Haematuria warrants further investigations


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Assessment of the lower urinary

tract History

Quality of Life assessment (QoL)

questionnaires Frequency/volume chart (in/out/wet)

Physical examination general,

abdominal,pelvic


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tract InvestigationsBasic Investigations Urinalysis

Urine specimen MSU

Residual check (by U/S or catheterization)

Pad test

Cystourethroscopy +/- biopsy

indications:

Recurrent UTI

Haematuria

Bladder pain Suspected urinary tract injury or fistula

To exclude bladder tumour or stones

If interstitial cystitis is suspected


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tract - Imaging Ultrasonography Plain abdominal radiograph

Intravenous urography foreign bpdies or calculi

Micturating cystourethrography neuropathic bladder, fistulae

Contrast CT MRI

Conditions requiring imaging of urinary tract:

Recurrent UTI

Haematuria

Urethral diverticula, which need to be differentiate from paravaginal

cysts Suspected ureteric injuries

Suspected urethral or vesical fistulae

Suspected malignancy or renal stones


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tract urodynamic investigationsCombination of test that look at the ability of thebladder to store and void urine

Uroflowmetry can be used to screen forvoiding difficulties

Cystometry involves measuring thepressure/volume relationship of the bladderduring filling and voiding

Video-urodynamics enables detection of

detrusor sphincter dyssynergia, vesico-uretericreflux, presence of abnormalities

Ambulatory urodynamic monitoring


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Stress Urinary Incontinence

SUI (Stress Urinary Incontinence) isthe complaint of involuntary leakage ofurine on effort/exertion/sneezing/coughing

USI(Urodynamic Stress UrinaryIncontinence) is the involuntary leakageof urine during increased intra-abdominal

pressure in the absence of detrusorcontraction can be only diagnosed byurodynamic testing


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Incidence 1 in 10 women; 50% complain of pure stressincontinence; 30-40% have mixed symptoms of urge and stressincontinence

Pathophysiology and aetiology

1. SUI occurs when the intravesical pressure exceeds the closing

pressure on the urethra2. Childbirth is the most common causative factor, leading to

denervation of the pelvic floor, using durin delivery

3. Oestrogen deficiency at the time of menopause, leads toweakening of the pelvic support and thinning of the urothelium

4. Occasionally, weakness of the bladder neck occur congenitally or

through trauma from radical pelvis surgery or irradiation


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Clinical features:

Symptoms:

Leakage of urine when she coughs,sneezes, runs, jumps, carries heavyloads the leakage is usually samll ,discrete amount , coinciding with

physical activities Signs: prolapse of the urethra and

anterior vaginal wall


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Investigations Midstream Urinary Sample to exclude

infection or glycosuria

Frequency/volume chart Urodynamic studies check for voiding

dysfunction and coexisting detrusor

overactivity


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conservative management Lifestyle interventions weight reduction if BMI>30/smoking cessation/treatment of chronic cough andconstipation

Pelvic floor muscle training for at least 3 months

Biofeedback - refers to the use of a device to convertthe effect of pelvic floor contraction into a visual orauditory signal to allow women objective assessment ofimprovement

Electrical stimulation Vaginal cones for applying graded resistance against

which the pelvic floor muscles contract


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conservative management Pharmacological management of SUI Duloxetine for moderate to severe SUI

Indications for conservative treatment od SUI:

1. Mild or easily manageable symptoms

2. Family incomplete

3. Symptoms manifest during pregnancy

4. Surgery contraindicated by coexisting medicalconditions

5. Surgery declined by patient


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surgical managementPeriurethral injections Bulking agents have a lower immediate success

rate(40-60%) and a long-term continued decline incontinence

Most commonly used: Glutaraldehyde crosslinkedbovine collagen and Macroparticulate siliconparticles(Macroplastique)

May be appropriate for:

1. Frail, elderly, or unfit women2. Women who have had other multiple failed procedures


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surgical managementBurch colposuspension Largely replaced by TVT

Now rarely performed

The retropubic space is entered through a lowtransverse suprapubic incision and two or threesutures places between the paravaginal fasciaand ipsilateral ileopectinal ligament (Coopers

ligament) at the level of the bladder Efficacy as primary procedure 90%, as repeat

procedure 83%


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surgical managementLaparoscopic colposuspection

Efficacy and complications similar to those

of the open procedure The surgery is technically more

demanding and requires considerable

laparoscopic expertise

But quick recovery and low cost due to

spitalisations


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surgical managementTVT (Tension free Vaginal Tape) The most commonly performed surgical procedure for USI in the

UK

A polypropylene tape is placed under mid-urethra via a smallvaginal incision, using a local or general anaesthesia

Cystourethroscopy is carried out to ensure no damage to thebladder or urethra

Is minimally invasive and return to normal activity within 2 weeks

Complications:

1. Moderately high risk of bladder injuries 5-10%, but these do notseems to have long-term sequelae, if treated appropriately

2. Bleeding in retropubic space, infections and voiding difficulties3. Tape erosion into the vagina and urethra has also been reported

The objective cure rate is 82-98%


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surgical managementTOT (Transobturator Tape)

The polypropylene tape is passed via a

transobturator foramen through thetransobturator and puborectalis muscles

The main difference from TVT is the

retropubic space is not entered and the

risk of bladder perforation is low

Similar success rate with TVT


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Overactive Bladder Syndrome

(OAB) Is a chronic condition defined as urgency, with or withouturge incontinence, usually with frequency or nocturia

Is affecting 1 in 6 women

The incidence is increasing with age

Is the second most common cause of urinaryincontinence

Aetiology

Idiopathic in most cases

Neurogenic detrusor overactivity multiple sclerosis,

spina bifida, upper motor neuron lesions Secondary to pelvic floor surgery

OAB due to outflow obstruction is uncommon in women


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(OAB)Clinical features of OAB

Urinary frequency

Urgency

Urge incontinence Nocturia

Nocturnal enuresis

Provocative factors: cold weather, opening the

front door, hearing running water, by raisedintra-abdominal pressure-coughing, sneezing,

QoL can be significantly impaired by theunpredictability and large volume of leakage


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(OAB) - Investigations Urine culture

Frequency/volume chart

Urodynamics is essential for diagnosis of

OAB with multiple and complex symptoms

Other factors need to be excluded when diagnosisof OAB is made:

1. Metabolic abnormalities diabetes orhypercalcemia

2. Physical causes prolapse or faecal impaction

3. Urinary pathology UTI or interstitial cystitis


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(OAB) - managementConservative management

Behavioral therapy 1-1,5l of liquids/day;avoid caffeine based drinks and alcohol; somediuretics or antipsyhotics drugs need to bereviewed

Bladder retraining ability to suppress urinaryurge and to extend the intervals betweenvoidings

Hypnotherapy and acupuncture Antidepessants

oestrogens


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(OAB) - managementPharmacological interventions

Anticholinergic(antimuscarinic)drugs

- they block the parasympathetic nerves thereby relaxing the detrusormuscle

- the dosage need to be titrated against efficiency and adverse effects

(dry mouth, blurred vision, dizziness, insomnia, palpitations andarrhythmia)

Contraindications:

Acute (narrow angle) glaucoma

Myasthenia gravis

Urinary retention or outflow obstruction

Severe ulcerative colitis

Gastrointestinal obstruction

E.g.: Oxybutynin, Propiverine, Solifenacin, Tolterodine, Trospium,Darifenacin


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(OAB) - management


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Genital prolapseGenital prolapse

ISMAEL YOUSIFISMAEL YOUSIF


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DefinitionDefinition

Genital Prolapse:Genital Prolapse:

Is herniation of the genital organsIs herniation of the genital organs

through the genital tract.through the genital tract.


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Support of the pelvic organs:Support of the pelvic organs:

The main support is by the :The main support is by the :

11--pelvic floor muscles:pelvic floor muscles:

--Levator aniLevator ani--CoccygeusCoccygeus

--Internal ObturatorInternal Obturator

--PiriformisPiriformis--Transverse perineal musclesTransverse perineal muscles


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Support of the pelvic organsSupport of the pelvic organs

22-- Pelvic ligaments:Pelvic ligaments:

-- Transverse cervical ligaments (Cardinal)Transverse cervical ligaments (Cardinal)

-- Uterosacral ligamentsUterosacral ligaments-- Pubocervical ligamentsPubocervical ligaments

-- Pubourethral ligamentsPubourethral ligaments

33-- Pelvic FasciaPelvic Fascia


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Minor support:Minor support:

Round ligamentRound ligament

Broad ligamentBroad ligament


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ClassificationClassification

Vaginal wall prolapse:Vaginal wall prolapse:

#Anterior:#Anterior:

11-- Urethrocele:Urethrocele:

Descend of the lower part of the anteriorDescend of the lower part of the anteriorvaginal wall containing the urethra.vaginal wall containing the urethra.

22-- Cyctocele:Cyctocele:

Descend of the upper part of the anteriorDescend of the upper part of the anteriorvaginal wall containing the bladder.vaginal wall containing the bladder.


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#Posterior:#Posterior:

11-- Enterocele:Enterocele:

Descend of the upper posterior vaginal wallDescend of the upper posterior vaginal wallcontaining small bowl from the pouch ofcontaining small bowl from the pouch ofDouglasDouglas

22-- Rectocele:Rectocele:

Descend of the lower posterior vaginal wallDescend of the lower posterior vaginal wallcontaining the rectum.containing the rectum.


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#Middle:#Middle:

Vault prolapse:Vault prolapse:

Descend of the vaginal vault afterDescend of the vaginal vault afterhysterectomy , usually contains : smallhysterectomy , usually contains : small

bowl and omentum.bowl and omentum.


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Uterine Prolapse:Uterine Prolapse:

11-- First degree:First degree:

The uterus is with in the vagina.The uterus is with in the vagina.

22-- Second degree:Second degree:The cervix protrudes outside through theThe cervix protrudes outside through the

introitus .introitus .

33-- Third degree (Procidentia):Third degree (Procidentia):The entire uterus has come out the vagina.The entire uterus has come out the vagina.


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Uterine ProlapseUterine Prolapse


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Uterine ProlapseUterine Prolapse


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Vaginal Vault ProlapseVaginal Vault ProlapseVaginal Vault Prolapse


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Vaginal Vault ProlapseVaginal Vault Prolapse


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AetiologyAetiology

Major causes:Major causes:

11-- CCongenital weakness of the pelvic floorongenital weakness of the pelvic floorligaments and fascia.ligaments and fascia.

22-- CChild birth:hild birth:Pregnancy, prolonged or difficult labour,Pregnancy, prolonged or difficult labour,

bearing down before full cervical dilatation,bearing down before full cervical dilatation,multiparity and instrumental delivery.multiparity and instrumental delivery.

33-- CClimacteric: weakness and denervation of thelimacteric: weakness and denervation of thepelvic floor muscles due to oestrogen deficiency.pelvic floor muscles due to oestrogen deficiency.


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AetiologyAetiology

Minor causes:Minor causes:

--CChronichronic CCoughough

--ChronicChronic CConstipationonstipation

--Increased Intra abdominal pressure:Increased Intra abdominal pressure:

.Masses.Masses

.Ascitis.Ascitis

.Pulmonary disease.Pulmonary disease

.heavy lifting.heavy lifting


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Presentation:Presentation:

Minor Prolapse can be asymptomaticMinor Prolapse can be asymptomatic

Uterovaginal prolapse patients can complain ofUterovaginal prolapse patients can complain of

feeling of some thing coming down .feeling of some thing coming down .

.. Pelvic insecurityPelvic insecurity

.. Low backache ,relieved by lying flat.Low backache ,relieved by lying flat.

Procidentia may present with bloody stainedProcidentia may present with bloody stained

vaginal discharge some times purulent due to :vaginal discharge some times purulent due to :Decubitus ulcer of the vaginal skin of the cervix.Decubitus ulcer of the vaginal skin of the cervix.


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Management:Management:

Prevention:Prevention:

..Reducing weightReducing weight

..Avoid smokingAvoid smoking

..Avoid difficult labourAvoid difficult labour

..ContraceptionContraception

..Pelvic floor exercise after delivery.Pelvic floor exercise after delivery.


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Medical management:Medical management:

HRT:HRT:

.Hormone replacement therapy:.Hormone replacement therapy:

Increases vaginal blood supply andIncreases vaginal blood supply andcollagen turnovercollagen turnover


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Ring Pessaries:Ring Pessaries:

Indications:Indications:

Patient requestPatient request

Patient is medically unfit for surgeryPatient is medically unfit for surgery

Therapeutic test before surgeryTherapeutic test before surgery

To relieve symptoms while the patient isTo relieve symptoms while the patient is

awaiting surgeryawaiting surgery During and after pregnancies if the patientDuring and after pregnancies if the patient

want to preserve her fertilitywant to preserve her fertility


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Surgical management:Surgical management:

Cyctourethrocele:Cyctourethrocele:

Anterior ColporrhaphyAnterior Colporrhaphy

Rectocele:Rectocele:

Posterior ColpoperineorrhaphyPosterior Colpoperineorrhaphy Uterine Prolapse:Uterine Prolapse:

11stst 22ndnd Degree:Degree:

Manchester RepairManchester Repair

33ed Degree (procedentia):ed Degree (procedentia):Vaginal hysterectomyVaginal hysterectomy

Female Incontinence

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