Dr. swati singh

Registrar

IntroductionIncidenceAnatomy / PhysiologyTypes of IncontinanceAetiology ManagementConclusion

INTRODUCTION

Continence is the ability to pass urine or faeces voluntarily in a socially acceptable place.The continent person can:

recognize the need

identify the correct place

hold on until he reaches the correct place

to pass urine or faeces

Incontinence - involuntary loss of urine which is objectively demonstrable & it is social and hygienic problem.

INCIDENCEUrinary incontinence - not a recent

medical or social phenomena. Disorders of urinary tract written in ancient times.

1 in 3 female age 55 or more complain of incontinence.

1 in 10 women will have surgery for prolapse or SI in life time. One third will need further surgery.

Physiology of Micturition • Bladder innervation: somatic, parasympathetic (PSN) and sympathetic (SNS)

• ~150-300 ml in bladder before the brain

recognizes bladder fullness

Physiology of Micturition

• Low bladder volumes: SNS is stimulated and PNS is inhibited

• Bladder full: PNS stimulated (bladder contracts) SNS inhibited (internal sphincter relaxes)

• Intravesical pressure > resistance within the urethra: urine flows

• Pudenal nerve innervates external sphincterPudendal nerve is inhibited external

sphincter opens facilitation of voluntary urination

Physiology of Micturition

PHYSIOLOGICAL ANATOMYThe bladder neck and upper third or half of

the urethra are above the level of the pelvic floor.

The internal urethral sphincter The internal urethral sphincter ::Is an

involuntary muscle which surrounds the bladder neck.

The external urethral sphincterThe external urethral sphincter : :

is a voluntary muscle found between the superficial and deep perineal membranes and surrounds the middle part of the urethra compessor urethrae muscle

PHYSIOLOGICAL ANATOMYPHYSIOLOGICAL ANATOMY

It empties the urethra after the act of micturition,

Interrupts the flow of urine on desire

It acts as a secondary defensive

mechanism against escape of urine.

The external urethral sphincterThe external urethral sphincter

At rest the urethra makes an angle of 90-100 degrees with the base of the urinary bladder called the posterior urethrovesical angle.

The urethra also makes an angle of less than 30 degrees with the vertical line.

PHYSIOLOGICAL ANATOMYPHYSIOLOGICAL ANATOMY

TYPES:1. True incontinence.

2. False incontinence

3. Stress or

sphincter incontinence.

4. Urge incontinence (precipitancy-detrusor

instability or detrusor

dyssynergia).

5. Nocturnal enuresis.

Incidence of Subtypes of Urinary Incontinence in Women

Stress Incontinence 50% Urge Incontinence 20%

Mixed 30%

STRESS INCONTINENCE )SPHINCTER INCONTINENCE-GENUINE STRESS INCONTINENCE

It is involuntary escape of few drops of urine with increased intra-abdominal pressure as during straining, sneezing, coughing,

laughing ... etc.

DEGREES OF STRESS INCONTINENCE

Grade I Incontinence occurs only with severe stress,

such as coughing, sneezing, etc …Grade II Incontinence with moderate stress, such as

rapid movement or walking up and down stairsGrade III Incontinence with mild stress, such as standing.

The patient is continent in the supine position

TYPES OF STRESS INCONTINENCEType 1 : There is complete loss of the

posterior urethrovesical angle.

Type 2 : There is complete loss of the posterior urethrovesical angle together with increase in the angle between the urethra and vertical line to be more than 30 degrees.

AETIOLOGYWeakness of the internal urethral sphincter or Descent of bladder neck below the level of the

pelvic floor.

Congenital weakness of the internal urethral

sphincter, seen in the young nullipara. Congenital defects as:

1.Epispadias,

2.Short urethra (less than 1 cm),

3.Wide bladder neck, and

4.Separation of symphysis pubis.

3. Trauma to the region of the bladder neck due to vaginal delivery or operation. In fact vaginal delivery is the commonest In fact vaginal delivery is the commonest cause of stress incontinence.cause of stress incontinence.

4. Pregnancy and continuous administration of oestrogen-progestogen preparation to induce psuedopregnancy state to treat endometriosis.

The hormonal imbalance with increased progesterone

weakens the internal urethral sphincter.

AETIOLOGYAETIOLOGY

5. Menopause: Lack of oestrogen leads to atrophy of bladder neck supports.

6. Genital prolapse:

7. Organic nervous diseases as disseminated sclerosis.

AETIOLOGYAETIOLOGY

Pathophysiology of Stress IncontinenceThe basic pathology is urethral incompetence. This can be either due to:

A)Urethral hypermobility (80 - 90% of patients)

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

A) Urethral hypermobility(80 - 90% of patients)

This results from loss of the normal pelvic support mechanism of the bladder and urethra due to:

1. Trauma and repeated vaginal delivery 2. Hysterectomy 3. Hormonal changes ( Menopause) 4. Pelvic denervation 5. Congenital weakness

B) Intrinsic Sphincter Dysfunction (10 - 20% of patients) This results from damage to the sphincter

due to:1. Multiple prior operations 2. Trauma 3. Radiation 4. Neurogenic disorders including Diabetes

Mellitus 5. Atrophic changes: lack of estrogen.  

1. A detailed history differentiates between the different types of incontinence.

2. Stress incontinence and detrusor instability frequently occur together.

3. Gradual onset after menopause suggests oestrogen deficiency.

4. History of vaginal repair or operation in the region of the bladder neck and history of any neurologic disease.

Urinalysis and urine culture help to diagnose urinary tract infection.

Blood test is required know the compromised renal function, diabetes, syphilis, or other systemic diseases are suspected.

Stress TestThe bladder must be moderately full. The patient in the lithotomy position, the two labia

are separated, and the patient is asked to cough. If urine escapes, the patient is incontinent. If no urine escapes, the test is repeated while the

index and middle fingers in the vagina press on the perineum to abolish reflex contraction of the levator ani muscles during straining.

If still no urine escapes, the test is repeated while the patient is standing with the legs separated.

Bonney testIt is indicated in case of a positive stress

test associated with a cystocele. To know if incontinence is due to descent

of bladder neck or weakness of the sphincter.

The index and middle fingers are placed on both sides of the urethra to elevate the bladder neck upwards.

If no urine escapes on stress it means that the incontinence is due to descent of the bladder neck, but if urine still escapes it means weakness of the sphincter.

Indicated in case of a negative stress test associated with a large cystocele to diagnose hidden stress incontinence.

The cystocele is reduced, the cervix is grasped with a volsellum and pushed upward, then the patient is asked to cough.

If urine escapes, it indicates that the patient was continent because of kinking of the urethra.

Yousef TestYousef Test

The Cotton-Tip Applicator (Q-Tip) TestA sterile applicator with a small piece of cotton

at its tip is introduced to reach the bladder neck.

The angle between the applicator and the horizontal is measured.

The patient then strains maximally using the Valsalva manoeuvre.

This causes descent of the bladder neck and upward movement of the applicator producing a new angle with the horizontal.

(Q-Tip) TestIn normal patients the increase in the angle is less than 30 degrees.

In stress incontinence the change is more than 30 degrees indicating poor support and abnormal descent of bladder neck

The test is positive in more than 90% of cases with stress incontinence.

A radio-opaque dye is injected by a catheter into the bladder.

On straining, the lateral view will show absence of the posterior urethrovesical angle in more than 90% of cases.

Funneling of the bladder neck in the antero-posterior view may be seen in some cases.

CystourethrographyCystourethrography

Urodynamics

1.Cystometrogram( most important test), Filling Cystometry and Voiding Cystometry

2. Electromyography3. Uroflometry

4. Urethral pressure profile : significant lowering of urethral closure presure during strain

Stress incontinence occurs if the length is

less than 1 cm.

Measurement of Measurement of Urethral LengthUrethral Length

Transvaginal ultrasoundWhen damage affects the upper part of the

sphincter, the urethra appears "funnel-shaped".

When damage affects the lower part, the urethra appears "vase-shaped".

When damage affects the whole length of the sphincter, the urethra appears short and irregular.

laboratory testsPostvoid residual urine After the patient voids, there should be less than 50 ml of urine in the bladder ( measurements greater than 100-200 ml) may have an underlying neurologic disorder.

Tests are most helpful in differentiating between GSI and DICystometrogramCystoscopy :

should be performed especially in patients with: irritative bladder symptoms such as urgency, frequency, and hematuria

To rule out:1. inflammation, 2. tumors, or 3. anatomic deformities

1. During labour, the bladder should be kept empty.2. Episiotomy is performed if necessary.3. Physiotherapy. Pelvic floor exercises are started after delivery.

These include repeated stoppage of the urinary stream during micturition and repeated contractions

of the pelvic floor muscles.

Indications:1.Mild stress incontinence2.Patient is unfit for surgery or refuses

surgery.3.When stress incontinence is combined

with detrusor instability. Conservative treatment cures or improves 50% of cases and include:

1.Physiotherapy: Kegal perineometer may be used.

Conservative (non-surgical) Conservative (non-surgical) TreatmentTreatment

2. Faradic current stimulation of the levator ani muscles to improve their tone.

3. Vaginal cones: A set consists of 5 or 9 cones. Weight ranges from 20 to 100 grams. Patient inserts the cone in the vagina and

keeps it for 15 minutes twice daily. If this succeeds she inserts the next cone. This improves the tone of the pelvic floor

muscles.

4.Oestrogen therapy for menopausal patients:

It causes thickening of the urethral mucosa and engorgement of the underlying blood vessels

5. Alpha-adrenergic stimulants: which stimulate contraction of the internal urethral sphincter, e.g. ephedrine.

6.Large vaginal diaphragms, Hodge pessary to elevate ' and support the bladder neck.

7. Reduction of weight in obese patients to reduce intra-abdominal pressure.

8. Stop caffeine (to avoid diuresis) and smoking (to avoid coughing)

9. Injection of Teflon or bovine collagen in the submucosal layer in the region of the bladder neck. This leads to narrowing of the urethral lumen and increased urethral resistance.

1. Urethroplasty (Kelly,Kennedy,etc….)2. Urethropexy (Retropubic

urethropexy e.g. Marshall-Marchetti-Krantz, etc….)

3. Colposuspension (Burch operation, Preyera)

4. Urethral slings (Aldridge operation, etc)

5. Tension free Vaginal Tape (TVT)

Surgical Treatment

CONCLUSION:• Urinary incontinence is a common problem,

causes distress to a large no of female population.

• Current diagnosis and management involves good understanding of the condition.

• Therapy for UI is often long term and requires pt explanation of pathology.

• In future, further understanding of pathophysiology of condition may lead to further advances.