URINARY INCONTINENCE

Dr nadia gantriAssociated professor

WHAT IS CONTINENCE?

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

reach the correct place

pass urine or faeces when he gets there

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

INCIDENCE

• 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.

• Urinary incontinence - not a recent medical or social phenomena. Disorders of urinary tract written in ancient times.– Women more willing to talk about it.

– Improved understanding of the diverse pathophysiology of incontinence.

– Advent of new treatment.

– Development of urology & urogynaecology as a specialty.

• Bladder,bowel &sexual functions- parasympathetic & somatic via S2,3,4.

• Sympathetic supply - T10-L2 segments - detrusor muscle.

• Parasympathetic promotes micturition - contracting detrusor, relaxing urethra.

• Sympathetic - B receptors in bladder - relaxation, A receptors in bladder neck increasing urethral resistance.

• Central control - pontine center, receiving afferent and efferent from cerebral cortex, cerebellum and spinal center.

• Normally detrusor is reflexly inhibited by sympathetic neurones (storage and filling), control acquired in infancy. Detrusor contraction mediated by parasympathetic supply. M3 receptors .

NERVE SUPPLY

ANATOMY

• .

• Urethra supported by - Externally: pubourethral ligament, striated muscle of pelvic floor. Internally : smooth muscle of urethra, ext urethral sphincter, periurethral collagen & connective tissue, submucosal venous plexus, mucosal coaptation of the urothelium.

• Proximal urethra is well supported so a rise in intraabdominal pressure is equally transmitted to bladder & urethra.

TYPES OF INCONTINENCE

Genuine stress incontinence

Detrusor instability

Mixed (GSI and DI)

Overflow

Fistulae

INCONTINENCE• Genuine Stress Incontinence:

Is the involuntary loss of urine in the absence of a detrusor contraction,when the intra abdominal pressure exceeds the intravesical. Pressure.

• Detrusor InstabilityInvoluntary detrusor contractions either spontaneous or provoked which cannot be suppressed and may cause incontinence. It is associated with a strong desire to void. Abnormal nerve supply to bladder (spinal cord injury, spina bifida) - detrusor hyperreflexia.

• Overflow Incontinence is an involuntary loss of urine associated with over distension of the bladder. May present as SI or dribble. Due to bladder outlet obstruction or impaired detrusor contraction. More common in males.

Genuine StressIncontinence

Hypermobilityexcessive descent of

bladder neck, so poor transmission of increase

in ab pressure to

proximal urethra.

Intrinsic Sphincter Deficiency

poor urethral closure due to scarring - surgery, childbirth,

neurological injury.

RISK FACTORS FOR STRESS INCONTINENCE

1 Increasing parity, probably related to obstetrical trauma

2 Increased intra-abdominal pressurea medical factors (eg smoking, chronic bronchitis or

other pulmonary problems, constipation with chronicstraining at stool, obesity (?))

b environmental factors (eg jobs requiring heavy liftingor straining)

3 Pelvic floor trauma and denervation injurya obstetric traumab nonobstetric trauma (eg pelvic fractures and radical

surgery)

4 Hormonal status and estrogen deficiency

5 Connective tissue disorders

Symptom GSI Detrusor(%) Instability

Frequency 57 86

Nocturia 29 80

Urgency 46 92

Urge Incontinence 37 88

Stress Incontinence 99 26

COMMON DRUGS AFFECTING LOWER URINARY TRACT FUNCTION

• Sedative hypnoticsBenzodiazepinesAlcohol

• Diuretics

• Anticholingeric agentsAntihistamines AntidepressantsAntipsychotics AntispasmodicsAnti-Parkinsonian agents

• Andrenergic agentsSympathomimetics Sympatholytics (Prazosin)

• Calcium channel blockers

PATIENT ASSESSMENT Patient history. Frequency, nocturia, urgency, urge

incontinence, stress incontinence, voiding patterns, drinking habits, drugs, medical problems,surgical history quality of life. Frequently female pts present with mixed incontinence.

Physical examination: general, abdominal, pelvic - atrophic vaginitis, uterine descent, vaginal wall prolapse, pelvic muscle strength,

Frequency/volume chart: intake, output, episodes of dampness, leaking, acts as a teaching aid.

Urine examination

Urodynamics

INCONTINENCE TREATMENTCONSERVATIVE

• Global: Evaluation of cough, change of medication, wt loss/

• Pharmacological

• Behavioural Changes

- adequate water (1.5 l/d)- Decrease dietary irritants- Manage constipation- Pelvic muscle exercises- Bladder retraining - instructing pt to void at predetermined intervals. Very successful in young motivated women(85%)

• Pelvic Muscle Exercises- Verbal feedback / written

instructions- Vaginal weights- Biofeedback

• Electrical Stimulation

URODYNAMIC TESTS

Flow studies

Cystometry (+/- Videourodynamics)

Urethral pressure profilometry

Ambulatory urodynamics

Electromyography

URODYNAMIC MEASUREMENTS

Bladder pressure - storage and voiding

Abdominal pressure

Urethral pressure

Urine flow

Bladder capacity

Volume voided

Residual

UROFLOWMETRY

Patient voids into a flow meter Flow rate Volume voided Residual - catheter

- ultrasound

URINE FLOW RATESWOMEN

Under 50 years - 25 ml/sec Over 50 years - 18 ml/sec

FILLING CYSTOMETRY First desire to micturate

Capacity

Detrusor activity

WHEN TO DO A CYSTOSCOPY? Microscopic hematuria

Abnormal cytology

Periurethral abnormality

For reassurance

DETRUSOR INSTABILITY

• 2nd common cause of incontinence in UD studies.Incidence increases with age. Normal control of detrusor is lost. 15% incidence of DI following bladder neck surgery.

• Important to identify DI prior to continence surgery as urgency may be worsened. Frequency, urgency, urge incontinence, key in door leaking are typical of DI.

DETRUSOR INSTABILITY

• Rarely completely cured by any form of treatment. Symptoms and QOL can be improved. Continence adviser essential member of continence service. Behavioural & conservative therapies are helpful

• Anticholinergic drug eg Oxybutinin is used in DI. S/E: dry mouth, blurred vision, constipation, drowsines, urinary retention. A new antimuscarinic, Tolteradine is in market now..

• TCA,, Ca channel blockers.

• Oestrogen therapy : systemic no effect, topical decreases UTI. Good for atrophic vaginitis.

• Surgical: cystodistension, clam cystoplasty, diversion procedures

SURGICAL APPROACH FOR THE TREATMENT OF GENUINE STRESS

INCONTINENCE (GSI)

Operation

Anterior colporrhaphy

Marshall-Marchetti-Krantz

Burch colposuspension

Needle bladder neck suspension (Stamey)

Indication

Significant uterovaginal prolapse. Should not be considered as first line procedure for GSI

Primary or secondary GSI

Primary or secondary GSI with cystocele

GSI in the surgically difficult patient

Operation

Suburethral sling procedures

Periurethral bulk enhancing agents (GAX collagen/ous fat)

Complex surgical procedures (eg artificial sphincter/ neourethra/ urinary diversion)

TVT

Indication

Severe recurrent GSI. Intrinsic urethral deficiency.

Surgically difficult pelvis/medically unfit, vaginal scarring.

Intractable recurrent urethral sphincter incompetence

Short hospital stay, rapid recovery. Bladder trauma 4%, voiding difficulty 10%, similar efficacy for colposuspension.

INCONTINENCE TREATMENTSURGICAL

PROS:Previous surgery - subjective and objective results

Procedure % continentMarshall-Marchetti-Kranz 84.5Colposuspension 84.0Bladder sling 83.4All bladder neck suspensions 76.5Bladder buttress 58.6

Most failures apparent immediately

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 and use of UD prior to continence surgery.

• Therapy for DI is often long term and requires pt explanation of pathology and mode of action &S/E of drugs used.

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