ugsa mus sling workshops preamble · – ectopic ureter, epispadias, bladder exostrophy, cloacal...
TRANSCRIPT
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Joseph Lee
Bernard Haylen
Oliver Daly
Christopher Maher
UGSA MUS sling workshops
SUI Pathophysiology 2016
Preamble
Pathophysiology & Etiology of SUI
Epidemiology
Assessment of UI
Management of SUI
Enhorning’s (pressure equalisation) Theory & Hammock Theory
(urethral backstop)
Conservative & Surgery
Management of intra & post operative complications
Case discussions
Womens HealthUrinary Incontinence – Australia: Prevalence
• stress incontinence peaked at 25.3% for females aged 35–44
• urge incontinence peaked at 24.2% for females aged 75 and over
• mixed incontinence peaked at 20.6% for females aged 55–64.
R Botlero Maturitas 62 (2009) 134–139
Categorise and Treat
SUI UUI
International Continence Society (ICS)International Urogynaecological Association (IUGA)
Stress49%2
Urgency 22%2
Urgency symptomsUrgency urinary incontinence (UUI) is
the complaint of involuntary
leakage accompanied by or
immediately preceded by urgency
Stress symptomsStress urinary incontinence (SUI) is the
complaint of involuntary leakage on
effort or exertion, or on sneezing or
coughing
Mixed29%2
Mixed symptoms
Definition of urinary incontinence
1. Haylen B et al. Int Urogynecol J 2010; 21: 5 – 26. Neurourol Urodyn 2010;29:4-202. Hampel C et al. Urology 1997; 50(suppl 6A): 4–14
� Stress Urinary Incontinence SUI
� Urge(ncy) Urinary Incontinence UUI (OAB Wet)
� Mixed Urinary Incontinence MUI = SUI + UUI
� Overflow
� Congenital
– Ectopic ureter, epispadias, bladder exostrophy, cloacal exostrophy
� Fistula (vesico - vaginal fistulae)
– Gynae Surg (hysterectomy, anterior repair, laparoscopic pelvic surgery)
– Obstetrics (Third World)
� Functional
– Delirium, Infection, Atrophic changes, Pharmacological,Psychological, Excess Urine Output,
Restricted Mobility, Stool Impaction (DIAPPERS)
Types of urinary incontinence
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� Bladder Neck hypermobility
� Intrinsic sphincter deficiency
� Detrusor overactivity
� Oversensitive bladder
� Hypotonic or acontractile detrusor
� Obstruction
� Combination of urgency and stress
� Leakage during ‡intra-abdominal pressure
� Involuntary leakage
� Strong desire to void
� Often one symptom predominant
� ‡ with age
� Bladder distension
� Frequent to constant dribbling
SUI UUI MUI Overflow
Types of urinary incontinence
� Congenital– Ectopic ureter, epispadias, bladder exostrophy, cloacal
exostrophy
� Fistula (vesico - vaginal fistulae)– Gynae Surg (hysterectomy, anterior repair, laparoscopic pelvic
surgery)
– Obstetrics (Third World)
� Functional– Delirium, Infection, Atrophic changes,
Pharmacological,Psychological, Excess Urine Output, Restricted Mobility, Stool Impaction (DIAPPERS)
Types of urinary incontinence
� Enhorning GE1,2
– Pressure equalization
– Urinary incontinence achieved
urethral pressure ≥ intravesical
pressure
– Bladder neck retropubic
position
– Hypermobility results in
unequal pressure transmission
– Procedures focussed on
stabilizing urethra in fixed
retropubic position
Pressure equalisation
Enhorning GE Acta Chir Scand 1961, Enhorning GE Urol Int 1976
� Delancey JO3
– Hammock hypothesis from cadaveric dissection
– Fixed anterior vaginal wall serves as support for urethra
– Disruption of vaginal wall attachments creates bellowing hammock
– Ineffective backstop for urethra
Urethral hammock support
MUS provide a suburethral backstop during increased Abd pressure
Delancey JO AmJOG 1994
Risk Factors for SUI – simple to complex
Risk factors for stress urinary incontinence. Adapted from Bump RC, Norton PA. Obstet Gynecol ClinNorth Am. 1998;25:723–746.
Genetics Association studies - SUI
Cartwright Systematic Review and Metaanalysis of genetic association studies of urinary symptoms and prolapse in women. AmJOG 2015
Stress urinary incontinence
OR 2.1 [1.4, 3.2 n= 190]
Forest plot of studies reporting associations between rs1800012 single-nucleotide
polymorphism (SNP)* of collagen type 1 alpha 1 gene and either stress urinary incontinence
(SUI) or pelvic organ prolapse (POP). *RefSNP alleles G/T. Plot presented as risk associated
with minor allele T.
rs1800012 polymorphism
of the COL1A1 gene
was associated with
Prolapse OR 1.3 [1.0, 1.7 n = 838]
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Postpartum UI FI risk calculator
http://www.r-calc.com/ExistingFormulas.aspx?filter=CCQHS
Predispose: Sex, Race
Incite: Childbirth
Promote: BMI
Preamble
Pathophysiology & Etiology of SUI
Epidemiology
Assessment of UI
Management of SUI
Enhorning’s pressure equalisation Theory & Hammock Theory
(urethral backstop)
Conservative & Surgery
Management of intra & post operative complications
Case discussions
Questions