urinary incontinence ( ui )

7/30/2019 Urinary Incontinence ( UI )

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URINARY

INCONTINENCE( UI )

Prof. Kamal Anwar


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Mechanism of continence of urine:

The proximal part of the urethra is intra-

abdominal ( above the levator ani ):

When the intraabdominal pressure is

increased ,it is transmitted equally to the bladder

and proximal urethra

The pubo-urethral ligament and levator ani keepthe proximal part of the urethra intra-abdominal


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Urethral muscular components:

External urethral sphincter ( EUS )supplied by

pudendal nerve: outer layer of striated muscle

arranged in a circular pattern

Internal urethral sphincter ( IUS ) : internal to

EUS smooth muscle arranged in a longitudinal

pattern Vascular plexus deep to these layers forms

a watertight seal by coaptation of mucosal

surface


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Micturition cycle :

Bladder filling ( Sympathatic fibres from

hypogastric plexus ) occurs with relaxation of

detrusor muscle and contraction of IUS

Bladder evacuation ( parasympathatic fibres

from sacral plexus ): occurs with contraction of

detrusor muscle


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Sympathetic nerves (T11-12)

Inhibit detrusor contraction

Increase sphincter tone

Inhibit parasympathetic tone

Somatic nerves (S2-4)

Maintain tone in pelvic floor mus

Bladder filling

Urination

Parasympathetic nerves (S2-4)

Contract the detrusor muscle

Relax sphincter tone

Nervous Control


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Urinary incontinence is defined as involuntary

leakage of urine

Types of Urinary incontinence :

1-stress urinary incontinence ( genuine stressincontinence ) :

It is the most common type of urinary

incontinence , accounting for 50-70 % of cases It occurs when the abdominal pressure exceeds

the bladder pressure


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Stress incontinence is triggered by activities(coughing, sneezing, laughing, running, orlifting) that apply pressure to a full bladder.

Childbirth and menopause increasing the risk

for it Urethral hypermobility :

Weakness of fibromuscular tissue that support thebladder neck and urethra

Interinsic sphincter deficiency due to damageof uretheral sphincter resulting in failure to closethe urethro-vesical junction

.


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2-Overactive bladder (Urge urinaryincontinence )

Involuntary leakage of urine immediately

preceded by the urge to void due to involuntarydetrusor contraction.

patients complain of inability to reach the toilet

in time

Urge incontinence is marked by a need tourinate frequently. There are many causes of

urge incontinence, including medical conditions,

Parkinsons disease, multiple sclerosis, stroke,

and spinal cord injuries), surgeries


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3-Overf low incon t inenceoccurs when the

bladder cannot empty completely, which leads

to dribbling. Bladder obstruction and inactive

bladder muscle can cause overflowincontinence.

Overflow incontinence happens when the

normal flow of urine is blocked and thebladder cannot empty completely


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overflow incontinence can be due to a

number of conditions:

A partial obstruction. In this case the urine

cannot flow completely out of the bladder, soit never fully empties :

Tumors

Scar tissue


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An inactive bladder muscle. In contrast to

urge incontinence (overactive bladder), with

overflow incontinence the bladder is less

active than normal. It cannot empty properly and so becomes

distended, or swollen. Eventually this

distention stretches the internal sphincteruntil it opens partially and leakage occurs.

Certain medications and nerve damage

increase the risk :


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Certain medications (such as anticholinergics,

antidepressants, antipsychotics, sedatives,

narcotics, and alpha-adrenergic blockers)

Nerve damage. When nerves in the bladder aredamaged the body cannot feel when the bladder

is full and the bladder does not contract. Nerve

damage can be caused by spinal cord injuries,

previous surgery in the colon or rectum, orpelvic fractures. Diabetes, multiple sclerosis

also can cause this problem.


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4-Func t ional inco nt inence

Patients with functional incontinence have mentalor physical disabilities that keep them fromurinating normally ( impair a persons ability to use

or get to the toilet ) although the urinary systemitself is structurally intact.

Conditions that can lead to functionalincontinence include:

Parkinson's disease Alzheimer's disease and other forms of dementia.

Severe depression. In such cases, people maybecome incontinent because they have difficultywith self-control


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5 -Mixed incont inence. Many people have

more than one type of urinary incontinence.

Symptoms of both stress and urgeincontinence may exist together


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6- True incontinence or Bypass incontinence( urogenital fistula ):

It is due to communication between urinary andgenital tract

Causes : Trauma during gynecologic surgery

Obstetric injuries :

Necrotic obstetric fistula

Direct traumatic obstetric fistula:Forceps delivery

Rupture uterus

Others: radiation, genital malignancy


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Risk factors for UI

Parity

Childbirth :Vaginal delivery causes damage to

pelvic structure

Medical conditions : diabetes, obesity,

Chronically increased intra-abdominal

pressure Estrogen deficiency

Drugs Diuretics , caffeine and anticholinergics


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Diagnosis of UI :

Symptoms Stress incontinence appears on stress as

coughing Overactive bladder presents as urinary urgency

with daytime frequency or nocturia

Examination :

Stress test : The bladder should not be empty

Ask the patient to cough and inspect the urethra

Involuntary leakage of urine from uretheral

meatus indicates stress urinary incontinence


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Neurological examination :

UI may be a symptom of neurological disease

Evaluate the motor and sensory function of the

lower limbs

Pelvic examination :

Assess pelvic floor including innervation ,

muscular and connective tissue support The strength of levator ani is assessed by

placing 2 fingers in the vagina and ask the

patient to squeeze


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Q-tip test

It evaluate urethral support

A cotton swab is placed in the urethra up to the

bladder neck

During straining ,the change of angle between

the Q-tip and the horizantal plane is measured.

If it is greater than 30 degrees ( abnormal ) , itindicates descent of the bladder neck due to

urethral hypermobility


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Investigations:

Urine analysis to exclude urinary tract infection

Postvoid residual urine measurement :

It aids in diagnosing overflow incontinence

Normally , it should be less than 100 ml

Cystourethroscopy :

It assesses the anatomy and function of lower

urinary tract


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Cystourethrography : Lateral view: loss of the posterior urethro-vesical

angle

Antero-posterior view : Funneling

Urodynamic study: This is done to differentiate between stress

incontinence and detrusor instability

In detrusor instability ,there is abnormal

contraction during filling In stress incontinence,there is decreased

urethral closure pressure which is the differencebetween the pressure in the urethra and bladder

rea men o r nary


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rea men o r naryIncontinence

Treatment options for urinary incontinencedepend on the type of incontinence and the

severity of the condition. Treatments include: Lifestyle Changes. Significant weight gain can

weaken pelvic floor muscle tone, leading tourinary incontinence. Losing weight through

healthy diet and exercise is important.Regulating the time you drink fluids andavoiding alcohol and caffeine are also helpful.


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Treatment of stress urinary

incontinence:

Non- surgical :

Postmenopausal atrophy :

Estrogen replacement therapy

Pelvic muscle exercise( Kegel exercise ) for 3-

6months

Vaginal pessaries in case of pelvic organ

prolapse


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Surgical treatment of SUI:

A-Cystocele repairwith Kelly suture for anteriorvaginal prolapse

Kelly suture: plication of pubo-urethral ligament

around the bladder neck

B-Colposuspension

Indicated in hypermobile bladder neck

Burch retropubic colposuspension:

Permanent sutures are placed in thefibromuscular tissue lateral to the bladder neck

and proximal urethra to be attached to

iliopectineal line ( Cooper ligament )

Success rate over 80 %


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Marshall- Marchetti

Krantez operation:

Similar to Burch but the stitches are placedthrough the periosteum of the symphysis pubis

C-Suburethral sling :

A sling is passed below the mid-urethra as ahammock providing stabilization of the urethra

Tension-free vaginal tape ( TVT )

A mesh is placed without tension at the mid-

urethra through retropubic space. Bladder perforation is the most common

complication

( 5 % )


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Tension free obturator tape ( TOT ):

TOT is passed through amid vaginal incision to

obturator foramen


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Treatment of overactive bladder

Medical treatment is the primary line

Medications used inhibit involuntary detrusor

contractions

A- Anticholinergics :

Oxybutynin ( Ditropan ) 5 10 mg / 8 hrs

B- Tricyclic antidepressants :

Imipramine 25 mg 1-4 times daily


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urinary incontinence ( ui )

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