Professional Documents
Culture Documents
DR . JASSIM AL-HIJJI
CONSULTANT
OBS. & GYN.
UROGYNECOLOGY UNIT.
ADAN HOSPITAL
1
EMBRYOLOGY
2
EMBRYOLOGY AND
ANATOMY
3
LONGITUDINAL SECTION OF A 4-WEEK-
OLD EMBRYO
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LONGITUDINAL SECTION OF A 5-WEEK-
OLD EMBRYO
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LONGITUDINAL SECTION OF A 6-WEEK-
OLD EMBRYO
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LONGITUDINAL SECTION OF A 8-WEEK-
OLD EMBRYO
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Embryologic Contribution Of Various Structures Of
Female Urogenital System
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ANATOMY
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10
BLADDER ANATOMY
•
• Body (or dome) and
Fundus :
- supple, mobile and
highly distensible
-
capable of expanding
into abdomen,
depending on
amount of urine stored
13
14
BLADDER MUSCLES
Main smooth muscle
layer includes:
(1) Detrusor and Trigone
Muscle .A mesh of
smooth muscle
bundles, Collagen &
elastin.
6 cm Diameter
when distended
• Extends from
bladder neck
behind Symphysis
pubis
• Embedded in
anterior wall of 16
FLOOR
third of urethra
Anatomically separate
from Pelvic floor
muscles.
Pelvic floor muscles help
18
The levator ani, seen from the side when the
ischium is removed. Arcus tendineus levatores ani
runs from the ischial spine to the pubic bone. Note
the perineal membrane that supports distal
portions of the urethra and vagina.
19
The levator ani, with patient in the
semirecumbent position. The muscle fibers
of the pelvic diaphragm form a broad,
anteriorly directed, U-Shaped muscle layer.
The pelvic organs pass within this U-Shaped
area, called the urogenital hiatus.
20
PHYSIOLOGY
21
NORMAL MICTURITION
•
• Cycle begins with urine filling bladder through
ureters
• Pressure in bladder remains low during gradual
filling
• When bladder reaches certain distension, stretch
receptors in bladder wall send this information
to spinal cord; other nerves relay it to brain as
sensation of fullness
• If time and place are right, emptying takes place:
- Urethral sphincter relaxes & urethral
pressure decreases
- Detrusor muscle contracts & bladder
pressure rises
- Bladder neck and urethra open
- Urine flow begins and continues until
bladder is empty 22
NEURAL PATHWAYS
• Motor pathways
from brain,
through spinal
Cord to
sacrum, on to
bladder &
urethra
• Sensory nerve
fibers pass
information
back 23
24
PERIPHERAL INNERVATIONS
25
Actions Of The Autonomic And Somatic Nervous
Systems During Bladder Filling / Storage And
Voiding
FILLING/STORAGE
• Inhibition of parasympathetics
• Stimulation of sympathetics
• alpha-contraction
• beta-relaxation
• Stimulation of somatic nerves
to striated
urogenital sphincter
VOIDING
•
• Stimulation of
parasympathetics
• Inhibition of sympathetics
• Inhibition of somatic nerves to
striated
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• urogenital sphincter
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Urinary Incontinence
It is the involuntary leakage of
A condition of involuntary
urine loss that is a social or
hygienic problem and is
objectively demonstrable. 29
Genuine Stress
Incontinence(GSI)
Urodynamic stress
incontinence (previously
known as genuine stress
incontinence) is a solely
urodynamic diagnosis which
occurs when an
incompetent urethra allows
leakage of urine in the 30
TYPES OF URINARY INCONTINENCE
• Stress Incontinence
Urine leakage occurs with increases in abdominal
pressure (hence, mechanical “stress”).
• Urge Incontinence
Often referred to as “overactive bladder.” an abrupt and
uncontrollable desire to void the bladder.
• Mixed Incontinence
When two or more causes contribute to urinary incontinence. Often
refers to the presence of both stress and urge incontinence.
• Overflow Incontinence
The involuntary loss of urine resulting from an overfilled bladder
without any corresponding feeling or urge to void.
• Functional Incontinence
Leakage (usually resulting from one or more causes) due to factors
impairing reaching the restroom in time because of physical
conditions (e.g., arthritis)
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•
32
Urinary Incontinence
33
PREVALENCE AND INCIDENCE
An estimated 13 million adults of all ages
suffer from urinary incontinence – women
account for nearly 85 % of cases.
• Vesical
• Ureteral
• Urethral
• Congenital:
– Ectopic Ureter
– Epispadias
37
Non genitourinary Etiology
• Functional
• Neurologic
• Cognitive
• Environmental
• Pharmacologic
• Metabolic
38 •
Non-Urologic Causes of
Incontinence
• Behavioural problems
• Immobility
• Medication
• Diabetes.
•
• Race:
Genital prolpse, enterocele and
stress incontinence are uncommon
in:
39
Non-Urologic Causes of
Incontinence
• Child Birth:
Child birth injury leading to pelvic support
abnormalities and stress incontinence
• Menopause:-
Vagina and urethra have similar epithelial
linings due to embryologic origin.Normal urethral
function in the female is affected by age and
estrogen status
• Smoking:-
Significant association between cigarette 40
Non-Urologic causes of
Incontinence
• Obesity:
Significantly more common in women with
GSI and D.I
•
• Psychologic Changes:
U.T is a complex phenomenon with multiple
causes including psychogenic causes.The anxiety,
depression and other psychologic abnormalities may
be related .
•
• Sexual Changes:
Sexual dysfunctionL U T dysfunction can effect
on sexual function.Leaking urine with intercourse
• Economic Issues:
Costs of caring for elderly incontinence people
in nursing homes. 41
MEDICATIONS THAT CAN AFFECT LOWER URINARY TRACT
FUNCTION
LOW ER URIN ARY TRACT TYPE OF M ED ICATION
EFFECTS
Polyu r ia , fr e q u e n cy u r g e n cy D iu r e t ics
• History
• Physical Examination
• Gynecologic
Examination
• Office Tests.
44
• Do you leak urine when you cough, sneeze , or laugh?
• Do you ever have such an uncomfortably strong need
to urinate that if you don't reach the toilet you will
leak?
• If " Yes" to No.2, do you ever leak before you reach the
toilet?
• How many times during the day do you urinate?
• How many times do you void during the night after
going to bed?
• Have you wet the bed in the past year?
• Do you develop an urgent need to urinate when you
are nervous, under stress, or in a hurry?
• Do you ever leak during or after sexual intercourse?
• Do you find it necessary to wear a pad because of your
leaking?
• How often do you leak ? 45
Questions in the Evaluation of Urinary
Incontinence
47
Urodynamic Studies
A urodynamicstudy is a series of detailed
measurements that gives an idea of the
function of the bladder and urethra
•These tests can evaluate any problems
with storing urine or voiding urine from
the body.
• Accurate differentiation between types of
incontinence is vital . However,
empirical treatment without urodynamic
assessment can be commenced if
symptoms of idiopathic detrusor
overactivity are uncomplicated.
If treatment fails, or secondary adverse48
49
50
Genuine stress
Incontinence
•
In intact L U T : Continence is maintained as long
as the pressure closing the urethra is greater
than the intra vesical pressure.
Etiology:
• Failure of neuromuscular
components that reflexly increase
intraurethral pressure in response
52
Genuine Stress Incontinence
(GSI)
• Anatomic S.I
• True S.I
• Urinary S.I
It is the involuntary loss of urine through the urethra
occurring simultaneously with an increase in
intra-abdominal pressure in the absence of
detrusor muscle contraction.
• Continent at rest has intraurethral pressure greater
than the intra-vesical pressure.
• The pressure difference or urethral closure pressure
(Total U.P – Intravesical P.) = Represents the
margin of continence.
• If the resting intravescial pressure + any increase in
pressure generated during stressful activities
exceeds the intraurethral Pressure at rest + any
increase in urethral pressure generated during
stressful activities, the urethral closure pressure will
53
Treatment Of GSI
• Non Surgical Measures:
– Medical devices that block or capture
urine.
– Kegel exercises
– Medication to increase or decrease
the activity of the bladder muscle, or
medication to increase or relax the
closure of the bladder sphincter.
– Electrical stimulation to help return
injured muscles to fitness and
biofeedback to record progress in
strengthening treatments and
exercises.
– Magnetic Stimulation.
54
– Estrogen replacement
Pelvic Floor Muscle Training
It is the most recommended physical
therapy for women with stress urinary
incontinence. Adjuncts, as biofeedback or
electrical stimulation, are also commonly
used with pelvic floor muscle training.
Training regimens vary markedly from
area to area.
The inconsistency of intervention coupled
56
DULOXITINE & GSI
A combined noradrenalin and serotonin
reuptak inhibitor,duloxetine,was used in
animal studies. In the cat model
duloxetine significantly increased
sphincteric activity and bladder capacity.
Duloxetinehas been trialled in a phase II
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ABDOMINAL BURCH
COLPOSUSPENSION.
60
Sling Procedures:
There are two main types of sling
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Laparoscopic Colpo-
suspension
Laparoscopic surgery has the
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BOTULINUM TOXIN
LOCAL INTRAVESICAL INJECTION
78
SURGERY FOR URGENCY
INCONTINENCE
• Augmentation cystoplasty
• Auto augmentation
79