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EMBRYOLOGY AND ANATOMY
LONGITUDINAL SECTION OF A 4-WEEKOLD EMBRYO
LONGITUDINAL SECTION OF A 5-WEEKOLD EMBRYO
LONGITUDINAL SECTION OF A 6-WEEKOLD EMBRYO
LONGITUDINAL SECTION OF A 8-WEEKOLD EMBRYO
Embryologic Contribution Of Various Structures Of Female Urogenital System
• • Body (or dome) and
Fundus : - supple, mobile and highly distensible capable of expanding into abdomen, depending on amount of urine stored distensible holds orifices (uretersand urethra) in place
• Base of bladder not so
FEMALE URETHRA & SURROUNDINGS
Main smooth muscle layer includes: (1) Detrusor and Trigone It is the most important Muscle .A mesh of smooth muscle bundles, Collagen & elastin.
(2) The Trigoneis a thin smooth muscle lining over the bladder base, with a Collar around ureteric orifices – Actual function still 15
Adult female urethra 4 cm in length, up to 6 cm Diameter when distended • Extends from bladder neck behind Symphysis pubis • Embedded in anterior wall of
• Smooth muscle extends
throughout Length of urethra. • No well-defined sphincter at bladder neck. • Striated sphincter (external sphincter) Located along middle third of urethra Anatomically separate from Pelvic floor muscles. Pelvic floor muscles help keep urethra closed & support bladder
The parts of the urethral support and sphincteric mechanisms: the proximal urethra and bladder neck are supported by the anterior vaginal wall and its musculofascial attachments to the pelvic diaphragm. Contraction of the levator anielevates the anterior vagina and bladder neck and proximal urethra, contributing to bladder neck closure. The sphincter urethrae, urethrovaginal sphincter, and compressor urethrae are all parts of the striated urogenital sphincter muscle.
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.
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.
• 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
• Motor pathways
from brain, through spinal Cord to sacrum, on to bladder & urethra Sensory nerve fibers pass
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
• Stimulation of
• Inhibition of sympathetics • Inhibition of somatic nerves to
• urogenital sphincter
It is the involuntary leakage of urine .It occurs when the pressure in the bladder (expulsive force) exceeds that within the urethra (closure force)
The ICS Definition
A condition of involuntary urine loss that is a social or hygienic problem and is objectively demonstrable.
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
Genuine Stress Incontinence(GSI)
TYPES OF URINARY INCONTINENCE
• Stress Incontinence
Urine leakage occurs with increases in abdominal pressure (hence, mechanical “stress”). Often referred to as “overactive bladder.” an abrupt and uncontrollable desire to void the bladder. When two or more causes contribute to urinary incontinence. Often refers to the presence of both stress and urge incontinence. The involuntary loss of urine resulting from an overfilled bladder without any corresponding feeling or urge to void.
• Urge Incontinence
• Mixed Incontinence
• Overflow Incontinence
• 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)
PREVALENCE AND INCIDENCE
An estimated 13 million adults of all ages suffer from urinary incontinence – women account for nearly 85 % of cases.
38% of Women
• SEX: 18% of Men
• AGE: The prevalence of urinary
incontinence appears to increase with advancing age : 4% of women aged 15 to 24 16% of women aged 75 and greater. Reasons for the increase in prevalence of urinary incontinence with age are 34 (Unknown).
voiding, bladder compliance and urinary flow rate probably decrease with ADVANCING AGE in both sexes. Uninhibited bladder contractions and post void residual urine volume increase with age. Maximal urethral closure pressure and functional urethral length decrease in women. Changes in bladder and urethral function probably are related directly to aging process. Another age related change is an 35 alteration in the pattern of fluid excretion.
Filling / Storage disorders • Genuine stress incontinence • Detrusor instability (Idiopathic) • Detrusor hyperreglexia (Neurogenic) • Mixed types • Overflow incontinence
Fistula: • Vesical • Ureteral • Urethral • Congenital: – Ectopic Ureter – Epispadias
Non genitourinary Etiology
• Functional • Neurologic • Cognitive • Environmental • Pharmacologic • Metabolic
Non-Urologic Causes of Incontinence
• Behavioural problems • Immobility • Medication • Diabetes. • • Race:
Genital prolpse, enterocele and stress incontinence are uncommon in:
• Child Birth:
Non-Urologic Causes of Incontinence
Child birth injury leading to pelvic support abnormalities and stress incontinence Vaginal delivery directly damages pelvic fascial supports and may cause partial denervation of the pelvic floor and urethral muscles. Vagina and urethra have similar epithelial linings due to embryologic origin.Normal urethral function in the female is affected by age and estrogen status Significant association between cigarette
Non-Urologic causes of Incontinence
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 41 in nursing homes.
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 Ur in a r y r e t e n t ion , ov e r f low in con t in e n ce Se d a t ion , I m p a ir e d m ob ilit y, d iu r e sis An t ich olin e r g ic a ct ion s, se d a t ion An t ich olin e r g ic a ct ion s. se d a t ion Se d a t ion , m u scle r e la xa t ion , con f u sion St r e ss in con t in e n ce Ur in a r y r e t e n t ion Ur in a r y r e t e n t ion Ur in a r y r e t e n t ion , ov e r f low in con t in e n ce D iu r e t ics An t ich olin e r g ic a g e n t s Alcoh ol Psy ch ot r op ic a g e n t s AAn t id e p r e ssa n t s An t ip sych ot ics Se d a t iv e s / H y p n ot ics Alp h a -a d r e n e r g ic b lock e rs Alp h a -a d r e n e r g ic a g on ist s Be t a -a d r e n e r g ic a g on ist s Ca lciu m -ch a n n e l b lock e r s
Evaluation of Incontinence
• History • Physical Examination
Examination • Office Tests.
• 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 Incontinence
• Have you had bladder, urine, or • • • • • •
kidney infections? Are you troubled by pain or discomfort when you urinate? Have you had blood in your urine? Do you find it hard to begin urinating? Do you have a slow urinary stream? Do you have to strain to pass your urine? After you urinate, do you have dribbling or a feeling that your
The cotton-tipped applicator (Q-tip) test for the assessment of urethral and bladder support. A: The resting angle of the cotton-tipped applicator is normal. B: With straining, the urethrovesical junction descends, causing the end of the stick to rotate upward.
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. 48 If treatment fails, or secondary adverse
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: 1.Lowered urethral pressure 2.Detrusor contractions 3.Greater transmission of intra-abdominal pressure to the bladder than to the urethra 4.Passive increases in intra-vesical pressure due to distention beyond the elastic limits of the bladder 5.By passing of the continence mechanism due to 51
Etiology Of GSI
Proposed Mechanisms: urethra below its normal intraabdominal position during stressful.
• Anatomic decent of the proximal
• Altered anatomic relationships
between the urethra and bladder. components that reflexly increase intraurethral pressure in response 52
• Failure of neuromuscular
• Anatomic S.I • True S.I • Urinary S.I
Genuine Stress Incontinence (GSI)
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 53 stressful activities, the urethral closure pressure will
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 with different measures of success make these trials difficult to compare. Results show that an improvement can be 55 expected in 40–60% of women.
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 & III & a double-blind placebo controlled study. The effective dose was 40 mg twice daily. This dose elicited significant improvements with 50% of the women experiencing a 64–100% reduction in 57
SURGERY FOR STRESS INCONTENENC
– –Intraurethral injection –Abdominal procedures –Vaginal procedure –Classical Sling procedure
Abdominal procedure to correct stress incontinence. A: anterior vaginal wall has been mobilized. Two sutures have been placed on either side and far lateral from the midline. Distal sutures are opposite the mid urethra. Proximal sutures are at the end of the vasicourethral junction. Sutures are attached to coopers ligament. B: Cross section shows urethra free in retropubic space with anterior vaginal wall lifting and supporting it.
ABDOMINAL BURCH COLPOSUSPENSION.
There are two main types of sling procedure: the classic open bladder neck sling and the newer suburethral slings such as TVT, TVT- O , TOT and TVT - S. Success rates are approximately 80%, with little diminution over time, and tend to be higher with synthetic materials. However, their use increases the risk of erosion and sinus formation. The risk of voiding disorder is in the region of 10% and de novo detrusor overactivity is variable, at approximately 14%.
TVT trocar in position behind the symphysis pubis after the first pass
Laparoscopic surgery has the presumed advantage of avoiding a large incision, resulting in a shorter hospital stay and a quicker return to normal daily activities. Large differences in surgical techniques in this area confound comparison. There are few randomised controlled trials and these have limited follow-up.
URGE URINARY INCONTINENCE
• It is the complaint of involuntary leakage
accompanied by, or immediately preceded by, urgency. • It is often associated with increased frequency of micturition and nocturia. Up to 15% of the population complain of urgency although not all will be incontinent. • While urge urinary incontinence is a symptom of many conditions , idiopathic detrusor overactivity (formerly known as detrusor instability) 66
• It is a re-education or learning process in
which the patient is retrained using information about usually unconscious physiological responses. • In the example of idiopathic detrusor overactivity these would be unstable bladder contractions. • An auditory, visual or tactile signal is relayed back to the patient so that she can take action such as performing relaxation techniques or tightening certain muscle groups. 67 Although this has been shown to be
• Bladder drill involves instructing the
patient to void at predetermined intervals during the day. She must not void between these times but instead must either wait or be incontinent. The voiding interval is then increased once the initial goal has been achieved. This process is continued until voiding can be deferred to every 3-4 hours without urgency or incontinence between these times. A normal fluid intake should be maintained (1.5 1/day). It is most successful in young, well-motivated 68
Changes to the central nervous system have been implicated in pathology of stress incontinence. The suggestion is that the neurotransmitters serotonin and noradrenalin influence the contraction of the urethral sphincter. Abnormalities in their release can act alone or in combination with local damage or degeneration to the sphincteric mechanisms. A strong association has been found between depression and idiopathic incontinence.
This suggests a common pathology
• Urethra is mainly innervated by
alpha-adrenergic sympathetic Nervous system.
• Elimination of medications that exert
ganglionic or alpha Adrenergic blocking activity – Guanethidine, Methyldopa and Prazosin for improve urethral tone.
• Alpha- Adrenergic agonists may
DRUG TREATMENT OF OVERACTIVE BLADDER Oxbutynin (Ditropan): 2.5mg twice daily to 5mg 4 times a day Propantheline (Norpanth, Probanthine)
• Imipramine (Tofranil):
7.5mg twice daily to 15mg 4 times a day 25mg 2-3 times daily
• Flavoxate (Urispas):
100mg twice daily to 200mg 4 times a day Hyoscyamine (Cystospaz, Levsin,):
0.125-0.25mg 3- 4 times daily.
• Prostaglandin synthetase inhibitors
(nonsteroidal anti-inflammatory agents, e.g Ibuprofen, Fenoprofen, Sulindac) Advil, Clinoril, Naprosyn, 73
• It is a tertiary amine, and a highly
selective M1 and M3 muscarinic receptor antagonist and a direct muscle relaxant. It is the standard treatment against which other drugs and therapies have been tested. Its effectiveness in idiopathic detrusor overactivity is well documented but the incidence of its main adverse effect, dry mouth,
• Tolterodine is a muscarinic
receptor antagonist that appears to target bladder receptors over the salivary glands. Several randomised, double-blind, placebocontrolled trials on patients with idiopathic detrusor instability have shown a significant reduction in incontinent episodes and
• Imipramine has systemic Anti
-cholinergic effects, which are thought to improve the symptoms of detrusor overactivity. However, evidence of its benefits is conflicting and it should not be used as first-line treatment. The benefits of its sedative effects may be useful in
VASOPRESSIN (ANTI D URETIC HORMONE)
BOTULINUM TOXIN LOCAL INTRAVESICAL INJECTION
SURGERY FOR URGENCY INCONTINENCE
• Augmentation cystoplasty
• Auto augmentation
• Sacral nerve stimulation
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