Urinary incontinence

Abel G( MD,MPH)
Diredaw University
 Anatomy of LUT

Bladder
Muscular layer (epithelium, mucosa,
submucosa, muscle, subserosal layer)
under voluntary control.

Urethra:-
Approx 4cm long and 6mm in diameter.
Upper third, clearly separable from adjacent
vagina but lower portion is fused with it.
 Urogenital Sphincter
As the bladder fills, synchronized contraction of the
striated urogenital sphincter is integral to
continence.
Components of this sphincter include:
(1) the sphincter urethrae (SU),
(2) the urethrovaginal sphincter (UVS), and
(3) the compressor urethrae (CU).
The sphincter urethrae is striated muscle and wraps
circumferentially around the urethra.
The UVS and CU are striated muscle bands that arch
ventrally over the urethra and insert into the
fibromuscular tissue of the anterior vaginal wall.
Two sphincter mechanisms
Internal urethral sphincter

Extrinsic urethral sphincter mechanism

- has 2 components.
a) Inner portion- Sphincter urethras,

b) Outer portion
 The wall of urethra
Normally soft and pliable so that external forces
act on it to effect closure.
Mucosal lining of urethra
- Has complex folds.
- Secret mucus
- Hormone sensitive
Submucosal vasculature
- has well developed vascular plexus with large
venules.
 Support of the urethra
Urethral Support
The support of proximal urethra is provided
by
Endopelvic fascia and
Anterior vaginal wall.
The layer is stabilized by its lateral attachment
both to
Arcus tendineus fascia pelvis and
Medial margin of levator ani.
 Innervation of LUT
A. Motor
1. Autonomic nervous system (ANS)
a) Sympathetic Nervous System
b) parasympathetic Nervous system
2. Somatic nervous system

B. Sensory
1. Visceral sensation
2. Somato sensory perception
 Physiology of Continence
Factors which contribute for structural and
functional integrity of urethral sphicter are:
a) Extrinsic factors.
1. Endopelvic fascia and integrity of attachment
of pelvic side walls.
2. Levator ani muscle and its strength
3. Connection of levator ani muscle to
endopelvic fascia
4. Coordination of levator ani muscle
contraction with coughing
b) Intrinsic factors
1. Sympathetic innervation through adrenegic
receptors
2. Smooth muscle of urethral wall
3. Striated muscle of urethral wall
4. Elasticity of urethral wall
5. Mucosal coaptation of urothelium
6. Vascular congestion of submucosal venous
plexus.
Incontinences
 Incontinence
Definition according to International Continence
Society:
a condition of involuntary urine loss that is
objectively demonstrable and is a social or hygienic
problem.
May be caused by
Physiologic factors.
Pharmacologic factors.
Pathologic factors. or
Psychological factors.
 Effect on quality of life

1. To reduce social relationship and activities

2. Impair emotional and psychological well being
3. Impair sexual relationship
4. Cause avoidance behavior
5. Patients with UI react with embarrassment and
diminished self esteem.
Incontinence
Age
Pregnancy
Childbirth
Menopause
Hysterectomy
Obesity
Urinary symptoms
Functional impairment
Cognitive impairment
Chronically increased abdominal pressure
Chronic cough
Constipation
Occupational risk
Smoking
 Causes
Cause varies based on the type of urinary
incontinence.
Most common cause for the commonest type of
urinary incontinence in developing countries is
prolonged obstructed labor.
In developed nations for the prevalent types of
incontinences, the causes can be multiple and in
most patients may not be accounted for by a
single etiology.
Physiologic etiology includes
Structural and functional abnormalities of the CNS,
spinal cord, bladder, and urethra
 Classification of UI
A. Extra B. Trans Urethral
1.Genuine stress incontinence (GSI)
urethral Anatomic hyper mobility of bladder neck is urethra

i. Congenital Intrinsic sphincter dysfunction

Combination
Ectopic Ureter 2. Detrusor over activity (Urge incontinence)
Bladder extrophy Idiopathic detrusor instability
Neuropathic detrusor hyperreflexia
ii. Acquired
3. Mixed (combined GSI &Detrusor over
- Fistulae activity)
- Vesical 4. Overflow incontinence
5. Urethral diverticulum
- Ureteric 6.Congenital urethral abnormalities (e.g. Epispadias)
- Urethral 7.Uninhibited urethral relaxation (urethral
instability)
- Combination
 Major types of
incontinences
1. Urinary incontinence from Fistula (by pass)
2. Stress incontinence or genuine stress
incontinence(GSI)
3. Urge incontinence(UI)
4. Overflow incontinence
5. Mixed incontinence
6. Functional incontinence
 Incontinence
Stress incontinence is characterized by urine
leakage associated with increased abdominal
pressure from laughing, sneezing,
coughing, climbing stairs, or other
physical exertion.

Prevalence
29- 75% percent of cases.
2x more common in woman than men.
Epidemiological studies (ICS) showed that
22% among 514 (45 years) old women in an
interview study and
14% among more than 3000 (30-59 years)
old women in a questionnaire study.
Predisposing factors of SUI
1. Age-common in aged women
2. Obesity:-independent risk factor for UI
of all types
3. Child birth
4. Pregnancy
5. Menopause
6. Pelvic surgery
a) Hysterectomy
b) pop surgery
 Pathophysiology of SUI
1. Anatomic hypermobility of proximal urethra and
bladder neck.

2. Failure of neuromuscular component that reflexly

increase intra-urethral pressure in response to
increased IAP

3. Factors that weaken urethral closure mechanisms

such as
# estrogen deficiency,
# Scarring,
# denervation and
# medications
 Diagnosis of SUI
No single test is diagnostic of GSI.
Objective demonstration of
- Stress induced urinary leakage.
- Defect in anatomic support of proximal
urethra are necessary.
Unstable bladder, over flow incontinence and
infection must be ruled out.
a) History
- Stress induced urinary leakage
- is classic symptom
- diagnostic of GSI in 50-70% of case.
 continued
Duration of symptoms
Precipitating factors
Any treatment
Severity
History of predisposing factors
- Gynecological
- Surgical
- Medical
- Obstetric
- Drug intake
 Diagnosis of SUI continued
b) Physical examination
i) General physical condition of a patient
ii) Neurological screening examination
-Special emphasis on the lower extremities and perineal area
1) Testing the tone, strength and movement of lower limbs
2) Sacral reflex
- Bulbo cavernosus reflex
3) Sensory testing
- Testing the sensitivity of skin over perineum, buttocks and
medial thigh by pin prick and light touch evaluates sacral
nerve integrity
iii) Urogyenecological examination
-Vulva- excoriation and atrophy of external genitalia
- Evidence of vaginal atrophy.
- Bimanual pelvic examination
- Stress incontinence should be demonstrated
- Urine leakage- intra urethral
- extra urethral
c) Diagnostic tests
1) Midstream urine
- Urine analysis
- Culture and sensitivity
2) Cystoscopy
- Evaluates bladder mucosa for intrinsic lesions
3) Stress test- objective demonstration of urinary leakage
with stress.
Examination is done with subjectively full bladder or instillation of 300
ml sterile saline
Position. Lithotomy / standing with feet spread out to shoulder width .
Patient asked to cough repeatedly.
Demonstrate for the presence of urinary leakage simultaneously with
coughing
(trans urethral)
- Stress leakage : evidence of GSI
- Flow leakage : that a patient cant inhibit is evidence of detrussor
instability.
Pad test- objective demonstration of UI for
patients who have not demonstrated leakage in
the stress test.
Pre-weighted perineal pad used and patient
completes a 1 hr series of preset maneuvers,
then pad is reweighed. An increase in weight by >
2gm is indicative of urinary loss.
4) cystometry
is a method by which pressure volume relationship of bladder
is measured.
a) Mixed symptomatology
b) with suspected voiding disorders
c) bladder neck surgery
d) Previous un successful incontinence surgery
e) conservative of measures fail
f) Neuropathic bladder disorders
- Procedure:
a) Position-upright
b) pressure catheters are inserted to bladder and rectum
c) fluid (sterile H2O, saline) infused at a rate of 50-100ml/min to
the bladder
d) provocative maneuvers such as coughing, listening to running
water to reproduce patients symptom
e) The volume infused and pressure measurements are recorded
continuously
 Diagnosis of SUI continued c
Then, Normal cystometric valves for women are
a) Residual urine < 50cc
b) sensation of fullness occurs between 150-250cc infused
c) sensation of urgency shouldn't occur until > 250cc.
d) Cystometric capacity-between 400-600 cc
e) Maximum detrussor pressure during filling < 15 cm H2O
f) Flow rate during voiding is >15ml/sec with detrussor pressure
less than 50 cmH2O
g) No uninhibited detrussor contraction during filling despite
provocation
h) No stress or urge incontinence demonstrated, despite
provocation.
Ultrasonography:- To visualize the bladder neck
during rest, coughing and valsalva maneuver.
Bladder neck mobility can be visualized by vaginal,
rectal and perineal ultrasonography.
Hyper mobility is defined as a bladder neck descent
>1cm during valsalva.
Simple cystometry: - Crude diagnostic modality
Fill the bladder is filled with normal saline, 50ml
increments (By gravity), using a catheter attached to
syringe with the piston removed.
A rise in the fluid level by > 15 ml in the absence of
intra abdominal pressure associated with urgency or
leakage is suggestive of detrusor instability.
 Q-tip test (office cotton swab test): Measurement of
the urethral axis as a method to assess the degree of
mobility of urethrovesical function.
Lubricated sterile cotton swab is inserted into the urethra
up to the level of bladder neck
Patient is asked to cough/strain
Maximum deflection of the swab stick from the horizontal
measured using a simple plastic protractor.
A maximum straining angle >30o is generally taken to
represent the presence of Urethral hyper mobility
Urodynamic studies: to identify and quantify the
etiologic factors contributing to lower urinary tract
dysfunction.
Pressure volume relation of the bladder is measured
Assesses bladder sensation, bladder capacity, bladder
compliance and detrusor activity.
 Multi-channel Urethrocystometry: measures
bladder, urethral and abdominal pressures
The bladder is filled at a standard rate of saline
(50-100ml/min) and the patients sensations are
recorded and correlated with the subtracted
detrusor pressure.
Normal values are:
Residue urine <50ml
First desire to void 150- 250ml
Cystometric capacity 400- 600ml
Max-detrusor pressure <15cm H 2O
Max-detrusor pressure during voiding <70cm
H2O
 Diagnosis of SUI continued
5) Q-tip test
6) Cysto urethrography:-
- Descent of bladder neck with obliteration of posterior
urethro
- vesical angle hypermobility of urethra
- Open proximal urethra and bladder neck at rest
ISD
7) U/S
8. MRI
 Management of GSI
Conservative Mx
1. An operation should be done when the problem
becomes so severe that a patient wants to have
corrected.

2. Some patents may not get worried by degree of

urinary leakage to have expense and risk of surgery.

3. Some patients became reluctant as to surgical Mx

because women may not complete her family then
fear of damage of surgical repair during pregnancy,
labour and delivery.

4. Some incontinent women are frail and elderly, then

reluctant to surgery because of their general health.
i) Reduction of factors that worsen the problem
- Reduction of weight
- Avoiding strenuous exercise and heavy lifting
- Avoid smoking.
ii) Pelvic floor physiotherapy
-First described by kegel in 1948
- Main stay of conservative Mx in GSI
- To be effective:-
- Procedure
a) Tensing muscultare of pelvic floor and holding
the contraction for 5 seconds each, 15-
20X/session, three sessions per day.
b)Pre therapy and pos therapy urodynamic and
radiographic evaluations
c) When done for three months in one study
Outcome:
- 32% cured
- 68% marked improvment
- After 12-36 months follow up 77%
maintain functional level
Generally, pelvic muscle exercise improves
pelvic support and sphincter competence.
 iii) Drug therapy
a) adrenergic agonists
Acts on adrenergic receptor sites on bladder neck and proximal
urethra to produce smooth muscle contraction
- Produces satisfactory improvement in mild case.
- Usually used with pelvic floor exercises.
- because of side effects of drugs.
- HTN, CVS disease and hyperthyroidism
-Drug are:
1) Ephedrine 15-30mg po.TID
2) Pseudoephedrine -30-60mg,Po.TID
3) Imipramine- 10-25mg. Po.BID
4) Norefenefrine - 15-30mg. Po.TID
5) Phenylpropanolamine - 50-75mg Po.BID
6) Noreephedrine -100mg Po.BID
 Conservative (drugs)

b) Estrogen
- Ideal for postmenopausal women with SUI
Mechanism
- Mucosal proliferation with a consequently
improved mucosal seal.
- Enhacement of adrengic contractile response of
urethral smooth muscle to endogenous
catecholamines.
In one study
- 2g conjugated-estrogen vaginal cream daily for
6 weeks in 11 patients with SUI, outcome 6 were
cured
IV- Pessaries
- Indicated for
- Older women with prolapse and incontinence
who are poor surgical candidate
- For young women who experience stress
incontinence only during intensive exercise
Mechanism
- Increase urethral resistance
- Proximal urethra are stabilized in an appropriate
anatomic position during episode of stress.
- An appropriate fitting ring pessary may result in
continence up to 75% of women.
V. Functional electrical stimulation
- alternate to treat SUI or urge incontinence (in some
centers)
- no wide clinical practice to this mode, under study in
research setting
B. Surgical Rx:
- The world medical literature produces more
than 1 paper/week on SUI and probably
more than 200 operations have been,
suggested as surgical cure for GSI.
- This shows that ideas operation has yet to be
devised
-
In surgical Rx:
- The first operation must be the best one and one
should choose the right operation for the right patient.
- Factors which enables to select proper operations for SI
.
1. Technical goal
- Is the objective to correct urethral hypermobility, or is
it to compensate for ISD?
2. A vigorous active patient may need more durable
urethral support than an elderly.
3. A morbidly obese woman with chronic respiratory
problems who is a heavy smoker is different from a
thin women with normal lungs and sedentary habits.
4. Does the patient need a laparatomy or operations
for UVP other than SUI?
a) Anterior vaginal colporrhaphy
- Oldest operation for SUI
- Because of poor long term results in most cases suburethral
plication is no longer recommended for surgical correction
of GSI
b) Operations designed to correct incontinence due to
urethral hypermobility.
1. Retropubic bladder neck suspension (Retropubic
urethropexy)
- aim is to attempt to prevent urethral hypermobility and
stress incontinence that results by stabiliting endopelvic
fascia from above.
- All operations of retropubic urethropexy share 2 xics
- they are perormed through a low abdominal incision into
retzius space.
- They all involve attachment of periurethral endo pelvic
fascia to some other supporting strucutre in anterior
pelvis.
-
i) Marshall- Marchetti -Krantz (MMK)
- First retropubic bladder neck operation for SUI described in 1949.
- Performed by placing a series of sutures along urethra to level of
bladder neck and then driving the needle directly into periosteum
of S.Pubis.
- Success rates 52-85% after one year of surgery.
ii) Burch corposuspension
Dr. John Burch, 1961 described a modification of original MMK
procedure because MMK operation
- Is not always easy to perform
- field is often deep and bloody
- edge of urethra is difficult to define
- Periosteum on posterior aspects of s. pubis is far from ideal as a
holding structure
Is surgical good standard for GSI due to hypermodility of
urethra
Done by placing 2-4 sutures into endopelvic fascia at the level of
bladder neck and along bladder edge proximal to bladder neck.
 The end of the needle is then passed at right angle
through the thick portion of coopers ligament.
This leaves 1-2 finger breadths of free space
between urethra and of s.pubis
Adv. Of Burch corposuspension over MMK are:
1. Pectineal ligament is a strong supporting structure
than pubic periosteum.
2. Placement of sutures farther from urethra
decrease the risk of Periurethral fibrosis and
denervation.
3. Shorter time to resumption of spontanous voiding,
shorter hospital stay and lower associated morbidity
4. Small cystoceles are corrected.
success rate (after 2 years):
89% 10 procedures
72% Recurrent case
iii) Turner-warwick vaginal obturator shelf
procedure:
- Endopelvic fascia is sutured to fascia covering
obturator internus muscle.
2) Needle suspension procedure (Trans vaginal
urethropexy):
- 1st needle suspension Dr. Armond Pereyra (in
1950)
- done by suspending urethra and bladder neck
through a technique that involved passage of
permanent suture between vagina and antererior
abdomen through Retzius space using a specially
designed long needle carriers.
 Prevention:
1. C/s delivery
2. Vacuum extraction may afford more protection
against UI than forceps delivery
3. Postnatal pelvic floor exercise
4. Hormone replacement Rx in post meno pausal
women
5. Avoiding- excessive weight gain
 Urge incontinence
Definition:
It is characterized by involuntary urine loss accompanied by
a sudden strong desire to pass urine that is difficult to
suppress
Is a result of uninhibited bladder contraction from detrusor
hyperactivity.
Can be caused by abnormalities of the CNS inhibitory
pathway such as strokes and cervical stenosis.
Other causes are bladder inflammation from
Urge incontinence usually entails urgency,
frequency, or nocturia.
These symptoms are often referred to as the
overactive bladder syndrome (OAB).
Some individuals may have a pure sensory
abnormality where they exhibit urinary
frequency and urgency without urine loss.
This is often referred to as overactive bladder
dry.
Elderly persons frequently experience urinary
loss without the sensation of urge, but the
underlying mechanism of detrusor hyperactivity
is still the same.
Detrusor overactivity accounts for up to 33% of
incontinence cases,
 Mixed incontinence
Definition:
It characterized by involuntary loss of urine
associated with urgency as well as exertion,
cough, sneeze, or any effort that increase
intra-abdominal pressure
Mixed incontinence is the coexistence of stress
and urge incontinence.
It is the most common type of incontinence
in women.
 Overflow incontinence
Definition:
Overflow incontinence is incomplete bladder emptying
secondary to impaired detrusor contractility or bladder
outlet obstruction.
Factors involved are physical obstruction, such as
Pelvic organ prolapse and
Neurological abnormalities, such as spinal cord injuries.
It is also commonly associated with bladder neuropathy as
occurs in diabetes mellitus.
Patients often complain of continuous small-volume
leakage associated with
Weak urinary stream
Dribbling
Hesitancy
Frequency and
Nocturia .
 Uro-genital Fistula
Definition:
- Is an abnormal communication between lower
urinary tract and genital organs
Etiologically, there are two types:
1. Obstetric
2. Non obstetric
Non obstetric
Infections
Malignancies
Radiation therapy
Surgery
Other traumas
 Obstetric Fistula
The most common type of urinary incontinence
in developing world.
Results from ischemic injury as a result of
prolonged obstructed labor.
Normal tissue perfusion is disrupted by
compression of the soft tissues between the
bony parts of the maternal pelvis and fetal
head.
This leads to ischemia, tissue death,
subsequent necrosis, and fistula formation.
In an unequal world ,those
women are unequal among the
most unequals
My name is Telaneshi Shebere. I am 14 years
old.
I was promised in marriage when I was 3,
betrothed at 10, and pregnant at 12.
After 3 days of labor, I was carried on a
stretcher to a hospital, where my baby died 2
hours later.
The obstructed labor left me incontinent. I
smell, and I feel so ashamed
Every minute, a woman dies in
pregnancy or childbirth
, and for every woman who dies, 20-30
others will survive but with morbidity,
one of which is obstetric fistula
 The obstructed injury
complex
Involves:
Urologic injuries
Gynecologic injuries
Gastrointestinal injuries
Musculoskeletal injury
Dermatological injuries
Fetal injury
Social injury
 Functional incontinence
Occurs when normal urine control exists but
trouble getting to the bathroom in time.
This might be as a result of arthritis or other
diseases that make it hard to move around.
Functional incontinence occurs in situations
in which a woman cannot reach a toilet in time
because of physical, psychological, or
mentation limitations.
In most instances, this group would be continent
if these issues were absent.
MX
Depends on the type of incontinence
 Thank you

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