Female Incontinence

Dr Alin Ciopec
Trust SGO O&G
EDGH
21/10/10
Clasification of urinary incontinence
• Stress Urinary Incontinence – involuntary leakage of urine on effort or
exertion, or on sneezing, or coughing. It commonly arises as a result of
urethral sphincter weakness
• Urge Urinary Incontinence – involuntary leakage of urine accompanied by,
or immediately preceded by, a strong desire to pass urine (void). Can be a
symptom of overactive bladder syndrome
• Mixed Urinary Incontinence – involuntary leakage of urine associated both
with urgency and with exertion, effort, sneezing, or coughing. Usually, one
of this is predominant
• Overflow Incontinence – occurs when the bladder becomes large and
flaccid and has little or no detrusor tone or function – usually due to injury or
insult after surgery or postpartum. Condition is diagnosed when the urinary
residual is more than 50% of bladder capacity. The bladder simply leaks
when it becomes full
• Continuous Urinary Incontinence – classically associated with fistula or
congenital abnormality, e.g. ectopic ureter
• Other Types of Incontinence – arising from UTI, medications, immobility
or cognitive impairment. Situational incontinence e.g giggle incontinence
 Urinary Symptoms
• Urinary incontinence – stress or urge incontinence
• Daytime frequency – normal 4-7 voids/day
• Nocturia – up to the age of 70 years more than a single void is considered abnormal
• Nocturnal Enuresis
• Urgency – sudden compelling desire to pass urine , which is difficult to defer -
secondary to detrusor overactivity, or interstitial cystitis
• Voiding difficulties – hesitancy (difficulty in initiating micturition), straining to void,
slow or intermittent urinary stream. All suggestive of urethral obstruction, an
underactive detrusor muscle, or loss of coordination between detrusor contraction
and urethral relaxation. Intermittency is seen in neurological disease
• Postmicturition – feeling of incomplete bladder emptying, terminal dribble (a
prolonged final part of micturition), postmicturitional dribble (involuntary lost of urine
immediately after passing urine)
• Absent or reduce bladder sensation – overflow - caused by spinal cord injuries or
pelvic surgery
• Bladder pain – intravesical pathology
• Urethral pain
• Dysuria – UTI
• Haematuria – warrants further investigations
 Assessment of the lower urinary
tract
• History
• Quality of Life assessment (QoL)
questionnaires
• Frequency/volume chart (in/out/wet)
• Physical examination – general,
abdominal,pelvic
 Assessment of the lower urinary
tract – Investigations
Basic Investigations
• Urinalysis
• Urine specimen – MSU
• Residual check (by U/S or catheterization)
• Pad test

Cystourethroscopy +/- biopsy

indications:
• Recurrent UTI
• Haematuria
• Bladder pain
• Suspected urinary tract injury or fistula
• To exclude bladder tumour or stones
• If interstitial cystitis is suspected
 Assessment of the lower urinary
tract - Imaging
• Ultrasonography
• Plain abdominal radiograph
• Intravenous urography – foreign bpdies or calculi
• Micturating cystourethrography – neuropathic bladder, fistulae
• Contrast CT
• MRI
Conditions requiring imaging of urinary tract:
• Recurrent UTI
• Haematuria
• Urethral diverticula, which need to be differentiate from paravaginal
cysts
• Suspected ureteric injuries
• Suspected urethral or vesical fistulae
• Suspected malignancy or renal stones
 Assessment of the lower urinary
tract – urodynamic investigations
Combination of test that look at the ability of the
bladder to store and void urine
• Uroflowmetry – can be used to screen for
voiding difficulties
• Cystometry – involves measuring the
pressure/volume relationship of the bladder
during filling and voiding
• Video-urodynamics – enables detection of
detrusor sphincter dyssynergia, vesico-ureteric
reflux, presence of abnormalities
• Ambulatory urodynamic monitoring
 Stress Urinary Incontinence
• SUI (Stress Urinary Incontinence) – is
the complaint of involuntary leakage of
urine on effort/exertion/sneezing/coughing
• USI(Urodynamic Stress Urinary
Incontinence) – is the involuntary leakage
of urine during increased intra-abdominal
pressure in the absence of detrusor
contraction – can be only diagnosed by
urodynamic testing
 Stress Urinary Incontinence
• Incidence – 1 in 10 women; 50% complain of pure stress
incontinence; 30-40% have mixed symptoms of urge and stress
incontinence
• Pathophysiology and aetiology
1. SUI occurs when the intravesical pressure exceeds the closing
pressure on the urethra
2. Childbirth –is the most common causative factor, leading to
denervation of the pelvic floor, using durin delivery
3. Oestrogen deficiency at the time of menopause, leads to
weakening of the pelvic support and thinning of the urothelium
4. Occasionally, weakness of the bladder neck occur congenitally or
through trauma from radical pelvis surgery or irradiation
 Stress Urinary Incontinence
• Clinical features:
• Symptoms:
Leakage of urine when she coughs,
sneezes, runs, jumps, carries heavy
loads – the leakage is usually samll ,
discrete amount , coinciding with
physical activities
• Signs: prolapse of the urethra and
anterior vaginal wall
 Stress Urinary Incontinence
Investigations
• Midstream Urinary Sample – to exclude
infection or glycosuria
• Frequency/volume chart
• Urodynamic studies – check for voiding
dysfunction and coexisting detrusor
overactivity
 Stress Urinary Incontinence
conservative management
• Lifestyle interventions – weight reduction if BMI>30/
smoking cessation/treatment of chronic cough and
constipation
• Pelvic floor muscle training – for at least 3 months
• Biofeedback - refers to the use of a device to convert
the effect of pelvic floor contraction into a visual or
auditory signal to allow women objective assessment of
improvement
• Electrical stimulation
• Vaginal cones – for applying graded resistance against
which the pelvic floor muscles contract
 Stress Urinary Incontinence
conservative management
• Pharmacological management of SUI
• Duloxetine – for moderate to severe SUI
• Indications for conservative treatment od SUI:
1. Mild or easily manageable symptoms
2. Family incomplete
3. Symptoms manifest during pregnancy
4. Surgery contraindicated by coexisting medical
conditions
5. Surgery declined by patient
 Stress Urinary Incontinence
surgical management
Periurethral injections
• Bulking agents have a lower immediate success
rate(40-60%) and a long-term continued decline in
continence
• Most commonly used: Glutaraldehyde crosslinked
bovine collagen and Macroparticulate silicon
particles(Macroplastique)
• May be appropriate for:
1. Frail, elderly, or unfit women
2. Women who have had other multiple failed procedures
 Stress Urinary Incontinence
surgical management
Burch colposuspension
• Largely replaced by TVT
• Now rarely performed
• The retropubic space is entered through a low
transverse suprapubic incision and two or three
sutures places between the paravaginal fascia
and ipsilateral ileopectinal ligament (Cooper’s
ligament) at the level of the bladder
• Efficacy as primary procedure – 90%, as repeat
procedure – 83%
 Stress Urinary Incontinence
surgical management
Laparoscopic colposuspection
• Efficacy and complications similar to those
of the open procedure
• The surgery is technically more
demanding and requires considerable
laparoscopic expertise
• But quick recovery and low cost due to
spitalisations
 Stress Urinary Incontinence
surgical management
TVT (Tension free Vaginal Tape)
• The most commonly performed surgical procedure for USI in the
UK
• A polypropylene tape is placed under mid-urethra via a small
vaginal incision, using a local or general anaesthesia
• Cystourethroscopy is carried out to ensure no damage to the
bladder or urethra
• Is minimally invasive and return to normal activity within 2 weeks
• Complications:
1. Moderately high risk of bladder injuries 5-10%, but these do not
seems to have long-term sequelae, if treated appropriately
2. Bleeding in retropubic space, infections and voiding difficulties
3. Tape erosion into the vagina and urethra has also been reported
• The objective cure rate is 82-98%
 Stress Urinary Incontinence
surgical management
TOT (Transobturator Tape)
• The polypropylene tape is passed via a
transobturator foramen through the
transobturator and puborectalis muscles
• The main difference from TVT is the
retropubic space is not entered and the
risk of bladder perforation is low
• Similar success rate with TVT
 Overactive Bladder Syndrome
(OAB)
• Is a chronic condition defined as urgency, with or without
urge incontinence, usually with frequency or nocturia
• Is affecting 1 in 6 women
• The incidence is increasing with age
• Is the second most common cause of urinary
incontinence
Aetiology
• Idiopathic in most cases
• Neurogenic detrusor overactivity – multiple sclerosis,
spina bifida, upper motor neuron lesions
• Secondary to pelvic floor surgery
• OAB due to outflow obstruction is uncommon in women
 Overactive Bladder Syndrome
(OAB)
Clinical features of OAB
• Urinary frequency
• Urgency
• Urge incontinence
• Nocturia
• Nocturnal enuresis
• Provocative factors: cold weather, opening the
front door, hearing running water, by raised
intra-abdominal pressure-coughing, sneezing,
• QoL can be significantly impaired by the
unpredictability and large volume of leakage
 Overactive Bladder Syndrome
(OAB) - Investigations
• Urine culture
• Frequency/volume chart
• Urodynamics – is essential for diagnosis of
OAB with multiple and complex symptoms

Other factors need to be excluded when diagnosis

of OAB is made:
1. Metabolic abnormalities – diabetes or
hypercalcemia
2. Physical causes – prolapse or faecal impaction
3. Urinary pathology – UTI or interstitial cystitis
 Overactive Bladder Syndrome
(OAB) - management
Conservative management
• Behavioral therapy – 1-1,5l of liquids/day;
avoid caffeine based drinks and alcohol; some
diuretics or antipsyhotics drugs need to be
reviewed
• Bladder retraining – ability to suppress urinary
urge and to extend the intervals between
voidings
• Hypnotherapy and acupuncture
• Antidepessants
• oestrogens
 Overactive Bladder Syndrome
(OAB) - management
Pharmacological interventions
• Anticholinergic(antimuscarinic)drugs
- they block the parasympathetic nerves thereby relaxing the detrusor
muscle
- the dosage need to be titrated against efficiency and adverse effects
(dry mouth, blurred vision, dizziness, insomnia, palpitations and
arrhythmia)
Contraindications:
• Acute (narrow angle) glaucoma
• Myasthenia gravis
• Urinary retention or outflow obstruction
• Severe ulcerative colitis
• Gastrointestinal obstruction
• E.g.: Oxybutynin, Propiverine, Solifenacin, Tolterodine, Trospium,
Darifenacin
Overactive Bladder Syndrome
(OAB) - management
Genital prolapse
ISMAEL YOUSIF
 Definition
Genital Prolapse:

Is herniation of the genital organs

through the genital tract.

 Support of the pelvic organs:
• The main support is by the :
1-pelvic floor muscles:
-Levator ani
-Coccygeus
-Internal Obturator
-Piriformis
-Transverse perineal muscles
 Support of the pelvic organs
2- Pelvic ligaments:
- Transverse cervical ligaments (Cardinal)
- Uterosacral ligaments
- Pubocervical ligaments
- Pubourethral ligaments

3- Pelvic Fascia
 Minor support:
• Round ligament

• Broad ligament
 Classification
• Vaginal wall prolapse:
#Anterior:
1- Urethrocele:
Descend of the lower part of the anterior
vaginal wall containing the urethra.
2- Cyctocele:
Descend of the upper part of the anterior
vaginal wall containing the bladder.
 Vaginal wall prolapse:

#Posterior:
1- Enterocele:
Descend of the upper posterior vaginal wall
containing small bowl from the pouch of
Douglas
2- Rectocele:
Descend of the lower posterior vaginal wall
containing the rectum.
 Vaginal wall prolapse:
#Middle:
Vault prolapse:
Descend of the vaginal vault after
hysterectomy , usually contains : small
bowl and omentum.
 Uterine Prolapse:
1- First degree:
The uterus is with in the vagina.
2- Second degree:
The cervix protrudes outside through the
introitus .
3- Third degree (Procidentia):
The entire uterus has come out the vagina.
Uterine Prolapse
Uterine Prolapse
Vaginal Vault Prolapse
Vaginal Vault Prolapse
Vaginal Vault Prolapse
 Aetiology
• Major causes:
1- Congenital weakness of the pelvic floor
ligaments and fascia.
2- Child birth:
Pregnancy, prolonged or difficult labour,
bearing down before full cervical dilatation,
multiparity and instrumental delivery.
3- Climacteric: weakness and denervation of the
pelvic floor muscles due to oestrogen deficiency.
 Aetiology
• Minor causes:
-Chronic Cough
-Chronic Constipation
-Increased Intra abdominal pressure:
.Masses
.Ascitis
.Pulmonary disease
.heavy lifting
 Presentation:
• Minor Prolapse can be asymptomatic
• Uterovaginal prolapse patients can complain of
feeling of some thing coming down .
. Pelvic insecurity
. Low backache ,relieved by lying flat.
• Procidentia may present with bloody stained
vaginal discharge some times purulent due to :
Decubitus ulcer of the vaginal skin of the cervix.
 Presentation:
• Cyctocele and cyctourethrocele :
.Dragging discomfort .
.Sensation of lump in the vagina.
.Urinary symptoms.
.Recurrent UTI.
• Rectocele:
.Difficulty with defecation.
.Incomplete defecation.
 Diagnosis:
• History:
.Age , Obstetric history, Medical history
• Examination:
.General, weight , Chest, Abdomen,
Speculum examination.
• Investigations:
.Urine, RFT , Chest X-Ray, U/S
 Management:
• Prevention:
.Reducing weight
.Avoid smoking
.Avoid difficult labour
.Contraception
.Pelvic floor exercise after delivery.
 Medical management:
• HRT:
.Hormone replacement therapy:
Increases vaginal blood supply and
collagen turnover
 Ring Pessaries:

Indications:
• Patient request
• Patient is medically unfit for surgery
• Therapeutic test before surgery
• To relieve symptoms while the patient is
awaiting surgery
• During and after pregnancies if the patient
want to preserve her fertility
 Surgical management:
• Cyctourethrocele:
Anterior Colporrhaphy
• Rectocele:
Posterior Colpoperineorrhaphy
• Uterine Prolapse:
1st 2nd Degree:
Manchester Repair
3ed Degree (procedentia):
Vaginal hysterectomy