Urinary incontinence

MBChB
OBG 7020
2019
 Definition of Urinary Incontinence

“ The involuntary loss of urine

which is objectively
demonstrable
and a social or hygienic
problem.”
* The International Continence Society
 INTRODUCTION

• Most women do not seek help for incontin

ence
– Because of social embarrassment
– Be unaware that help is available
 INTRODUCTION
• Incontinence is part of the “normal” aging
process is no longer acceptable
• The advances in modern medicine during t
he last 80 years have increased the life ex
pectancy of women well into the eighth an
d ninth decades
• We are caring for patients longer and bette
r than ever, enabling women to enjoy long
er and more productive lifetimes
 Normal Changes
Which Predispose the Elderly to Incontine
nce
DECREASED INCREASED
• Bladder Capacity • Residual Volume
• Inhibitory Ability • Uninhibited Detru
• Urethral Closing sor Contractions
Pressure
 The lower urinary tract can be divided into
ANATOMY three parts:
• Bladder
—hollow muscular organ lined with
transitional epithelium designed for urine
storage
-- consists of three layers of smooth
muscle, which are densely intertwined and
constitute the detrusor muscle
-- stays relaxed to facilitate urine storage
and contracts periodically to completely
evacuate its contents when appropriate
and acceptable
--trigone at the bladder base
• Vesical neck
• Urethra
–3-4cm long
--composition and support of the urethra
and bladder neck play key roles in the
function and maintenance of UI
 NEUROANATOMY
• Neuronal innervation of the lower
urinary tract is considered part of the
autonomic and somatic nervous
systems
• The autonomic system receives
visceral sensation and regulates
smooth muscle activity during
conscious and involuntary LUTF
• Voluntary control of micturition is
controlled by the central nervous
system
• Receiving both sensory afferent and
modulating motor efferent nerves, the
net effect is that the brain provides
tonic inhibition of detrusor contraction
• Lesions in the frontal lobe chiefly cause loss of voluntary control of micturiton and thus
loss of suppression of the detrusor reflex, resulting in uncontrolled voiding or urge
urinary incontinence
• A reflex activation in the central brainstem and peripheral spinal cord mediate a
coordinated series of events, consisting of relaxation of the striated urethral
musculature and detrusor contraction that result in opening of the bladder neck and
 Drugs/Dietary
Contributors to Incontinence
Decreased Storage Increased Retention
• Alpha blockers • Alpha agonists
• Beta blockers • Beta agonists
• Cholinergic agents • Anticholinergic agents
• Diuretics • Ca channel blockers
– Caffeine • Narcotics
– ETOH
• Artificial sweeteners, citr
us, carbonation
 URINARY INCONTINENCE

• Types and Definition

• Evaluation

• Treatment
 Types and Definition

• Stress urinary incontinence (SUI)

• Urge incontinence
• Mixed incontinence
• Overflow incontinence
• Extraurethral sources of urine
 Types and Definition
SUI
• Loss of urine that occurs with increased a
bdominal pressure, such as coughing or st
raining
• Result of loss of anatomic support of the u
rethrovesical junction or urethra
• It most commonly occurs following pelvic fl
oor muscle and nerve damage that resulte
d from childbearing
 Types and Definition

Urge incontinence
– is defined by the symptom of urine loss t
hat occurs when the patient experiences
urgency, or a strong desire to void
– is often accompanied by symptoms of ur
inary frequency, urgency, and nocturia
 Types and Definition

Mixed incontinence
• Occurs when both stress and detrusor ins
tability occur simultaneously
• Patients may present with symptoms of bo
th types of incontinence
 Types and Definition

Overflow incontinence
• Occurs because of underactivity of the det
rusor muscle
• Be associated with retention of urine
• The bladder does not empty completely, a
nd “dribbling” of urine occurs
 Types and Definition

Extraurethral sources of urine

• Include genitourinary fistulas
• Be congenital or follow pelvic surgery or ra
diation
• These typically cause continuous leaking o
f urine
 Evaluation

• History

• Physical examination

• Diagnostic tests

• Cystoscopy
 Evaluation
A detailed history is essential and should include:
a. Urinary symptoms, including the presence of voiding freq
uency, nocturia, urgency, precipitating events, and freque
ncy of loss. A voiding diary allows the patient to documen
t voiding frequency and incontinence episodes during a s
pecific period
b. Previous urologic surgery
c. Obstetric history, including parity, birth weights, and mod
e of delivery
d. CNS or spinal cord disorders
e. Use of medications, including diuretics, antihypertensive
s, caffeine, alcohol, anticholinergics, decongestants, nico
tine, and psychotropics
f. Presence of other medical disorders (e.g., hypertension o
r hematuria)
 Evaluation
Physical examination may detect:
a. Exacerbating conditions, such as chronic
obstructive pulmonary disease, obesity, or
intra-abdominal mass
b. Hypermobility of the urethra
c. POP
d. Neurologic disorder
 Evaluation
Diagnostic tests

a. A midstream urine specimen

b. Postvoid residual urine volume
c. The Q-tip test
d. Urodynamic testing
 Evaluation

Diagnostic tests -- midstream urine specime

n
• Be collected for urinalysis or culture and s
ensitivity
• Infection may aggravate urinary incontinen
ce
 Evaluation

Diagnostic tests -- Postvoid residual urine vo

lume
• should be measured (by ultrasound or cat
heterization) after the patient has voided
• Typically, the postvoid residual urine volum
e is less than 50 to 100 ml
 Evaluation
Diagnostic tests -- The Q-tip test
• is an indirect measure of the urethral axis
• A Q-tip is inserted into the urethra with the
patient in the lithotomy position
• If the Q-tip moves more than 30 degrees fr
om the horizontal with straining, urethra hy
permobility is present
Q-TIP TEST At rest the Q-tip is in a horizontal position,
but with straining & coughing it shows a positive deflection
owing to inadequate support at the urethrovesical junction.

Bladder at rest

Bladder with straining

Q-TIP TEST At rest the Q-tip is in a horizontal position,
but with straining & coughing it shows a positive deflection
owing to inadequate support at the urethrovesical junction.

Bladder at rest

Bladder with straining

 Evaluation
Diagnostic tests -- Urodynamic testing
• including a cystometrogram and voiding studies,
may be useful for demonstrating the type of inco
ntinence present
• These tests measure pressures within the bladd
er and abdomen during bladder filling and empty
ing
• Urodynamic testing is indicated for complex cas
es of urinary incontinence such as mixed inconti
nence or in patients with incontinence and retent
ion of urine
 Evaluation

Cystoscopy
• is performed in some patients
• to examine the bladder and urethral muco
sa for abnormalities such as diverticula or
neoplasms
Cystoscopy
What can irritate bladder?

Urinalysis:
WBC, RBC,
Bacteria
Culture:
Positive
 Treatment
Therapy depends on the underlying diagnosis.
• Treatment of exacerbating factors
• Pelvic muscle rehabilitation
• Pessaries are useful conservative therapie
s for SUI
• Drug therapy
• Surgery
 Treatment

Treatment of exacerbating factors may impr

ove SUI
• excess weight

• chronic cough

• constipation
 Treatment

Pelvic muscle rehabilitation -- be helpful

for both SUI and DI
a. Kegel exercises
b. Vaginal cones
c. Biofeedback
d. Electrical stimulation
 Treatment
Drug therapy is the mainstay of treatment for DI bu
t is of limited value in treating SUI.
a. Antispasmodic agents (tolterodine) are highly eff
ective and are the most commonly prescribed tre
atments for DI
b. α-Adrenergic stimulating agents increase smoot
h muscle contraction in the urethral sphincter an
d may decrease SUI symptoms
c. Estrogens improve irritative bladder symptoms s
uch as urgency and dysuria in postmenopausal
women but do not significantly improve urinary le
akage. HRT does not reduce the incidence of uri
nary symptoms in postmenopausal women
 Treatment

Surgery is extremely effective in the treatme

nt of SUI. It is rarely helpful for DI
a. Injection of bulking agents around the uret
hra
b. Retropubic urethropexy
c. Transvaginal needle procedures
d. Suburethral sling procedures
 Fistula
• Definition-connection between 2 epithelial
surfaces
• Commonest is vesico-vaginal fistula
• Others
– Urethro-vaginal
– Uretero-vaginal
 Causes of fistula
• Obstructed labour
• Iatrogenic
• Malignancy
• Infections
• radiation
 diagnosis
• Good history
• Continuous leakage
• Role of 3 swab test
 Management
• Iatrogenic at operation may be closed imm
ediately
• Following obstructed labour
– Catheterize
– Small leaks may close with up to 2 weeks of c
atheter
– Otherwise wait for 3 months
– Best operator to do first repair
 Post op care
• Hyadration
• Ensure catheter not blocked
• Elective C/S in next pregnancy
 Prophylactic Treatment
1. During labour, the bladder should be kept em
pty.
2. Episiotomy is performed if necessary.
 prevention
• Avoid prolonged labour by use of partogra
m
THANK YOU FOR YOUR ATTENTI
ON