URINARY INCONTINENCE

DR. SASHMI MANANDHAR

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
DH - KUH
MECHANISM OF CONTINENCE

 CLOSURE PRESSURE:

 Difference between vesical pressure and

intraurethral pressure
 Normal: more than 10 cm of water

 Intra urethral pressure: 20 – 50 cm of water

 Intravesical pressure: 10 cm of water

Maintenance of Continence

 URETHROVESICAL ANGLE:

 Angle formed by the junction of bladder wall and

the urethra
 Normal: more than 100 degree
Maintenance of continence
Maintenance of continence

 Urethrovesical angle important in assessment of urethral

mobility
 Normal: Increase in the angle by 110 to 120 degree with straining

 Type I: Straightening of the angle by 180 degrees or more; downward

urethral movement of 2 or 3 cms

 Type II: Urethral hypermobility of more than 45 degrees to the vertical

plane; downward and backward movement of urethra by 3 to 6 cms or

more
 Type III: Non mobility; intrinsic spinchter deficiency
Maintenance of continence

 At rest: Intraurethral pressure is maintained

by:
 Rhabdomyospinchter

 Tonic contraction of smooth muscles of proximal

urethra and bladder neck

 Submucosal vascular pelxus
Maintenance of continence

 During Stress: additional factors

 Centripetal force of the intra abdominal pressure transmitted to proximal urethra

▪ Occurs as long as the bladder neck is above the pelvic diaphragm

 Reflex contraction of the urethral striated spinchter and periurethral striated

musculature

 Kinking of the urethra

▪ Bladder neck pulled upward and forward behind the pubic symphysis

▪ Preferential better support to posterior wall of the urethra than the base of the bladder
given by pubovesical fascia
Maintenance of Continence

 Normal:

 Bladder neck and proximal urethra above the pelvic

diaphragm
 Urethrovesical angle is maintained

 Increased intra abdominal pressure equally

distributed to bladder and urethra, due to which

closure pressure is maintained
 Abnormal:
 Damage to pudendal nerve or atony

 Bladder neck descent below the levator ani

 Urethrovesical angle lost

 Incomplete urethral closure

 Incontinence
 RISK FACTORS

 Predisposing factors

 Obstetrics and Gynaecologic

 Promoting factors

Med Clin N Am 95 (2011) 101–109 doi:10.1016/j.mcna.2010.08.022

Predisposing factors

 Neurologic
 Race: Caucasian women
 Spina bifida

 Spinal cord injury

 Brain injury
 Genetics: Increased risk of
 Parkinson disease

incontinence if other female  Multiple sclerosis

 Stroke
family member is incontinent
 Dementia

 Transverse myelitis

 Guillaine-Barre syndrome
 Congenital: Congenital defects
 Herpes zoster

(eg, ectopic ureter)  Pelvic surger

Obstetrics and Gynaecologic

 Pregnancy/Childbirth/Parity

 Vaginal delivery, episiotomy, and instrumental

delivery; Obstructed labour

 Large infant birth weight over 4 kg

 Side effects of pelvic surgery and radiotherapy

 Pelvic organ prolapse

Promoting Factors

 Age: increased age

 Comorbidities: Diabetes, vascular disease, and congestive heart failure

 Obesity

 Increased intra-abdominal pressure

 Constipation

 Lung disease

 Occupational and recreational activities

 Cognitive impairment: Dementia and cognitive impairment Menopause

 Medications
TYPES OF INCONTINENCE
URETHRAL CAUSE EXTRA URETHRAL CAUSE
Stress incontinence Congenital
e.g. ectopic ureter
Urge incontinence Acquired
e.g. urinary fistulas
Mixed incontinence
Overflow incontinence
STRESS INCONTINENCE
DEFINITION

 Involuntary escape of urine from the external urinary

meatus when the intra abdominal pressure (and therefore,

intravesical pressure) is increased

 GENUINE STRESS INCONTINENCE:

 Involuntary loss of urine when the intra vesical pressure exceeds

the intra urethral pressure in the absence of detrusor activity

INCIDENCE

 Most common type of urinary incontinence

 Common in younger age group

ETIOPATHOGENESIS

 Strictly an anatomic problem

 Normal:

 Bladder neck and urethra above the pelvic floor in

standing position
 Intra urethral pressure more than intra vesical pressure
Etiopathogenensis

 Incontinence is due to:

 Bladder neck descent (75 to 80 %)

▪ Hypermobility of the urethra due to distortion in the normal urethro
vesical angle
▪ Descent does not allow the intra urethral pressure to increase during
straining

 Intrinsic spinchter defect (20 to 25%)

▪ Failure to close the urethra at the urethro vesical junction
▪ Severe incontinence
Etiopathogenesis

 Factors responsible are:

 Developmental weakness of the supporting structures

maintaining the bladder neck and urethra in position

 Childbirth trauma causing damage to the pelvic floor

and pubocervical fascia

 Denervation of the smooth and striated component of

the spinchter mechanism

Etiopathogenenis
 Pregnancy:
 High level of progesterone

 Postmenopausal:
 Atrophy of the supporting structures
 Diminished periurethral vascular resistance

 Trauma:
 Injury to symphysis pubis

 Surgeries:
 Anterior colporrhaphy, repair of VVF or bladder neck surgery
 Fibrosis of urethra and urethral musculature

 Obesity
MORBID ANATOMIC CHANGES

 Intrinsic spinchter dysfunction

 Bladder base becomes flat and lies in line

with the posterior wall of the proximal

urethra
 Descent of the proximal urethra
CLINICAL FEATURES

 HISTORY:

 Involuntary loss of urine

▪ Brief and coincides with the period of increased abdominal
pressure
▪ Unassociated with desire to pass urine

▪ Rarely occurs in supine position or during sleep

▪ Patients are fully aware of it

▪ Amount lost is small

CLINICAL FEATURES

 ASSOCIATED HISTORY:

 Diabetes

 Chronic pulmonary disease

 Neurological disease

 Surgeries of spine and genitourinary tract

 Medications
QUALITY OF LIFE MEASURE

 Physicians caring for incontinent women

should ask them about the way the

incontinence specifically affects their lives and
to what degree the incontinence bothers them

 Quality of life questionnaires

 Quality of life questionnaires:

 Quality of life in persons with urinary incontinence

 Incontinence impact questionnaire

EXAMINATION
 NEUROLOGIC:  MOBILITY:
 Mental status  Gait
 Perineal sensation
 Perineal reflexes  PELVIC EXAMINATION:
 Patellar reflexes
 Prolapse
 Atrophy
 ABDOMINAL
 Levator ani palpation
 Masses
▪ Symmetry
▪ Ability to squeeze
 CARDIOVASCULAR:  Urethral mobility (cotton
 CCF swab)
DEMONSTRATION OF STRESS
INCONTINENCE

 Examination should be done in both erect

and supine position

 Bonney’s test

 Marchetti test

 Q tip test
 BONNEY’S TEST:
 Objective of seeing whether
an uplift of the urethrovesical
junction will stop the
incontinence during stress
 Technique:
▪ Light pressure is applied
immediately at the sides of the
upper urethra and is directed
forwards
 Positive Test
▪ Shows that the closure of the
internal spinchter by pressure
from the vagina controls the
urinary leak
 MARCHETTI TEST:

 Same as Bonney’s test, but two Allis forceps are

used instead of fingers

 Q TIP TEST:
 Assess the urethral hypermobility and the response to
surgery

 Lithotomy position
 Lubricated cotton swab is passed through the urethra to the
bladder and withdrawn to the level od urethrovesical junction
 The axis of the urethrovesical junction at rest and during
straining is measured using goniometer
 If the cotton swab moves up by more than 30 degrees,
indicative of urethral hypermobility.
INVESTIGATIONS

 AIMS:
 To confirm the diagnosis
 To rule out other pathologies
Investigations

 Primary Care level tests  Advanced Tests

 Urinalysis  Uroflowmetry
 Voiding Diary  Filling cystometry
 Post void residual volume  Tests of urethral function
 Cough stress test
 Voiding cystometrogram
 Pad test
 URINALYSIS:

 To rule out infection, hematuria and metabollic

abnormalities
 Treatment of the infection may improve the

symptoms
 Causes of hematuria should be ruled out with other

investigations
 PAD TEST:
 An hour extended pad test recommended when clinical stress test is negative

 Technique:
▪ Patient wears a pre weighed sanitary pad
▪ Drinks about 500 ml of water
▪ Rests for 15 minutes
▪ Performs exercises like walking, climbing for 30 minutes
▪ Performs provocative exercises like bending, jumping, coughing for 15 minutes
▪ After 1 hour, sanitary pad is removed and weighed

 Interpretation:
▪ An increase in weight by 1 gm is considered significant for 1 hour and 4 gm for 24
hours
 COUGH STRESS TEST:

 Full bladder

 Supine position and asked to cough

 Standing position and asked to cough

 URINARY DIARY:
 Patient is asked to record her fluid intake, output, episodes of
leakage in relation to time and activity

 Recorded for at least 7 days

 Gives idea about the

▪ daily urine output
▪ number of voids per day
▪ Number of night time voids
▪ Average voided volume
▪ functional bladder capacity
Urodynamic studies

 For pure stress incontinence, urodynamic

studies are not significant

 Evaluation needed for

 Mixed symptomatology
 Associated frequency/ nocturia/ voiding
difficulties
 Associated neuropathy
 Previous failed surgeries
 UROFLOWMETTRY:

 Normal flow rate: 15 – 25 ml/sec

 In stress incontinence:
▪ Normal flow rate
▪ Nil or insignificant residual urine
 CYSTOMETRY:

 If uroflowmetry is normal, cystometry to be done to exclude

detrusor instability or urge incontinence.

 Filling cystometry

 Voiding cystometry

 Both normal in stress incontinence

 URETHRAL PRESSURE PROFILES:

 Continent women: urethral pressure higher than the bladder

pressure
 Technique:
▪ Special catheter having microtip pressure transducers which is slowly
pulled down from the bladder (filled with 250 ml od normal saline) along
the urethra to outside
▪ Measurement of intra urethral and intra vesical pressure
▪ Pressures ploted in a curve called urethral pressure profile
 Abnormalities:

▪ Functional length of urethra decreased usually below 3 cms

▪ Peak urethral pressure decreases in both supine and erect
position
▪ Intra vesical pressure rises to a greater extent than the intra
urethral pressure during strain
▪ During strain, there is significant lowering of urethral
closure pressure. Pathognomic of stress incontinence
 LEAK POINT PRESSURE TEST:

 Idea about spinchter strength

 Patient asked to strain when the bladder is filled to reasonable volume (200

ml) to increase intra vesical pressure

Minimum pressure at which leakage is observed is recorded as “valsalva leak

point pressure”

If no leakage is observed even at the highest pressure exerted, it is recorded

as “ no leakage”
 Videocystourethrography and Transvaginal

Endosonography to assess the anatomy of

bladder neck, urethra and bladder wall
thickness.
DIAGNOSIS OF STRESS
INCONTINENCE
 Clinical Stress test: positive
 Pad test: positive
 Mid stream urine analysis: normal
 Urinary diary
 Uroflowmetry: normal
 Cystometry: normal
 Leak point pressure: positive
 Cystourethroscopy: negative
 Videourethrography: bladder neck funnelling
 Transvaginal endosonography: descent of
urethrovesical junction and bladder base
CLINICAL GRADING

 GRADE I:
 Incontinence during coughing and sneezing

 GRADE II:
 Incontinence during mild exercise like walking

 GRADE III:
 Incontinence even in recumbinant position or with
the change in position
TREATMENT

 Preventive

 Definitive
Preventive treatment

 Avoidance of repeated child birth trauma and delay

in second stage

 Management of:

 Obesity

 Diabetes

 Chronic pulmonary and neurological diseases

Definitive Treatment

 AIMS:

 Restoration of the function of the muscles of the

urethrovesical junction
 Strengthening the support of urethra

 Conservative

 Surgical
Conservative treatment

 Lifestyle changes

 Physical therapy

 Vaginal and Urethral devices

 Medications
Conservative treatment

 LIFESTYLE CHANGES:

 Weight loss

 Postural Changes:
▪ Crossing the legs during the period of increased
abdominal pressure

 Decreasing caffeine intake

Conservative treatment

 PELVIC FLOOR EXERCISE – KEGEL EXERCISE:

 First line conservative management

 Principle: To strengthen the muscular part of rhabdospinchter

and pelvic floor muscle, so that the urethral pressure is back

 Will not help strengthen the involuntary muscles of the bladder

base and proximal urethra

 Technique: drawing up the anus and tightening the vagina

 100 times a day, for several months

Conservative treatment

 ELECTRICAL STIMULATION:

 Activation of the pelvic floor muscles by

stimulation of pudendal nerves with low level

current
 Probe placed in the vagina or rectum

 More useful for treatment of overactive bladder

Conservative Treatment

 VAGINAL AND URETHRAL DEVICES:

 Vaginal Devices: pessaries

 Urethral inserts:

▪ Sterile inserts placed into the urethra by the patient and removed
before a void
▪ Appropriate for women with pure stress incontinence, no recurrent
UTI or no contraindications to bacteriuria (artificial heart valves)
▪ FemSoft
Conservative treatment - Drugs

 ESTROGEN:

 Presence of estrogen receptors in the bladder, urethra and levator ani muscles

 Postmenopausal women

 Improves the urethral closure pressure by increasing the collagen support and

vascular pulsations of the submucosal plexuses

 Estradiol 2 mg per day

 Recent trials:
▪ Conjugated estrogen with or without progestin should not be prescribed for the
prevention or relief of urinary incontinence
Conservative treatment - Drugs

 SYMPATHOMIMETIC DRUGS:

 Tone of the urethra and bladder neck maintained by alpha adrenergic activity of the

sympathetic system
 Improves the tone of the urethra and bladder neck

 Imipramine10 – 25 mg PO BD

 Ephedrine 15 – 30 mg PO BD

 Others:
▪ Pseudoephedrine

▪ Phenylpropanolamine
▪ Norephinephrine

NO DRUGS ARE CLEARED BY FDA

Conservative treatment - Drugs

 PERIURETHRAL INJECTION OF GAX

COLLAGEN:
 Prevents premature bladder opening
Surgical treatment
BLADDER NECK DESCENT INTRINSIC SPINCHTER DEFECT
URETHRAL HYPER MOBILITY
VAGINAL 1. Sling surgeries
1. Kelly’s TVT
2. Needle suspension surgery TOT
Pereyra 2. Periurethral collagen injection
Stamey through cystoscopy
Raz 3. Artificial urinary spinchter

ABDOMINAL URETHROPEXY
1. Bursch Colposuspension
2. Marshall Marchetti Krantz
 Choice of surgery is usually between

retropubic urethropexy and a sling operation.

 RETROPUBIC URETHROPEXY:

 Abdominal procedure

 Involves attaching the fascia around the urethra and bladder neck to a

supporting structure in the anterior pelvis.

 Elevates the bladder neck to an intra abdominal position.

 Complications:

▪ Post operative voiding dysfunction

▪ Detrusor overactivity

▪ POP
 Two types:
 Burch colposuspension
▪ Fascia at the level of
bladder neck are attached
to iliopectineal ligament or
Cooper’s ligament
▪ Most commonly done
▪ Success rate: 95%
 Marshall Marchetti
Krantz
▪ Attachment of peri urethral
fasciato the back of the
pubic symphysis
▪ Complication: Osteitis
pubis
▪ No longer used
 SLING OPERATION:

 Sling passed around the bladder neck and the urethra

 Attached above to the anterior rectus fascia so that a

supporting hammock is created for the urethra

 Urethra is supported and occluded when the intra

abdominal pressure is increased

 Tension free vaginal tape:
▪ Propylene mesh is placed at the mid urethra through the
retropubic space
▪ Complications:
▪ Bladder perforation
▪ Bowel injury
▪ Vascular injury
 Trans obturator tape insertion:
▪ Propylene mesh is passed through a mid urethral vaginal
cision medial to obturator foramen instead of through
the retropubic space
 OTHER PROCEDURES:

 Kelly’s plication:
▪ Elevation of bladder neck by placating the fascia under
the urethra
▪ Not recommended nowadays
 Periurethral bulking agents:
▪ Used in recurrent stress incontinence

▪ Collagen is injected transurethrally