Incontinence of urine

Definition of urinary incontinence

“ The involuntary loss of urine

which is objectively demonstrable
and a social or hygienic problem.”

* The International Continence Society

 Epidemiology

• The precise prevalence is difficult to estimate

• 200 million people worldwide, 10-13 million in USA
• Underestimated b/c only half of patients report to health providers
• ranges from 25 to 51 percent.
• increases with age;  
• Affects 30 to 60 percent of pregnant women .
• The prevalence of specific types= about half of affected
women have stress incontinence, with mixed stress and urge
next common, and urge incontinence least common .
 RISK FACTORS AND CONTRIBUTING FACTORS

•  Established risk factors are :

age, childbearing, obesity, other
urinary symptoms, and functional impairment
•  suggested risk factors :
– high impact physical activities,
– diabetes, stroke, depression, functional impairment
vaginal delivery, episiotomy, estrogen depletion,
– genitourinary surgery (eg, hysterectomy) and radiation 
– comorbid conditions, medications, and functional factors
may cause or worsen incontinence
 Female urethral anatomy

• 4 cm long; and composed of 4 separate tissue layers that kept

it closed
– Inner mucosa
– The vascular spongy submucosa
– Middle muscular layer
– Outer seromuscular layer
• Urethral musculature : has smooth and striated
– Striated muscles: sphincter urethrae(proximal 2/3rd ),
compressor urethrovaginal sphincter(distal 1/3rd).
– Levator ani complex (pubbovisceral portion) plays role in
urethral closure
Physiology of Micturition
 During micturition the following changes
occur:
1. Descent of the bladder neck with complete loss of the
posterior urethrovesical angle (angle becomes 180
degrees).
2. Opening (funneling) of the bladder neck and upper
urethra.
3. Descent of the urethra leading to increase in the angle
between it and vertical line, so the angle becomes more
than 30 degrees.
. In stress incontinence, one or all of the above changes
occur with increased intra-abdominal pressure.
• At rest the urethra makes an angle of 90-100
degrees with the base of the urinary bladder
called the : posterior urethrovesical angle.

• The urethra also makes an angle of less than

30 degrees with the vertical line.
 pathogenesis
• Continence depends on:
– integrity of LUT, pelvic support and neurological
system
– Intact functional ability to toilet oneself
– Mobility and manual dexterity
– Cognitive ability
• Impairment of one of these leads to UI
• The underlying pathology varies among
different types of incontinence
 Types of UI
• Extra urethral: • Transurethral
– Congenital – Stress urinary
• Ectopic ureter incontinence (SUI)
• Bladder extrophy – Urge urinary
– Aquired(fistulas) incontinence .(UUI)
• Ureterovaginal – Mixed urinary
incontinence (MUI)
• Vesicovaginal(VVF)
– Overflow incontinence
• Urtherovaginal
• complex
combinations.
 1. True (continuous) incontinence
• In this case, urine escapes continuously by day
and by night.
• It is caused by:
(a) Urinary fistulae as vesicovaginal fistula;
(b) Ectopia vesica.
2. False incontinence (Overflow incontinence)

• It is involuntary loss of urine following overdistension of

the bladder.

• Overflow incontinence, usually short-term, can occur after

vaginal delivery—especially if epidural anesthesia was
used.

• Other causes include diabetes, neurological diseases,

severe genital prolapse, and post surgical obstruction.
 3. Urgency incontinence
(precipitancy-detrusor instability or detrusor dyssynergia).

• The woman feels the desire to micturate but before she reaches the
bathroom, urine passes involuntarily.

• It is due to irritability of the bladder muscle and so the patient

cannot inhibit it.
 Detrusor instability (DI)
• Detrusor instability, also called overactive bladder, is a
condition in which the bladder contracts involuntarily in
response to filling.

• It was called detrusor dys-synergia in the past.

• It commonly presents as urge incontinence—leakage of

urine associated with a strong desire to void.

• No cause is identified in more than 90% of these patients.

• Advancing age is an important risk factor.

IV. STRESS INCONTINENCE
)SPHINCTER INCONTINENCE-
GENUINE STRESS
INCONTINENCE)
 DEFINITION
• It is involuntary escape of few drops of urine
with increased intra-abdominal pressure as
during straining, sneezing, coughing,
laughing ... etc.
 AETIOLOGY
• Congenital weakness of the internal urethral sphincter, seen
in the young nullipara
• Congenital defects as:
1. Epispadias,
2. Short urethra (less than 1 cm),
3. Wide bladder neck, and
4. Separation of symphysis pubis.
• Trauma to the region of the bladder neck due to vaginal
delivery or operation.
• Menopause
• Pregnancy
• UVP
Pathophysiology of Stress Incontinence
• The basic pathology is urethral
incompetence. This can be either due to:

A) Urethral hypermobility
B) Intrinsic Sphincter Dysfunction
 A) Urethral hypermobility (80 - 90% of
patients)
• This results from loss of the normal pelvic
support mechanism of the bladder and
urethra due to:
1. Trauma and stretching of vaginal delivery
2. Hysterectomy
3. Hormonal changes ( Menopause)
4. Pelvic denervation
5. Congenital weakness
 B) Intrinsic Sphincter Dysfunction (10 - 20%
of patients)
• This results from damage to the sphincter
due to:
1. Multiple prior operations
2. Trauma
3. Radiation
4. Neurogenic disorders including Diabetes
Mellitus
5. Atrophic changes: lack of estrogen.  
 DETRUSOR INSTABILITY
• The patient complains of urgency
incontinence, frequency and nocturia.
• Involuntary loss of urine also occurs when the
women sits for a long time and stands to go to
the bathroom.
• She may pass urine with the sight or sound of
water
Diagnosis
 A. History
1. A detailed history differentiates between the
different types of incontinence.
2. Stress incontinence and detrusor instability
frequently occur together.
3. Gradual onset after menopause suggests
oestrogen deficiency.
4. History of vaginal repair or operation in the
region of the bladder neck and history of any
neurologic disease.
Diagnostic tests
 1. Stress Test
• The bladder must be moderately full.
• The patient in the lithotomy position, the two labia are
separated, and the patient is asked to cough.
• If urine escapes, the patient is incontinent.
• If no urine escapes, the test is repeated while the index and
middle fingers in the vagina press on the perineum to abolish
reflex contraction of the levator ani muscles during straining.
• If still no urine escapes, the test is repeated while the patient
is standing with the legs separated
 2. Bonney test
• It is indicated in case of a positive stress test associated
with a cystocele.
• To know if incontinence is due to descent of bladder
neck or weakness of the sphincter.
• The index and middle fingers are placed on both sides of
the urethra to elevate the bladder neck upwards.
• If no urine escapes on stress it means that the
incontinence is due to descent of the bladder neck, but
if urine still escapes it means weakness of the sphincter.
 3. Examination of Urine
• Urinalysis, culture and sensitivity to exclude
cystitis.
 Urodynamics
• Classification:
1.Cystometrogram( most important test),
Filling Cystometry and Voiding
Cystometry
2.Urethral pressure profile
3.Uroflow
4.Electromyography
 1. Cystometrogram
• To measure the intravesical pressure while the bladder
is filled with sterile water or carbon dioxide gas.
• It diagnoses stress incontinence and detrusor instability.
• Involves filling the bladder to measure volume-pressure
relationships.
• As the bladder is filled to its normal capacity of 300-500
ml, the pressure inside the bladder should remain low.
• The patient usually experiences the first urge to void at
150-200 ml.
• Patients with DI often have reduced bladder capacity
(< 300 ml) and demonstrate urinary incontinence that
is associated with involuntary bladder contractions
• In patients with GSI, incontinence is demonstrated
when the patients coughs or strains (e.g., Valsalva
maneuver).
• The intravesical pressure at which leakage is noted
(leak point pressure) is generally < 60 cm of water
pressure if intrinsic sphincter deficiency is present.
 2. Q tip test
• A sterile applicator with a small piece of cotton at its tip
is introduced to reach the bladder neck.
• The angle between the applicator and the horizontal is
measured.
• The patient then strains maximally using the Valsalva
manoeuvre.
• In normal patients the increase in the angle is less than
30 degrees.
• In stress incontinence the change is more than 30
degrees indicating poor support and abnormal descent
of bladder neck
 3. Sonographic

• It gives information about funneling of the

bladder neck, both at rest and with Valsalva
manoeuvre.
 I. Prophylactic Treatment
1. During labor, the bladder should be kept
empty.
2. Episiotomy is performed if necessary.
3. Physiotherapy.
• Pelvic floor exercises are started after delivery.
II. Conservative (non-surgical) Treatment

Indications:
1.Mild stress incontinence.
2.The patient not completed her family as
vaginal delivery may damage a bladder neck
repair
3.Patient is unfit for surgery or refuses surgery.
4.When stress incontinence is combined with
detrusor instability.
Conservative treatment cures or improves 50%
of cases and include:
1. Physiotherapy: Kegl perineometer may be used.
2. Faradic current stimulation of the levator ani muscles to
improve their tone.
3. Vaginal cones:
• A set consists of 5 or 9 cones.
• Weight ranges from 20 to 100 grams.
• Patient inserts the cone in the vagina and keeps it for 15
minutes twice daily.
• If this succeeds she inserts the next cone.
• This improves the tone of the pelvic floor muscles.
Conservative treatment cures or improves 50% of
cases and include:
4.Oestrogen therapy for menopausal patients:
• It causes thickening of the urethral mucosa and
engorgement of the underlying blood vessels thus
increasing the urethral pressure and resistance.
Oestrogen is given orally or as vaginal cream.
5. Alpha-adrenergic stimulants: which stimulate
contraction of the internal urethral sphincter, e.g.
ephedrine.
6.Large vaginal diaphragms, Hodge pessary to
elevate ' and support the bladder neck.
UI: Pessaries
Conservative treatment cures or improves 50%
of cases and include:
7. Reduction of weight in obese patients to
reduce intra-abdominal pressure.
8. Stop caffeine (to avoid diuresis) and smoking
(to avoid coughing)
 Conservative Management : 3

Drugs :
Duloxetine : Dose:40mg x bid

• Serotonin & noradrenalin reuptake inhibitor at the

level of spinal cord.
• Increased activity of the pudendal nerve.
• Increased contractions of the urethral sphincter at
the opening of the bladder.
 Il. Surgical Treatment
• It is the primary treatment of stress
incontinence.
• The operation is done vaginally, abdominally,
or abdomino-vaginally.
• Almost 200 operations have been described.
 Surgical Management :
Abdominal
• Burch Procedure -Laproscopic
• MMK
• Abdominal Paravaginal Repair
Vaginal
• Anterior colporrhaphy
• Periurethral Collagen Injection
Abdomino-Vaginal
• Sling Procedures
• Stamey procedure
• TFVT
• TOT, TVT-O
Artificial Sphincter
 Goals of Surgical Treatment :

1. To elevate & maintain the proximal urethra &

urethrovesical junction in retropubic
position.
A. Vaginal operations
 Mid-Urethral Tape

• In UK- mid-urethral retropubic tape

procedures were introduced in mid to late
1990’s
 TVT
• TVT described in 1996 by Ulmsten
• Three possible mechanisms for correction of SI
* Bladder neck elevation
* Mid Urethral Support
* Urethral compression ( AUS)
• Minimal invasive, day case procedure
• Local & regional anaesthesia.
• Polypropylene mesh tape (prolene, Ethicone)
• Mid Urethral Support Without Tension
• Simple, easy, relatively safe with short recovery & little
pain.
• Reported cure is 86% & improvement is 11%.
• Complications: urine retention, parautrethral & paravesical
hemorrhage, infection , bladder &bowel injury.
 TVT Equipment
• TVT Device
– Prolene mesh tape
(45cm long) covered
by plastic sheath,
connected to two
5mm stainless steel
needles
• TVT Introducer
– Stainless steel handle
• Catheter Guide
– Stainless steel
Tension Free Vaginal Tape
B. Abdominal procedure
 1. Mashall-Marchetti-Krantz 1949
• The stitches are placed in the fascia on each side of
the bladder neck and upper half of the urethra and
are attached to the periosteum on the back of the
symphysis pubis.
• This restores the normal intra-abdominal position of
the urethra.
• Main complication is osteitis pubis (0.5-5%).
• Nonabsorpable (as mersilene) or delayed
absorbable sutures (as Vicryl or Dexon) are used.
 2. Burch Operation 1968
• Burch colposuspension is the operation of choice.
• It corrects both stress incontinence and cystocele.
• The stitches are placed in the fascia on each side
of the bladder neck and the base of the bladder and
are attached to the iliopectineal ligaments (Cooper
Ligaments),
(The pectineal part of the inguinal ligament)
• Nonabsorpable or delayed absorbable sutures are
used.
• Operation can be done through the laparoscope.
Burch Suspension

MMK
•The success rate of
the above abdominal
operations is
80-90%
 DETRUSOR INSTABILITY (DI)

• Women typically complain of urgency followed

by a large loss of urine.
• Cystometry confirms the diagnosis.
• Involuntary detrusor contractions of 15 cm of
water or more occur during filling of the
bladder.
 TREATMENT of (DI)
1. Bladder retraining drills:
The patient is asked to pass urine every hour during
daytime and to increase the interval by 15
minutes every week until she passes urine every
2-3 hours.
 Drug Treatment of Overactive Bladder

• Which inhibit the contractions of detrusor muscle as anticholinergic drugs,

– tricyclic antidepressants,
– Ephedrine : stimulates alpha-adrenergic receptors in the internal urethral
sphincter leading to contraction, and stimulates beta-adrenergic receptors in
the detrusor muscle leading to relaxation.

• Anticholinergic Drugs are mainstay

– Oxybutynin ( Ditropan) 2.5-5 mg bid-qid
– Oxytrol patch TDS 3.9 mg 2x/wk
– Tolterodine tartrate IR 1-2 mg bid
– Detrol LA 2-4 mg daily

New Drugs:
– Trospium chloride (Sanctura) 20 mg bid
– Darifenicin (Enablex) 7.5-15 mg daily
– Solefenicin (Vesicare) 5-10 mg daily
Obstetric
Fistula
 1.INTRODUCTION
Definition
Obstetric Fistula
-Genitourinary fistula or genito-rectal fistula
related to labor and delivery.
VVF
-abnormal connection b/n bladder &vagina
-leakage of urine via vagina .
RVF
 Introduction
• Causes
1-Developing world, majority (98%)-are due to
childbirth injuries.
2-Developed-gynecolgic surgery(82%), Obstetric
procedures(8%), Radiation(6%), trauma(4%)

• In unrelieved obstructed labor

-Many mothers die of exhaustion or ruptured uterus
-The fistula patients are the survivors.
• Social acceptance
–outcaste, lives with out hopes and friends
 3.PREVALENCE
• Prevalent in
-all Africa,
-south Asia,
-less developed -Oceania, L.America, m. East.
(third world nations)
• 80-90% are in Africa.
• In developing countries, obstetric fistulas occur at a rate
of 2-5 per 1000deliveries ( no access to functioning
obstetric service).
• “ Urinary incontinence in developing world’’.
 Prevalence

• True Magnitude of Fistula problem world wide is

underestimated because ignored and
outcasted.
• In June 2003,UNFPA and Engender Health
- 2 million are living with the problem, mostly in
Sub-Saharan Africa.
 Obstetric fistula pathway

• Low Socio economic status ,Illiteracy, Limited social roles

↓ ( developing countries)
Early marriage
↓
Child bearing before pelvic growth is complete
+
Lack of emergency obstetric services
↓
Obstructed labor
↓
Fistula formation
• ETHIOPIA
.9000 new cases
 4.PATHOPHYSIOLOGY OF OBS.FIST.

A. Obstructed labor (pressure necrosis)

• Common etiology of obstetric fistula.
• Obstruction not relieved within 3 hours ,tissue necrosis
starts to develop.
• By 5th day of puerperium, the slough begins to separate &
urine/feces dribbles into the vagina.
 PATHOPHYSIOLOGY---

B. Iatrogenic (traumatic) causes

 Injury associated with the procedure itself ,or
done after obst. labour (already ischemic insult)
 PATHOPHYSIOLOGY---

• Time interval from antecedent event to incontinence

-traumatic causes-leakage is immediately
-Obstructed labor-leakage is several days after
the event(usu.5-10 days).
• Once ischemic insult develops, the subsequent fistula
formation is independent of the mode of delivery.
 5.classification

• No standardized method for fistula classification.

• Inter & intra-observer differences by site, or size.
• A number of classification have been described
a) Marion Sims classification(1852)
b) Lawson’s Classification(1968)
C) Hamlin & Nicholson classification(1969)
d) Waaldijk classification(1995)
• International Continence Society
 Classification
1.Vesico-vaginal Fistula
-most common obstetric fistula(78% of cases)
-classified -juxta-urethral, mid-vaginal, juxta-cervical
a) juxta-urethral
-near or at urethro-vesical junction
-commonest type of VVF
b) Mid-Vaginal
-hole in the mid-vagina
-easy to repair
 6.Diagnosis

1.History
-young women
-smaller than the average size
-Usually primigravid
-History of prolonged labor
-offensive smell due to incontinence
 Diagnosis

2.physical exam.
a) Inspection
-evidence of urine &/or feces in the vagina
-excoriation of labia & perineum
b) speculum exam-diagnose type of fistula
c) Digital Exam
-feel the fistula &characterize
. size, site ,number
-infection , slough of vagina
-presence of Scarring/ stenosis of vagina .
 Diagnosis

d) Associated complication of obs. Labor

• Neurological complication
foot drop
• Gynecologic complication
20 amenorrhea
• Dermatologic complication
Urine dermatitis
 Diagnosis
3. Dye test /Methyllene blue/
• Indication
i) doubt about fistula or fistula is very small(<0.5cm)
ii) to differentiate bladder fistula from ureteric f.
(3 cotton swab test)
 procedure
Results
a) If leakage into vagina is blue stained→ VVF
b) If leakage into vagina is not stained or wet with clear
fluid→ureterov.f. (confirmed by +ve i.v indigo carmine test,
or oral pyrimidium).
c) If dye comes via cervix → vesicocervical fistula.
 6.MANAGEMENT

A. Non-surgical Repair (catheter treatment)

-Small fistula up to 2cm in diameter may close
spontaneously by continuous free catheter
drainage for 4-5 weeks.
-By catheter drainage, spontaneous healing
occurs in up to 15-50% of cases.
-Antibiotics have no part to play in the healing of
fistula-the cause is ischemic necrosis,
not infection
• Catheter should be inserted for all obstructed
labor as a prophylaxis to prevent VVF.
• The duration of catheterization depends on
the duration of obstruction
connection catheter_infusion set
for open drainage