PROLAPSE, INCONTINENCE &

INFECTION
BY:

DR SONALI SOUMYASHREE(PT)
ASST PROF.
ABSMARI
- CONTENTS TO BE COVERED:
- PROLAPSE
- INCONTINENCE
- INFECTIONS OF FEMALE GENITAL TRACT
- PROLAPSE:
PROLAPSE UTERUS
- HERNIATION OF UTERUS
THROUGH THE VAGINA IS
CALLED AS UTERINE
PROLAPSE.
- NORMAL POSITION OF
UTERUS
- ANTEVERTED &
ANTEFLEXED
- LIES INBETWEEN
BLADDER AND RECTUM
- THE POSITION IS
SUPPORTED BY A 3 TIER
SYSTEM
- THIS SYSTEM PREVENTS
THE DESCEND THROUGH
THE HIATUS & PELVIC
FLOOR
UPPER TIER:
• MAINTAIN THE
UTERUS IN
ANTEVERTED
POSITION
• ENDOPELVIC FASCIA
COVERING THE
UTERUS
• ROUND LIGAMENTS
• BROAD LIGAMENTS
MIDDLE TIER
• STRONGEST SUPPORT OF THE UTERUS.
• PERI-CERVICAL RING
• PELVIC CELLULAR TISSUES
• PERI CERVICAL RING:
• COLLAR OF FIBROELASTIC CONNECTIVE
TISSUE ENCIRCLING THE
SUPRAVAGINAL CERVIX
• CONNECTED WITH :
• ANTERIORLY: PUBOCERVICAL
LIGAMENTS & VESICOVAGINAL SEPTUM
ANTERIORLY
• LATERALLY: CARDINAL LIGAMENTS
• POSTERIORLY: RECTOVAGINAL SEPTUM
FUNCTION: IT STABILIZES THE
CERVIX AT THE LEVEL OF
INTERSPINOUS DIAMETER ALONG
WITH THE OTHER LIGAMENTS
• PELVIC CELLULAR TISSUES—
• ENDOPELVIC FASCIA CONSIST OF CONNECTIVE TISSUES AND SMOOTH
MUSCLES
• BLOOD VESSELS AND NERVES SUPPLYING THE UTERUS, BLADDER, AND
VAGINA PASS THROUGH IT FROM THE LATERAL PELVIC WALL.
• AS THEY PASS, THE PELVIC CELLULAR TISSUES CONDENSE SURROUNDING
THEM AND GIVE GOOD DIRECT SUPPORT TO THE VISCERA
• THE ENDOPELVIC FASCIA AT PLACES IS CONDENSED AND REINFORCED
BY PLAIN MUSCLES TO FORM LIGAMENTS.
• MACKENRODT’S,
• UTEROSACRAL, AND
• PUBOCERVICAL
• ON THE MEDIAL SIDE, THESE ARE ATTACHED TO THE PERICERVICAL
RING COVERING THE CERVICOVAGINAL JUNCTION AND ON THE OTHER
END ARE ATTACHED TO THE LATERAL, POSTERIOR, AND ANTERIOR
WALLS OF THE PELVIS
• THIS HAMMOCK-LIKE ARRANGEMENT OF CONDENSED PELVIC
CELLULAR TISSUES IS THE CARDINAL SUPPORT OF THE UTERUS.
INFERIOR TIER
• INDIRECT SUPPORT TO THE UTERUS
• PELVIC FLOOR MUSCLES (LEVATOR ANI), ENDOPELVIC FASCIA, LEVATOR
PLATE, PERINEAL BODY, AND THE UROGENITAL DIAPHRAGM
- AETIOLOGY:
- INJURY DURING CHILDBIRTH: FORCEP DELIVERY, DELIVERY OF LARGE BABY, HOME
DELIVERY BY UNTRAINED PROFESSIONAL.
- MUSCULOFASCIAL ATONY: DURING MENOPAUSE,PELVIC TISSUE LOOSE THEIR TONE &
CERVIX & VAGINA BECOMES MORE MOTILE.
- RISE IN INTRA ABDOMINAL PRESSURE: CHRONIC BRONCHITIS, OBESITY & CONSTIPATION.
- DEVELOPMENTAL DEFECT: SPINA BIFIDA OCCULTA, SPLIT PELVIS.
- DEGREE OF PROLAPSE(SHAW’S CLASSIFICATION)
- 1ST DEGREE- DESCENT OF CERVIX IN ISCHIAL SPINE
- 2ND DEGREE- DESCENT OF CERVIX TO THE OPENING OF VAGINA.
- 3RD DEGREE- DESCENT OF CERVIX OUTSIDE THE VAGINA
 CLINICAL TYPES OF
PELVIC ORGAN PROLAPSE

• VAGINAL PROLAPSE
• UTERINE PROLAPSE
VAGINAL PROLAPSE UTERINE PROLAPSE
• ANTERIOR WALL • UTEROVAGINAL
• POSTERIOR WALL PROLAPSE
• VAULT PROLAPSE • CONGENITAL
ANTERIOR WALL VAGINAL PROLAPSE:
• CYSTOCELE:
• FORMED BY LAXITY AND DESCENT OF THE
UPPER TWO-THIRDS OF THE ANTERIOR
VAGINAL WALL.
• HERNIATION OF THE BLADDER THROUGH
THE LAX ANTERIOR WALL.
• URETHROCELE:
• WHEN THERE IS LAXITY OF THE LOWER-
THIRD OF THE ANTERIOR VAGINAL WALL
• THE URETHRA HERNIATES THROUGH IT
POSTERIOR WALL
• RELAXED PERINEUM
• TORN PERINEAL BODY PRODUCES
GAPING INTROITUS WITH BULGE OF
THE LOWER PART OF THE POSTERIOR
VAGINAL WALL.
• RECTOCELE
• LAXITY OF THE MIDDLE-THIRD OF THE
POSTERIOR VAGINAL WALL AND THE
ADJACENT RECTOVAGINAL SEPTUM.
• HERNIATION OF THE RECTUM
THROUGH THE LAX AREA.
VAULT PROLAPSE
• ENTEROCELE:
• LAXITY OF THE UPPER-THIRD OF
THE POSTERIOR VAGINAL WALL
RESULTS IN HERNIATION OF THE
POUCH OF DOUGLAS.
• MAY CONTAIN OMENTUM OR EVEN
LOOP OF SMALL BOWEL AND HENCE
• SECONDARY VAULT PROLAPSE
• OCCUR FOLLOWING EITHER VAGINAL OR
ABDOMINAL HYSTERECTOMY
UTEROVAGINAL PROLAPSE
• PROLAPSE OF THE UTERUS, CERVIX
AND UPPER VAGINA.
• COMMONEST TYPE.
• OCCURS
• FIRST FOLLOWED BY TRACTION
EFFECT ON THE CERVIX CAUSING
RETROVERSION OF THE UTERUS
• INTRA-ABDOMINAL PRESSURE HAS
GOT PISTON LIKE ACTION ON THE
UTERUS THEREBY PUSHING IT DOWN
INTO THE VAGINA.
CONGENITAL
• NO CYSTOCELE.
• UTERUS HERNIATES DOWN ALONG WITH INVERTED UPPER VAGINA.
• NULLIPAROUS WOMEN AND HENCE CALLED NULLIPAROUS PROLAPSE.
• CAUSE: CONGENITAL WEAKNESS OF THE SUPPORTING STRUCTURES HOLDING THE UTERUS
IN POSITION
- C/F:
- SYMPTOMS:
- SOMETHING COMES OUT PER VAGINA DURING STRAINING OR EVEN
STANDING.
- DIFFICULTY IN WALKING IN PROCIDENTIA
- LOW, MID SACRAL BACKACHE.
- MICTURITION DISTURBANCE
- CONSTIPATION.
 CLINICAL EXAMINATION
• A COMPOSITE EXAMINATION — INSPECTION AND PALPATION: VAGINAL, RECTAL,
RECTOVAGINAL OR EVEN UNDER ANESTHESIA MAY BE REQUIRED TO ARRIVE AT A
CORRECT DIAGNOSIS.
• GENERAL EXAMINATION — DETAILS, INCLUDING BMI, SIGNS OF MYOPATHY OR
NEUROPATHY, FEATURES OF CHRONIC AIRWAY DISEASE OR ANY ABDOMINAL MASS
SHOULD BE DONE.

• PELVIC ORGAN PROLAPSE (POP) IS EVALUATED BY PELVIC EXAMINATION IN BOTH

DORSAL AND STANDING POSITIONS. THE PATIENT IS ASKED TO STRAIN AS TO PERFORM A
VALSALVA MANEUVER DURING EXAMINATION. THIS OFTEN HELPS TO DEMONSTRATE A
PROLAPSE WHICH MAY NOT BE SEEN AT REST.

• A NEGATIVE FINDING ON INSPECTION IN DORSAL POSITION SHOULD BE RECONFIRMED BY

ASKING THE PATIENT TO STRAIN ON SQUATTING POSITION.
- TREATMENT:
- PREVENTIVE
- CONSERVATIVE
- SURGICAL
- PREVENTIVE TREATMENT:
- EFFECTIVE ANTENATAL CARE: GOOD NUTRITION, ANTENATAL HYGIENE.
- ADEQUATE INTRANATAL CARE: AVOID PROLONGED 2ND STAGE LABOUR,
PREVENT PREMATURE FORCEPS APPLICATION, PROPER EPISIOTOMY.
- ADEQUATE POSTNATAL CARE
- GENERAL PRECAUTIONS: AVOID STRENUOUS ACTIVITIES FOR 6 MONTHS
FOLLOWING DELIVERY
- CONSERVATIVE TREATMENT:
- PALLIATIVE TREATMENT
- PESSARY TREATMENT:
- PESSARY CANNOT CURE PROLAPSE BUT RELIEVES THE SYMPTOMS BY
STRETCHING THE HIATUS UROGENITALIS, THUS PREVENTING VAGINAL AND
UTERINE DESCENT.
- SURGICAL TREATMENT
- ANTERIOR COLPORRHAPHY
- COLPOPERINEORRHAPHY
- PELVIC FLOOR REPAIR
- VAGINAL HYSTERECTOMY.
 PHYSIOTHERAPY FOR PROLAPSE

- PELVIC-FLOOR MUSCLE TRAINING (PFMT)

- INTRAVAGINAL VIBRATORY STIMULATION (IVVS) 
- INTRAVAGINAL ELECTRICAL STIMULATION (IVES)
- PELVIC FLOOR MUSCLE RETRAINING:
- EXPLANATION AND DESCRIPTION OF THE
PELVIC FLOOR.
- INSTRUCTION REGARDING HOW TO
CONTRACT AND RELAX PELVIC FLOOR
MUSCLES
-  IF UNABLE TO PERFORM THIS TASK, USE
FEEDBACK THROUGH DIGITAL PALPATION
-  IF INSUFFICIENT CONTROL DEMONSTRATED,
USE MYOFEEDBACK OR ELECTRICAL
STIMULATION
- TAUGHT CORRECT TECHNIQUE FOR
CONTRACTING PELVIC FLOOR MUSCLES
BEFORE AND DURING INCREASES IN
ABDOMINAL PRESSURE
- INFORMATION ABOUT WASHROOM HABITS
AND LIFESTYLE
- OVERACTIVE PELVIC FLOOR MUSCLES:
- RELAXATION TO BE FOCUSED.
- PRACTICE AT HOME 3-5 TIMES PER WEEK, 2-3 TIMES PER DAY
- KEGEL BRIDGE EXERCISE:
- EMPTY BLADDER BEFORE THE EXERCISE
- SUPINE POSITION, RELAXED THE BODY AND MIND
- BENT THEIR LEGS APART, FEELING LIKE PUSHING THE FLOOR WHEN STEPPING ON IT.
- TIGHTENED THE INNER THIGHS AND STRAIGHTENED THE ANUS UPWARD. THEY WERE ASKED
TO ADJUST THE ANAL CONTRACTION ACCORDING TO THE BREATHING RHYTHM, CONTRACT
WHEN INHALING AND RELAX WHEN EXHALING
- EACH CONTRACTION FOR 3 SEC FOR A TOTAL OF 20-30 MINUTES, 2-3 TIMES/DAY
- VAGINAL DUMBBELL TRAINING.
- PATIENTS WERE ASKED TO PUT THE VAGINAL DUMBBELL INTO THE VAGINA AND HOLD THE
DUMBBELL THROUGH MUSCLE CONTRACTION.
- PATIENTS SHOULD USE THE LIGHTEST DUMBBELL AND GRADUALLY INCREASE THE DUMBBELL
WEIGHT ACCORDING TO THEIR VAGINAL BEARING CAPACITY.
- EACH TIME LASTED FOR 15 MIN, ONE TIME A DAY.
- BIOFEEDBACK & ELECTRICAL STIMULATION’
- HALF LYING POSITION AND SEPARATE THEIR LEGS
- ELECTROMYOGRAPHIC PELVIC FLOOR MUSCLE TREATMENT HEAD WAS PUT INTO THE
VAGINA, WITH THE INITIAL CURRENT INTENSITY GRADUALLY INCREASING FROM 0 MA TO 60
MA.
- FOR TYPE I MUSCLE FIBERS COULD BE SET AS 10-35 HZ INCREASED TO 35-50 HZ 
- TYPE II MUSCLE FIBERS COULD BE SET AS 20-50 HZ INCREASED TO 70-80 HZ
- EACH SESSION: 30 MIN, TWO TIMES A WEEK
 SURGICAL MANAGEMENT OF PROLAPSE

- ANTERIOR COLPORRHAPHY
https://www.youtube.com/watch?v=2gktrhohjzw

- COLPOPERINEORRHAPHY
https://www.youtube.com/watch?v=Ur4suJiL_hI
- PT BEFORE PROLAPSE SURGERY:Physiotherapy treatment before prolapse surgery involves 2 main
approaches:

- Assessing and training your pelvic floor muscles

- Identifying and modifying your lifestyle risk factors
- Assessing and training your pelvic floor muscles
- The pelvic floor muscles work with the strong tissues that prevent prolapse.
- Surgery will repair these strong tissues however repaired tissues can stretch and fail causing
repeat prolapse
- Muscles will stretch and fail if the pelvic floor muscles aren’t working well too.
TRAINING:
- Pelvic floor exercises (kegels) before surgery increase the strength of pelvic floor muscles after
prolapse surgery 
- Usually started 5 months before surgery.
- IDENTIFYING AND MODIFYING YOUR LIFESTYLE RISK FACTORS
- Risk factors:
- Constipation, heavy lifting, obesity
- Inappropriate general exercises e.G. High impact exercises or intense core abdominal exercises
- Coughing with chest problems, asthma, smoking or hay fever
Training:
- Coughing, sneezing and heavy lifting with precaution
- Physiotherapy treatment for recovery after prolapse surgery:
- During early recovery in hospital:-
- How to rest pelvic floor to promote recovery
- daily routine for walking and sitting out of bed
- Techniques to protect prolapse repair especially during coughing or sneezing
- Most comfortable resting positions
- How to minimize risk of lower back pain
- How to move in and out of bed without straining prolapse repair
- Physiotherapy after discharge from hospital:
- PROGRESSIVE PELVIC FLOOR MUSCLE TRAINING
- 4-6 weeks after prolapse surgery
- Brief gentle pelvic floor exercises lying down
- Exercises are then progressed and training in upright positions (sitting and standing)
-  Feel comfortable and pain free.
- MANAGING POST OPERATIVE PROBLEMS
- Problems encountered: Bladder emptying, constipation, lower back pain or bladder control

- ADVICE FOR SAFE RETURN TO WORK, EXERCISE AND REGULAR ACTIVITIES

- General activities of daily living such as safe lifting looking after children/grandchildren, safe bending
during home duties such as house cleaning, gardening and shopping.
INFECTIONS OF GENITAL TRACT
- PUERPERAL SEPSIS:
- AN INFECTION OF THE GENITAL TRACT WHICH OCCURS AS A COMPLICATION OF
DELIVERY IS CALLED PUERPERAL SEPSIS.
- PREDISPOSING FACTORS:
- ANTEPARTUM FACTOR
- MALNUTRITION & ANAEMIA, PREMATURE RUPTURE OF MEMBRANE
- INTRAPARTUM FACTORS
- INTRODUCTION OF SEPSIS IN UPPER GENITAL TRACT DURING INTERNAL EXAMINATION AFTER
RUPTURE OF MEMBRANE OR DURING MANIPULATIVE THERAPY.
- OTHER FACTORS
- DIABETIC MOTHER, HIV, TB
- ORGANISM RESPONSIBLE:
- AEROBIC ORGANISM: STRP, STAPHY., E.COLI
- ANAEROBIC ORGANISM: BACTEROIDS
- PROTOZOA
- MODE OF INFECTION:
- ENDOGENOUS: BACTERIA INSIDE THE GENITAL TRACT
- AUTOGENOUS:MIGRATES TO GENITALIA FROM ELSE WHERE IN THE BODY
- EXOGENOUS:INTRODUCED BY ATTENDANT
 - C/F:
- C/F: - SIGNS:
- SYMPTOMS: - PYREXIA
- FEVER,CHILLS,RIGOR - ABDOMINAL TENDERNESS
- LOOSE MOTION - SIGNS OF PNEUMONIA
- COUGH WITH EXPECTORATION - THROMBOPHLEBITIS
- DYSURIA - FOUL SMELLING DISCHARGE FROM
- PAIN IN ABDOMEN VAGINA
- DEHYDRATION
- TACHYCARDIA
- DECREASED BP
- INVESTIGATION:
- HIGH VAGINAL & ENDOMETRIAL SWAB FOR CULTURE
- MID STREAM COLLECTION OF URINE.
- BLOOD TEST
- BLOOD CULTURE
- CLOTTING PROFILE
- SERUM UREA & CREATININE ESTIMATE
- TREATMENT:
- PATIENT SHOULD BE PLACED IN SEPARATE WARD.
- DIETARY RESTRICTION WITH ADEQUATE FLUID & ELECTROLYTE
- BLOOD TRANSFUSION TO CORRECT ANEMIA
- MONITOR VITALS
- ANTIBIOTICS: AMPICILLIN(500 GM), GENTAMYECIN, METRINIDAZOLE
- SURGICAL TREATMENT:
- PERINEAL WOUND SHOULD BE STITCHED & DRAINED PUS.
- PELVIC ABSCESS DRAINED BY COLPOTOMY
- HYSTERECTOMY: RUPTURE, MULTIPLE ABSCESS, GANGRENOUS UTERUS
- VIRAL HEPATITIS
- THE ACUTE INFECTION IS MANIFESTED BY FLU LIKE ILLNESS AS MALAISE, ANOREXIA,
NAUSEA AND VOMITING.
- THERE MAY BE ARTHRALGIA AND SKIN RASH. IN MAJORITY, IT REMAINS
ASYMPTOMATIC.
- JAUNDICE IS RARE AND FEVER IS UNCOMMON.
- DIAGNOSIS IS CONFIRMED BY SEROLOGICAL DETECTION OF HBSAG, HBEAG,
(DENOTE HIGH INFECTIVITY) AND ANTIBODY TO HEPATITIS B CORE ANTIGEN (HBC)
AND HBV DNA TITER.
- SCREENING: ALL PREGNANT WOMEN SHOULD BE SCREENED FOR HBV INFECTION AT
FIRST ANTENATAL VISIT AND IT SHOULD BE REPEATED DURING THE THIRD
TRIMESTER FOR “HIGH RISK” GROUPS (INTRAVENOUS DRUG ABUSERS, SEXUAL
PROMISCUITY, HEMOPHILICS, PATIENTS ON HEMODIALYSIS OR HAVING MULTIPLE
SEX PARTNERS).
- MANAGEMENT
- PROPHYLAXIS
- IMPROVEMENT IN SANITATION, SUPPLY OF SAFE DRINKING WATER AND ADEQUATE CARE OF
PERSONAL HYGIENE.
- USE OF DISPOSABLE SYRINGE OR BOILING OF SYRINGE PRIOR TO USE.
- SCREENING OF BLOOD DONORS FOR HBSAG SHOULD BE ROUTINELY DONE
- SERONEGATIVE MOTHER
- SHOULD HAVE HB IMMUNOGLOBULIN (HBIG), 0.06 ML/KG IM, SOON FOLLOWING EXPOSURE
AND A SECOND DOSE AFTER 1 MONTH
- RECOMBINANT DNA VACCINE INTRAMUSCULARLY 1 ML, 3 DOSES AT 0, 1 AND 6 MONTHS
- SYPHILIS
- SYPHILIS IS A SEXUALLY TRANSMITTED DISEASE CAUSED BY TREPONEMA PALLIDUM
- MOTHER—SYPHILIS ACCELERATES THE COURSE OF HIV INFECTION IN PREGNANT
WOMAN
- BABY—CONGENITAL INFECTION RESULTS FROM TRANSPLACENTAL MIGRATION OF
SPIROCHETE TO THE FETUS OBLITERATIVE ENDARTERITIS
 - INVESTIGATIONS:
(A) SEROLOGICAL TEST:VDRL(VENEREAL DISEASE RESEARCH LABORATORY (VDRL)
VENEREAL DISEASE RESEARCH LABORATORY)
(B) FLUORESCENT TREPONEMAL ANTIBODY ABSORPTION TEST (FTA-ABS) AND
TREPONEMA PALLIDUM MICROHEMAGGLUTINATION (MHA-TP)
(C) DETECTION OF SPIROCHETES FROM THE CUTANEOUS LESION IF ANY
(D) POLYMERASE CHAIN REACTION (PCR) OF T PALLIDUM IN AMNIOTIC FLUID, FETAL
SERUM OR SPINAL FLUID
- CLINICAL FEATURES OF CONGENITAL SYPHILIS:
- EARLY: MACULOPAPULAR RASH, RHINITIS, HEPATOSPLENOMEGALY, JAUNDICE,
LYMPHADENOPATHY, CHORIORETINITIS AND PNEUMONIA.
- LATE: HUTCHINSON TEETH, DEAFNESS, SADDLE NOSE, SABER SHINS, HYDROCEPHALUS,
MENTAL RETARDATION, CLUTTON JOINT, INTERSTITIAL KERATITIS AND OPTIC NERVE
ATROPHY
- TREATMENT:
- MOTHER:
- BENZATHINE PENICILLIN 2.4 MILLION UNITS INTRAMUSCULARLY SINGLE DOSE
- NEUROSYPHILIS—AQUEOUS CRYSTALLINE PENICILLIN G 18–24 MILLION UNITS IV DAILY FOR
10–14 DAYS IS GIVEN
INCONTINENCE
- DEFINITION:
- Urinary incontinence (UI) is
a multifactorial syndrome
produced by
- a combination of
genitourinary pathology,
age-related changes, and
comorbid conditions
- that impair normal
micturition or the functional
ability to toilet oneself, or
both
Detrusor:
- Storage and emptying of urine from the bladder
- Specialized smooth muscle that forms the bladder wall.
- It retains the structural integrity of the bladder when stretched.
- Receives innervation from both the sympathetic and parasympathetic nervous sysytem
- The sympathetic – hypogastric nerve (T12 – L2), causes relaxation of the detrusor
muscle, promoting urine storage.
- The parasympathetic – pelvic nerve (s2-s4) and increased signals from this nerve
cause contraction of the detrusor muscle, stimulating micturition.
- The somatic- pudendal nerve (s2-4). It innervates the external urethral sphincter,
providing voluntary control over micturition.
- Sensory (afferent) nerves-  reports to the brain and spinal cord. They are found in the
bladder wall (stretch receptors) and signal the need to urinate when the bladder becomes
full.
The bladder stretch reflex
- It is a primitive spinal reflex
- Micturition is stimulated in response to the stretch
of the bladder wall
- The reflex arc:
• The bladder fills with urine, and the bladder
walls stretch. Sensory nerves detect stretch and
transmit this information to the spinal cord.
• Interneurons within the spinal cord relay the signal
to the parasympathetic efferents (the pelvic nerve).
• The pelvic nerve acts to contract the detrusor
muscle and stimulate micturition.
- TYPES:
- TRANSIENT INCONTINENCE
- URGE INCONTINENCE
- STRESS INCONTINENCE
- OVERFLOW INCONTINENCE
- Transient incontinence
- Combination of stress & urge incontinence
- UI precipitated by remediable factors is called transient incontinence.
- Causes
- Caused by a temporary (transient) situation such as an infection or new medicine. Once
the cause is removed, the incontinence goes away.
- Urge incontinence:
- It is characterized by abrupt urgency, frequency, and nocturia; the volume of leakage
may be small or large
- Cause:
- Detrusor overactivity (DO) that may be age-related, idiopathic, secondary to
lesions in central inhibitory pathways (eg, stroke, cervical stenosis), or due to local
bladder irritation (infection, bladder stones, inflammation)
- Stress incontinence:
- Second most common type of UI in older women, results from failure of the sphincter
mechanism(s) to preserve outlet closure during bladder filling.
- Cause:
- Increased intra-abdominal pressure, in the absence of a bladder contraction.
- Leakage is due to impaired pelvic supports or, less commonly, failure of urethral
closure; the latter intrinsic sphincter deficiency occurs with trauma
- Overflow incontinence
- Overflow UI results from detrusor underactivity, bladder outlet obstruction, or both.
Leakage is small in volume but continual.
- Symptoms include dribbling, weak urinary stream, intermittency, hesitancy, frequency,
and nocturia.
- Associated urge and stress leakage may occur
- Assessment of urinary incontinence
- Routine urodynamic testing
- Cystometry
- Measurement of abdominal pressure
- Management
- General measures
- Fluid management
- Avoid caffeinated beverages and alcohol,
- Minimize evening intake if nocturnal UI
- Urge incontinence
- Bladder-suppressant medications: oxybutynin( 2.5 mg two to three times daily )
- Behavioral treatment:
- Frequent voluntary voiding to keep bladder volume low,
- Retraining of central nervous system and pelvic mechanisms to inhibit detrusor
contractions and leakage
- Bladder retraining, with timed voiding while awake and suppression of precipitant urges by
relaxation techniques.
- When a precipitant urge occurs, patients are instructed to stand still or sit down
and concentrate on making the urge decrease and pass: to take a deep breath
and let it out slowly, or to visualize the urge as a wave that peaks and then falls.
- Once in control of the urge, they should walk slowly to a bathroom and void.
- Stress incontinence

- Pelvic muscle exercises (PME)

- Strength training (isometric repetitions at maximal exertion)

- PME instruction should focus on isolation of pelvic muscles; avoidance of buttock, abdomen,
or thigh muscle contraction; moderate repetitions of the strongest contraction possible (3 sets
of 8 to 10 contractions held for 6 to 8 seconds 3 to 4 times a week); and contraction for
progressively longer times (up to 10 seconds, IF POSSIBLE).
- Biofeedback may help patients perform correct muscle contraction and monitor
progress.
- Electrical or magnetic stimulation of pelvic muscle contractions, and progressively
weighted cones retained in the vagina during ambulation can be followed.
- Systemic or topical estrogen may reduce stress and urge ui
- Surgical correction
- Bladder neck suspension procedure