Female Urology & Incontinence in Women Dr Sanjay Garg Senior Consultant Urology Dr Vijayant G Gupta Asso Consultant Urology

Urinary incontinence in the female Involuntary loss of urine which is objectively demonstrable & is a social or hygienic problem. Stress incontinence: Involuntary expulsion of urine under conditions of stress like rise of intra-abdominal pressure due to coughing, sneezing , laughing or lifting weights.

Types True incontinence – Continuous Leakage Urge incontinence- it is associated with strong desire to void Stress incontinence-leaking on stress Overflow incontinence-It is sequel of prolonged and neglected retention

Prevalence of Problem Upto 57% in women 45-64 yrs. 14% in general population. Common condition, but rarely life threatening Adverse effect on quality of life Embarrassment and anxiety.

Definition of SUI Stress urinary incontinence (SUI) is defined by the international continence society (ICS) as the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.

Causes of urinary incontinence Genuine stress incontinence Urinary loss which occurs with sudden elevation of the intra abdominal pressure without detrusor contraction Detrusor instability Retention with overflow incontinence Urogenital fistula Urethral diverticulum

Grading of SUI Grade 0 Incontinence without leakage Grade 1 Incontinence with only severe stress, such as coughing, sneezing, and jogging Grade 2 Incontinence with moderate stress, such as fast walk, going up and down the stairs Grade 3 Incontinence with mild stress such as standing

Etiology Age Multiparty Obesity Smoking Prolapse Constipation Pregnancy and puerperium Athletes

Investigations Uroflowmetry- 15-25ml/sec Advanced Uroflowmetry- 15-25ml/sec Cystometry Urethral pressure profilometry Cystourethroscopy Micturition cystography General Urine- Routine/microscopy, c/s Frequency/volume chart or urinary diary. Pad test.

Stress Test Excellent method of demonstrating objectively the presence of SUI Steps Catheterisation Urine sample is sent for culture 250 ml warm saline instilled into the bladder Leakage noted in sitting and supine position Net weight gain of 2g or more is indicative of GSI

Bonneyʼs test Bonney test Absence of leakage of urine following bladder neck elevation is indicative of beneficial outcomefollowing surgical repair

Management Conservative Fluid intake and voiding habits Weight loss Physiotherapy Reduce caffein intake and smoking Drugs - Dapoxetine Intraurethral and vaginal devices Electric stimulation Surgical

Fluid Management Fluid intake and voiding habits Trials have been demonstrated that increase in fluid intake increases the episodes of incontinence thus decreasing the fluid intake is helpful in for patient with high fluid consumption Voiding prior to strenous activity beneficial in mild SUI

Pelvic Floor Exercises Kegel described the PFM exercises in 1948 for female UI Reported success rate is more than 80% Offer a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment to women with stress or mixed UI. [2006] Pelvic floor muscle training should comprise at least 8 contractions performed 3 times per day for 3-6 month. [2006]

Weight loss Several studies shows association between obesity and development of incontinence a study examining women who had lost weight as a result of bariatric surgery found that there was significant decrease in both subjective and objective SUI and UUI

SNRI Duloxetine Promising Drug – Increases Bladder Neck Tone One study conduct in north america showed incontinence episodes decreased by 50% in duloxetine group versus 27% in placebo group

Anti Cholinergic Roliten/Solifine Reduces Bladder Contraction/Increases Capacity

Electric Stimulation Electric stimulation Tried if SUI is caused by denervation of pudendal nerve during delivery Useful in women with weak pelvic floor muscles

Surgery Suspension Procedures (For Hypermobile Bladder Neck) Burch Colposuspension Retropubic Slings – Artifical Mesh or Rectus Sheath Slings Mid Urethral Slings (Gold Standard) Artificial Urinary Sphincters

Sling

Complications of Surgery Injury to bladder Mesh Infection/ Migration Hyper Continence – Urine Retention Bleeding/ Injury to Iliacs Nerve Injuries – Chronic Neuralgia

Take Home Message Stress Urinary Incontinence is a major problem in the women of India It is underidentified and undertreated Cause of Major Embarrassment and Poor Quality of life in women

Effective long term treatment of this problem exists Involve your Urologist colleagues in the management of these problems Thank You