Urinary incontinence

Urinary incontinence is the involuntary loss of urine that is objectively demonstrated with social and hygienic problem. it result from failure to store the urine during filling phase of bladder due to abnormality of the bladder smooth muscle or the urethral sphincter

Classification of incontinence. Anatomic or genuine urinary stress incont. Urge incont. Neuropathic incont. Congenial incont. Overflow incont. Iatrogenic incont. Fistulous incont.

Stress incontinence is an involuntary loss of urine that occurs during increase intera abdominal pressure like during coughing sneezing Bet 15-30% of women over age of 65 have incont. Mostly of stress type 30-50%of women with stress incont.have ergency frequency and /or urge incont .so called mixed incont Causes . Classic or genuine stress incont. Is caused by urethral hyper mobility or displacement of the urethra and bladder neck from their normal anatomical position

It can occur as result of intrinsic sphinctor deficiency like due to surgery,estrogen deficincy ,truma Anatomy The anatomic feaure is hypermobility or a lowering of the position of the VU segment Normally movement of VU junction is about 2cm so intra abdominal pressure diffuse on both bladder and urethra ,but in incontinence there is hypermobility causing movement accede 2 cm and bladder descend more and pressure will press on bladder only angle of inclination is more than 30 Posterior VU angle change

Risk Factors Gender ; women more than men in men usually post prostatectomy and transit Genetic Race ,culture and enverment white > blacks Overweight Pregnancy and childbirth it most important due to baby weight, relaxing hormon,viginal delivery causing stretching of pelvic floor nerves,tear or episitomy had 3 time increasing risk Smoking :due to chronic cough Age :weeking of muscle making elderly people susceptible to stress incontinence

8.Medication: like alpha blocker Diagnostic evaluation Causes of transit incontinence should role out due to it treatable Drug side effects Delirium or hypoxia Impaired mobility UTI Atrophic vigintis Stool impiction Evaluation History Examination

Urinalysis Post void urine volume Micturition diary Pad test Urodynamic evaluation History : Assess characteristic,severty and impact on life Assess risk factores and/or transit causes Examination Neurological exam :like gait,lumbosacral nerve root assess Abdomenal and flank for destintation

Rectal exam :for prostate and anal tone. Cough test bladder full in lithotomy position pat. Ask to cough to reproduce incont. The Q-Tip test: assess the degree of urethral mobility straining angle more than 30 Vaginal exam anterior vaginal wall (cystocele) posterior vaginal wall (enterocele) Pelvic floor strength (urethra and trigone are estrogens dependent Urinalysis: for UTI Residual urine volume: normally less than 50ml Maturation Diary :Including time of maturation. time and type of incont .and voided volume

Pad Test A semi objective measurement of urine loss over a given period of time Weight gain sanitary towel of up to 8 gram is normal Urethral pressure profilometery Changes are Low urethral closure pressure Shorting of functional segment of urethra Week response to stress Fall in closure pressure in upright position

Treatment Non surgical treatment Alpha agonist Oestrogen Behaviour modification Pelvic floor exercises Biofeedback Electrical stimulation Surgical treatment Urethral hypermobility then we do suspension of the bladder neck and proximal urethra through Reteropubic suspension (marshall-marchetti-krantz and burch colposuspension

2. Transvaginal suspension Intrinsic sphenictor defect Pubovaginal sling (TVT,TOT) Periurethral injections Sphincter prostheses Urge Incontinence Itis involuntary urine leakage accompanied by or immediately preceded by sudden strong desire to void The basic feature is detrusor instability and urine loss while attempting to inhibit maturation There is overactive bladder with frequency ,ergency,and nocturia

over activity can result from bladder inflamination obstruction or neurololgical trauma Any thing increase intravasical pressure lead to urge incontinency Urodynamic feeatures normal or high closure pressure Normal response to stress and filling Detrusor hyperirritability Treatment Bladder training Decrease fluid intake Intravesical botulinun toxin Scheduled voiding Surgery

Neuropathic incontinence Active found in patients who have spastic lesion but in whom the sphincteric mechanism, still exerts adequate closure pressure. Active incontinence is most often associated with suprasegmental or upper motor neuron lesion . Passive neuropathic incontinence occurs when the sphincteric mechanism is weakened or completely lacking. Passive incontinence is most often associated with lesion involving the micturition center or more distal lesion.

Classfication A –failure of reservoir function can be caused by poor compliance of the urinary bladder. Intravesical pressure raised with minimal bladder filling exceeding the outlet resistance & causing urinary leakage. B –failure of retention function (arflxia) total loss of smooth & striated sphincteric activity due to complete lesion of the sacral segment or cauda equina. The external sphincter offer minimal resistance. The bladder musculature is atonic & lax

Diagnosis. A complete urologic & neurologic evaluation should be done to determine whether the condition arise from detrusor or sphincteric dysfunction. History, physical examination, excretory urography, cystourethrography, & urodynamic study are recommended. One must be alert to the possibility of overlapping causes. .

Treatment. conservative management 1- failure of reservoir function. Anticholinergic drugs like oxybutynin Tricyclic antidepresent like Imipramine Antihistaminic drugs 2-Failure of retention mechanism. Clean intermittent catheterization Drug less effective like alpha agonist. surgical management. 1- sphincterotomy. 4. diversion 2- Bladder augmentation. 5.Neurostimulation 3- Artificial sphincter. .