Urinary incntinence By Dr. Dalya Muthefer

urinary incontinence: Is defined as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. It increases with age <45 it 5% >45years old it 10% >65 yrs old it 20%

Common symptoms associated with incontinence Stress incontinence is a symptom and a sign and means loss of urine on physical effort. It is not a diagnosis. Urgency means a sudden desire to void. Urge incontinence is an involuntary loss of urine associated with a strong desire to void. Overflow incontinence occurs without any detrusor activity when the bladder is over distended.

Frequency is defined as the passing of urine seven or more times a day, or being awoken from sleep more than once a night to void. In addition, women may also have complaints of prolapse, sexual dysfunction due to leakage and coexisting anal incontinence.

Classification of incontinence Urethral causes: 1 –urethral sphincter incompetence (urodynamic stress incontinence) 2-Detrusor overactivity or the unstable bladder- this is either neurogenic or non neurogenic 3- retention with overflow 4- Congenital causes 5- Miscellaneous Extra urethral causes: 1- congenital causes 2- fistula

Urethral causes urodynamic stress incontinence USI, is defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction Previously called genuine stress incontinence, is noted during filling cystometry.

symptoms Stress incontinence is the usual symptom, but urgency , frequency and urge incontinence may be present. There may also be an awareness of prolapse. On clinical examination, it may be demonstrated when the patient coughs.

Aetiology of USI Damage to the nerve supply of the pelvic floor and urethral sphincter caused by child birth leads to progressive changes in these structures resulting in altered function. Menopause and associated tissue atrophy Congenital cause in some nulliparous due to altered connective tissue Chronic cause such as obesity and chronic obstructive pulmonary disease and constipation

Understanding the pathophysiology of USI 1- Abnormal descent of the bladder neck and proximal urethra, so there is failure of equal transmission of intra-abdominal pressure to the proximal urethra, leading to reversal of the normal pressure gradient between the bladder and urethra, with a resultant negative urethral closure pressure.

2- an intraurethral pressure which at rest is lower than the intravesical pressure, this may be due to urethral scarring as a result of surgery or radiotherapy .it also occurs in older women due to oestrogen deficiency.

3- laxity of suburethral support normally provided by the vaginal wall, endopelvic fascia, arcus tendineus fascia and levator ani muscles acting as a single unit results in ineffective compression during physical stress and consequent incontinence.

Detrusor overactivity Previously called detrusor instability , is urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked.

Symptoms of detrusor overactivity The combination of urgency, frequency and nocturia is termed the overactive bladder syndrome with or without urgency incontinence, in the absence of urinary tract infection. Examination :any masses that cause compression of the bladder must be excluded and prolapse must be examined for If there is vaginal atrophy ,this may also cause some urgency and frequency.

Understanding the pathophysiology of detrusor overactivity Poor toilet habit training and psychological factors . More recently UTI may be a trigger. An idiopathic variety is more prevalent after the menopause. Childhood enuresis increase the likelihood of overactive bladder Neuropathy appears as a factor Incontinence surgery, outflow obstruction and smoking are also associated.

Retention with overflow: Insidious failure of bladder empting may lead to chronic retention and , finally ,when normal voiding is ineffective, to overflow incontinence. The causes may be : Lower motor neurone or upper motor lesions. Urethral obstruction pharmacological

Symptoms of retention include poor stream, incomplete bladder emptying and straining to void, together with overflow stress incontinence. Cystometry is usually required to make the diagnosis and bladder ultrasonography or intravenous urogram.

Congenital : Epispadias, which is due to faulty midline fusion of mesoderm, results in a widened bladder neck, shortened urethra, separation of the symphysis pubis and imperfect sphincteric control Miscellaneous: Acute urinary tract infection or faecal impaction in the elderly may lead to temporary incontinence.

Extraurethral causes of incontinence Congenital: 1- Bladder exstrophy and ectopic ureter: There is failure of mesodermal migration with breakdown of ectoderm and endoderm, resulting in absence of the anterior abdominal wall and anterior bladder wall. 2- fistula: is an abnormal opening between the urinary tract and the outside.

investigations Midstream urine specimen Urinary diary :is a simple record of patients fluid intake and output .episodes of urgency and leakage and precipitating events are also recorded for 3-5 consecutive days. Pad test: Are used to verify and quantify urine loss .the international continence society pad test takes 1 hour. Patient wears a pre-weighed sanitary towel, drinks 500 ml of water and rests for 15 min. after a series of defined manoeuvres, the pad is reweighed; a urine loss of more than 1g is considered significant.

uroflowmetry Is the measremement of urine flow rate and is a simple ,non –invasive, outpatient test. The normal flow curve is bell shaped .a flow rate <15 ml /second on more than one occasion is considered abnormal in females The voided volume should be >150 ml , if smaller volumes the flow rates are not reliable. A low peak rate and a prolonged voiding time suggest a voiding disorder.

cystometry It involves the measurement of the pressure-volume relationship of the bladder.it is the most fundamental investigation It involves simultaneous abdominal pressure recording in addition to intravesical pressure monitoring during bladder filling and voiding. Electronic subtraction of abdominal from intravesical pressure enables determination of the detrusor pressure.

Intravesical pressure is measured using catheter and other catheter is inserted into the rectum to measure intra abdominal pressure. During filling, the patient is asked to indicate her first and maximal desire to void and these volumes are noted.

The parameters of normal bladder function: Residual urine of <50 ml First desire to void between 150 and 200ml Capacity between 400 and 600 ml Detrusor pressure rise of <15 cmH2O during filling and standing . Absence of systolic detrusor contractions. No leakage on coughing. A voiding detrusor pressure rise of <70 cmH2O with a peak flow rate of >15 ml/second for a volume >150 ml.

Videocystourethrography: if a radio-opaque filling medium is used during cystometry, the lower urinary tract can be visualized by x-ray screening with an image intensifier. Intravenous urography: little information but indicated in hematuria ,neuropathic ,and fistula.

Ultrasound: becoming more widely used in urogynaecology. Magnetic resonance imaging: produces anatomical pictures of pelvic floor Cystourethroscopy: establishes the presence of disease in the urethra or bladder. Urethral pressure profilometry: to maintain continence , the urethral pressure must remain higher than the intravesical pressure Ambulatory monitoring: fine microtip transducers are inserted into the bladder and rectum

treatment Prevention Conservative management: physiotherapy is the mainstay of the conservative treatment of stress incontinence. Surgery: the aims of surgery are: -to provide suburethral support; -restoration of the proximal urethra and bladder neck to the zone of intra-abdominal pressure transmission; -to increase urethral resistance; -a combination of both.

The colposuspention operation used to be considered the gold standard for stress incontinence. Since the introduction of the tension-free vaginal tape(TVT)the popularity of the colposuspension has waned. TVT procedure involved the placement of a polypropylene tape under the midurethra through a single 1-2cm anterior vaginal incision wall and two suprapubic 0.5cm incisions approximately 4-5 cm apart.

A needle introducer is passed either side of the urethra through the vagina incision and passed through the retropubic space to emerge through the ipsilateral suprapubic incision. Modifications of the TVT have involved a departure from the retropubic approach to the external incisions being made lateral to the labia over the obturator foramina bilaterally(TOT). Single incision tapes are evolving, and in this the tapes are inserted through a vaginal incision and attached to either the obturator internus muscle or into the obturator membrane.

The artificial sphincter is used where conventional surgery has failed. Periurethral bulking agent:contigen collagen is usually injected paraurethrally and Macroplastique transurethrally Evidence-based medicine has shown TVT and colposuspension to be the most widely practised and most effective operation for stress incontinence.

The anterior repair and endoscopic bladder neck suspensions are not good operations in the medium or long term for this condition. Detrusor overactivity can be treated by bladder retraining biofeedback or hypnosis. Anticholinergic agents, such as oxybutynin 2.5 mg twice daily or tolterodine 2 mg twice daily. Sacral nerve stimulator offers another alternative Botulinum toxin injections under cystoscopic control into the detrusor muscle are being used for women with DOA

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