URINARY INCONTINENCE Dr Fatima Z Ashrafi DGO (Dub), FRCS (Edin), MRCOG (Lon), FRANZCOG Gisborne Hospital, New Zealand

WHAT IS CONTINENCE? Continence is the ability to pass urine or faeces voluntarily in a socially acceptable place. The continent person can: recognize the need identify the correct place hold on until he reaches the correct place reach the correct place pass urine or faeces when he gets there Incontinence - involuntary loss of urine which is objectively demonstrable & is social and hygienic problem.

INCIDENCE 1 in 3 female age 55 or more complain of incontinence. 1 in 10 women will have surgery for prolapse or SI in life time. One third will need further surgery. Urinary incontinence - not a recent medical or social phenomena. Disorders of urinary tract written in ancient times. Women more willing to talk about it. Improved understanding of the diverse pathophysiology of incontinence. Advent of new treatment. Development of urology & urogynaecology as a specialty.

HOW DOES INCONTINENCE OCCUR? Factors affecting the bladder: incompetent urethral closure weakness of pelvic floor muscles urethral obstruction overactive urethral closure underactive detrusor detrusor/sphincter dyssynergia unstable detrusor Factors affecting our ability to cope with the bladder: impaired mental function other psychological factors mobility and dexterity problems environmental problems drug treatment

NERVE SUPPLY Bladder,bowel &sexual functions- parasympathetic & somatic via S2,3,4. Sympathetic supply - T10-L2 segments - detrusor muscle. Parasympathetic promotes micturition - contracting detrusor, relaxing urethra. Sympathetic - B receptors in bladder - relaxation, A receptors in bladder neck increasing urethral resistance. Central control - pontine center, receiving afferent and efferent from cerebral cortex, cerebellum and spinal center. Normally detrusor is reflexly inhibited by sympathetic neurones (storage and filling), control acquired in infancy. Detrusor contraction mediated by parasympathetic supply. M3 receptors .

ANATOMY Bladder functions as low pressure reservoir allowing intermittent voiding within socially acceptable limits. Continence is maintained as UCP is higher than expulsion pressure. Urethra supported by - Externally: pubourethral ligament, striated muscle of pelvic floor. Internally : smooth muscle of urethra, ext urethral sphincter, periurethral collagen & connective tissue, submucosal venous plexus, mucosal coaptation of the urothelium. Proximal urethra is well supported so a rise in intraabdominal pressure is equally transmitted to bladder & urethra.

TYPES OF INCONTINENCE Genuine stress incontinence Detrusor instability Mixed (GSI and DI) Overflow Fistulae

INCONTINENCE Genuine Stress Incontinence: Is the involuntary loss of urine in the absence of a detrusor contraction, the intravesical pressure exceeds the urethral pressure. There is not an associated desire to void. Detrusor Instability Involuntary detrusor contractions either spontaneous or provoked which cannot be suppressed and may cause incontinence. It is associated with a strong desire to void. Abnormal nerve supply to bladder (spinal cord injury, spina bifida) - detrusor hyperreflexia. Overflow Incontinence is an involuntary loss of urine associated with over distension of the bladder. May present as SI or dribble. Due to bladder outlet obstruction or impaired detrusor contraction. More common in males.

Intrinsic Sphincter Deficiency Genuine Stress Incontinence Hypermobility excessive descent of bladder neck, so poor transmission of increase in ab pressure to proximal urethra. Intrinsic Sphincter Deficiency poor urethral closure due to scarring - surgery, childbirth, neurological injury.

RISK FACTORS FOR STRESS INCONTINENCE 1 Increasing parity, probably related to obstetrical trauma 2 Increased intra-abdominal pressure a medical factors (eg smoking, chronic bronchitis or other pulmonary problems, constipation with chronic straining at stool, obesity (?)) b environmental factors (eg jobs requiring heavy lifting or straining) 3 Pelvic floor trauma and denervation injury a obstetric trauma b nonobstetric trauma (eg pelvic fractures and radical surgery) 4 Hormonal status and estrogen deficiency 5 Connective tissue disorders

Symptom GSI Detrusor (%) Instability Frequency 57 86 Nocturia 29 80 Urgency 46 92 Urge Incontinence 37 88 Stress Incontinence 99 26

COMMON DRUGS AFFECTING LOWER URINARY TRACT FUNCTION Sedative hypnotics Benzodiazepines Alcohol Diuretics Anticholingeric agents Antihistamines Antidepressants Antipsychotics Antispasmodics Anti-Parkinsonian agents Andrenergic agents Sympathomimetics Sympatholytics (Prazosin) Calcium channel blockers

INCIDENCE OF NEUROPATHIC BLADDER IN NEUROLOGICAL DISEASE Condition Incidence Abdominoperineal resection 10%-44% Radical hysterectomy 7%-80% Polio (almost always recovers) 4%-42% Diabetic neuropathy 2%-83% Lumbar disc disease 6%-18% Multiple sclerosis Presenting symptom 2%-12% Overall incidence 33%-78% Parkinsonism 37%-70% Stroke 34%-53% Meningomyelocele 97%

PATIENT ASSESSMENT Patient history. Frequency, nocturia, urgency, urge incontinence, stress incontinence, voiding patterns, drinking habits, drugs, medical problems, quality of life. Frequently female pts present with mixed incontinence. Physical examination: general, abdominal, pelvic - atrophic vaginitis, uterine descent, vaginal wall prolapse, pelvic muscle strength, S234. Frequency/volume chart: intake, output, episodes of dampness, leaking, acts as a teaching aid. Urine examination Urodynamics

INCONTINENCE TREATMENT CONSERVATIVE Global: Evaluation of cough, change of medication, wt loss/ Pharmacological Behavioural Changes - adequate water (1.5 l/d) - Decrease dietary irritants - Manage constipation - Pelvic muscle exercises - Bladder retraining - instructing pt to void at predetermined intervals. Very successful in young motivated women(85%) Pelvic Muscle Exercises - Verbal feedback / written instructions - Vaginal weights - Biofeedback Electrical Stimulation

URODYNAMIC TESTS Flow studies Cystometry (+/- Videourodynamics) Urethral pressure profilometry Ambulatory urodynamics Electromyography

URODYNAMIC MEASUREMENTS Bladder pressure - storage and voiding Abdominal pressure Urethral pressure Urine flow Bladder capacity Volume voided Residual

UROFLOWMETRY URINE FLOW RATES WOMEN Patient voids into a flow meter Flow rate Volume voided Residual - catheter - ultrasound URINE FLOW RATES WOMEN Under 50 years - 25 ml/sec Over 50 years - 18 ml/sec

FILLING / VOIDING CYSTOMETRY Bladder catheters - intravesical - pressure (pves) - fill Rectal catheter - abdominal - pressure (pabd) Position - lying / sitting / standing Fill speed * - slow / medium / fast * frequency / volume chart

FILLING CYSTOMETRY WHEN TO DO A CYSTOSCOPY? First desire to micturate Capacity Detrusor activity WHEN TO DO A CYSTOSCOPY? Microscopic hematuria Abnormal cytology Periurethral abnormality For reassurance

DETRUSOR INSTABILITY 2nd common cause of incontinence in UD studies.Incidence increases with age. Normal control of detrusor is lost. 15% incidence of DI following bladder neck surgery. Cost: Australia - 1997, NIH - $17.5 billion on urinary incontinence, $12.7 billion on overactive bladder, $13.8 on osteoarthritis, $11 billion on gynae & breast cancer Important to identify DI prior to continence surgery as urgency may be worsened. Frequency, urgency, urge incontinence, key in door leaking are typical of DI.

DETRUSOR INSTABILITY Rarely completely cured by any form of treatment. Symptoms and QOL can be improved. Continence adviser essential member of continence service. Behavioural & conservative therapies are helpful Anticholinergic drug eg Oxybutinin is used in DI. S/E: dry mouth, blurred vision, constipation, drowsines, urinary retention. A new antimuscarinic, Tolteradine is in market now. Darifenacin - highly selective M3 blocker - phase 3 trials. TCA, DDAVP, Ca channel blockers. Oestrogen therapy : systemic no effect, topical decreases UTI. Good for atrophic vaginitis. Surgical: cystodistension, clam cystoplasty, diversion procedures

SURGICAL APPROACH FOR THE TREATMENT OF GENUINE STRESS INCONTINENCE (GSI) Operation Anterior colporrhaphy Marshall-Marchetti-Krantz Burch colposuspension Needle bladder neck suspension (Stamey) Indication Significant uterovaginal prolapse. Should not be considered as first line procedure for GSI Primary or secondary GSI Primary or secondary GSI with cystocele GSI in the surgically difficult patient

Operation Suburethral sling procedures Periurethral bulk enhancing agents (GAX collagen/macroplastique/autologous fat) Complex surgical procedures (eg artificial sphincter/ neourethra/ urinary diversion) TVT Indication Severe recurrent GSI. Intrinsic urethral deficiency. Surgically difficult pelvis/medically unfit, vaginal scarring. Intractable recurrent urethral sphincter incompetence Short hospital stay, rapid recovery. Bladder trauma 4%, voiding difficulty 10%, similar efficacy for colposuspension.

INCONTINENCE TREATMENT SURGICAL PROS: Previous surgery - subjective and objective results Procedure % continent Marshall-Marchetti-Kranz 84.5 Colposuspension 84.0 Bladder sling 83.4 All bladder neck suspensions 76.5 Bladder buttress 58.6 Most failures apparent immediately

CON’S Significant potential for severe long term voiding problems post op - (less than 5%) De novo detrusor instability (7-27%) Erosion of synthetic materials 3% Lower urinary tract damage 3% Infection

CONCLUSION: Urinary incontinence is a common problem, causes distress to a large no of female population. Current diagnosis and management involves good understanding of the condition and use of UD prior to continence surgery. Therapy for DI is often long term and requires pt explanation of pathology and mode of action &S/E of drugs used. In future, further understanding of pathophysiology of condition may lead to further advances.