1. URINARY INCONTINENCE DR. UGWU, E.O.V. MBBS,MPH,FWACS,FMCOG

2. URINARY INCONTINENCE Definition Epidemiology Pathophysiology Classification Genuine stress incontinence Detrusor instability

3. Urinary incontinence UI is defined as an involuntary loss of urine (which is a social or hygienic problem) that is objectively demonstrable Epidemiology: Commoner in whites Incidence about 20-30% of adult female population Incidence increases with age Post menopausal estrogen deficiency implicated Usually assoc with pelvic relaxation in developed countries eg POP In developing countries, assoc with childbirth commonly Twice commoner in women than men

4. Pathophysiology of UI Normally, urine leaves bladder via urethra when IVP exceeds the MUP. In UI not due to fistula, the IVP easily exceeds MUP because of defective urethral sphincter mechanism as in GSI or because of excessively high detrusor pressure as in DI

5. Classification of UI Genuine stress incontinence(GSI) Urge incontinence [Detrusor instability (DI)] Overflow incontinence (Retention/overflow) Mixed incontinence (GSI & DI) Transient incontinence Fistulous incontinence (VVF)

6. Genuine stress incontinence (GI) Defined as the involuntary loss of urine when the IVP exceeds the MUP in the absence of dextrusor activity. Pathophysiology: Normally, the bladder neck & the proximal urethra are situated intra-abdominally above the PF & are supported by PUL. Damage to PF &/or PUL may result in decent of the BN & PU In such situations, IAP increases affects only the detrusor part of the bladder but not the BN & PU. Consequently, the IVP then exceeds MUP & urine leaks.

7. Causes of GSI POP (UV-prolapse) Pregnancy/Parturition Pelvic surgery Menopause Vaginal/urethral surgery Incontinence surgery Recurrent urethral infection Radiotherapy Chronic cough Intra-abd/pelvic mass Ascitis Congenital eg bladder exstrophy, ectopic ureter, etc

8. Clinical presentation of GSI Involuntary leakage of urine when px coughs, laughs, or exercises. Frequency & urge incontinence may be assoc. Demonstrable on clinical exam with px in dorsal position & asked to cough…leakage of urine (95% predictive of GSI)

9. INVESTIGATIONS Mid stream urine m/c/s Urinary diary Pad test…urine loss of more than 1gm per hr is considered significant. Urodynamic studies, including  Simple cystometry  Subtracted cystometry  Uroflometry  Videocystourethrography (VCU) Others, including  IVU  Utrasound  MRI  Cystourethroscopy  Urethral pressure profilometry  Ambulatory monitoring

10. Treatment of GSI Simple measures : sufficient for most mild cases of GSI and other UI. Includes the following:  Exclusion of UTI  Restriction of fluid intake  Treating chronic cough & constipation  Modifying medications eg diuretics Conservative treatment: indicated for mild GSI or when px with severe GSI is medically unfit for surgery or does not wish to undergo surgery, and in those who have not yet completed their families. It includes the following:  Physiotherapy (Kegel pelvic floor exercise)….40-60% success rate in mild GSI  Perineometry  Vaginal cones  Maximal electrical stimulation  Faradism  Inferential therapy  Incontinence devices

11. Treatment of GSI continues Surgery : Very useful for severe cases and the most effective way of curing GSI. Cure rate of ≥ 90% possible for primary surgery. Aims of surgery are to restore intra-abd position of the BN & PU, Increase urethral resistance, or both. Surgical procedures include the following:  Vaginal procedures  Anterior colporrhaphy with kelly/pacey sutures  Tension free vaginal tape placement (TVTP)  Abdominal procedures  Marshal-Marchetti-Krantz procedure  Burch colposuspension…….associated with the highest success rate (95%)  Laparoscopic methods  Laparoscopic colposuspension  Combination methods  Sling  Endoscopic bladder neck suspension by Stamey & Raz  Complex procedures eg Neourethra construction, artificial sphincter, urinary diversion, periurethral bulking with collagen,etc.

12. Prevention of GSI Avoid prolonged second stage of labor Avoid traumatic delivery Use of HRT for postmenopausal women Pelvic floor exercise

13. Dextrusor instability & overactivity Dextrusor overactivity (DO) refers to presence of spontaneous or provoked detrusor contractions during the filling phase of the bladder even when the patient is attempting to inhibit micturiction. When above occurs as a result of known UMN lesion, it is referred to as detrusor hyperreflexia (DH). When there is no neuropathy, it is referred to as dextrusor instability (DI). Both DH & DI are referred to as DO

14. Epidemiology of DO Aetiology usually unknown Commoner in elderly Usually follows failed incontinence surgery Emotional /psychosomatic factors often involved In some cases, may be secondary to UMNL eg multiple sclerosis Outflow obstruction sometimes implicated Diagnosis should be suspected in px with multiplicity of symptoms including SI, UI,enuresis, freguency, nocturia esp during coitus, etc. Diagnosis confirmed by urodynamic studies (failure to inhibit detrusor contraction during cystometry).

15. Treatment of DO Behavioral therapy: Obj. is bladder training via timed voiding to re-establish cortical control of micturiction. DH does not respond to behavioral therapy. Drug therapy  Anticholinergics eg oxybutynin,hyoscyamine,tolterodine,etc Combination of BT & drugs (best treatment) Surgery: reserved for severe intractable DO not responding to BT & DT.  ‘Clam’ iliocystoplasty …operation of choice.

16. Fistulous incontinence Urinary fistula is an abnormal opening b/w the UT & another structure. A typical e.g. VVF Obstetric causes; mainly obstructed labor. Gynecological causes; mainly pelvic surgery, pelvic malignancy & radiotherapy. Treatment mainly by surgical repair of the fistula.

17. Question Urinary incontinence is a major public health problem affecting the quality of life of the affected women with resultant psychological loss of self esteem. Discuss the strategies available for reducing the incidence and morbidities associated with this condition.

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