1. GENUINE STRESS INCONTINENCE PRESENTER:DR SWETA SINGH MODERATOR:DR DEEPA CHUDAL

3. DEFINATION GSI: Genuine stress incontinence is defined,according to the international continence society(ICS)as involuntary urethral loss of urine when the intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. INCIDENCE:40% in association with prolapse.

4. ETIOPATHOGENESIS GSI is anatomic problem. Urethral sphincter incompetence is principally due to 1.Hypermobility of urethra due to distortion of normal urethravesical anatomy –descent of the bladder neck and proximal urethra which normally lies above the urogenital diaghram hinders rise of intraurethral pressure during straining 2.Lowered urethral pressure at rest below the intravesical pressure

5. RISK FACTORS Developmental weakness of supporting structures. Childbirth trauma Pregnancy Postmenopausal Trauma Following surgery Age: increasing Obesity(BMI≥30)

6. MORBID ANATOMIC CHANGES In GSI,the main defects are 1.Intrinsic sphincter dysfunction 2.Bladder base becomes flat and lies in line with the posterior wall of the proximal urethra GSI is the ultimate symptom of varying severity due to anatomic urethral hypermobility(80%) and / or intrinsic sphincter deficiency (20%)

7. DIFFERENTIAL DIAGNOSIS Stress incontinence Urge incontinence Detrusor instabilty

8. DIFFERENCE IN CLINICAL PRESENTATION Stress incontinenceUrge incontinenceDetrusor instability Leakage of urine coincides with stress Unable to control the escape of urine, once there is urge to void The incontinence may occur abruptly even without a full bladder No prior urge to void Amount – SmallAmount – Large Patient – Fully aware of itPatient – Aware of the urgePatient – Not aware of it Micturition – NormalUrgency and frequencyFrequency and nocturia

9. DIAGNOSIS OF GSI: Clinical stress test Pad test – Positive Midstream urine analysis – Normal Urinary diary (volume frequency chart ) Uroflowmetry-normal Cytometry-normal Significant lowering of urethral closure pressure during strain Leak point pressure-positive Cystourethroscopy – negative findings Videocystourethrography-bladder neck funneling Transvaginal endosonography-altered anatomical relationship (descent) of urethrovesical junction and bladder base.

10. NORMAL FINDINGS IN CYSTOMETRY Residual volume : 0-50ml First sensation of urnation:150-200ml Capacity:400-600ml Intravesical pressure on filling and standing:0-15cm of H2O. Absence of systolic detrusor contraction No leakage on coughing Able to interrupt the urine flow on command Maximum detrusor pressure during voiding<50cm of H2O Peak urinary flow rate>15 ml/sec

11. GRADES OF GSI Grade I : Incontinence on cough or sneeze Grade II: With mild exercise Grade III: Even with change of posture