1. Female Urology & Incontinence in Women
Dr Sanjay Garg
Senior Consultant Urology
Dr Vijayant G Gupta
Asso Consultant Urology

2. Urinary incontinence in the female
Involuntary loss of urine which is objectively demonstrable & is a social or hygienic problem.
Stress incontinence: Involuntary expulsion of urine under conditions of stress like rise of intra-abdominal pressure due to coughing, sneezing , laughing or lifting weights.

3. Types True incontinence – Continuous Leakage
Urge incontinence- it is associated with strong desire to void
Stress incontinence-leaking on stress
Overflow incontinence-It is sequel of prolonged and neglected retention

4. Prevalence of Problem Upto 57% in women 45-64 yrs.
14% in general population.
Common condition, but rarely life threatening
Adverse effect on quality of life
Embarrassment and anxiety.

5. Definition of SUI
Stress urinary incontinence (SUI) is defined by the international continence society (ICS) as the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.

6. Causes of urinary incontinence
Genuine stress incontinence
Urinary loss which occurs with sudden elevation of the intra abdominal pressure without detrusor contraction
Detrusor instability
Retention with overflow incontinence
Urogenital fistula
Urethral diverticulum

7. Grading of SUI Grade 0 Incontinence without leakage Grade 1
Incontinence with only severe stress, such as coughing, sneezing, and jogging
Grade 2
Incontinence with moderate stress, such as fast walk, going up and down the stairs
Grade 3
Incontinence with mild stress such as standing

8. Etiology Age Multiparty Obesity Smoking Prolapse Constipation
Pregnancy and puerperium
Athletes

9. Investigations Uroflowmetry- 15-25ml/sec
Advanced
Uroflowmetry ml/sec
Cystometry
Urethral pressure profilometry
Cystourethroscopy
Micturition cystography
General
Urine- Routine/microscopy, c/s
Frequency/volume chart or urinary diary.
Pad test.

10. Stress Test
Excellent method of demonstrating objectively the presence of SUI
Steps
Catheterisation
Urine sample is sent for culture
250 ml warm saline instilled into the bladder
Leakage noted in sitting and supine position
Net weight gain of 2g or more is indicative of GSI

12. Bonneyʼs test Bonney test
Absence of leakage of urine following bladder neck elevation is indicative of beneficial outcomefollowing surgical repair

13. Management Conservative Fluid intake and voiding habits Weight loss
Physiotherapy
Reduce caffein intake and smoking
Drugs - Dapoxetine
Intraurethral and vaginal devices
Electric stimulation
Surgical

14. Fluid Management Fluid intake and voiding habits
Trials have been demonstrated that increase in fluid intake increases the episodes of incontinence thus decreasing the fluid intake is helpful in for patient with high fluid consumption
Voiding prior to strenous activity beneficial in mild SUI

15. Pelvic Floor Exercises
Kegel described the PFM exercises in 1948 for female UI
Reported success rate is more than 80%
Offer a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment to women with stress or mixed UI. [2006]
Pelvic floor muscle training should comprise at least 8 contractions performed 3 times per day for 3-6 month. [2006]

16. Weight loss
Several studies shows association between obesity and development of incontinence a study examining women who had lost weight as a result of bariatric surgery found that there was significant decrease in both subjective and objective SUI and UUI

17. SNRI Duloxetine Promising Drug – Increases Bladder Neck Tone
One study conduct in north america showed incontinence episodes decreased by 50% in duloxetine group versus 27% in placebo group

18. Anti Cholinergic Roliten/Solifine
Reduces Bladder Contraction/Increases Capacity

19. Electric Stimulation Electric stimulation
Tried if SUI is caused by denervation of pudendal nerve during delivery
Useful in women with weak pelvic floor muscles

22. Surgery Suspension Procedures (For Hypermobile Bladder Neck)
Burch Colposuspension
Retropubic Slings – Artifical Mesh or Rectus Sheath
Slings
Mid Urethral Slings (Gold Standard)
Artificial Urinary Sphincters

23. Sling

24. Complications of Surgery
Injury to bladder
Mesh Infection/ Migration
Hyper Continence – Urine Retention
Bleeding/ Injury to Iliacs
Nerve Injuries – Chronic Neuralgia

25. Take Home Message
Stress Urinary Incontinence is a major problem in the women of India
It is underidentified and undertreated
Cause of Major Embarrassment and Poor Quality of life in women

26. Effective long term treatment of this problem exists
Involve your Urologist colleagues in the management of these problems
Thank You