1. Urinary incontinence

2. Urinary incontinence is the involuntary loss of urine that is objectively demonstrated with social and hygienic problem.
it result from failure to store the urine during filling phase of bladder due to abnormality of the bladder smooth muscle or the urethral sphincter

3. Classification of incontinence.
Anatomic or genuine urinary stress incont.
Urge incont.
Neuropathic incont.
Congenial incont.
Overflow incont.
Iatrogenic incont.
Fistulous incont.

4. Stress incontinence
is an involuntary loss of urine that occurs during increase intera abdominal pressure like during coughing sneezing
Bet 15-30% of women over age of 65 have incont. Mostly of stress type
30-50%of women with stress incont.have ergency frequency and /or urge incont .so called mixed incont
Causes
. Classic or genuine stress incont. Is caused by urethral hyper mobility or displacement of the urethra and bladder neck from their normal anatomical position

5. It can occur as result of intrinsic sphinctor deficiency like due to surgery,estrogen deficincy ,truma
Anatomy
The anatomic feaure is hypermobility or a lowering of the position of the VU segment
Normally movement of VU junction is about 2cm so intra abdominal pressure diffuse on both bladder and urethra ,but in incontinence there is hypermobility causing movement accede 2 cm and bladder descend more and pressure will press on bladder only
angle of inclination is more than 30
Posterior VU angle change

6. Risk Factors
Gender ; women more than men in men usually post prostatectomy and transit
Genetic
Race ,culture and enverment white > blacks
Overweight
Pregnancy and childbirth it most important due to baby weight, relaxing hormon,viginal delivery causing stretching of pelvic floor nerves,tear or episitomy had 3 time increasing risk
Smoking :due to chronic cough
Age :weeking of muscle making elderly people susceptible to stress incontinence

7. 8.Medication: like alpha blocker
Diagnostic evaluation
Causes of transit incontinence should role out due to it treatable
Drug side effects
Delirium or hypoxia
Impaired mobility
UTI
Atrophic vigintis
Stool impiction
Evaluation
History
Examination

8. Urinalysis
Post void urine volume
Micturition diary
Pad test
Urodynamic evaluation
History :
Assess characteristic,severty and impact on life
Assess risk factores and/or transit causes
Examination
Neurological exam :like gait,lumbosacral nerve root assess
Abdomenal and flank for destintation

9. Rectal exam :for prostate and anal tone.
Cough test bladder full in lithotomy position pat. Ask to cough to reproduce incont.
The Q-Tip test: assess the degree of urethral mobility straining angle more than 30
Vaginal exam anterior vaginal wall (cystocele)
posterior vaginal wall (enterocele)
Pelvic floor strength (urethra and trigone are estrogens dependent
Urinalysis: for UTI
Residual urine volume: normally less than 50ml
Maturation Diary :Including time of maturation. time and type of incont .and voided volume

10. Pad Test
A semi objective measurement of urine loss over a given period of time
Weight gain sanitary towel of up to 8 gram is normal
Urethral pressure profilometery
Changes are
Low urethral closure pressure
Shorting of functional segment of urethra
Week response to stress
Fall in closure pressure in upright position

11. Treatment
Non surgical treatment
Alpha agonist
Oestrogen
Behaviour modification
Pelvic floor exercises
Biofeedback
Electrical stimulation
Surgical treatment
Urethral hypermobility then we do suspension of the bladder neck and proximal urethra through
Reteropubic suspension (marshall-marchetti-krantz and burch colposuspension

12. 2. Transvaginal suspension
Intrinsic sphenictor defect
Pubovaginal sling (TVT,TOT)
Periurethral injections
Sphincter prostheses
Urge Incontinence
Itis involuntary urine leakage accompanied by or immediately preceded by sudden strong desire to void
The basic feature is detrusor instability and urine loss while attempting to inhibit maturation
There is overactive bladder with frequency ,ergency,and nocturia

13. over activity can result from bladder inflamination obstruction or neurololgical trauma
Any thing increase intravasical pressure lead to urge incontinency
Urodynamic feeatures
normal or high closure pressure
Normal response to stress and filling
Detrusor hyperirritability
Treatment
Bladder training
Decrease fluid intake Intravesical botulinun toxin
Scheduled voiding Surgery

14. Neuropathic incontinence
Active found in patients who have spastic lesion but in whom the sphincteric mechanism, still exerts adequate closure pressure.
Active incontinence is most often associated with
suprasegmental or upper motor neuron lesion .
Passive neuropathic incontinence
occurs when the sphincteric mechanism is weakened or completely lacking.
Passive incontinence is most often associated with lesion involving the micturition center or more distal lesion.

15. Classfication
A –failure of reservoir function
can be caused by poor compliance of the urinary bladder.
Intravesical pressure raised with minimal bladder filling exceeding the outlet resistance & causing urinary leakage.
B –failure of retention function (arflxia)
total loss of smooth & striated sphincteric activity due to complete lesion of the sacral segment or cauda equina.
The external sphincter offer minimal resistance.
The bladder musculature is atonic & lax

16. Diagnosis.
A complete urologic & neurologic evaluation should be done to determine whether the condition arise from detrusor or sphincteric dysfunction.
History, physical examination, excretory urography, cystourethrography, & urodynamic study are recommended.
One must be alert to the possibility of overlapping causes. .

17. Treatment.
conservative management
1- failure of reservoir function.
Anticholinergic drugs like oxybutynin
Tricyclic antidepresent like Imipramine
Antihistaminic drugs
2-Failure of retention mechanism.
Clean intermittent catheterization
Drug less effective like alpha agonist.
surgical management.
1- sphincterotomy diversion
2- Bladder augmentation Neurostimulation
3- Artificial sphincter. .