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

3. 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.

4. 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.

5. 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

6. 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 .

7. 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.

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

9. 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.

10. 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.

12. 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

13. Symptom GSI Detrusor
(%) Instability
Frequency
Nocturia
Urgency
Urge Incontinence
Stress Incontinence

14. 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

15. 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%

16. 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

18. 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

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

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

21. 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

23. 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

24. 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

25. 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 , 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.

26. 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

27. 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

28. 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.

29. 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

30. 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

31. 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.