1. Urinary Incontinence
Dr. Nedaa Bahkali
2012

2. Definitions:
Urinary incontinence is defined as involuntary leakage of urine.

3. Definitions: Stress urinary incontinence (SUI):
involuntary urine leakage on exertion or with sneezing or coughing.
Urge urinary incontinence:
women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay.
If urge urinary incontinence is objectively demonstrated by cystometric evaluation, the condition is known as detrusor overactivity (DO).

4. Definitions: Mixed urinary incontinence :
When both stress and urge components are present, it is called.

5. Epidemiology: Prevalence of 25 - 55 %.
Among women with urinary incontinence,
the most common condition is stress incontinence, which represents 29 to 75 %of cases.
Detrusor overactivity accounts for up to 33 % of incontinence cases.
whereas the remainder is attributable to mixed forms.

6. Anatomy and Physiology of Micturition

7. Anatomy and Physiology of Micturition
Detrusor muscle
External and Internal sphincter
Normal capacity cc
First urge to void 150cc

8. Anatomy and Physiology of Micturition

9. Anatomy and Physiology of Micturition

10. Anatomy and Physiology of Micturition
Storage Reflex

11. Anatomy and Physiology of Micturition
Micturition Reflex

12. Risks for Urinary Incontinence:
Age
Pregnancy
Childbirth
Menopause
Hysterectomy
Obesity
Chronically increased abdominal pressure
  Chronic cough
  Constipation
  Occupational risk
Smoking

13. Continence Theories
Pressure Transmission
Urethral Support

14. Pressure Transmission
In an ideally supported urogenital tract, increases in intra-abdominal pressure are equally transmitted to the bladder, bladder base, and urethra.
In women who are continent, increases in downward-directed pressure from cough, laugh, sneeze, and Valsalva maneuver are countered by supportive tissue tone provided by the levator ani muscle and vaginal connective tissue .

15. Pressure Transmission
In those with a weakened supportive "backboard", however, downward forces are not countered.
This leads to funneling of the urethrovesical junction, a patent urethra, and in turn, urine leakage.

16. Pressure Transmission

17. Urethral Support Urethral support is integral to continenc
(1) ligaments along the lateral aspects of the urethra, termed the pubourethral ligaments;
(2) the vagina and its lateral fascial condensation;
(3) the arcus tendinous fascia pelvic;
(4) levator ani muscles .
With loss of urethral support, the urethra's ability to close against a firm supportive backboard is diminished.

18. Urethral Support

19. Urethral Support

20. Urethral Support

21. Diagnosis History : Voiding Diary
Duration, severity, symptoms, previous treatment,(Urinary Frequency, Urinary Retention, volume of urine lost , Postvoid dribbling is classically associated with urethral diverticulum)
medications, Past medical hx, GU surgery, Ob hx
Voiding Diary

22. Symptom Comparison of Women with Stress or Urge Incontinence
Stress Incontinence
Symptom No
Yes
Urgency
Frequency with urgency
Urine leakage with increased intra-abdominal pressures
small
Large
Amount of urinary leakage with each incontinence episode
Often No
Ability to reach the toilet in time following an urge to void
Seldom
Usually
Waking to void at night

23. Medications That May Cause Incontinence
Diuretics
Anticholinergics - antihistamines, antipsychotics, antidepressants
Seditives/hypnotics
Alcohol
Narcotics
α-adrenergic agonists/antagnists
Calcium channel blockers

24. Physical Examination General Inspection and Neurologic Evaluation
evidence of atrophy.
neurologic evaluation of the perineum:
bulbocavernosus reflex
normal circumferential anal sphincter contraction, colloquially called an "anal wink",

25. Pelvic Support Assessment
Pelvic Organ Prolapse Evaluation

26. Pelvic Support Assessment
Q-Tip Test

27. Diagnostic Testing Urinalysis and Culture Postvoid Residual
Cystometrics
Uroflowmetry

28. Treatment,,

29. Treatment Options Conservative/Nonsurgical:
Pelvic Floor Strengthening Exercises
Pelvic Floor Muscle Training (PFMT)

30. Electrical Stimulation
Biofeedback Therapy
Dietary
Scheduled Voiding
Estrogen Replacement

31. Treatment of Stress Urinary Incontinence

32. Treatment of Stress Urinary Incontinence
Medications:
Pharmaceutical treatment plays a minor role in the treatment of women with SUI.
imipramine is reasonable to aid urethral contraction and closure.
Recently, duloxetine a selective serotonin and norepinephrine reuptake inhibitor, has been evaluated for the treatment of SUI

33. Pessaries

34. Surgical Treatment of Intrinsic Sphincteric Deficiency
Periurethral Bulking Agents

35. Surgical Treatment of Anatomic Stress Incontinence
Retropubic Urethropexy
Pubovaginal Slings
Midurethral Slings

36. Treatment of Urge Urinary Incontinence

37. Treatment of Urge Incontinence
Antimuscarinics: tertiary amines that act to block the muscarinic receptors in response to acetocholine
First line
Oxybutinin (Ditropan)
Tolteridine (Detrol)