1. Dr. Abdullah Ahmad Ghazi (R5) KSMC 22/01/1433H

2.  Incontinence define: any involuntary loss of urine  Stress UI:  Urge UI:  Mixed UI:  Unconscious UI:  Continuous UI:  Nocturnal enuresis:  Postmicturation dribbling:  Overflow UI:  Extraurethral UI:

3.  W:M2:1  Prevelance 5-72%. ◦ Adult life 20-30% ◦ Middle age 30-40% ◦ Elderly 30-50% mixed ◦ Severe incontinence 6-11% ◦ Prevelance with pregnancy 31-60% stress

4.  Urethral hypermobility.  Intrinsic sphinctric deficiency.  Transient causes.  Neurological causes  Medication.

5.  Age  Parity  Rout of delivery  Obesity  Others; menopause, smoking, chronic cough & prior pelvic surgery.

6.  Delirium  Infection  Atrophic vaginitis  Psychological  Pharmacologic  Excess urine production  Restricted mobility  Stool impaction

7.  Characteristics  Severity  Impact on quality of life  Evaluate of risk factor  Transient causes  Acute/chronic  Neurological condition Hx of surgery Radiation Medication Hx bowel, sexual function, obstetric, menstrual & hormonal replacement therapy.

8.  Neurological: gait, speech, facial asymmetry.  Abdomin: hernia, palpable bladder.  Rectal: prostate.  Sacral: sphincter tone & control, genital sensation, bulbocavernosus reflex.  Pelvic Ex  Anterior/posterior vaginal wall  Pelvic floor strength.

9.  U/A  PVR  Voiding diary  Pad test  Dye test  UFM  UDS

10.  Bladder filling require: ◦ Accommodation of increase volume of urine at a low intravesical pressure ( N compliance) and appropriate sensation. ◦ A bladder outlet that closed at rest and remain closed in increase intraabdominal pressure. ◦ Absence of involuntry bladder contraction.

11.  Bladder empty require: ◦ A coordination of the bladder smooth musculature of adequate magnitude and duration. ◦ Lowering of resistance at the level of sphincter. ◦ Absence of anatomical obstruction

12.  Rehabilitative techniques: ◦ Behavior modification ◦ Pelvic floor muscle training ◦ Biofeedback ◦ Electrical stimulation

13.  Oral pharmacologic treatment ◦ Antimuscarinic agent ◦ Impiramine

14.  Intravesical/intradetrusor therapy: ◦ Oxybutynin ◦ Botulinum toxin

16.  Surgery: ◦ Sacral nerve neuromodulation  Effective non-neurogenic population, effective frequency/urgency & idiopathic AUR. ◦ Denervation procedures  Bladder transection & reattachment  Complete S2-S4 rhizotomy  Partial rhizotomy ◦ Subtrigonal phenal/alcohol injection. ◦ Augmentation cystoplasty. ◦ Autoaugmentation of the bladder. ◦ Diversion

17.  Rehabilitative technique.  Pharmacologic treatment ◦ A-adrenergic agent (ephedrine, …) ◦ Impramine ◦ Duloxetine ◦ Estrogens.

18.  Urethral bulking agents “collagen, silicon macropaticles”.  Surgery: ◦ Sling procedure “TVT, TOT” 80-94% ◦ Suspension procedures 83-84% ◦ Sphincter prosthesis Associated with prolapse

19.  120 pt.  F/U 12-30M  Age 31-86y (mean 58y)  70% pure SUI

20.  Results: ◦ Operative time: 12min ◦ Catheterization time 0.9day ◦ 13 minor lateral vaginal tear. ◦ 3 urethral, 1 bladder perforation (learning phase) ◦ 2 have AUR need SPC and tab release  80% completely dry  12% greatly improved  Global satisfaction 78%