1. Detrusor instability

2. This is defined as a bladder which contracts uninhibitedly spontaneously during the filling phase,if there is evidence of neuropathy it is called hyper-reflexia. The symptoms include urgency,urge incontinence,frequency,nocturia,stress incontinence,enuresis & sometimes voiding difficulties. It can only be diagnosed on cystometry.

3. management It can be treated by bladder retraining,biofeedback or hypnosis to increase the interval between voids& inhibit symptoms of urgency. This is together with Anticholinergic drugs such as pro-banthine oxybutynin or imipramine.

5. Retention with overflow

6. Insidious failure of bladder emptying may lead to chronic retention & finally when normal voiding is ineffective,to overflow incontinance. Causes Lower motor neurone or upper motor neurone lesions Urethral obstruction Pharmacological Chronic bladder distention

7. symptoms The patient may be present with increasing difficulty in bladder emptying or with frequency ultimately normal emptying stops &stage of chronic retention with overflow develops Poor stream,incomplete bladder emptying & straining to void,together with stress incontinence

8. diagnosis *Cystometry is required to make the diagnosis *renal ultrasonography is required to indicate the state of upper tract. Treatment To facilitate bladder emptying by the use of clean intermittent self –catheterization or an indwelling suprapubic or urethral catheter.

10. Voiding difficulties

11. The underlying mechanism is either failure of detrusor contraction & sphincteric relaxation or urethral obstruction due to causes such as impacted retroverted gravid uterus.

12. Symptoms Poor stream Incomplete emptying Straining to void Frequency occurs due to increase in amount of residual urine Incontinence may follow when chronic retention& overflow develop Symptoms of urinary infection due to infection of residual urine.

13. On clinical examination A full bladder may be palpated & there may be the primary signs of the cause of voiding difficulty. Investigations Uroflowmetry,cystometry& lumbosacral spine X_ray.

14. Management Includes relieving voiding difficulty& treating the cause. Urinary catheterization for retention Drugs that aids detrusor contraction or relax urethral sphincter which is relatively ineffective

15. Congenital causes

16. Epispadias Is congenital cause of incontinence which is due to faulty mid-line fusion of mesoderm results in a widened bladder neck,separation of symphysis pubis & imperfect sphincteric control. The patient complain of stress incontinence which is noticeable when standing up.

17. The physical appearance of epispadias is pathognomonic with reduction of pubic hair in the mid-line & separation of clitoris Plain X-ray of the pelvis will show symphysial separation. Management Urethral reconstruction or artificial urinary sphincter because conventional surgery is insufficient.

18. Extra urethral causes of incontinence

19. Congenital 1.Bladder exstrophy There is failure of mesodermal migration withbreak down of ectoderm & endoderm resulting in absence of anterior of anterior abdominal wall &anterior bladder wall. Extensive reconstructive surgery is necessary in the neonatal period.

20. 2-ectopic ureter May be single or bilateral &present with incontinence if the ectopic opening is outside the bladder as it may opened within the vagina or to the perineum Treatment By excision of the ectopic ureter & the upper pole of the kidney which it drains.

21. fistula A urinary fistula is abnormal opening between urinary tract& outside. Causes Obstructed labour with compression of the bladder between the presenting head &the bony wall of the pelvis. Gynaecological causes are associated with pelvic surgery & pelvic malignancy.

22. Vesicovaginal fistula

23. treatment It can be treated by primary closure or surgery delayed until tissue inflammation resolved The surgical technique involves isolation& removal of the fistula track,careful debridement,suture& closure of each layer separately & without tension.

24. Urinary diary

25. Diagram showing colposuspension. Diagram showing colposus pension.