Fifth stage
Gynecology
Lec-5
د.داليا
10/4/2017
Urinary incontinence
urinary incontinence:
• Is defined as the involuntary loss of urine that is objectively
demonstrable and is a social or hygienic problem.
• It increases with age <45 it 5% >45years old it 10% >65 yrs old it
20%
Common symptoms associated with incontinence:
• Stress incontinence is a symptom and a sign and means loss of
urine on physical effort. It is not a diagnosis.
• Urgency means a sudden desire to void.
• Urge incontinence is an involuntary loss of urine associated with a
strong desire to void.
• Overflow incontinence occurs without any detrusor activity when
the bladder is over distended.
• Frequency is defined as the passing of urine seven or more times
a day, or being awoken from sleep more than once a night to void.
• In addition, women may also have complaints of prolapse, sexual
dysfunction due to leakage and coexisting anal incontinence.
Classification of incontinence:
Urethral causes:
1 –
urethral sphincter incompetence (urodynamic stress
incontinence)
2-Detrusor overactivity or the unstable bladder- this is either
neurogenic or non neurogenic
3- retention with overflow
4- Congenital causes
5- Miscellaneous
Extra urethral causes:
1- congenital causes
2- fistula
Urethral causes (urodynamic stress incontinence):
• USI, is defined as the involuntary leakage of urine during
increased abdominal pressure in the absence of a
detrusor contraction
• Previously called genuine stress incontinence, is noted
during filling cystometry.
Symptoms:
• Stress incontinence is the usual symptom, but urgency ,
frequency and urge incontinence may be present.
• There may also be an awareness of prolapse.
• On clinical examination, it may be demonstrated when the
patient coughs.
Aetiology of USI:
• Damage to the nerve supply of the pelvic floor and urethral
sphincter caused by child birth leads to progressive changes in
these structures resulting in altered function.
• Menopause and associated tissue atrophy
• Congenital cause in some nulliparous due to altered connective
tissue
• Chronic cause such as obesity and chronic obstructive pulmonary
disease and constipation
Understanding the pathophysiology of USI
1- Abnormal descent of the bladder neck and proximal urethra, so
there is failure of equal transmission of intra-abdominal pressure
to the proximal urethra, leading to reversal of the normal pressure
gradient between the bladder and urethra, with a resultant
negative urethral closure pressure.
2- an intraurethral pressure which at rest is lower than the
intravesical pressure, this may be due to urethral scarring as a
result of surgery or radiotherapy .it also occurs in older women
due to oestrogen deficiency.
3- laxity of suburethral support normally provided by the vaginal
wall, endopelvic fascia, arcus tendineus fascia and levator ani
muscles acting as a single unit results in ineffective compression
during physical stress and consequent incontinence.
Detrusor overactivity:
• Previously called detrusor instability , is urodynamic observation
characterized by involuntary detrusor contractions during the
filling phase which may be spontaneous or provoked.
Symptoms of detrusor overactivity:
• The combination of urgency, frequency and nocturia is termed the
overactive bladder syndrome with or without urgency
incontinence, in the absence of urinary tract infection.
• Examination :any masses that cause compression of the bladder
must be excluded and prolapse must be examined for
• If there is vaginal atrophy ,this may also cause some urgency and
frequency.
Understanding the pathophysiology of detrusor overactivity:
• Poor toilet habit training and psychological factors . More recently
UTI may be a trigger.
• An idiopathic variety is more prevalent after the menopause.
Childhood enuresis increase the likelihood of overactive bladder
• Neuropathy appears as a factor
• Incontinence surgery, outflow obstruction and smoking are also
associated.
• Retention with overflow:
• Insidious failure of bladder empting may lead to chronic retention
and , finally ,when normal voiding is ineffective, to overflow
incontinence.
The causes may be :
• Lower motor neurone or upper motor lesions.
• Urethral obstruction
• pharmacological
• Symptoms of retention include poor stream, incomplete bladder
emptying and straining to void, together with overflow stress
incontinence.
• Cystometry is usually required to make the diagnosis and bladder
ultrasonography or intravenous urogram.
Congenital :
• Epispadias, which is due to faulty midline fusion of mesoderm,
results in a widened bladder neck, shortened urethra, separation
of the symphysis pubis and imperfect sphincteric control
Miscellaneous:
• Acute urinary tract infection or faecal impaction in the elderly may
lead to temporary incontinence.
Extraurethral causes of incontinence:
Congenital:
1- Bladder exstrophy and ectopic ureter:
There is failure of mesodermal migration with breakdown of
ectoderm and endoderm, resulting in absence of the
anterior abdominal wall and anterior bladder wall.
2- fistula: is an abnormal opening between the urinary tract
and the outside.
Investigations:
• Midstream urine specimen
• Urinary diary :is a simple record of patients fluid intake
and output .episodes of urgency and leakage and
precipitating events are also recorded for 3-5 consecutive
days.
• Pad test:Are used to verify and quantify urine loss .the
international continence society pad test takes 1 hour.
Patient wears a pre-weighed sanitary towel, drinks 500 ml
of water and rests for 15 min. after a series of defined
manoeuvres, the pad is reweighed; a urine loss of more
than 1g is considered significant.
Uroflowmetry:
• Is the measremement of urine flow rate and is a simple ,non –
invasive, outpatient test. The normal flow curve is bell shaped .a
flow rate <15 ml /second on more than one occasion is considered
abnormal in females
• The voided volume should be >150 ml , if smaller volumes the
flow rates are not reliable.
• A low peak rate and a prolonged voiding time suggest a voiding
disorder.
Cystometry:
• It involves the measurement of the pressure-volume relationship
of the bladder.it is the most fundamental investigation
• It involves simultaneous abdominal pressure recording in addition
to intravesical pressure monitoring during bladder filling and
voiding.
• Electronic subtraction of abdominal from intravesical pressure
enables determination of the detrusor pressure.
• Intravesical pressure is measured using catheter and other
catheter is inserted into the rectum to measure intra abdominal
pressure.
• During filling, the patient is asked to indicate her first and
maximal desire to void and these volumes are noted.
The parameters of normal bladder function:
• Residual urine of <50 ml
• First desire to void between 150 and 200ml
• Capacity between 400 and 600 ml
• Detrusor pressure rise of <15 cmH2O during filling and standing .
• Absence of systolic detrusor contractions.
• No leakage on coughing.
• A voiding detrusor pressure rise of <70 cmH2O with a peak flow
rate of >15 ml/second for a volume >150 ml.
• Videocystourethrography: if a radio-opaque filling medium is
used during cystometry, the lower urinary tract can be visualized
by x-ray screening with an image intensifier.
• Intravenous urography: little information but indicated in
hematuria ,neuropathic ,and fistula.
• Ultrasound: becoming more widely used in urogynaecology.
• Magnetic resonance imaging: produces anatomical pictures of
pelvic floor
• Cystourethroscopy: establishes the presence of disease in the
urethra or bladder.
• Urethral pressure profilometry: to maintain continence , the
urethral pressure must remain higher than the intravesical
pressure
• Ambulatory monitoring: fine microtip transducers are inserted
into the bladder and rectum
Treatment:
• Prevention
• Conservative management: physiotherapy is the mainstay of the
conservative treatment of stress incontinence.
• Surgery: the aims of surgery are:
-to provide suburethral support;
-restoration of the proximal urethra and bladder neck to the zone
of intra-abdominal pressure transmission;
-to increase urethral resistance;
-a combination of both.
• The colposuspention operation used to be considered the gold
standard for stress incontinence.
• Since the introduction of the tension-free vaginal tape(TVT)the
popularity of the colposuspension has waned.
• TVT procedure involved the placement of a polypropylene tape
under the midurethra through a single 1-2cm anterior vaginal
incision wall and two suprapubic 0.5cm incisions approximately 4-
5 cm apart.
• A needle introducer is passed either side of the urethra through
the vagina incision and passed through the retropubic space to
emerge through the ipsilateral suprapubic incision.
• Modifications of the TVT have involved a departure from the
retropubic approach to the external incisions being made lateral
to the labia over the obturator foramina bilaterally(TOT).
• Single incision tapes are evolving, and in this the tapes are
inserted through a vaginal incision and attached to either the
obturator internus muscle or into the obturator membrane.
• The artificial sphincter is used where conventional surgery has
failed.
• Periurethral bulking agent:contigen collagen is usually injected
paraurethrally and Macroplastique transurethrally
• Evidence-based medicine has shown TVT and colposuspension to
be the most widely practised and most effective operation for
stress incontinence.
• The anterior repair and endoscopic bladder neck suspensions are
not good operations in the medium or long term for this
condition.
• Detrusor overactivity can be treated by bladder retraining
biofeedback or hypnosis. Anticholinergic agents, such as
oxybutynin 2.5 mg twice daily or tolterodine 2 mg twice daily.
Sacral nerve stimulator offers another alternative
• Botulinum toxin injections under cystoscopic control into the
detrusor muscle are being used for women with DOA
