Post on 31-May-2015
Urinary Incontinence
• Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.
• Affects physical, psychological, social well being → Reduce quality of life
• Prevalence, ↑ with age • Common in institutionalized women, those in
residential nursing homes
Some definitions…• Stress incontinence is loss of urine on physical
effort• Urge Incontinence is an involuntary loss of urine
associated with a strong desire to void.• Overflow Incontinence occurs without any
detrusor effort when the bladder is over-distended.
• Urgency is a sudden desire to void• Frequency is passing of urine seven or more/day
or being awoken from sleep more than once a night to void.
Classification of IncontinenceURETHRAL CAUSES• Urethral Sphincter
Incompetence (Urodynamic stress Incontinence)
• Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic)
• Retention with overflow• Congenital causes• Miscellaneous
EXTRA URETHRAL CAUSES
• Congenital causes• Fistula
1. URETHRAL CAUSES
1a : Urodynamic Stress Incontinence
• Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction.
• Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ±
• Examination: Stress incontinence when cough, look for prolapse, cystourethrocelesAlso asses her vaginal capacity and her ability to elevate
bladder neck.• Urodynamic studies will define cause of
incontinence
• Causes of USI– Damage to nerve supply of pelvic floor and urethral
sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries)
– Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince
– Congenital cause (nulliparous women) – Connective tissue disorder esp collagen
– Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation
1b: Detrusor Over-activity
• Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked.
• Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties
• Examination: Any mass that may compress bladder, prolapse TRO
• Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw
1c: Retention with overflow• Insidious failure of bladder empting may lead to
chronic retention and finally, when normal voiding is ineffective, to overflow incontinence
• Caused by: LMN/UMN lesions, urethral obstructions, pharmacological
• Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence
• Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux
1d: Congenital
• Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence
• Rx with urethral reconstruction or artificial urinary sphincter
2. EXTRA URETHRAL CAUSES
2A: Congenital
• Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period
• Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains
2B: FISTULA
• Abnormal opening between the urinary track and outside.
• Obstetric cause: Obstructive labour with compression of bladder between presenting head and bony pelvis
• Gynecological cause: AW pelvic surgery, radiotherapy, pelvic malignancy
• Treated by primary closure or surgery
INVESTIGATIONS
• Urine C&S- tro Infections• Pad test• Measure Postvoidal Residual Volume by
bladder ultrasound or urethral catheter >100mL in more than one occasion→+
• Cough Stress Test. 250mL into bladder• Abdominal leak point pressure
• Urodynamic studies– Uroflowmetry. Bladder outlet obstruction– Cystometry. Detrusor activity, differentiate involuntary
detrusor contraction or increase intraabdominal pressure
• Cystogram– Stress incontinence, Cystocele, Sphincter activity,
fistula
• Cystoscopy– Tumors, stones
Treatment• Palliative – Fluid restriction, Protective perineal
pads, Bladder retraining, Pelvic Floor exercise (Kegel)
• Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms
• Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance
Colposuspension Operation, Artificial Sphincter