URINARY INCONTINENCE :Objectives To outline different types of urinary incontinence-1 .

To enumerate the lines of treatment of urinary incontinence-2 :DEFINITION .It is involuntary loss of urine per urethra .N.B: this definition exclude urinary fistula :NORMAL URINARY CONTROL Bladder: low intravesical pressure during filling phase (1 .Urethra: a)-adequate sphincter activity (2 .b)-intra-abdominal position of urethra .C-mucosal factor .d)-length of urethra :ANATOMY OF BLADDER & URETHRAL SPHINCTER * .The bladder composed of single mesh like muscle layer called detrusor muscle:The urethral has two sphinctersa) Proximal sphincter (situated at bladder neck & composed only of smooth .(muscles :b) Distal sphincter (situated at the membranous urethra & it has two parts (Intrinsic (smooth muscle only -1 Extrinsic (skeletal muscle) which merge with pelvic floor -2 .muscle :NORMAL BLADDER & URETHRAL FUNCTION :The bladder has two functions.(a) Storage of urine (bladder act as reservoir .b) Evacuation of urine

:BLADDER & URETHRAL INNERVATION The bladder muscle has stretch receptors in between muscles cells connect toafferent parasympathetic nerve --- sacral spinal center S2,3,4 (situated behind

body of 1st lumbar vertebra) ---efferent parasympathetic nerve --- detrusor .muscle The urethral sphincter: 1-proximal: is supplied by the efferent sympathetic.fibers distal: intrinsic smooth muscle & extrinsic skeletal muscle-2 supplied by the pudendal nerve S2, 3, 4 The sacral micturation center is primitive & autonomous. After the age of 3years a higher center in the pons & cerebral cortex take the upper hand in urinary control. A sample of the impulses reaching the spinal center ascends in spinal cord white matter to these high centers. These high centers always send .inhibitory impulses to the sacral center during voiding

Vesical pressure Maximum urethral closure pressure Urethral sphincterPMG

Storage phase Low 0-10 cm.H2O High 80-100 cm.H2O contracted

Evacuation phase High 40-60 cm.H2O Low 0 cm.H2O relaxed

:INVESTIGATION .Urine analysis: pus cell cystitis -1 .CBC: anemia RF -2 .Renal function: inc. blood urea RF -3 .Radiological: plain X-ray & IVU -4 U/S -5 .Urodynamic study: flowmetry, cystometry, urethral pressure & RMG -6 :CLINICAL TYPES .A) True .B) False .C) Stress .D) Urge .E) Enuresis Type Bladder Urethral sphincter

True Overflow Stress Urge DIAGNOSIS

Empty, normal Full, atonic Normal Uninhibited contraction

.Both inactive .Normal + Obstruction Both are weak + Lax .pelvic floor Normal

.History: a) Trauma -1 (b) Operation (perineal prostatectomy, TURP .c) Obstetric .d) Drugs .Investigation -2 .Clinical picture -3 :TREATMENT :According to clinical type a) Neurogenic incontinence: - uninhibited bladder parasympatholytic .((probanthine,cetipren .atonic bladder parasympathomimetics b) True incontinence: - artificial sphincter Collagen injection .Corporal approximation .(All aim at urethral compression) .c) False incontinence: - congenital reconstruction of bladder neck & urethra d) Stress incontinence: - the objective is to restore the bladder neck & urethra into .the pelvic cavity :The operation is called Colposuspention Open surgery: Marshall Marquette (the para urethral - (1 tissue is sutured to back of the symposia & cooper's .ligament Needle suspension (2