Urinary Incontinence

Ahmad Hafiz bin Ahmad Shafruddin Bangalore Baptist Hospital May 2012

Subtopics

Anatomy of Bladder & Urethra Urinary Incontinence

Stress Urinary Incontinence Urge Incontinence Mixed Incontinence Functional and Transient Incontinence

Anatomy of Bladder and Urethra

Urinary Bladder

Mucosa Transitional epithelium Detrusor muscle - outer longitudinal, middle circular &
inner longitudinal Serosa Covers anterior and superior surface

Urethra

Inner Mucosa Proximal Transitional epithelium Distal Stratified squamous epithelium Outer Muscle Layer

Inner smooth muscle - Intrinsic sphincter Outer circular striated muscle Extrinsic sphincter Upper two-third Sphincter urethrae rhabdosphincter for urethral closure Lower one-third Levator ani additional force

Innervation

gambar

Stress Urinary Incontinence

Urinary Incontinence: complaint of involuntary leakage of urine Stress Urinary Incontinence: complaint of involuntary leakage of urine with increased intra-abdominal pressure in the absence of detrusor contraction Most common Pathogenesis

Urethral hypermobility damage to supports Intrinsic sphincter deficiency urethra damaged

Urethral Hypermobility

Intra-abdominal pressure weak support of levator ani & vaginal connective tissue to counter funneling gambar

Intrinsic Sphincter Deficiency

Integrity maintained by

Epithelium Subepithelial vascular plexus Muscular layer Prior surgery Trauma of delivery denervation & scarring lead pipe or rigid urethra Ineffective closure leakage

Damage

Risk Factors

Age Multiparity Vaginal Delivery Obesity Menopause Chronic increase in intra-abdominal pressure Smoking Previous surgery

Clinical Evaluation

History

Age Parity Obstetric History Menopausal Status Urine leakage

Duration Frequency Quantity Provocative factors

Is it a social problem?

Physical Examination

General Examination

Height, weight, BMI RS Neurological system Mass arising from the pelvis Excoriation of vulva Prolapse

Abdominal examination

External Genitalia

Speculum Examination

Investigations
Simple Tests Urine Microscopy and culture Q-tip test Postvoid residual urine measurement Office cystometry Voiding diary Stress test Exclude UTI Assess urethral hypermobility Exclude overdistended bladder Exclude overactive bladder Assess urinary output/frequency Assess urethral hypermobility

Q-tip test

gambar

Urodynamic Study Cystometry simple/multichannel Stress Incontinence Detrusor overactivity Bladder capacity Urethral function Voiding dysfunction Stress incontince Detrusor overactivity Bladder capacity Urethral closure Intrinsic sphincter deficiency Evaluate bladder

Uroflowmetry Cystometrography

Test of urethral function - Urethral pressure profilometry - Valsalva leak point pressure Cystourethroscopy

Management

Lifestyle Modification weight reduction, cessation of smoking Non-surgical Treatment

Kegel's exercise Pessaries and urethral devices Medication imipramine, oestrogen, SSRI Vaginal Abdominal Laparoscopic

Surgical Management

Vaginal Procedure

Anterior colporraphy + Kelly's stitch

In cystocoele also Plication of pubovesicocervical fascia Transverse stitches at the level of bladder neck Elevation of bladder neck

Tension-free vaginal tape (TVT) procedure

Most common, can be combined with surgery for POP

Trans-obturator tape (TOT) procedure

Abdominal & Laparoscopic Procedures

Marshall-Marchetti-Krantz procedure Burch colposuspension Laparoscopic colposuspension

Combined procedures
Traditional sling procedure Endoscopic bladder neck suspension Proximal urethra and bladder neck to abdominal wall Bladder neck to rectus sheath

Management of Intrinsic Sphincter Deficiency

Periurethral injection of bulking agents like bovine collagen

Urge Incontinence

Definition

Involuntary leakage or urine accompanied by or immediately preceded by urgency Urgency: Sudden, strong desire to pass urine that is difficult to defer Frequency: more than 8 voids per day

Overactive bladder syndrome

Symptoms of urgency with or without urge incontinence, usually with frequency and nocturia Detrusor activity, dx made after urodynamic testing Other causes: neurological, psychogenic, idiopathic

Management

Bladder drill void 30-60min, distration method, kegel Biofeedback behavioural therapy (visual, auditory or verbal feedback during muscle training) Medications anticholinergic

Oxybutynin Hyoscyamine Dicyclomine

Intravesical Theraypy Capsaicin, botulinum toxin, resiniferatoxin. Lasts months

Mixed Incontinence

Both stress & urge Managed medically for detrusor overactivity If repeat urodynamic study shows stress incontince surgical intervention

Functional & Transient Incontinece

Occurs due to causes unrelated to physiological voiding mechanisms DIAPPERS

Delirium Infection Atrophy Pharmacological Psychological Endocrinopathy Restricted mobility Stool impaction