Dr. H.

Amir Fauzi, SpOG(K)

LUT can be divided into:
1. The bladder: consists of
 the detrusor muscle
 covered by an adventitia and serosa over its dome,
 lined by a submucosa and transitional cell epithelium

2. Urethra:
 holds urine in the bladder  determine urinary continenceprimary factor responsible
for stress incontinence.
 > 50% of stress incontinence is directly attributable to max urethra closure pressure
 The urethra is a complex tubular viscus extending below

3. the vesical neck : at the junction

1. Bladder: muscle within the detrusor
2. Urethra: sphincter urethra, urethrovaginal sphincter, compressor
urethrae
3. Vesical neck: urogenital sphincter muscle
1. Pelvic Diaphragm: the urethral lumen traverses the bladder wall before
becoming surrounded by the urethral wall. It contains portions of the bladder
muscle, and also elements that continue into the urethra.
2. The pelvic floor relates to:
 Micturition
 Continence
 pelvic organ support: bladder and urethra depend upon attachments to the pelvic floor
for their shape and position
I. Outlet dysfunction: bladder outlet and pelvic floor
A. Underactive outlet (decreased urethral resistance)
Symptomatic: Stress urinary incontinence (SUI)
1. Anatomical support defects (SUI-A) (types I and II SUI): anatomical motion creates inequities in
transmission pressures to bladder and outlet, overcoming urethral resistance, and/or and conformational
changes caused by vaginal wall motion disrupt outlet integrity.
2. ISD (SUI-ISD) (type III) (LUCP): deficiency of the urethral closure mechanism secondary to decreased
innervation, vascularization or trauma to mucosa, submucosa or smooth, non-striated skeletal or skeletal
musculature of urethra–intrinsic deficiency of the closure mechanism.
3. Combined SUI (SUI-A-ISD): a degree of both anatomical motion and sphincter dysfunction.
4. Failure to inhibit the detrusor: decreased pelvic fl oor inhibitory activity of bladder (etiology for OAB–see
C): failure to contract pelvic floor releases detrusor reflex and decreases ability to inhibit active contraction.
B. Overactive outlet (increased urethral resistance)
Symptomatic: overflow incontinence/retention; frequency–urgency.
I. Outlet dysfunction: bladder outlet and pelvic floor
A. Underactive outlet (decreased urethral resistance)
B. Overactive outlet (increased urethral resistance): overflow incontinence/retention; frequency–urgency.
1. Anatomical obstruction (physical blockage): increased outlet resistance
secondary to compression or narrowing.
2. Functional obstruction (failure of relaxation): increased outlet resistance–
inappropriate contraction or failure of normal relaxation.
3. Combined anatomical and functional obstruction
4. Inhibition of detrusor activity: increased pelvic floor activity: failure to relax
pelvic floor inhibits initiation of detrusor activity and inhibits ability to develop
or continue a sustained
(a) Neurological: (suprasacral) overactivity/hyperreflexia (dyssynergia pelvic floor
activity)
(b) Behavioural: failure to relax pelvic floor (learned, acquired, maladaptive,
psychogenic).
(c) Situational: “voluntary” inhibition secondary to environment or pain.
I. Outlet dysfunction: bladder outlet and pelvic floor
II. Bladder dysfunction
A. Detrusor overactivity (increased intravesical pressure)
Symptomatic: urgency incontinence (with or without sensation)– (OAB) wet.
B. Underactive bladder (decreased intravesical pressure)
Symptomatic: overflow incontinence/retention
III. Combined outlet and bladder dysfunction (I and II)
IV. Disorders of sensation:
A. Decreased sensation: denervation, myopathy, behavioral, pharmacological
B. Increased sensation: neuropathic, inflammatory, mucosal permeability defect, psychogenic,
afferent amplification
Assessment of Urethral Anatomy
 Physical Examination
 Ultrasound
Fluoroscopy (Videourodynamics): a diagnostic tool that incorporates urodynamics with simultaneous
imaging of the LUT during bladder filling & voiding for determining the site of bladder outlet
obstruction, the integrity of the sphincter mechanism, and the presence of VU reflux, bladder
diverticula, fistulae, and trabeculation
A. Detrusor External Sphincter Dyssynergia (DESD)
B. Acquired Voiding Dysfunction (AVD)—Hinman’s Syndrome
Abdominal Leak Point Pressure (ALPP): The lowest bladder pressure at which
leakage occurs, correlated with bladder volume, Cough vs. Valsalva to Measure
ALPP
 Detrusor leak point pressure (DLPP)
 Valsalva leak point pressure (VLPP)
1. Pura (Urethral Pressure) Profile = UPP (Urethral Pressure Profile):
provides information regarding the functional status of the urethra.
 obtained under non-voiding conditions with the urethra at
rest
 during coughing (stress Pura profile) and voiding
(micturition Pura profile) to obtain functional information
of the urethra
2. Retrograde Pura Profile: Urethral Retro-resistance Pressure (URP): the pressure
required to achieve and maintain an open sphincter
1. Elctromyogrphy (EMG) :
 is the extracellular recording of bioelectrical activity generated by muscle fibers
 is used to make the diagnosis of Detrusor External Sphincter Dyssynergia (DESD), and used
to distinguish the three types of DESD
 EMG Changes After Vaginal Delivery : complicated vaginal delivery  decreased
intramuscular nerve density in the urethral sphincter and decreased muscular tissue
incontinence and pelvic organ prolapse
2. Conduction Studies of The Sacral Motor System: Testing Conduction of Nerves and
Nervous Pathways Function
 Three age tiers to the
Prevalence of prevalence of regular
incontinence (USA) incontinence in women
among women 60 years
• 15 to 34 years (4–5.5%)
and older living in the
• 35 to 74 years (8.8–11.9%)
community : 38% • 75 years and older (16–16.2%)
 In Asia, the prevalence of UI in the study population was
14.8% (359/2422)
 Nearly half of the incontinent individuals (47.9%) presented
with the mixed type.
 81 women (22.6%) had stress incontinence
 10% presented with urge incontinence
improve bladder control by teaching
patients skills for preventing urine
loss

Improving bladder function through

voiding schedules, such as with bladder
training
Another approach targets the bladder
outlet, such as pelvic floor muscle training
and exercise.

safe and without risks

side effects associated with

some other therapies
 Bladder training is a behavioral intervention to break the cycle
of urgency and frequency using consistent and incremental
voiding schedules
 Bladder training (BT) requires patients to resist the sensation of
urgency, to postpone voiding, and to urinate by the clock rather
than in response to an urge.
 Mechanisms of action are bladder retraining improves cortical
inhibition over detrusor contractions, facilitates cortical ability
over urethral closure during bladder filling, strengthens pelvic
striated muscles, and alters behaviors that affect continence
 Pelvic physiotherapy is often considered as first line treatment
 In stress urinary incontinence (SUI), physiotherapy is especially aimed on strength
improvement and coordination of the periurethral and pelvic floor muscles (PFMs)
 For detrusor overactivity,physiotherapy is aimed at the reduction or elimination of
involuntary detrusor muscle contractions through reflex inhibition.
 Treatment modalities are patient information and education, toilet training, bladder
(re-)training, or behavioral therapy
 Electrical stimulation, and magnetic stimulation. Especially, electrical therapy to be
an effective treatment modality.
 In patients with detrusor overactivity electrical stimulation theoretically stimulates
the detrusor inhibition reflex (DIR) and pacifies the micturition reflex, resulting in a
decrease of overactive bladder dysfunction
 LUT uropharmacology
addresses the innervations
and receptor contents of
the bladder, urethra, and
pelvic floor