Urinary Incontinence PDF

Urinary Incontinence Dr. Ahmed Reda Lecturer in Obstetrics and Gynecology The urinary tract Kidney (2) Upper urinary tract Ureter (2) Urinary bladder Lower urinary tract Urethra The Kidney Two kidneys: right and left Shape...

Urinary Incontinence Dr. Ahmed Reda Lecturer in Obstetrics and Gynecology The urinary tract Kidney (2) Upper urinary tract Ureter (2) Urinary bladder Lower urinary tract Urethra The Kidney Two kidneys: right and left Shape  typical Blood supply: – Arterial  renal artery ( a direct branch from the aorta) – Venous  renal vein to the inferior vena cava Parts: – Fibrous capsule – Cortex – Medulla – Collecting ducts (major and minor calyces) – Pelvis Function: production of urine (average = 1ml / minute) The Ureter Two ureters: right and left Structure: a hollow muscular canal Length = 25 cm Start at  the pelvis of the kidney Ends at  the urinary bladder Parts: – Abdominal – Pelvic Function: transportation of urine from the kidney to the urinary bladder The Urinary bladder The bladder is a midline hollow sac that lies directly behind the pubic symphysis Layers: – Mucosa (inner) = transitional epithelium – Musculosa = detrosur muscle which is composed of 3 layers (outer & inner longitudinal / middle circular) – Serosa (outer) = connective tissue composed of collagen and elastic fibers Parts: – Dome = upper part of bladder – Trigone Triangular area The apex points downward at urethral opening The base is uppermost and the ureters enter at the two corners of the base The Urinary bladder Relations: – The posterior part of the superior surface is related to the uterus – The posterior surface is related to the cervix and vagina Function: storage of urine Urinary bladder innervation The posterior urethro-vesical angle At rest the urethra makes an angle of 90-100° with the base of the urinary bladder. The urethra also makes an angle of less than 30° with the vertical line The Urethra A fibromuscular tube of approximately 3–4 cm in length It is embedded in the anterior wall of the vagina and lies behind the symphysis pubis It has 2 openings: – The internal meatus opens at urinary bladder – The external meatus opens at the vaginal vestibule Urethral support : – Pubourethral ligaments – Urogenital diaphragm – Pelvic diaphragm muscles Function: transport of urine from the bladder to outside the body The Urethral sphincter Intrinsic sphincter: (smooth muscle) – Outer circular smooth muscle of urethra – Middle circular smooth muscle of the bladder – Extrinsic sphincter: (striated muscle) – Upper part = urethral sphincter proper – Lower part is made up of two striated muscle bands The urethrovaginal sphincter The compressor urethrae The micturition cycle Filling phase: The detrusor muscle is relaxed and the detrusor pressure is usually less than 15 cm H2O The first mild desire to void is commonly felt at a volume of 150–200 mL Normally this desire can be postponed With increasing stored volume the sensation of fullness becomes more consciously apparent and persistent Voiding phase: A decision to void is taken when a socially acceptable site is found and necessary preparations are made. The levator ani and urethral sphincter muscles relax and then the detrusor muscle contracts  Filling Micturition cycle Voiding Mechanism of continence at rest Factors maintaining low intra-vesical pressure : – Passive factors = elastic properties of bladder wall  allows distensability i.e. compliance – Active factors = neurological control  the bladder doesn’t contract in response to stretch Factors increasing the intra-urethral pressure : – The mucosal seal – Vascular cushion – Urethral sphincters – The hammock theory Posterior urethro-vesical angle of 90-100° The hammock theory The Posterior urethro-vesical angle Mechanism of continence at stress 1. Intra-abdominal situation of both bladder & upper part of urethra : – This leads to equally transmitted pressure on both bladder & urethra upon cough – increase at both intravesical & intraurethral pressures at the same time i.e. no leak 2. Additional action of the extrinsic striated muscles 3. The Hammock – Compresses the urethra against the anterior vaginal wall 4. Kinking of the urinary bladder neck URINARY INCONTINENCE Definitions Continence a term used to describe the normal ability of a person to store urine temporarily, with conscious control over the time and place of micturition Incontinence is involuntary loss of urine Stress urinary incontinence: involuntary loss of urine on effort or physical exertion (e.g., sporting activities), or on sneezing or coughing. Urgency urinary incontinence: involuntary loss of urine associated with urgency (a sudden, compelling desire to pass urine which is difficult to defer). Mixed urinary incontinence: involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing. Nocturnal enuresis is involuntary loss of urine during sleep Female Urinary Incontinence Transurethral Extraurethral Functional Delirium Stress Congenital Infection Atrophy Pharmacological Psychological Urgency Acquired Endocrine Recumbence Mixed DIAPPER Stress Urinary Incontinence Involuntary loss of urine on effort or physical exertion (e.g., sporting activities), or on sneezing or coughing The phrase ‘stress incontinence’ may be used as  Symptom: The patient complains of incontinence on stress  Sign: An involuntary droplet of urine is observed to leave the urethra immediately on an increase in intra-abdominal pressure  Diagnosis: the name coined to denote the condition Mechanism of incontinence Anatomic: hypermobility of the urethra – Weak pelvic floor support (loss of the sub-urethral hammock) – Usually associated with genital prolapse – It is marked by rotational descent of urethra below the symphysis pubis Intrinsic sphincteric deficiency (ISD) Combined Urethral hypermobility Urgency Urinary Incontinence Urgency: a sudden, compelling desire to pass urine which is difficult to defer. Urgency urinary incontinence: involuntary loss of urine associated with urgency.  Contributing Factors Weak tissues – Congenital Connective tissue disorder Genetic predisposition – Acquired Menopause Surgery Radiation Pregnancy and Childbirth Obesity Increase intraabdominal pressure – Chronic cough – Chronic constipation – Heavy lifting – Mass Assessment Detailed history: – Escape of small amounts (drops) immediately following cough – Usually the patient is multiparous – Symptoms worsens during pregnancy, sexual intercourse and menopause – Past medical and surgical history – Current medications Examination: – General  Menopausal changes, Chest conditions, Obesity – Local  Associated prolapse – Cough stress test  observation of urine leakage with stress Investigations: – Urine analysis – Voiding diaries – Pad test – Urodynamics Management Non surgical management is the first step in management of urinary incontinence If no improvement then treatment according to type of incontinence – Stress urinary incontinence  surgical treatment – Urgency incontinence  medical treatment (as over active bladder) – Mixed incontinence  treatment according to the dominant component I. Non surgical treatment Non surgical management is the first step in management of urinary incontinence A. Life style intervention – Modify fluid intake – Weight loss for obese women (BMI>30) B. Physical therapies – Pelvic floor muscle training first-line treatment to women with stress or mixed urinary incontinence For at least 3 months If beneficial continue program – Electrical stimulation of the levator ani muscles to improve their tone (not routine) C. Behavioral therapies (bladder training for at least 6 weeks) D. Devices (not recommended) II. Surgical treatment It is the primary treatment of stress incontinence More than 200 procedures have been described in the literature for the treatment of stress incontinence The operation is done vaginally, abdominally, or abdomino- vaginally A. Vaginal operations – Kelly’s operation – Tension free Vaginal tape (TVT) – Transobturator tape (TOT) B. Abdominal operations – Mashall-Marchetti-Krantz – Burch colposuspension C. Abdomino-vaginal operations – Pubo-vaginal sling III. Bulking agents permanent injectable materials repeat injections may be needed to achieve effectiveness III. Medical treatment It is the primary treatment of urgency incontinence More than 200 procedures have been described in the literature for the treatment of stress incontinence The operation is done vaginally, abdominally, or abdomino- vaginally A. Anticholinergic B. Selective beta agonist C. Antispasmodics D. Tricyclic antidepressant E. Hormonal treatment F. Duloxitene (antidepressant)  for SUI Any questions?? Thank you