Urinary incontinence- Dr. Sirisha

Urinary incontinence

  • Urinary incontinence is a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable
  • TYPES

True incontinence/continual
Urge incontinence- it is associated with strong desire to void Stress incontinence-leaking on stress

Overflow incontinence-it is sequel of prolonged and neglected retention

Stress urinary incontinence

  • Sir eardly holland 1n 1922 introduced the term SUI
  • Stress urinary incontinence (SUI) is defined by the international continence society (ICS) as the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.

 

Genuine stress urinary incontinence

 

  • Urinary loss which occurs with sudden elevation of the intra abdominal pressure without detrusor contraction is called stress urinary incontinence

 

Grading of SUI

  • Grade0

Incontinence without leakage

  • Grade1

Incontinence with only severe stress, such as coughing, sneezing, and jogging

  • Grade2
    Incontinence with moderate stress, such as fast walk, going up and down the stairs
  • Grade3
    Incontinence with mild stress such as standing

 

Types of SUI

  • Type 1
    Incontinence due to loss of posterior urethrovesical angle

alone
• Type 2

Incontinence due to loss of posterior urethrovesical angle as well as urethral hypermobility

  • Type 3
    Incontinence due to ISD

 

Anatomical classification

Blaivis and Olsson, 1998

Based on urodynamic method

Types

During Rest

During Stress

 

Bladder base position (IMPS)

Bladder neck & Proximal urethra

Bladder base position

Bladder neck & Proximal urethra

Type 0

Normal position

closed

Rotational descent

No leakage

Type 1

Normal position

closed

Descent <2cm

Open leakage +ve

Type 2A

Normal position

closed

Rotational descent

Open Leakage

Type 2B

At or below the

closed

Further descent

Open Leakage

Type 3 or ISD

Normal position

Open

Not descent

Open and leakage

 

 

 

  • Pathophysiology

 

Anatomical theories

  • Urethrocele is dislocation of urethra and it is the cause of incontinence Mann’s American System of Gynecology 19 cent.
  • Kellyinventedcystoscopein1914

The cystoscopic picture presents a gaping internal sphincter orifice which closes sluggishly.

  • Bonney attributed SUI to vesical neck funneling and he hypothesised cause of this is loss of elasticity of urethral and vesical sphincter.
  • Incontinence caused by sagging of pubocervial muscle sheet which interfere with the sphincter mechanism (bonney 1923)
  • Kennedy 1923 suggested injury to the urethral sphincter as the principal etiology of SUI
  • Funneling of the bladder floor towards the urethra and flattening of urethro vesical angle of the bladder showed in sagittal image in cystogram (1937)
  • SUI is now thought to be due to abnormality in urethra

On MRI of the pelvic floor SUI was associated with unequal movement of anterior and posterior wall of bladder neck and urethra in the presence of increased intra abdominal pressure

Urethral luemen pulled open as the posterior wall moved away from the anterior wall
The Pathophysiology of Stress Urinary Incontinence: A Historical Perspective .2004

 

Pressure transmission theory

  • Enhorning 1961
  • Demonstrated the unequal pressure transmission in bladder and urethra during increased intra abdominal pressure in incontinent subjects

campbell walsh urology:expert consult

 

Hammock hypothesis

  • In 1996, De Lancey proposed a consolidated theory of SUI
  • He hypothesized that the pubocervical fascia provides hammock like support for the vesical neck and there by creates a backboard for the compression of proximal urethra during increased intra abdominal pressure.
  • Loss of this support would compromise equal transmission of intra abdominal pressure.

 

 

 

 

Sphincteric Dysfunction Theory

  • Agency for Health Care Policy and Research, 1992
  • SUI the condition of “intrinsic sphincteric deficiencyʼʼ

In this condition, the urethral sphincter is unable to generate enough resistance to retain urine in the bladder especially during stress maneuver

 

Pathophysiology

  • Urethral hypermobility
    • Sphincter deficiency without descent(ISD)

 

Risk factor for ISD

Congenital CNS dysfunctions/lesions

Smooth muscle disorders

Striated muscle disorders

Acquired Childbirth

Prior pelvic surgery

Radiation therapy

CNS lesions

Peripheral neuropathies

Chronic catheter drainage

Other Hypoestrogenism

Aging

 

Aetiology

  • Age
    • Multiparity
    • Obesity
    • Smoking
    • Prolapse
    • Constipation
    • Pregnancy and puerperium • Atheletes
    • Hereditary

 

 

 

Investigations

  • Stress test
    • Cotton swab test
    • Marshall and bonneyʼs test • Urethroscopy
    • Urodynamic studies

 

 

 

Stress test

  • Excellent method of demonstrating objectively the presence of SUI

 

 

 

Steps

  • Catheterisation
    • Urine sample is sent for culture
    • 250ml warm saline instilled into the bladder
    • Leakage noted in sitting and supine position
    • Net weight gain of 2g or more is indicative of GSI

 

 

 

Q tip cotton test

  • A Q tip cotton swab stick dipped in xylocain jelly is placed in urethra
  • Patient asked to strain or cough

 

Marshall and bonneyʼs test

  • Bonney test
    Absence of leakage of urine following bladder neck elevation is indicative of beneficial outcome following surgical repair
  • Marshall test

vagina in the bladder neck is infiltrated with local anaesthetic, and area elevated with an open allis clamp

 

Urethroscopy

Provides Information about the:

  • Openning pressure • Urethritis
    • Diverticula
    • Rigid urethra
  • Urethrpvesical junction

 

Urodynamic studies

  • Cystometry- measurement of pressure within the bladder and urethra during artificial filling
  • Uroflowmetry-urine flow rate and volume
    • Micturition cystourethrography- for posterior urethro vesical angle
  • Uroproflowmetry – it measures the dynamic urethral pressure it is gold standard in diagnosis of GSI

 

  • Ultrasound –for bladder volume and residual urine
  • Videocystourethrography-it combines the pressure studies with video position of bladder neck and urethrovesical angle
  • MRI- to detect the defect in pelvic floor muscle and supporting fasciae

 

Management

  • Conservative

Fluid intake and voiding habits                                                                                          Weight loss
Physiotherapy
Reduce caffein intake and smoking Drugs
Intraurethral and vaginal devices Electric stimulation

 

  • Surgical

 

Conservative therapy

Fluid intake and voiding habits

  • Trials have been demonstrated that increase in fluid intake increases the episodes of incontinence thus decreasing the fluid intake is helpful in for patient with high fluid consumption
  • Voiding prior to strenous activity beneficial in mild SUI

 

Pelvic floor exercises

  • Kegel described the PFM exercises in 1948 for female UI
  • Reported success rate is more than 80%
  • Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with stress or mixed UI. [2006]
  • Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day for 3-6 month. [2006]

.

 

  • Weight loss

Several studies shows association between obesity and development of incontinence a study examining women who had lost weight as a result of bariatric surgery found that there was significant decrease in both subjective and objective SUI and UUI

 

Oestrogen

Medical therapy

  • Estrogen has tropical effects on urethral epithelium subepithelial vascular plexus and connective tissues
  • Fentl at al reviewed 23 articles and found patient had subjective improvement but not there is no imrovement in objective parameters

 

  • Alpha-adrenoreceptor agonist

Ephedrine , Midorine, Methoximen

  • Tricyclic antidepressant

Imipramine

2 studies with 75 mg BD

1st study shows subjective improvement in 70% and in 2nd study shows objective improvement in 60% after 3month of treatment

 

  • Duloxetine
    It is still in investigational phase Phase 3rd studies appear promising

One study conduct in north america showed incontinence episodes decreased by 50% in duloxetine group versus 27% in placebo group

 

Intraurethral and vaginal devices

  • Ringpessary
    • Contiform(silasticvaginalcone)

Electric stimulation

Tried if SUI is caused by denervation of pudendal nerve during delivery

Useful in old women with weak pelvic floor muscles

  • Artificial urinary sphincter

800 model used in neurological condition Previous surgical failure
80% success rate

Disadvantages-

Expensive Infection mechanical failure

Surgical intervention

  • Vaginal operation

Anterior colporrhaphy

Kellyʼs repair

Paceyʼs repair

  • Abdominal approach

Retropubic colpo suspension

Marshall-marchetti-krantz operation Burch colpo suspension

  • Combined abdominal and vaginal operation

 

 

Sling procedures to treat stress incontinence

 

Most surgical procedures to treat stress incontinence fall into two main categories: sling procedures and bladder neck suspension procedures.

For a sling procedure, your surgeon uses strips of synthetic mesh, your own tissue, or sometimes animal or donor tissue to create a sling or “hammock” under the tube that carries urine from the bladder (urethra) or the area of thickened muscle where the bladder connects to the urethra (bladder neck). The sling supports the urethra and helps keep it closed — especially when you cough or sneeze — so that you don’t leak urine.

The sling procedure that’s best for you depends on your situation.

Tension-free sling

No stitches are used to attach the tension-free sling, which is made from a strip of synthetic mesh tape. Instead, body tissue holds the sling in place. Eventually scar tissue forms in and around the mesh to keep it from moving.

For a tension-free sling procedure, your surgeon may use one of three approaches:

  • With the retropubic approach, your surgeon makes a small cut (incision) inside your vagina just under your urethra. Your surgeon also makes two small openings above your pubic bone just large enough for a needle to pass through. Your surgeon then uses a needle to pass the sling under the urethra and up behind the pubic bone. A few absorbable stitches close the vaginal incision, and the needle sites may be sealed with skin glue or stitches.
  • With the transobturator approach, your surgeon makes a similar vaginal incision as in the retropubic approach and also creates a small opening on each side of your labia for the needle to pass through. The sling passes in a different pathway from the retropubic approach, but it’s still placed under the urethra.
  • Single-incision mini.With this approach, your surgeon makes only one small incision in your vagina to perform the procedure. Through this single incision, your surgeon places the sling in a manner similar to the retropubic and transobturator approaches. No other incisions or needle sites are needed.

 

Recovery time for tension-free sling surgery varies. Two to four weeks of healing before returning to activities that include heavy lifting or strenuous exercise. It may be up to six weeks before you’re able to resume sexual activity.

Using surgical mesh can be a safe and effective way to treat stress urinary incontinence. However, serious complications occur in some women, including erosion of the material, infection and pain.

Conventional sling

With a conventional approach, your surgeon makes an incision in your vagina and places a sling made of synthetic mesh tape — or possibly your own tissue or tissue from an animal or deceased donor — under the neck of your bladder. Through another incision in your abdomen, your surgeon pulls the sling to achieve the right amount of tension and attaches each end of the sling to pelvic tissue (fascia) or your abdominal wall using stitches.

A conventional sling sometimes requires a larger incision than does a tension-free sling. You might need an overnight stay in a hospital and usually a longer recovery period. You may also need a temporary catheter after surgery while you heal.

Suspension procedures to treat stress incontinence

 

A bladder neck suspension reinforces the urethra and bladder neck so that they won’t sag and provides something for the urethra to compress against to help prevent leakage.

To perform the procedure, your surgeon makes an incision in your lower abdomen or performs the surgery through small incisions using thin instruments and a video camera (laparoscopic surgery).

For bladder neck suspension performed abdominally, you’ll need general or spinal anesthesia. Recovery takes several weeks, and you might need to use a urinary catheter until you can urinate normally. Recovery time is likely to be shorter with laparoscopic surgery

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