Good morning, everyone. I’m Dr HONG shunjia from dept of O& G, Memorial hospital of this university. About twenty years ago, I was a student as you sitting in the classroom, listening to the professor and taking the lecture notes. At that time, we don’t have microsoft powerponit or windows media player. It is not easy for our professor to present all the things and explain clearly to us. But they done it. So, today, when I stand here, I have my responsibility to present to you what we need to know.
The prevalence of incontinence appears to increase gradually during young adult life (Fig. 23-1). A broad peak is noted at middle age and then steadily increases after age 65 (Hannestad, 2000). The type of incontinence may differ by age, with some studies suggesting a higher prevalence of stress incontinence in women younger than 60 years and urge incontinence in older women (Hannestad, 2000). Not all studies confirm this finding, and the causes of these age-related trends are not clearly understood (Rortveit, 2003).
Physiology of Micturition The bladder is a complex organ that has a relatively simple function: to store urine effortlessly, painlessly, and without leakage and to discharge urine voluntarily, effortlessly, completely, and painlessly. To meet these demands, the bladder must have normal anatomic support as well as normal neurophysiologic function.
The bladder is a bag of smooth muscle that stores urine and contracts to expel urine under voluntary control. It is a low-pressure system that expands to accommodate increasing volumes of urine without an appreciable rise in pressure. This function appears to be mediated primarily by the sympathetic nervous system. During bladder filling, there is an accompanying increase in outlet resistance. The bladder muscle (the detrusor) should remain inactive during bladder filling, without involuntary contractions. When the bladder has filled to a certain volume, fullness is registered by tension-stretch receptors, which signal the brain to initiate a micturition reflex. This reflex is permitted or not permitted by cortical control mechanisms, depending on the social circumstances and the state of the patient's nervous system. Normal voiding is accomplished by voluntary relaxation of the pelvic floor and urethra, accompanied by sustained contraction of the detrusor muscle, leading to complete bladder emptying.
Normal urethral closure is maintained by a combination of intrinsic and extrinsic factors. The extrinsic factors include the levator ani muscles, the endopelvic fascia, and their attachments to the pelvic sidewalls and the urethra. This structure forms a hammock beneath the urethra that responds to increases in intra-abdominal pressure by tensing, allowing the urethra to be closed against the posterior supporting shelf (Fig 23.1). When this supportive mechanism becomes faulty for some reasonâ€”the endopelvic fascia has detached from its normal points of fixation, muscular support has weakened, or a combination of these two processesâ€”normal support is lost, and anatomic hypermobility of the urethra and bladder neck develops. For many women, this loss of support is severe enough to cause loss of closure during periods of increased intraâ€“abdominal pressure, resulting in stress incontinence. However, many women remain continent in spite of loss of urethral support (1)
The intrinsic factors contributing to urethral closure include the striated muscle of the urethral wall, vascular congestion of the submucosal venous plexus, the smooth muscle of the urethral wall and associated blood vessels, the epithelial coaptation of the folds of the urethral lining, urethral elasticity, and the tone of the urethra as mediated by α adrenergic receptors of the sympathetic nervous system.
Micturition is triggered by the peripheral nervous system under the control of the central nervous system. It is useful to consider this event as occurring at a micturition threshold, a bladder volume at which reflex detrusor contractions occur. The threshold volume is not fixed; rather, it is variable and can be altered depending on the contributions made by sensory afferents from the perineum, bladder, colon, and rectum as well as input from the higher centers of the nervous system. The micturition threshold is, therefore, a floating threshold that can be altered or reset by various influences.
Effective urethral closure is maintained by the interaction of extrinsic urethral support and intrinsic urethral integrity, each of which is influenced by several factors (muscle tone and strength, innervation, fascial integrity, urethral elasticity, coaptation of urothelial folds, urethral vascularity). In the clinical setting, damaged urethral support is manifested clinically by urethral hypermobility, which often results in incompetent urethral closure during physical activity and presents as stress urinary incontinence. Clinical appreciation of the importance of extrinsic support and intrinsic urethral function led to the separation of stress incontinence into two broad types: Incontinence caused by anatomic hypermobility of the urethra Incontinence caused by intrinsic sphincteric weakness or deficiency
Defining urinary incontinence would seem an easy task: women that leak urine must be “incontinent”. The International Continence Society, an organization charged with defining the various disorders of pelvic floor dysfunction, recently defined incontinence as “the complaint of any involuntary leakage of urine”. Unfortunately, this definition does not take into account the wide variation in this symptom and the disruption it causes. For example, half of young nulliparous women report occasional minor urine leakage; for most this is not neither a bother nor a symptom for which they would seek treatment. At the other extreme, 5% to 10% of adult women have severe leakage daily.
Risk Factors for Urinary Incontinence Most of the data about risk factors for urinary incontinence come from clinical trials or crossâ€“sectional studies using survey design. Some risk factors have been more rigorously studied than others. Thus, the information available is limited in its general applicability and one cannot infer causality from it. Despite these limitations, there is some evidence that age, pregnancy, childbirth, obesity, functional impairment, and cognitive impairment are associated with increased rates of incontinence or incontinence severity (15,22). Some factors pertain more to certain age groups than others. For example, in studies of older women, childbirth no longer increases the risk of incontinence, possibly because of the presence of comorbidities and other factors that promote incontinence. Medical diagnoses that generally have been associated with urinary incontinence include diabetes, strokes, and spinal cord injuries. Other factors about which less is known or findings are contradictory include hysterectomy, constipation, occupational stressors, smoking, and genetics.
The initial evaluation of patients with incontinence requires a systematic approach to consider possible causes. The basic evaluation should include the following items: history (including assessment of quality of life and degree of bother from symptoms), physical examination, and simple primary care level tests. Most women can begin nonsurgical treatment after this basic evaluation.
A thorough medical history should be obtained from every incontinent patient. The history should include a review of symptoms, general medical history, review of past surgery, and current medications. The woman's most troubling symptoms must be ascertainedâ€”how often she leaks urine, how much urine she leaks, what provokes urine loss, what improves or worsens the problem, and what treatment (if any) she has had in the past.
Physicians caring for incontinent women should ask them about how the incontinence specifically affects their lives and to what degree the incontinence bothers them. Physicians who have a large number of incontinence patients or who wish to evaluate patients in a more standardized fashion before and after treatment may choose to use one of several well-designed, validated quality-of-life measures available.
The physical examination of the patient with incontinence should focus on both general medical conditions that may affect the lower urinary tract as well as problems related to urinary incontinence. Such conditions include cardiovascular insufficiency, pulmonary disease, occult neurologic processes (e.g., multiple sclerosis, stroke, Parkinson's disease, and anomalies of the spine and lower back), abdominal masses, and mobility.
A frequency/volume bladder chart (often termed a â€œbladder diaryâ€) is an invaluable aid in the evaluation of patients with urinary incontinence. A frequency/volume chart is a voiding record kept by the patient for several days. Patients are instructed to write down the time of every void on the chart and measure the amount of urine voided. The time of any incontinent episodes, as well as the specific activities associated with urine loss, should be recorded. If desired, the patient can also be instructed to keep a record of fluid intake. Although the type of intake may guide management suggestions, in most cases volume of intake can be estimated with some accuracy from the amount of urine produced. A frequency/volume bladder chart provides vital information about bladder function that is not provided by formal urodynamics studies:
Examination of the urine by dipstick testing and microscopy is done to exclude infection, hematuria, and metabolic abnormalities. Hematuria cannot be diagnosed on the results of a dipstick test alone; confirmation by microscopic evaluation is mandatory. If a urinary tract infection is documented by microscopy or culture, it is reasonable to see whether urinary tract symptoms improved with eradication of bacteriuria.
Incomplete bladder emptying may cause incontinence. Patients with a large postvoid residual urine volume (PVR) have a diminished functional bladder capacity because of the dead space occupied in the bladder by retained urine. This stagnant pool of urine also is a source of urinary tract infections because the major defense of the bladder against infection is frequent, nearly complete emptying. A large PVR can contribute to urinary incontinence in two ways. If the bladder is overdistended, increases in intraâ€“abdominal pressure can force urine past the urethral sphincter, causing stress incontinence. In some cases, bladder overdistention may provoke an uninhibited contraction of the detrusor muscle, leading to incontinence. These conditions may coexist, further complicating the problem. The PVR can be assessed by either direct catheterization or ultrasonography. It is generally agreed that a PVR level less than 50 mL is normal and greater than 200 mL is abnormal
Patients should be examined with a full bladder, particularly if stress incontinence is a consideration. Urine egress from the urethra at the time of a cough documents stress incontinence. If leakage is not observed when the woman is supine, she should stand with her feet separated to shoulder width and cough several times.
Lifestyle interventions can decrease stress urinary incontinence in many women (44). Weight loss in both morbidly and moderately obese women decreases leakage, and ways to incorporate this intervention in a management plan are being investigated. Postural changes (such as crossing the legs during periods of increased intraâ€“abdominal pressure) often prevent stress urinary incontinence. There is some evidence that decreasing caffeine intake improves continence; however, fluid intake in general seems to play a minor role in the pathogenesis of incontinence. Although smokers are at greater risk for incontinence, no data have been reported on whether smoking cessation resolves incontinence. The Cochrane Incontinence Group concluded that pelvic floor muscle training is consistently better than no treatment or placebo treatment for stress incontinence and should be offered as firstâ€“line conservative management to women. Intensive training sessions that include personal contact with a health care professional to teach and supervise pelvic floor muscle training may be more beneficial than standard care. Several factors improve the likelihood that pelvic muscle training will relieve stress urinary incontinence. The woman must do the exercises correctly, regularly, and for an adequate duration. Based on exercise training of skeletal muscles elsewhere in the body, many physical therapists recommend training sessions three to four times per week, with three repetitions of eight to ten sustained contractions each time. Bladder training focuses on modifying bladder function by changing voiding habits. Behavioral therapy focuses on improving voluntary control rather than bladder function (50). The key component to bladder training is a scheduled toileting program. After reviewing the patient's voiding diary, an initial voiding interval is chosen that represents the longest interval between voiding that is comfortable.
A. Urethral insert used for continence. (Courtesy of Rochester Medical.) The device consists of a short silicone tube that is covered by a mineral oil–containing sheath. The proximal end of the conformable sheath expands to a bulbous tip. At the device's distal end, a soft flange prevents migration of the entire tube into the bladder. B. For insertion, an applicator is used to aid placement. With insertion, mineral oil within the sheath is evenly distributed along its length, and the bulbous tip is collapsed. When properly placed, the tip enters the bladder and the mineral oil preferentially flows to the device's bulbous tip. The applicator is then removed. As a result, the bulbous tip occludes the urethra to improve continence. When voiding is desired, the flange is grasped and the entire single-use device is gently removed.
In 1996, Falconer et al. described the tension-free vaginal tape (TVT) for correcting stress urinary incontinence (120). In this technique, polypropylene mesh is placed under the midurethra with minimal tension (Fig. 23.12, A and B). A report of the 2-year follow-up of 344 women with urodynamic stress incontinence enrolled from 14 centers in a multicenter randomized clinical trial compared TVT and open Burch colposuspension. The objective cure rates (defined as a negative 1-hour pad test) ranged from 63% to 85% for the TVT procedure and 51% to 87% for open colposuspension, depending on how missing data were handled, leading the authors to conclude that “TVT may be better, worse, or the same as open colposuspension in the cure of stress incontinence”. Subjectively, only 43% of women in the TVT group and 37% of women in the open colposuspension group reported cure of their stress leakage.
With the increase in demand of treatment of pelvic floor dysfunction, a new sub-specialty called urogynecology and pelvic reconstructive surgery has been established and developed very rapidly in recent years. Here is a hospital episode statistics from Brazil. You can see colposuspension decreased but TVT procedure increased sharply resulting in a increase in total No of procedures. In US, for the year 2000-2004, more than 600000 cases of hysterectomy were done per year. For these cases, the three most common indications are uterine fibroid, endometriosis and uterine prolapse.
Urinary Incontinence (UI) Shunjia HONG 洪顺家 [email_address]
SUI occurs with increases in abdominal pressure (such as coughing, running, lifting) and can be treated with pelvic muscle exercises, vaginal devices, lifestyle changes, and surgery.
Urge urinary incontinence occurs with a sudden sense of urgency (such as on the way to the bathroom or when washing hands) and can be treated with bladder training, medications, lifestyle changes, and neuromodulation