Urinary Incontinence

Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. Affects physical, psychological, social well being -> Reduce quality of life Prevalence, ↑ with age Common in institutionalized women, those in residential nursing homes

Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.

Affects physical, psychological, social well being -> Reduce quality of life

Prevalence, ↑ with age

Common in institutionalized women, those in residential nursing homes

Some definitions… Stress incontinence is loss of urine on physical effort Urge Incontinence is an involuntary loss of urine associated with a strong desire to void. Overflow Incontinence occurs without any detrusor effort when the bladder is over-distended. Urgency is a sudden desire to void Frequency is passing of urine seven or more/day or being awoken from sleep more than once a night to void.

Stress incontinence is loss of urine on physical effort

Urge Incontinence is an involuntary loss of urine associated with a strong desire to void.

Overflow Incontinence occurs without any detrusor effort when the bladder is over-distended.

Urgency is a sudden desire to void

Frequency is passing of urine seven or more/day or being awoken from sleep more than once a night to void.

Classification of Incontinence URETHRAL CAUSES Urethral Sphincter Incompetence (Urodynamic stress Incontinence) Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic) Retention with overflow Congenital causes Miscellaneous EXTRA URETHRAL CAUSES Congenital causes Fistula

URETHRAL CAUSES

Urethral Sphincter Incompetence (Urodynamic stress Incontinence)

Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic)

Retention with overflow

Congenital causes

Miscellaneous

EXTRA URETHRAL CAUSES

Congenital causes

Fistula

1. URETHRAL CAUSES

1a : Urodynamic Stress Incontinence Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction. Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ± Examination: Stress incontinence when cough, look for prolapse, cystourethroceles Also asses her vaginal capacity and her ability to elevate bladder neck. Urodynamic studies will define cause of incontinence

Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction.

Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ±

Examination: Stress incontinence when cough, look for prolapse, cystourethroceles

Also asses her vaginal capacity and her ability to elevate bladder neck.

Urodynamic studies will define cause of incontinence

Causes of USI Damage to nerve supply of pelvic floor and urethral sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries) Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince Congenital cause (nulliparous women) – Connective tissue disorder esp collagen Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation

Causes of USI

Damage to nerve supply of pelvic floor and urethral sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries)

Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince

Congenital cause (nulliparous women) – Connective tissue disorder esp collagen

Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation

1b: Detrusor Over-activity Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked. Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties Examination: Any mass that may compress bladder, prolapse TRO Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw

Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked.

Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties

Examination: Any mass that may compress bladder, prolapse TRO

Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw

1c: Retention with overflow Insidious failure of bladder empting may lead to chronic retention and finally, when normal voiding is ineffective, to overflow incontinence Caused by: LMN/UMN lesions, urethral obstructions, pharmacological Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux

Insidious failure of bladder empting may lead to chronic retention and finally, when normal voiding is ineffective, to overflow incontinence

Caused by: LMN/UMN lesions, urethral obstructions, pharmacological

Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence

Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux

1d: Congenital Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence Rx with urethral reconstruction or artificial urinary sphincter

Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence

Rx with urethral reconstruction or artificial urinary sphincter

2. EXTRA URETHRAL CAUSES

2A: Congenital Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains

Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period

Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains

2B: FISTULA Abnormal opening between the urinary track and outside. Obstetric cause : Obstructive labour with compression of bladder between presenting head and bony pelvis Gynecological cause : AW pelvic surgery, radiotherapy, pelvic malignancy Treated by primary closure or surgery

Abnormal opening between the urinary track and outside.

Obstetric cause : Obstructive labour with compression of bladder between presenting head and bony pelvis

Gynecological cause : AW pelvic surgery, radiotherapy, pelvic malignancy

Treated by primary closure or surgery

INVESTIGATIONS Urine C&S- tro Infections Pad test Measure Postvoidal Residual Volume by bladder ultrasound or urethral catheter >100mL in more than one occasion->+ Cough Stress Test. 250mL into bladder Abdominal leak point pressure

Urine C&S- tro Infections

Pad test

Measure Postvoidal Residual Volume by bladder ultrasound or urethral catheter >100mL in more than one occasion->+

Cough Stress Test. 250mL into bladder

Abdominal leak point pressure

Urodynamic studies Uroflowmetry. Bladder outlet obstruction Cystometry. Detrusor activity, differentiate involuntary detrusor contraction or increase intraabdominal pressure Cystogram Stress incontinence, Cystocele, Sphincter activity, fistula Cystoscopy Tumors, stones

Urodynamic studies

Uroflowmetry. Bladder outlet obstruction

Cystometry. Detrusor activity, differentiate involuntary detrusor contraction or increase intraabdominal pressure

Cystogram

Stress incontinence, Cystocele, Sphincter activity, fistula

Cystoscopy

Tumors, stones

Treatment Palliative – Fluid restriction, Protective perineal pads, Bladder retraining, Pelvic Floor exercise (Kegel) Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance Colposuspension Operation, Artificial Sphincter

Palliative – Fluid restriction, Protective perineal pads, Bladder retraining, Pelvic Floor exercise (Kegel)

Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms

Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance

Colposuspension Operation, Artificial Sphincter