Urinary incontinence is defined as the involuntary loss ofurine that is objectively demonstrable and is a social orhygienic problem.It affects an individuals physical, psychological and socialwell-being and is associated with a significant reduction inquality Of life.
The prevalence increases with age, approximately 5 per cent of women between 15 and 44 years of age being affected, rising 10 per cent of those aged between 45 and 64 years, approximately 20 per cent of those older than 65 years. It is even higher in women who are institutionalized and may affect up to 40 per cent of those in residential nursing homes
• Stress incontinence is a symptom and a sign andmeansloss of urine on physical effort. It is not a diagnosis .• Urgency means a sudden desire to void.• Urge incontinence is an involuntary loss of urineassociated with a strong desire to void..
• Overflow incontinence occurs without any detrusoractivity when the bladder is over-distended.• Frequency is defined as the passing of urine sevenor more times a day, or being awoken from sleepmore than once a night to void
Urethral causes• Urethral sphincter incompetence (urodynamic stressincontinence)• Detrusor over-activity or the unstable bladder - this iseither neuropathic or non-neuropathic• Retention with overflow• Congenital causes• MiscellaneousExtra-urethral causes• Congenital causes• Fistula
Stress Incontinence Involuntary loss of urine due to increased intra- abdominal pressure Coughing Sneezing Laughing Most common type in young women Due to pelvic floor muscle weakening resulting in urethral hypermobility
Urge Incontinence (OAB) “Overactive Bladder”, Detrusor overactivity A strong sense to void followed by involuntary loss of urine Usually idiopathic, but can be due to infection, bladder stones, bladder cancer
Mixed Incontinence Most common in women overall Exact mechanism not well understood Characteristics of both Urge and Stress Incontinence
Overflow Incontinence Due to overdistension of the bladder Frequent or constant “dribbling” Either due to an outlet obstruction (prostate) or detrusor underactivity (medications, spinal chord injury, diabetic neuropathy, MS) Post void residual is often elevated
Functional Incontinence Especially in the elderly Cognitive or Physical limitations Diagnosis of exclusion as other types might be present in functionally limited individuals
Urodynamic stress incontinenceUrodynamic stress incontinence (USI) , previouslycalled genuine stress incontinence, is noted duringfilling cystometry, and is defined as the involuntaryleakage of urine during increased abdominal pressurein the absence of a detrusor contraction.
The likely causes of USI are as follows.• Abnormal descent of the bladder neck and proximalurethra• An intra-urethral pressure which at rest is lower thanthe intravesical pressure; this may be due to urethralscarring as a result of surgery or radiotherapy. It alsooccurs in older women.• Laxity of suburethral support normally provided bythevaginal wall, endopelvic fascia, arcus tendineus fasciaand levator ani muscles acting as a single unit resultsin ineffective compression during stress and consequentincontinence
The aetiology of USI is thought to be related to a number offactors.1-Damage to the nerve supply of the pelvic floor andurethral sphincter caused by childbirth leads to progressivechanges in these structures, resulting in altered function.2-Mechanical trauma to the pelvic floor musculature and endopelvic fascia and ligaments occurs as a consequence of vaginal delivery. Prolonged second stage, large babies and instrumental deliveries cause the most damage.3-Menopause and associated tissue atrophy may also damage tothe pelvic floor. cause4- A congenital cause may be inferred, as some nulliparouswomen suffer from incontinence. This may be due to alteredconnective tissue, particularly collagen;5-Chronic causes, such as obesity, chronic obstructive pulmonarydisease, raise intera-abdominall pressure and constipation mayalso result in problems.-
Differential diagnosis Normal Bladder OAB Stress Incontinence
Detrusor over-activity, previously called detrusorinstability, is a urodynamic observationcharacterized by involuntary detrusor contractionsduring the filling phase which may be spontaneousor provoked.
Detrusor over-activity.The largest group of women with this condition have an idiopathic variety. Neuropathy appears to be the most substantiated factor. Incontinence surgery. Out flow obstruction and smoking are also associated with detrusor over-activity.
Retention with overflowInsidious failure of bladder emptying may lead tochronic retention and finally, when normal voidingis ineffective, to overflow incontinence. The causes may be:• Lower motor neurone or upper motor neurone lesions• Urethral obstruction.• Pharmacological..
Symptoms include : Poor stream. Incomplete bladder emptying . Straining to void. Overflow stress incontinence. Often there will be recurrent urinary tract infection.Cystometry is usually required to make thediagnosis, and bladder ultrasonography orintravenous urogram may be necessary toinvestigate the state of the upper urinary tract toexclude reflux.
Epispadias, which is due to faulty midline fusion ofmesoderm, results in a widened bladderneck, shortened urethra, separation of the symphysispubis and imperfect sphincteric control.The patient complains of stress incontinence which may not be apparent when lying down but is noticeable when standing up. The physical appearance of epispadias is pathognomonic, and a plain X-ray of the pelvis will show symphysial separation.Management:urethral reconstruction or an artificial urinary sphinter.
Acute urinary tract infection. Faecal impaction in the elderly may lead to temporary urinary incontinence. A urethral diverticulum may lead to post- micturition dribble, as urine collects within the diverticulum and escapes as the patient stands up.
Bladder exstrophy and. In bladder exstrophy there is failure of mesodermal migration with breakdown of ectoderm and endoderm, resulting in absence of the anterior abdominal wall and anterior bladder wall. Extensive reconstructive surgery is necessary in the neonatal period. Ectopic ureterAn ectopic ureter may be single or bilateral and presentswith incontinence only if the ectopic opening is outsidethe bladder, when it may open within the vagina oronto the perineum. The cure is excision of the ectopicureter and the upper pole of the kidney that it drains.
A urinary fistula is an abnormal opening between the urinary tract and theoutside .Urinary fistulae have obstetric and gynaecological causes. The obstetric includeobstructive labour with compression of the bladder between the presenting head and the bony wall of the pelvis. The gynaecological causes are associated with pelvic surgery . pelvic malignancy . radiotherapy. Management the fistula must be accurately localized. It can be treated by primary closure or by surgery and can be delayed until tissue inflammation and oedema have resolved at about 4 weeks. The surgical techniques involve isolation and removal of the fistula tract, careful debridement, suture and closure of each layer separately and without tension and, if necessary, the interposition of omentum, which brings with it an additional blood supply.
Urinary tract infectionAcute and chronic urinary infections are importantand-avoidable sources of ill-health among women. The short urethra, which is prone to entry of bacteria during intercourse, Poor perineal hygiene The occasional inefficient voiding ability of the patient . Unnecessary catheterizations are all contributory factors.
A significant urinary infection is defined as the presence of a bacterial count > 100 000 of the same organism/mL of freshly plated urine. On microscopy there are usually red blood cells and white blood cells.The common organisms are Escherichia coli, Proteusmirabilis, Klebsiella aerogenes, Pseudomonasaeruginosa and Streptococcus faecalis. These gainentry to the urinary tract by a direct extension from thegut, lymphaticspread via the bloodstream or transurethrally from theperineum. Symptoms include dysuria, frequency andoccasionally haematuria. Loin pain and rigors and atemperature above 38 C usually indicate that acutepyelonephritis has developed.
A culture and sensitivity of mid-stream specimen of urineis required.Intravenous urography renal ultrasonographymay be required in patients with recurrent infection todefine anatomical or functional abnormalitiesWith acute urinary infection, once a mid-stream urinespecimen has been sent for culture and sensitivity,antimicrobial therapy can begin. If the patient is ill, thetreatment should not be delayed and an antimicrobiadrug regimen can be started immediately. The regimencan be changed later according to the results of theurine culture and sensitivity.
Commonly used drugs include trimethoprim 200 mg twice daily or nitrofurantoin 100 mg four times daily or a cephalosporin.Recurrent urinary tract infection for which anidentifiable source has not been found may bemanagedby long-term low-dose antimicrobial therapy, such astrimethoprim. Recently, ciprofloxacin andnorfloxacinhave proved effective.It is important to treat urinary tract infectionseffectively, especially in younger women.
INVESTIGATIONS An accurate and detailed history and examination provide a framework for the diagnosis, but there is often a discrepancy between the patients symptoms and the urodynamic findings. The aim of urodynamic investigations is to provide accurate diagnosis of disorders of micturition and they involve investigation of the lower urinary tract and pelvic floor function.
Mid-stream urine specimenUrinary infection can produce a variety of urinarysymptoms, including incontinence.A nitrate stick test can suggest infection, but adiagnosis is made from a clean mid-streamspecimen. The presence of a raised level of whiteblood cells alone suggests an infection and the testshould be repeated.Invasive urodynamics can aggravate infection, andtest results are invalid when performed in thepresence of infection.
Urinary diaryA urinary diary is a simple record of the patients fluidintake and output . Episodes of urgency and leakage and precipitating events are also recorded.There is no recommended period for diary keeping; a suggested practice is 1 week. These diaries are moreaccurate than patient recall and provide an assessmentof functional bladder capacity. In addition to alteringfluid intake, urinary diaries can be utilized to monitor conservative treatment, e.g. bladder re-education, electrical stimulation and drug therapy.
Pad testPad tests are used to verify and quantify urine loss.The International Continence Society pad test takes1 hour. The patient wears a pre-weighed sanitary towel, drinks 500 mL of water and rests for 15 minutes. After a series of defined manoeuvres, the pad is re-weighed; a urine loss of more than 1 g is considered significant.
If indicated, methylene blue solution can be instilledintravesically prior to the pad test to differentiatebetween urine and other loss, e.g. insensible loss orvaginal discharge. The popularity of 24-hour and48-hour pad tests is increasing because they are believed to be more representative. The woman performs normal daily activities and the pad is re- weighed after the preferred period.
UroflowmetryUroflowmetry is the measurement of urine flow rate and is a simple, non-invasive procedure that can be performed in the outpatient department.It provides an objective measurement of voidingfunction and the patient can void in privicy.Although uroflowmetry is performed as part of ageneral urodynamic assessment, the main indications are complaints of hesitancy or difficulty voiding in patients with neuropathy or a past history of urinary retention..
It is also indicated prior to bladder neck orradical pelvic cancer surgery to exclude voiding problems that may deteriorate afterwards.The normal flow curve is bell shaped. A flowrate <15mL/s on more than one occasion is considered abnormal in females
CystometryCystometry involves the measurement of the pressure volume relationship of the bladder. It is still considered the most fundamental investigation. It involves simultaneous abdominal pressure recording in addition to intravesical pressure monitoring during bladder filling and voiding.Electronic subtraction of abdominal from intravesical pressure enables determination of the detrusor pressure .
Cystometry is indicated for the following.• Previous unsuccessful continence surgery.• Multiple symptoms, i.e. urge incontinence, stressincontinence and frequency.• Voiding disorder.• Neuropathic bladder.• Prior to primary continence surgery
Prior to cystometry, the patient voids on theflowmeter. A 12 French gauge catheter is inserted to fill the bladder and any residual urine is recorded. Intravesical pressure is measured using a 1 mm diameter fluid-filled catheter, inserted with the filling line, connected to an external pressure transducer.
A fluid-filled 2 mm diameter catheter covered with a rubber finger cot to prevent faecal blockage is inserted into the rectum to measure intra-abdominal pressure.. The bladder is filled (in sitting and standing positions) with a continuous infusion of normal saline at room temperature.
The standard filling rate is between 10 and 100 mL/min and is provocative for detrusor instability. During filling, the patient is asked to indicate her first and maximal desire to void and these volumes are noted. The presence of symptoms of urgency and pain and systolic detrusor contractions are noted.
At maximum capacity, the filling line is removed and the patient stands. She is asked to cough and any leakage is documented. The patient then transfers to the uroflowmeter and voids with pressure lines in place.Once urinary flow is established, she is asked to interrupt the flow if possible.
The following are parameters of normal bladderfunction.• Residual urine of < 50 mL.• First desire to void between 150 and 200 mL.• Capacity between 400 and 600 mL.• Detrusor pressure rise of <15 cmH20 duringfilling and standing.• Absence of systolic detrusor contractions.• No leakage on coughing.• A voiding detrusor pressure rise of < 70 cmH20with a peak flow rate of> 15 mL/s for avolume > 150 mL.
Detrusor over-activity is diagnosed when spontaneousor provoked detrusor contractions occur whichthe patient cannot suppress. Systolic detrusor over activity is shown by phasic contractions, whereas lowcompliance detrusor instability is diagnosed whenthe pressure rise during filling is> 15 cmH20 and doesnot settle when filling ceases. Urodynamic stress incontinence is diagnosed if leakage occurs as a result of coughing in the absence of a rise in detrusor pressure.
Video -cystourethrographyrepresentation of subtracted cystometry. If a radio- opaque filling medium is used during cystometry, the lower urinary tract can be visualized by X-ray screening with an image intensifier.).
Intravenous urographyThis investigation provides little information about the lower urinary tract but is indicated in cases of haematuria, neuropathic bladder and suspected uretero-vaginal fistula.
UltrasoundUltrasound is becoming more widely used in urogynaecology.Post-micturition urine residual estimationcan be performed without the need for urethralcatheterization and the associated risk of infection.This is useful in the investigation of patients withvoiding difficulties, either idiopathic or followingpostoperative catheter removal. Urethral cysts anddiverticula can also be examined using this technique.
Magnetic resonance imagingMagnetic resonance imaging (MRI) produces accurate anatomical pictures of the pelvic floor and lower urinary tract and has been used to demarcate compartmental prolapse.
CystourethroscopyCystourethroscopy establishes the presence of disease in the urethra or bladder. There are few indications inwomen with incontinence.• Reduced bladder capacity.• History of urgency and frequency.• Suspected urethrovaginal or vesicovaginal fistula.• Haematuria or abnormal cytology.• Persistent urinary tract infection.
Urethral pressure profilometryUrethral pressure profiles can be obtainedusing a catheter tip dual sensor microtransducer.Measurement of intraluminal pressure along theurethra at rest or under stress (e.g. coughing) appears to be of little clinical value because of a large overlap between controls and women with USI.
Simple measures such as exclusion of urinary tract infection, restriction of fluid intake, modifying medication (e.g. diuretics) and treating chronic cough and constipation play an important role in the management of most types of urinary incontinence
Urodynamic stress incontinencePrevention Shortening the second stage of delivery and reducingtraumatic delivery may result in fewer women developingstress incontinence. The benefits of hormone replacement therapy have not been substantiated. The role of pelvic floor exercises either before or during pregnancy needs to be evaluated
Conservative managementPhysiotherapy is the mainstay of the conservative treatment of stress incontinence.1- ( Kegel execise ).With appropriate instruction and regular use,between 40 and 60 per cent of women can derive benefit from pelvic floor exercises to the point where they decline any further intervention.
Premenopausal women appear to respond betterthan their postmenopausal counterparts. Motivation and good compliance are the key factors associated with success.2-The use of biofeedback techniques,e.g. perineometry and weighted cones, can improvesuccess rates. Maximal electrical stimulation is gaining popularity. A variety of devices have been used but have not been very successful.
SurgeryFor women seeking cure, the mainstay of treatment is surgery.The aims of surgery are:restoration of the proximal urethra and bladder neck to the zone of intra-abdominal pressure transmission, to increase urethral resistance, a combination of both.
The choice of operation depends on the clinical and urodynamic features of each patient, and the route of approach.1-The colposuspension operation is associated with the highest success rates in the hands
2-The artificial sphincter has been used since 1972. It is used where conventional surgery has failed and the patient is mentally alert and manually dexterous.3-Peri-urethral bulking has attracted considerable interest because of the inherent simplicity of the of most surgeons.
Silicon (Macroplastique) have all beenevaluated in the last decade. Subcutaneous fat,although cheap, has poor efficacy and therefore has lost popularity.Contigen collagen is usually injected paraurethrally and Macroplastique transurethrally. Most surgeons inject collagen under local anaesthetic and Macroplastique under general anaesthetic.
4-Laparoscopic colposuspension may be performed, and in the best hands gives equivalent results to the open procedure but takes longer and does not appear to offer advantages in terms of postoperative recovery.
Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years. Urethral Hypermotility Marshall-Marchetti-Kantz procedure Needle neck suspension Intrinsic sphincter deficiency Sling procedure
Pessaries Diapers or pads Chronic catheterization Periurethral or suprapubic Indwelling or intermittant
Detrusor over-activity and voiding difficulty Detrusor over-activity can be treateed by bladderretraining, biofeedback or hypnosis, all of which tend to increase the interval between voids and inhibit the symptoms of urgency. These methods-are effective in between 60 and 70 per cent of individuals. Anticholinergic agents such as oxybutynin 2.5 mg twice daily or tolterodine 2 mg twice daily can be equally as effective.
The latter has fewer side effects, mainly dry mouth and constipation. Imipramine is often used for enuresis and desmopressin (an antidiuretic hormone analogue) is useful for nocturia.
Neuropathic and non-neuropathic detrusor instability can be treated with anticholinergic drugs.Bladder emptying can be achieved either by the use of clean intermittent self-catheterization or by an indwelling suprapubic or urethral catheter. Drug therapy to encourage and aid detrusor contraction or relax the urethral sphincter is relatively ineffective.
New developmentsThere is a wide variety of suburethraltape operations now available and these are currentlyundergoing evaluation. The most novel of these uses the obturator fossae as an approach route to insert a tape.(TOT)There are several new pharmaceutical agents being evaluated for the treatment of urge incontinence, and a new drug for stress incontinence, duloxetine, will be launched soon.