BHARATPUR HOSPITAL NEPAL

1. URINARY INCONTINENCE
• MODERATOR – PROFESSOR DR. SUNIL MANI POKHREL
SENIOR CONSULTANT AND HOD ( OBS AND GYNAE
DEPARTMENT ) BHARATPUR HOSPITAL AND PROFESSOR OF NAMS
• PRESENTOR – DR. INDRAJEET KUMAR RAJAK
2nd YEAR MD RESIDENT (OBS & GYNAE )

2. Definition
• “the complaint of any involuntary leakage of
urine” ( A/C the International Urogynecological
Association and the International Continence
Society )

3. EPIDEMIOLOGY
• In Western societies, epidemiologic studies indicate a
prevalence of urinary incontinence of 25 to 55 percent.
• It is estimated that only one in four women will seek
medical advice for incontinence due to embarrassment,
limited access to health care, or poor screening by health
care providers
• Among ambulatory women with urinary incontinence, the
most common condition is SUI, which represents 29 to75
percent of cases. Urge urinary incontinence accounts for up
to 33 percent of incontinence cases, whereas the remainder is
attributable to mixed forms

4. Risk Factors for Urinary Incontinence
• Family History - risk of urinary incontinence may be increased in the
daughters and sisters of incontinent women
• Age - 7 percent in those aged 20 to 40 years, 17 percent for ages 40
to 60, 23 percent for ages 60 to 80, and 32 percent for those older
than 80
• Pregnancy- higher in parous women compared with nulliparas
• Childbirth - First, fetal birthweight 4000 g increased the risk of all
urinary incontinence types . Secondly, cesarean delivery may have a
short-term protective effect preventing urinary incontinence
• Menopause - increase in urinary dysfunction after a woman enters
her postmenopausal years

5. • Hysterectomy - hysterectomy is a risk factor for
developing urinary incontinence
• Obesity - increased body mass index (BMI)
• Urinary symptoms
• Functional impairment
• Cognitive impairment
• Chronically increased abdominal pressure
Chronic cough
Constipation
Occupational risk
• Smoking

6. Reversible Causes of Incontinence
DIAPPERS :-
• D Delirium
• I Infection
• A Atrophic urethritis and vaginitis
• P Pharmacologic causes
• P Psychological causes
• E Excessive urine production
• R Restricted mobility
• S Stool impaction

7. Types of Disorders
• Stress Urinary Incontinence
• Urgency Urinary Incontinence and Overactive Bladder
• Mixed Incontinence
• Functional and Transient Incontinence
• Extraurethral Incontinence

8. Stress Urinary Incontinence
• occurs during periods of increased intra-abdominal pressure
(e.g., sneezing, coughing, or exercise)
• Most common in all women and is particularly common in
younger women

9. Urgency Urinary Incontinence and Overactive
Bladder
• involuntary leakage of urine accompanied by or immediately
preceded by urgency
• Most common in older women
• The term overactive bladder syndrome is defined as urinary
urgency, usually accompanied by frequency and nocturia,
with or without urgency urinary incontinence, in the
absence of urinary tract infection or other obvious pathology
.It is often referred to as OAB-dry when women with these
symptoms do not leak urine, and OAB-wet when it is
accompanied by incontinence.

10. Mixed Incontinence
• have symptoms of both stress and urge urinary incontinence
• older women mixed and urge incontinence predominate

11. Functional and Transient Incontinence
• incontinence that occurs because of factors unrelated to the
physiologic voiding mechanism
• related to such factor as decreased mobility, musculoskeletal
pain, or poor vision

12. Extraurethral Incontinence
• urine loss can also occur through abnormal openings
• Causes –
(1 ) Congenital –
Bladder exstrophy
Ectopic Ureter
(2) Acquired –
Obstructed labour , Trauma , surgery, malignancy,
and radiation therapy

13. • When significant urine leakage occurs, often 10
to 14 days following a laparoscopic
hysterectomy, ureterovaginal fistula should be
strongly considered in the differential diagnosis
• The incidence of ureterovaginal fistula after
laparoscopic hysterectomy appears to be 1% to
4%
• Vaginal and abdominal hysterectomies are
associated with a 0.02% to 0.85% incidence of
ureteral injury

14. Diagnosis

15. • INITIAL EVALUATION -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

16. Physical Examination of a Woman with Lower
Urinary Tract Dysfunction
• Neurologic
• Mental status
• Perineal sensation
• Perineal reflexes
• Patellar reflexes
• Abdominal examination
• Masses
• Cardiovascular
• Congestive heart failure
• Lower extremity edema
• Mobility
• Gait assessment
• Pelvic examination
• Prolapse
• Atrophy
• Levator muscle palpation (symmetry, ability to squeeze)
• Anal sphincter function
• Test of urethral mobility (e.g., cotton swab test)

17. Simple (Primary Care Level) Tests
• Voiding Diary - 24-hour urinary output, the total
number of daily voids, number of nighttime voids, the
average voided volume, and the functional bladder capacity
(largest volume voided in normal daily life)
• provides treatment options
• Urinalysis – Dipstick test and microscopy for Hematuria ,
diagnosis of UTI
to rule out kidney or bladder tumors – in case of hematuria
without bacteriurea

18. Postvoid Residual Volume
• After a woman voids, the PVR may be measured
with a handheld sonographic bladder scanner or
by transurethral catheterization.
• Test should be done with in 10 minutes of void
due to diuresis
• Less than 50 mL is normal
• greater than 200 mL is abnormal
• Mid-range value -Debate
• USG -15-20 % error

19. Postoperative Postvoid Residual
• A voided volume of at least 300 mL and PVR
less than 100 mL is desirable
• If she is unable to void within 4 to 6 hours of
removing the urinary catheter, then a catheter
is replaced, and the test is repeated a day or
more later.

20. Cough Stress Test
• If leakage is not observed when the woman is
supine, she should stand with her feet
separated and cough several times

21. Pad Tests
• In research not clinical practice
• Full bladder or saline instilled in to the bladder
• Short term for office hours and long term at
home for 24 to 48 hours
• Pad weight gain 1 gram – 1 hour ; 4 gram for
24 hours

22. Advance Testing

23. Urodynamics
• urodynamic study is anything that provides
objective evidence about lower urinary tract
function
• measurement of a patient’s voided urine
volume and catheterization to determine her
PVR volume are urodynamic studies
• frequency/volume chart is also a valuable
urodynamic study

24. Uroflowmetry
• volume of urine voided is plotted over time
• Flow time, peak flow rate, and time to peak
flow usually increase as the voided volume
increases

25. Filling Cystometry
• Cystometry is done to assess bladder and urethral function during
bladder filling.
• Pdet = Pves – Pabd.
• electronic microtip transducer pressure catheters, fluid-filled
pressure lines, fiber optic catheters, or air-charged catheters
• Both false positive and false negative results can occur with
urodynamic studies
• False positive – asymptomatic detrusor overactivity , detrusor
overactivity that is irrelevant to the symptoms or detrusor is
situational ( e.g. anxiety )
• False negative results can occur as 20-40 minutes cystometrogram
is not always measures 24 hour bladder activity

26. Tests of Urethral Function
• urethral pressure profilometry, Valsalva leakpoint pressures
and fluoroscopic and cystoscopic assessment of the bladder
neck
• Pclose = Pure – Pves.
• Pclose < 20 cm of H2O – poor prognosis
• Urthral pressure profilometry is not useful diagnostic test for
stress incontinence

27. Valsalva Leak-point pressure (LPP)
• is a urodynamic measure of the minimum
intraabdominal or intravesical pressure
required to cause incontinence during
abdominal strain or cough
• The abdominal leak point pressure (LPP) is
114 cm H2O (the abdominal pressure at
which the patient leaked urine).
• LPP measurement is done at bladder volume
200 or 300 ml

28. Approximate Normal Values of
Female Bladder Function
• Residual urine <50 mL
• First desire to void occurs between 150 and 250 mL infused
• Strong desire to void does not occur until after 250 mL
• Cystometric capacity between 400 and 600 mL
• Bladder compliance between 20 and 100 mL/cm H2O measured 60
sec after reaching cystometric capacity
• No uninhibited detrusor contractions during filling, despite
provocation
• No stress or urge incontinence demonstrated, despite provocation
• Voiding occurs as a result of a voluntarily initiated and sustained
detrusor contraction
• Flow rate during voiding is >15 mL/sec with a detrusor pressure of
<50 cm H2O

29. Voiding Cystometrogram
• vesical, abdominal, and urethral pressures are
measured simultaneously during bladder
emptying
• Valsalva voiding, low preoperative flow rate,
and high preoperative detrusor pressures
during voiding as risk factors for postoperative
voiding dysfunction
• This test of gives contrdictory results

30. Imaging Tests
• Role not established
• ultrasonography, fluoroscopy, functional
neuroimaging, and magnetic resonance
imaging (MRI)

31. Neurophysiologic Tests
• The neuromuscular function of the pelvic
floor is dependent on the integrity of the
nervous system.
• These tests are not routinely used in the
clinical evaluation of most incontinent
women

32. Pudendal Nerve Terminal Motor Latency
(PNTML)
• indirectly assesses the integrity and patency of the terminal portion of the
pudendal nerve, its neuromuscular junction, and the muscle it serves
• Done by specialized electrode affixed over the index finger, the pudendal
nerve is electrically stimulated near the ischial spine (either transrectally
or transvaginally), and the resulting muscular response is measured
• The response, termed a compound muscle action potential (CMAP), is
detected at the anal sphincter.
• The interval between the stimulation and the onset of the CMAP is
measured.
• A prolonged latency is noted with injury to large and heavily myelinated
axons.
• The latency time may be within the normal range when only smaller nerve
fibers are affected; thus, neurologic dysfunction may exist in the presence
of a normal latency time.

33. Sacral Reflexes
• Sacral reflexes can gather information about both the
afferent and efferent arc in the pelvic nerves
• A short train of dual impulses delivered next to the
clitoris and measured at the anal sphincter is termed
the clitoroanal reflex and provides information about
the integrity of the afferent and efferent arm of the
somatic pudendal nerve
• A stimulating electrode placed in the bladder sends
these signals along the visceral, autonomic fibers to the
spinal cord, and a reflex signal will return along the
pudendal nerve to the anal sphincter.

34. Somatosensory Evoked Potentials
• Normal pelvic floor and pelvic organ function
ultimately is controlled by higher centers in the central
nervous system, including the cerebral cortex
• electrical or magnetically induced stimuli can be
delivered at the motor cortex (or along the spine), and
the induced muscle action potentials can be detected
• Prolonged latencies not attributable to the peripherally
studied nerves (such as with a PNTML or sacral reflex)
are evidence of a central nervous system conduction flaw

35. Electromyography
• assesses the inherent electrical potentials
generated during neuronal activation of skeletal
muscle
• performed using surface electrodes or needle
electrodes
• Needle EMG of the pelvic floor can “map” the
anatomic location of muscles
• assess nerve injury and determine whether the
injury is acute and ongoing or chronic
• Single-fiber EMG can quantify the ratio of muscle
fibers to nerve fibers (the so-called fiber density)

36. Emerging Technologies
• Positron emission tomography and functional
magnetic resonance imaging studies
• used in the research setting only

37. Treatment
• Non Surgical Treatment
• Surgical Treatment

38. Nonsurgical Treatment
• treatment is based on the clinical findings and
the degree of discomfort experienced by the
patient, who should be fully informed of the
risks and expected outcome.
• Lifestyle Changes
• Physical Therapy
• Behavioral Therapy and Bladder Training
• Vaginal and Urethral Devices
• Medications

39. Lifestyle Changes
• weight loss in both morbidly and moderately
obese women decreases both stress and urge
urinary incontinence
• Postural changes (such as crossing the legs during
periods of increased intra-abdominal pressure)
often prevent stress urinary incontinence
• decreasing caffeine intake improves continence
• Although smokers are at greater risk for
incontinence, no data were reported on whether
smoking cessation resolves incontinence

40. Physical Therapy
• 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 first-line conservative management to
women
• The woman must do the exercises correctly, regularly, and
for an adequate duration - three to four times per week,
with three repetitions of eight to ten sustained contractions
each time
• Electrical stimulation therapy -delivering low levels of current
via a probe placed in the vagina or rectum

41. Behavioral Therapy and Bladder Training
• This program lasts for about 6 weeks
• Behavioral therapy focuses on improving voluntary control -
primary technique is pelvic floor muscle training
• Bladder training focuses on modifying bladder function by
changing voiding habits - key component “ 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

42. • Empty bladder when awake , and then every time during
the day that the interval is reached (for example, every 30
to 60 minutes)
• Urge suppression strategies - distraction or relaxation
techniques - mental exercises (such as mathematical
problems), deep breathing, or “singing” the words to a
song silently ; The main goal is to avoid running to the
bathroom at the moment of severe urgency
• Another strategy is to quickly contract the pelvic muscle
several times in a row (“freeze and squeeze”), which often
lessens urgency.
• Gradually, the interval is increased (usually weekly) until
the patient voids every 2 to 3 hours

43. • Patients with neurogenic detrusor overactivity, rather than
idiopathic detrusor overactivity, do not respond as well to
behavioral therapy because the problem is actually one of
neural pathway destruction rather than the need to
reestablish cortical control mechanisms.
• In a randomized trial, the guidance of a simple self-help
booklet was only somewhat less effective in reducing
leakage (mean reduction in leakage episodes 43%) than
behavioral training (mean reduction 69%) or behavioral training
plus electrical stimulation (mean reduction 72%).

44. Vaginal and Urethral Devices
Vaginal incontinence pessaries: (clockwise from top): A: Suarez ring (Cook
Urological,Spencer, IN), B: PelvX ring (DesChutes Medical Products, Bend, OR),
C: Incontinence dish (Milex Inc.Chicago, IL), D: Incontinence dish with support
(Mentor Corp., Santa Barbara, CA), E: Introl prosthesis (was Johnson and
Johnson; currently not available), F: Incontinence ring with support (Milex Inc.,
Chicago, IL), (middle): G: Incontinence dish with support (Milex Inc., Chicago, IL)

45. • Urethral inserts are sterile inserts placed into the urethra by
the patient and removed before a void, after which a new
sterile insert is placed.
• Appropriate for women with relatively pure stress
incontinence, no history of recurrent urinary tract infections,
and no serious contraindications to bacteriuria (e.g., artificial
heart valves)
• In a 5-year, multicenter trial involving 150 women with a
mean follow-up of 15 months, a statistically significant
reduction in incontinence episodes and pad weight were
observed with 93% of the women having a negative pad test
at 12 months.

46. Medications
STRESS INCONTINENCE -
• No drugs are cleared by the FDA to treat stress
incontinence.
• Duloxetine (Cymbalta), a selective serotonin-
and norepinephrine- reuptake inhibitor (SSRI),
has been evaluated for SUI treatment
• conjugated estrogen with or without progestin should not be
prescribed for the prevention or relief of urinary incontinence

47. Urge Incontinence and Overactive Bladder
• The drugs used for treating detrusor overactivity
can be grouped into different categories
according to their pharmacologic characteristics
• Anticholinergic agents that exert their effects on
the bladder by blocking the activity of
acetylcholine at muscarinic receptor sites
• Commonly used drugs are – Oxybutynin ,
Tolterodine , Trospium chloride , Solifenacin
succinate , Darifenacin
• Side effects : dry mouth , increased heart rate ,
constipation , blurred vision

48. • When initiating therapy with generic oxybutynin, it is best to start
with a lower dose (particularly for elderly patients) and increase it
as needed to a higher, more frequent dosage.
• Patients should be encouraged to titrate their medication to their
symptoms and to vary the dosage (within acceptable limits)
according to their needs. If this is not effective, the next step is to
move to one of the other anticholinergic agents. Some women may
respond better to one agent than another.
• A 2-week trial is sufficient to determine effectiveness.
• It is helpful to ask patients to record daily episodes of incontinence
or urgency before and during therapy so effectiveness can be more
accurately determined.

49. Nocturia and Nocturnal Enuresis
Medications that treat nocturia and nocturnal
enuresis have one of three aims:
• (i) to reduce urine output,
• (ii) to increase bladder capacity and reduce
unstable bladder contractions, and
• (iii) to act centrally on sleep and micturition
centers.

50. • An analogue of arginine vasopressin- DDAVP
• Available as nasal spray or oral ( 10 times dose more than nasal
spray )
S/E - Hyponatremia
• Tricyclic antidepressants – Imipramine- Acts by altering the sleep
mechanism, by providing anticholinergic or antidepressant effects,
or by affecting antidiuretic hormone excretion
• - typical starting dose of imipramine is 25 mg at bedtime,
which may be increased to as high as 75 mg
• S/E - increases the risk of hip fracture , orthostatic
hypertension
• Bumetanide (a loop diuretic) 1 mg decreases nocturia by 25%
compared with placebo

51. Surgical Treatment for Stress
Incontinence
• In 1997, the American Urological Association
convened a clinical guidelines panel to analyze
published outcomes data on surgical procedures
to treat female stress urinary incontinence and to
produce practice recommendations to guide
surgical decision making
• The panel concluded that colposuspension (e.g.,
Burch, Marshall-Marchetti-Krantz [MMK]) and
slings were more effective than transvaginal
needle suspensions or anterior repairs for long-
term success (48-month cure/dry rates)

52. • The median probability estimates for cure/dry
rates at 48 months and longer were 84% (95%
confidence interval [CI], 79%–88%) for
colposuspension and 83% (95% CI, 75%–88%)
for sling procedures, compared with 67% (95%
CI, 53%– 79%) for transvaginal needle
suspensions and 61% (95% CI, 47%–72%) for
anterior repairs.

53. Retropubic Urethropexy (Colposuspension)
• In 1949 Marshall et al. described their technique for
urethral suspension in a man with postprostatectomy
incontinence
• A variety of modifications of this operation were
described, all of which share at least two
characteristics
• They are performed through an open low abdominal
incision or with laparoscopically assisted exposure of
the space of Retzius and they all involve attachment of
the periurethral or perivesical endopelvic fascia to
some other supporting structure in the anterior pelvis

54. • MMK(Marshall-Marchett-Krantz procedure) -
operation, the periurethral fascia is attached to the
back of the pubic symphysis
• Burch colposuspension - involves the attachment of
the fascia at the level of the bladder neck to the
iliopectineal ligament (Cooper’s ligament)
• In paravaginal repair - the lateral endopelvic fascia
along the urethra and bladder is reattached to the
arcus tendineus fascia pelvis
• Turner-Warwick vaginoobturator shelf procedure - the
endopelvic fascia, vagina, or both are attached to the
fascia of the obturator internus muscle

55. complications
• Complications commonly associated with
these procedures can include de novo
detrusor overactivity, urinary retention, and in
the case of the MMK, osteitis pubis.
• addition, data suggest that performing a Burch
retropubic urethropexy concurrently with
abdominal sacrocolpopexy for vaginal vault
prolapse may significantly reduce rates of
symptomatic postoperative SUI

56. Traditional Pubovaginal Sling
• Sling operations traditionally were performed using a
combined vaginal and abdominal approach.
• The anterior vagina is opened, the space of Retzius is
dissected on each side of the bladder neck, and a sling
is passed around the bladder neck and urethra and
then attached to the anterior rectus fascia or some
other structure to cradle the urethra in a supporting
hammock
• This supports the urethra and allows it to be
compressed during periods of increased intra-
abdominal pressure

57. • The sling ca be made of organic or inorganic materials.
• Organic materials can be autologous tissues harvested from
the patient (e.g., fascia lata, rectus fascia, tendon, round
ligament, rectus muscle, vagina), processed allografts from
human donors (e.g., fascia lata, dermis), or heterologous
tissues harvested from another species and processed for
surgical use (e.g., ox dura mater, porcine dermis).
• Synthetic materials (e.g., Silastic, Gore-Tex, Marlex) are
popular because of their consistent strength and
availability, but historically these substances were plagued
by problems with erosion and infection when used around
the urethra .

58. • The multicenter Urinary Incontinence
Treatment Network conducted a randomized
clinical trial comparing Burch colposuspension
and fascial pubovaginal sling in 655 women
with stress urinary incontinence based on a
cough stress test, success rates were 71% in
the Burch group and 87% in the sling group,
while based on a pad test, rates were 84% and
85%, respectively.

59. Minimally Invasive Sling
• Tension-free vaginal tape (TVT) - Described by Falconer et al
in 1996 - for correcting stres urinary incontinence. In this
technique, polypropylene mesh is placed under the
midurethra with minimal tension
• To perform this operation, a small incision is made in the
vaginal epithelium mucosa. A 40- by 1-cm mesh tape
covered by a plastic sheath and attached to two 5-mm
curved trocars is passed lateral to the urethra and through
the endopelvic fascia into the retropubic space. The trocar
is passed along the back of the pubic bone, through the
rectus fascia, and into two small suprapubic skin incisions.
The tension on the tape is adjusted, the sheath is removed,
and the remaining tape is cut off at the level of the skin.

60. Transobturator tape procedure (also known as a
TOT) or transobturator suburethral tape
• Inserting the trocar through the obturator
space theoretically lessens the risk of bladder,
bowel, or vascular injury because the
procedure involves passing the polypropylene
midurethral sling through the obturator
membrane along its ischiorectal fossa path,
bypassing the pelvic cavity altogether
• There were no significant differences between groups in
postoperative urge incontinence, satisfaction with the
results of the procedure, or quality of life

61. Minislings
• Insertion of the minisling requires only a
single vaginal incision, less dissection, and the
potential to be placed in a clinic setting.
• Data are mixed, with some finding equivalent
success rates and others up to eightfold higher
failure rates in the minisling group than in the
full-length synthetic sling

62. Bulking Agents
• Injectable (so-called bulking) agents are less invasive than
surgery, and although they are less likely than surgery to
result in cure, they relieve symptoms in many women
• In the United States, glutaraldehyde cross-linked bovine
collagen (Contigen), carbon beads (Durasphere), cross-linked
polydimethylsiloxane (Macroplastique), and calcium
hydroxylapatite (Coaptite) are approved for use to treat
stress urinary incontinence and can be injected either peri-
or transurethrally
• Injecting a material around the periurethral tissues
facilitates coaptation of the urethra under conditions of
increased intra-abdominal pressure

63. Complications
• Bladder perforation
• Prolonged Catheterization
• vascular injury
• bowel injury
• severe infections
• retropubic hematoma
• injury to the epigastric vessel
• injury to the obturator nerve

64. • urinary tract infection
• failure to cure
• new onset detrusor overactivity
• voiding dysfunction
• genital prolapse
• excessive blood loss
• wound infection

65. Procedures for Urgency Urinary
Incontinence

66. Neuromodulation
• Sacral nerve stimulation therapy - is
performed in two phases. In the first phase, a
percutaneous nerve evaluation test is
performed to determine which patients
respond to this type of therapy. Those who
respond are implanted with a permanent
electrode lead adjacent to the third sacral
nerve root connected to a pulse generator

67. • Percutaneous Tibial Nerve Stimulation - This
therapy uses peripheral neurostimulation
technique with small (34-gauge) needle
electrode inserted at a 60-degree angle
approximately 5 cm cephalad to the medial
malleolus and slightly posterior to the tibia.
The treatment course typically consists of a
weekly 30- minute session for 12 weeks.

68. Botox Injections
• Botulinum toxin A (BtxA), a neurotoxin
produced by the anaerobic bacteria
Clostridium botulinum, acts on peripheral
cholinergic nerve endings to inhibit calcium-
mediated release of acetylcholine vesicles at
the presynaptic neuromuscular junctions.

69. Augmentation Cystoplasty and Urinary
Diversion
• Is for intractable detrusor overactivity not
responsive to any other form of management.
• These surgical options include -
(i) conduit diversion (creation of various
intestinal conduits to the skin) or continent
diversion (which includes a rectal reservoir or
continent cutaneous diversion),
(ii) bladder reconstruction,
(iii)replacement of the bladder with various
intestinal segments

70. Surgical Treatment of Fistulae
• The keys to closure of a vesicovaginal fistula
include wide mobilization of tissue planes so
that the fistula edges can be approximated
without any tension, close approximation of
tissue edges, closure of the fistula in several
layers, and meticulous attention to
postoperative bladder drainage for 10 to 14
days

71. • The closure of large fistulas will be enhanced
by the use of tissue grafts (e.g., Martius labial
fat-pad grafts, gracilis muscle flaps) that
provide an additional blood supply to nourish
an area that has sustained vascular injury. The
Latzko procedure used to close a vesicovaginal
fistula

72. Cystoscopy
• Scientific evidence does not support routine
cystoscopy in women with stress urinary
incontinence in the absence of other
pathologies
• Cystoscopy cannot be used to predict
intrinsic sphincteric deficiency, stress
incontinence, or detrusor overactivity

73. • Cystoscopy can be considered in the following
circumstances:
• (i) in women with urge incontinence to rule out
other disorders, especially in women with
microscopic hematuria
• (ii) in the evaluation of vesicovaginal fistulae,
• (iii) intraoperatively to evaluate possible
ureteral or vesical injury.

74. • Cystoscopes are available with several
viewing angles:
• 0 degree (straight) essential for viewing the
urethra
• 30 degrees (forward-oblique) -best view of
the bladder base and posterior wall
• 70 degrees (lateral) -provides the best view of
the anterior and lateral walls
• 120 degrees (retroview)

75. • For diagnostic cystoscopy, sterile water is an
ideal medium because it is readily available
and inexpensive
• Vaginal and abdominal hysterectomies are
associated with a 0.02% to 0.85% incidence
of ureteral injury (137) . The injury rate
increases in reconstructive pelvic surgeries,
reaching as high as 11% after uterosacral
ligament suspension

76. Voiding Dysfunction and Bladder
Pain Syndromes

77. Voiding Dysfunction
• Women are afflicted less commonly than men with
voiding difficulties
• defined as emptying dysfunction resulting from
relaxation of the pelvic floor musculature or failure of
the detrusor muscle to contract appropriately
• True outflow obstruction (defined as a detrusor
pressure of more than 50 cm H 2O in association with a
urine flow rate of less than 15 mL/sec) is rare in women
and, when seen, is usually found in those who
underwent obstructive bladder neck surgery for stress
incontinence

78. • For normal voiding to occur, the pelvic floor
and urethral sphincter must relax, which
should happen in conjunction with a
coordinated contraction of the detrusor
muscle that leads to complete bladder
emptying
• Fowler’s syndrome refers to unexplained
urinary retention occurring as an isolated
phenomenon

79. • Causes –
• Neurologic diseases - multiple sclerosis
Drugs - antihistamines and anticholinergic
agents
Infections - herpes simplex virus, and
urinary tract infections
obstruction - following bladder neck
surgery, or in women with advanced pelvic organ
prolapse), overdistension , severe
constipation ( particularly in the elderl
Rarely - Psychogenic factors.

80. Evaluation
• Physical examination - pelvic masses in
particular, low anterior myomas
• Neurologic examination of the perineum and
lower extremities may suggest the need to
focus on the spine
• Urodynamic evaluation – obstruction,
detrusor muscle is not contracting
• Cystourethroscopy - polyp, tumor, ureterocele,
or ball-valve stone

81. Treatment
• The mainstay in the treatment of voiding
difficulty is clean, intermittent self
catheterization
• Decreasing urinary urgency and incontinence
caused by detrusor overactivity, neuromodulation
of the sacral nerve roots may help women with
nonobstructive urinary retention
• α-blockers (e.g., prazosin,
• phenoxybenzamine, tamsulosin), which reduce
urethral tone

82. Bladder Pain Syndromes
• Definition - an unpleasant sensation (pain,
pressure,discomfort) perceived to be related to
the urinary bladder associated with lower
urinary tract symptom(s) of more than 6 weeks
duration, in the absence of infection or other
identifiable causes”
• Urgency and pain are the defining characteristics
of bladder pain syndrome
• International Continence Society

83. • EPIDEMIOLOGY
• According to Interstitial Cystitis Database
study - affected individuals are predominately
female (92%), white (91%), and report an
average age of symptom onset of 32.2 years

84. DIAGNOSIS
• History along with a sterile urine specimen for
analysis and culture
• The diagnosis of bladder pain syndrome or
interstitial cystitis is largely one of exclusion.
The ideal diagnostic test for interstitial
cystitis is not determined

85. • Other possible causes for painful voiding
must be considered in the differential
diagnosis, including urethral diverticula;
vulvar disease; endometriosis; chemical
irritation from soaps, bubble bath, or
feminine hygiene products; urinary stones;
urogenital atrophy from estrogen
deprivation; and sexually transmitted
disease.

86. Treatment
• medications used range from local anesthetics to
bladder specific medications including
resiniferatoxin, dimethyl sulfoxide, BCG, pentosan
polysulfate, and oxybutynin.
• Some patients benefit from the instillation into
the bladder of 50 mL of a 50% solution of
dimethylsulfoxide (DMSO) for 20 to 30 minutes
every other week for four or five sessions.
• Tricyclic antidepressants are commonly used in
patients with pain

87. • The FDA-recommended oral dosage of
pentosan polysulfate (heparin-like activity) is
100 mg, three times a day. Patients may not
feel relief from pain for the first 2 to 4 months,
and it may take up to 6 months for a decrease
in urinary frequency to occur.
• Other treatment - sacral neuromodulation
(InterStim), acupuncture, or intravesical Botox
injection associated with hydrodistension.

88. Vesicovaginal Fistula
• Constanat driblling of urine
• Constant wetness of genital area leads to
excoriation of the vulva , vagina , perineum
and thight
• Most common type in our country is VVF at
bladder neck following difficult child birth
• Affected women are short stature with
contracted pelvis

89. Examination
• Done in knee chest position under good light
• Speculum examination – size and location
• Bimanual examination – fixity and extent
scarring of the surrounding tissue
• Methylene blue test – positive test confirm
the diagnosis and helps to plan a repair
operation

90. Management
• In difficult child birth – prolong ctheterization
and antibiotcs
• Most VVF should be repaired vaginally
• LATZKO PROCEDURE - denuding vaginal
epithelium all around the fistulous edge ,
freshening the edge and then approximation
of the wide edge with absorbable suture

91. • CHASSAR MOIR TECHNIQUE - Widely
separating the vagina and bladder all around
the flap – splitting method then suturing the
bladder and vagina separately in two layers
• Suture line in bladder and vagina must not be
overlap
• Hemostasis should be meticulous for success
for the procedure

92. • In case of extensive fibrosis – omental graft ,
interpositioning of Gracillis muscle graft
between bladder and vaginal wall improves
the blood supply at the site of repair and
improves healing process
• Flap splliting surgery is superior than tension
free suture

93. • However in case of established fistula – wait
for 3 months – all tissue inflammation
subside, vascularization improve and local
infection to be clear
• If one attempt fails to heal fistula the 2nd
attempt of repair to be done after 3 months

94. Transvesical or transabdominal
approach
• Large fistula close to or involving the ureteric
orifice
• Failure of previous attempt of surgery of
fistula repair

95. Urinary diversion
• Extensive loss of bladder tissue
• Previous repeated failure of fistula repair
surgery
• Radiation fistula which failure to heal

96. Post operative management
• Catheter for 14 days
• Antibiotics
• No vaginal or speculum examination or
intercourse for 3 months after surgery
• C/S – following successful fistula surgery

97. Complications of fistula surgery
• Stress incontinence – due to rigid urethra, loss
of vesicourethral angle , small bladder and
short urethra

98. Referances
• Berek & Novak’s Gynaecology 15th Edition
• Shaw’s Textbook of Gynaecology 15th Edition
• Williams Gynaecology 2nd Edition

99. THANKS