FEMALE INCONTINENCE and management

1. Dr/ Hatem Wagih Aly
Fellow of European Board of Urology (FEBU)
Member of international continence society (UK)
Member of European association of Urology
Urologist in National Institute of Urology and Nephrology
Highlights on
Bladder overactivity

2. Introduction
 The lower urinary tract functions as a group of
Interrelated structures with a joint function in adults
to bring about efficient and low pressure bladder
filling ,low pressure urine storage with perfect
continence and periodic complete, low pressure
voluntary evacuation.

3. Relevant Anatomy
Bladder.
Body (Detrusor muscle) Base ( Trigone)
Urethra
Proximal. Distal.
Sphincters
Smooth (involuntary) Striated ( voluntary)

4.  Anatomy diagram page 10 urodynamic

5. Relevant Neurophisiology
1-Nervous systems:
Sympathatic nervous system. (T 11-L2)
Parasympathatic nervous system. (S2-S4 IMLC)
Somatic nervous system (S2-S4 Onuff neucleus)
2- Nerves : Hypogastric/Pelvic/Pudendal( all have sensory and
motor fibers)
3-Synaptic ganglia:in sympathatic and parasympathatic NS
4-Neurotransmitters : Mainly Acetyl choline and nor adrenaline
Ach is the transmitter of all pre and post ganglionic receptors except post
ganglionic sympathetic where transmitter is Noradrenaline
5-Receptors : Cholinergic ( Nicotinic / Muscarinic)
Adrenergic ( Alpha / Beta )

6. Sympathetic Nervous System
 Thoracolumbar (T11-L2)
 Hypo gastric Nerve
 Synaptic ganglia
 Preganglionic transmitter :Acetylcholine
 Ganglionic receptor : Cholinergic ( nicotinic )
 Postganglionic transmitter: Nor adrenaline
 Postganglionic receptor : Adrenergic ( alpha/beta)
 Action :Enhance urine storage/continence by:
Increase tone of smooth sphincter(alpha effect)/increase
detrusor relaxation(B effect)/decrease detrusor
contractions by inhibiting parasympathatic stimulation

7. Parasympathatic N.S
Intermediolateralcolumn S2-S4
Pelvic nerve.
Synaptic ganglia.
Preganglionic transmitter : Acetyl choline.
Preganglionic receptor: choinergic ( nicotinic)
Postganglionic transmitter: Acetylcholine
Postganglionic receptor : cholinergic ( muscarinic)
Action : enhances urine evacuation by causing coordinated
detrusor contraction

8. Somatic Nervous system
 Onuffs Nucleus (S2-S4)
 Pudendal Nerve.
 No synaptic ganglia
 Transmitter : Acetylcholine.
 Receptor : Cholinergic ( nicotinic )
 Action : Enhances continence by stimulating
contraction of striated urethral sphincter

9. Sensory pathway
 All the 3 nerves responsible for LUT function are
mixed nerves containing both sensory and motor
fibers.
 Strech receptors of the bladder( and nociceptors)
transmit impulses mainly via afferent fibers of pelvic
nerve.
 Ascending and descending tracts of spinal cord
coordinate actions between spinal and supraspinal
micturation control centers

10.  Diagram page 345

11. Innervation of LUT
 Diagram page 350

12. CNS Control of micturation
 Cerebral cortex
 Cerebellum/Basal ganglia
 Thalamus/ Hypothalamus
 Pontine micturation center
 Inhibitory effects on micturation

13. Micturation cycle
 Increased somatic and sympathetic stimulation
 Decreased parasympathetic
Sphincter contraction Complete evacuation
Detrusor relaxation
Urine storage sphincter relaxation and
Detrusor contractions
Bladder filling and
Stimulation of stretch
Receptors
Decrease somatic and symp.
increase parasympathetic

14. Functional classification of
voiding dysfunction
Failure to store Failure to empty
Bladder Outlet Bladder Outlet
Over activity hypersens GSI ISD BOO DSD
Neurogenic Neurogenic
Myogenic psychogenic Neurogenic
Inflammatory Inflammatory Myogenic
Idiopathic Idiopathic
Neurogenic
Myogenic
psychogenic
Idiopathic

15. AEITEOLOGY
 Bladder
 Neurogenic(LMNL/DM/SCI/Radicle pelvic surgery)
 Myogenic (detrusor failure due to prolonged obstruction)
 Idiopathic ( Fowler syndrome )
 Painful pelvic/perineal conditions (post operative pain)
Bladder Outlet
 ANATOMICAL
 Stones /BPH
 Bladder neck contracture
 POP
 Previous surgery (eg sling)
 Urethral (diverticulum/ mass/ stricture/compression)
 FUNCTIONAL:
 DSD // BLADDER NECK DYSFUNCTION

16. Neurourologic Evaluation
 p364

17. History
 Personal.
 Present /Analysis of complaint/LUTS.
 Past history ( diseases, medications, operations.)
 Family

18. Physical Examination
1-General : Non specific.
2-Focused :Lower abdomen/ genitalia/Rectum
Pelvic examination( prolapse/infection/trigger)
3-Neurologic Mental status( conscious level,orientation)
Motor ( function & coordination)
Sensory (eg saddle shaped area)
Reflexes (deep tendon,BCR,anal )

19. Lab Investigations
 Urine.
 Blood

20. Radiological Evaluation
 Upper tract imaging: KUB/US/IVU/ISOTOPE
 Indications :Decreased compliance/Neurogenic
bladder/coexisting Haematuria/ increased PVR….
 Lower tract imaging: Ascending and micturating
urethrocystogram.
 Indications : suspecion of anatomical BOO/Reflux

21. Endoscopic Evaluation
 Indications:
 When initial investigations suggest other pathology
(haematuria, pain, severe persistent symptoms of
overactive bladder ….)
 Patients who previously undergone bladder ,prostate,
pelvic surgery
 Suspicion of anatomical BOO if un identified by initial
investigations

22. Urodynamics Indication
 Uroflow + PVR is a simple non invasive test used to
confirm the prescence of urine outflow obstruction and
efficiency of bladder Evacuation.
 Limitations : Aeiteology of weak flow
Sensitivity/specificity

23. Urodynamics Indications
 Indications of other urodynamics tests.
 Failure of empiric treatment.
 Combined voiding and storage dysfunction.
 Significant morbidity of proposed treatment.
 Inability to demonstrate incontinence clinically inspite of patient
complaint.
 Following prior surgery for incontinence.
 Following radical pelvic surgery/Radiation.
 Known or suspected neurogenic disorder that may affect bladder
function.
 Female obstructive symptoms/Retention.
 Male incontinence

25. BOA Associated with decreased compliance

26. BOO

30. TREATMENT
 DETRUSOR HYPOCONTRACTILITY
 MEDICAL TREATMENT
 SURGICAL TREATMENT
 NEUROMODULATION
 CIRCUMVILLATING PROBLEM
 NEW RESEARCH PROJECTS

31. BLADDER OUT LET
 ANATOMICAL OBSTRUCTION
 TREAT CAUSE
 URINARY DRAINAGE
 FUNCTIONAL OBSTRUCTION
MEDICAL TREATMENT
MINIMALLY INVASIVE
NEURO MODULATION
SURGICAL INTERVENTION
URINARY DRAINAGE

32. THANK
 YOU

34. Definition
 Bladder overactivity is the presence of phasic involuntary
contractions of detrusor muscle associated mainly with
urgency +/- urge incontinence +/- decreased compliance
during the filling phase of micturation.
Bladder overactivity can be diagnosed after exclusion of
other pathologies causing similar symptoms( eg infection)

35. Objectives
Awareness about sub specialty.
Scientific objective.
Clinical objective.

36. Epidimiology
 Overactive bladder syndrome affects about 12 % of
adult
population.
 Two types of bladder overactivity:
Dry : 60 % Wet : 40%

37. Aeiteology
 Neurogenic
 Myogenic
 Inflammatory
 Idiopathic
 Others : eg aging ( due to neural degeneration) stress
incontinence ( due to sudden urine entery in proximal urethra).
 NB: Bladder hyper sensitivity can be misdiagnosed as bladder
overactivity

38. Bladder Diary
 Page 23 urodynamic

39. Pad Test
 1 hour pad test is more practical.
 Drinking 500 ml water.
 Weighing and wearing the pad
 Variable activities ( walking, climbing stairs bending
,washing hands….)
 Weighing pad after 1 hour.
 More than 1-1.4 gm increase in pad = positive

40. Urodynamics findings in OAB
 Voiding Diary : Frequency& nocturia/variable usually reduced
voided volumes/ urgency &/or urge incontinence.
 1 Hour pad test : greater than 1.4 gm increase in weight.
 Cystometry : Decreased capacity and compliance// increased
sensations// detrusor over activity.
 Video urodynamics : Bladder trabeculations,+/- diverticulae+/-
vesico ureteric reflux.

41. Neurogenic voiding Dysfunction
Supra pontine : CVA/CP/Dementia/Brain tumors …..
Main effects : DO / No DSD.
Pontine (PMC/PSC) : Parkinsonism/ M.S.
Main effects: Any type of dysfunction(DO/DF/DSD/ISD)
Suprasacral spinal : SCI/MS
Main effects : DO/DSD/High voiding pressures.
Sacral and Subsacral:Meningiomyocele/spina bifida/DM
Main effects : complete lumbosacral DO/ISD
complete sacral/subsacral DF
incomplete sacral/ sub sacral DO/DF/ISD

44. NON Neurogenic voiding dysfunction
Bladder Hypersensitivity (PBS)
 C/P :Long standing bladder/ urethral pain,pressure,
discomfort increasing with bladder filling associated with
frequency +/- urgency in the absence of any obvious cause.
 Diagnoses : Lab.
 Imaging.
 Endoscopy.
 Urodynamics: Increased sensations
No DO.
Increased voiding pressure

45. Urinary Incontinence
 Incontinence is involuntary leakage of urine.
Types
 Stress incontinence.
 Urge incontinence.
 Mixed incontinence.
 Unconscious incontinence.
 Situational incontinence.
 Continuous incontinence ( overflow/fistula)

46. Urge incontinence overactive bladder
 Involuntary urine leakage associated with a sudden
compelling desire to void ( can be triggered by many
factors or spontaneous)
 Etiology: Myogenic/Neurogenic/psychogenic/
Inflammatory / Idiopathic.
 Diagnoses : C/P / Exam/voiding diary/ pad test.
 Lab.
 Imaging.
 Urodynamics : Decreased capacity & compliance
Increased sensations & DO.
NB: Cough induced bladder over activity and urge incontinence

47. Cough induced detrusor overactivity

48. Treatment Objectives
 1- Protection of upper tract.
 2-Treat Pathology & restore function.
 3-Improve Quality of life

52. Clinical approach to patients with OAB.
The Golden Rule of 2
 Evaluate 2 : Inflammation ( infection/no infection).
 Obstruction (Anatomical/ functional)
 Exclude 2 : PBS / CPPS
 Categorise 2 : Neurogenic ( supra spinal/ spinal )
 Non Neurogenic( known aeiteology/idiopatic)
 Treat 2 : Cause (if possible) / Disease& complications
 Follow up 2: Disease progression / Upper tract

53. THANK
YOU

54. National Institute of Urology and Nephrology
Unit of Urodynamics & Neuromodulation
 Presented By / Dr Hatem Wagih Aly
Fellow of European Board of Urology
(FEBU)
Member of international continence society
(UK)
Member of European association of Urology
Urologist in National Institute of Urology
and Nephrology

55.  AIM IS HIGH
 LIMIT IS THE SKY
 PLANE / WORK HARD/ ALWAYS TRY

56. UNIT STRUCTURE /JOB DESCRIPTION
 DIRECTOR
 ASSISTANT DIRECTOR
 SPECIALISTS
 RESIDENTS


57. EQUIPMENTS AND FACILITIES
 URO DYNAMICS MACHINE
 UROFLOW METRY
 NEUROMODULATION & TENS
 CATHETERS / ACCESSORIES / DISPOSABLES
 REGULAR CHECK, REPAIR & EXCHANGE POLICY

58. PAPER WORK AND ARCHIVING
 COMPLETE VOIDING DYSFUNCTION SHEET
 PATIENT INSTRUCTIONS FORM
 INFORMED CONSENT FORM
 APPOINTMENT SCHEDULE &WAITING LIST
 FILLING AND ARCHIVING

59. PATIENT CIRCULATION ( 3 STATIONS )
 STATION ONE (FRONT DESK)
 EXPLANATION AND CONSENT
SHEET AND INVESTIGATIONS
STATION TWO ( BED ONE )
EXAMINATION & CATHETER FIXATION
STATION THREE ( URODYNAMIC BED)
TEST IN COMPLETE PRIVACY & MINMAL INTERRUPTION
NB: SECOND PATIENT SHOULD GIVE CONSENT, HISTORY,
EXAMINED AND CATHETERISED IN STATION 1& 2 WHILE FIRST
PATIENT IS DOING THE TEST IN STATION 3

60. REPORT WRITING AND REVISING
 REPORT SHOULD BE WRITTEN UNDER
COMPLETE SUPERVISION OF ATTENDING
SPECIALIST.
 DIFFICULT CASES SHOULD BE SUPERVISED AND
REVISED BY UNIT DIRECTOR OR HIS ASSISTANT
MOST IMPORTANT STEP

61. TRAINING & CME
 INTERNATIONAL TRAINING PROTOCOLS
 INTERNATIONAL GUIDELINES FOR URODYNAMIC TEST
PERFORMANCE
 DOCTORS EVALUATION
 LECTURES

62. RESEARCH
 YEARLY RESEARCH PLANE
 PROPER ARCHIVING
 PAPERS AND PRESENTATIONS
 RESEARCHERS REWARDS

63. INFECTION CONTROL
 ACCORDING TO INTERNATIONAL AND HOSPITAL
POLICY FOR INFECTION CONTROL AND UNDER
SUPERVISION OF INFECTION CONTROL
COMMITE

64. CO ORDINATION AND TEAM WORK
 HOSPITAL DEPARTMENTS
 OTHER HOSPITALS
 INTERNATIONAL RELATIONSHIPS

65. Female urinary incontinence
Diagnostic Tips
Dr/ Hatem Wagih Aly
 Fellow of European Board of Urology (FEBU)
 Clinical Fellow London University College Hospitals
 Member of international continence society (UK)
 Member of European association of Urology
 Head of Neuro & Female Urology unit
National Institute of Urology and Nephrology

66. UroloGynaecology/ Female Urology
Female Incontinence
GU
infection
Urology/
pregnancy
Female
sexual
dysfunction
POP
GU
Fistula
Female
Urethral
pathology
GU
Trauma
IC/
CPPS

67. Types
 Stress
 Urge
 Mixed
 Situational
 Over flow
 Extra Urethral (fistula / ectopic ureter )
 Non classified (psycological/ urge/ stress)
 +/- Nocturnal Enuresis

68. STRESS INCONTINENCE
 Genuine
 Mixed
 POP
 Stress induced Detrusor overactivity
 Urethral Hyper mobility/ ISD/urethral instability
 ISD (Trauma / congenital/ neurogenic/ idiopathic)

69. URGE INCONTINENCE
 Bladder Over activity
 Neurogenic
 Myogenic( BOO, fibrosis)
 Inflammatory/infection
 Idiopathic
 BladderHypersensitivity
 Inflammatory/infection
 Neurogenic
 psycogenic
 Idiopathic
 Obstruction
 POP
 Previous surgery (sling)
 Urethral diverticulum/mass
 DSD
 Stress induced DO

70. MIXED INCONTINENCE
 Consider all Aeiteologies & DD of Stress & Urge types
 More convinint & bothering type
 Concomitant / Staged treatment
 patient complaint/symptoms
 patient QOL/ Expectation
 Upper tract affection/Risk
 Type of treatment

71. SITUATIONAL INCONTINENCE
 Washing hands
 Getting of bed
 Opening the door( key in lock sign)
 Sexual intercourse
 THE ACTUAL CAUSE OF INCONTINENCE IN THESE
SITUATION CAN BE BLADDER OVERACTIVITY OR
BLADDER OUT LET INCOMPETENCE OR OTHER
INCONTINENCE AETIOLOGIES

72. EXTRA URETHRAL INCONTINENCE
 TYPES
 Fistula
 vesico vaginal
 uretro vaginal
 urethrovaginal
 Ectopic Ureters
 AIETEOLOGY
 Congenital
 Inflammatory
 Traumatic
 Neoplastic

73. NON CLASSIFIED INCONTINENCE
 Do not have the classic presentation of any of the
previous types although may have the same aieteology
 Bladder over activity in elderly & diabetics may cause
incontinence without any urgency sensation
 Severe ISD can cause incontinence without any stress,
straining or cough

74. DIAGNOSTIC TOOLS
 History
 Incontinence sevirity scoring systems/QOL
 Frequency volume charts
 Examination ( general, pelvic, neurologic, cough test,Q tip)
 Pad test
 Laboratory investigations (urine, creatinine …..)
 Imaging ( KUB/ US/ VCMG/ IVP/ CT/ MRI )
 Special Tests ( Urodynamics / urethrocystoscopy)

75. Endoscopic Evaluation
 Indications:
 When initial investigations suggest other pathology
(haematuria, pain, severe persistent symptoms of
overactive bladder ….)
 Patients who previously undergone bladder ,prostate,
pelvic surgery
 Suspicion of anatomical BOO if un identified by initial
investigations

76. Urodynamics Indications
 Indications of other urodynamics tests.
 Failure of empiric treatment.
 Combined voiding and storage dysfunction.
 Significant morbidity of proposed treatment.
 Inability to demonstrate incontinence clinically inspite of patient
complaint.
 Following prior surgery for incontinence.
 Following radical pelvic surgery/Radiation.
 Known or suspected neurogenic disorder that may affect bladder
function.
 Female obstructive symptoms/Retention.
 Male incontinence

77. Urodynamics Evaluation
Urodynamics Tests.
 Uroflowmetry.
 Cystometry.
 Pressure flow study.
 Abdominal Leak point pressure.
 Detrusor leak point pressure.
 Urethral pressure profile.
 Video urodynamics.
 EMG is an adjunct to urodynamics Tests

78. VU STRESS INCONTINENCE

79. VU STRESS INCONTINENCE

80. BOO WITH CYSTOCELE

81. Detrusor overactivity

82. BOA Associated with BOO

83. THANK
 YOU