The pathophysiology, presentation and management of urinary incontinence in males and females.

1. Urinary incontinence

2. Continence
“ability to store urine and post pone emptying
until socially acceptable place is available”

3. Mechanisms
Anatomy Physiology

4. Bladder outlet
Man VS Woman
Similar storage units
Different outlets

5. Storage

6. Outlets

7. Bladder outlet in Male

8. Bladder outlet in Male

9. Bladder outlet in Female

12. Urinary incontinence
“Involuntary loss of urine”

13. Pathophysiology
Decreased outlet resistance
Increased detrusor pressure
Abnormal communication
Overflow of reservoir

14. Classification
Based on precipitating event
• Stress incontinence dec outlet resistance
• Urge incontinence inc detrusor activity
• Mixed incontinence
• Overflow incontinence

15. Evaluation
• Basic evaluation
• History
• Physical examination
• Urinalysis
• Additional test:
• Patient's voiding diary
• Cotton-swab test
• Cough stress test,
• Post void residual urine
volume
• Cystoscopy
• Urodynamic studies

16. Bladder diary

17. Questionnaire

18. History
• Bowel habits
• Pelvic organ prolapse
• Coexistent medical
problems
• Obstetrical history
• History of pelvic
surgery
• Neurological symptoms
• Lifestyle issues
• Medications

19. History
• Severity and quantity of
urine lost
• Frequency of
incontinence episodes
• Duration
• Triggering factors
• Constant versus
intermittent urine loss
• Associated lower
urinary tract symptoms
• Urinary tract infections

20. Examination
• General
• Weight
• Wetness of clothes / pads
• Abdomen
• Scars in lower abdomen
• Abdominal straie
• Palpable bladder
• Visceromegaly

21. • Genitilia
– Examine in supine,
standing and left lateral
position
– Cough test
– Skin excoriation
– Use sim’s speculum
– Vaginal examination
• Vaginal wall prolapse
(anterior / posterior)
• Descent of cervix
• Strength of pelvic floor
– Digital rectal examination
– Anal tone
– Penile deformity

22. • Red Flags sings
• Hematuria
• Neurological deficit
• Suspected cancer
• Suspected fistula

23. Stress urinary incontinence
“loss of urine per urethra associated with excertion
(cough, sneez, straining)”

24. Pathophysiology
Urethral hypermobility Intrinsic sphincter deficiency

25. • Risk factors
• Childbirth
• Aging
• Estrogen withdrawl
• Pelvic surgery
• Obesity
• Neurological deficits
• Pelvic fracture
• Prostectomy
• Pelvic surgery
• Radiotherapy
• Neurological deficits

26. • Diagnosis
• Detailed history
• Examination
• Cough test
• Bladder diary
• Post void
• Uroflowmetery
• Cystoscopy
• Urodynamics

27. • Urodynamics
• Abdominal leak point pressure
– Intravesical pressure at which urine leaks from urethra
(generated through stress cough / Valsalva)
• Urethral hypermobility
– Decent of bladder neck on urodynamic study at time of stress
(cough / valsalva)

28. • Treatment
• Conservative measures
– Pelvic floor exercise
– Lifestyle modifications
– Medications

29. • Treatment
• Surgical
– Bulking agents
• Injected submucosally
• Several available agents
• Achieve urethral mucosa
approximation
• Repeated procedures are
often necessary

30. • Treatment
• Surgical
– Retropubic suspension
• For urethral
hypermobility
• Urethra is fixed in
Retropubic area
• Techniques
– Bursh colposuspension
– Vagino-obturator repair
– Marshall Marchetti Krantz
procedure

31. • Treatment
• Surgical
– Slings
• First line therapy for
SUI
• Synthetic
– Retropubic tape (TVT)
– Trans-obturator tape
(TOT, TVTO)
• Autologous
• Non-autologous

33. TVT
• Success rate 90% at one year
• More voiding dysfunctions
• Higher chance of bladder
perforation, lesser chance of
vaginal injury
• Lesser incidence of groin pain
TOT
• Success rate 80% at one year
• Lesser voiding dysfunction
• Lesser chance of bladder
perforation, higher chance of
vaginal injury
• Higher incidence of groin pain

34. • Treatment
• Surgical
– Artificial urinary sphincter • Used for moderate to sever
SUI
• Useful in cases of sphincter
deficiency
• Three units
– Cuff around urethra / bladder
neck
– Compressible pump
– Reservoir

35. Urge incontinence
“Loss of urine per urethra, preceded by strong sense
of voiding”

36. Overactive bladder
“Symptom complex that include urgency with or
without urge incontinence usually associated
with frequency and nocturia”

37. Pathophysiology
Urodynamic detrusor over activity

38. • Diagnosis
• Detailed history
• Examination
• Bladder diary
• Post void
• Uroflowmetery
• Cystoscopy
• Urodynamics

39. • Urodynamics
– Detrusor over activity
• Detrusor contractions during filling phase (spontaneous
/ provoke)
• Rise in vesical pressure and detrusor pressure,
abdominal pressure remain normal

40. • Treatment
– Conservative
• Pelvic floor exercise
• Life style modifications
• Behavioral therapy

41. • Treatment
– Medical
• Anticholinergics
• Beta-3-agonist
– 50% of patients will benefit
from medical therapy
– Various agents are available
– Side-effects: dry mouth, blur
vision, urinary retention
– Contraindicated in glaucoma,
myasthenia gravis, BOO

42. • Treatment
– Neuromodulation – Stimulate sacral nerves
to suppress detrusor over
activity

43. • Treatment
– Intravesical therapy
• Botulinum toxin A
– Acts by inhibiting
acetylcholine release at
synaptic junctions
– Injected sub-mucosally
– Effects take 7-30 days
– Effects last for 6-9 months

44. • Treatment
– Surgical
• CLAM augmentation
cystoplasty
• Decrease over activity
and intravescial
pressures
• Increase capacity
• Protects upper tract

45. • Post prostectomy incontinence
• TURP 1%
• Open prostectomy 0.5%
• Radical prostectomy 10-15 %

46. Pathophysiology
Loss of proximal sphincter mechanism
Decrease functional urethral length
Injury to distal sphincter mechanisms

47. • Treatment
– Conservative
• Pelvic floor exercise
• Lifestyle modifications

48. • Treatment
– Surgical
• Slings
• Artificial urinary
sphincter
– Slings placed around
bulbar urethra to elevate
it

49. Thankyou