This document discusses the management of incontinence in a 15-year-old girl. It outlines various potential causes of incontinence including urge incontinence, ectopic ureter, stress incontinence, neurological issues, urinary tract infections, and urethral diverticulum. The document describes the importance of obtaining a thorough history and physical examination. It recommends investigations such as urine testing, imaging, and urodynamics to evaluate the cause. Potential treatment options discussed include medications, surgery to address specific anatomical issues, and procedures like bladder drill and biofeedback.

1. Management of
incontinence in a 15
year old girl
Mr O’Malley
R Casey
Monday Teaching
18/07/05

2. Causes
 Urge incontinence
 De novo
 Latchkey
 Perimenstrual
 Giggle
 Enuresis risoria – Laughter activates micturition
reflex via intermediation of limbic system

3. Causes
 Ectopic ureter
 Infrasphincteric or vaginal
 Duplex system usually
 Usually detected in childhood

4. Causes
 Stress incontinence
 Post partum
 + Wide bladder neck anomaly
 Raised intra-abdominal pressures
 CF, constipation, heavy exercisers

5. Causes
 Urethrovaginal reflux
 Hydrocolpos –BOO or Incontinence

6. Causes
 Neurological
 DM
 DSD ( myelodysplasia/MS)
 3-5% children have first MS attack before 16 yo
 Spastic paraplegia
 Tethered cord syndrome
 Complication of spinal dysraphism
 Tight filum terminale – traction neuropathy
 Due to abnormal cranial migration of conus

7. Causes
 UTI’s
 5% of girls suffer at least one UTI
 40% associated with some underlying
urinary tract abnormality
 Associated with urge syndrome and
detrusor overactivity

8. Causes
 Urethral diverticulum
 Acquired usually
 Anterior vaginal wall
 Distal two thirds urethra where periurethral glands
open
 Infection of periurethral glands – formation of
retention cyst – ruptures into urethra
 No muscle in the diverticular sac

9. Management
 History
 Dribbling, dysuria, dyspareunia
 Urgency
 UTI
 Retention
 Provoking factors
 Marked disturbance of bowel habit

10. Physical examination
 Palpable bladder
 Intact hymen
 Suburethral mass
 Palpable urethral stone
 Expression of purulent material
 Hairy patch, cutaneous haemangiomata, sinuses –
Spinal dysraphism
 Sacral agenesis – flattened buttocks, absence of
sacrum

11. Physical Examination
 Lower limb hyper-reflexia
 Wasting of calves
 Deformity of feet

12. Investigations
 MSU/ Blood glucose
 Lumbar spine xr
 Renal U/S
 DMSA renogram
 Positive pressure retrograde urethrography
 MR urethra
 Cystoscopy + EUA
 Myelography
 MR brain/spinal cord
 Lumbar puncture (OCB’s)
 Urodynamics

13. Treatment
 Anticholinergics
 Antibiotic treatment +/- suppression
 Bladder drill, biofeedback, PFE’s
 Laminectomy
 Treatment of underlying cause
 MS, DM, Ectopic ureter

14. Treatment
 Ectopic ureter (infrasphincteric or
vaginal)
 Duplex
 Upper pole nephrectomy
 Pyelopyelostomy
 Reimplantation
 Single system ectopic ureter

15. Treatment
 SIC
 Bladder augmentation
 Intravesical botox