The document discusses urinary incontinence, specifically stress urinary incontinence (SUI). It defines SUI and describes its prevalence, types, grading, anatomical classification, and various pathophysiological theories. It discusses investigations for SUI including stress tests, urodynamic studies, and imaging. Management options covered include conservative approaches like pelvic floor exercises, medical therapies, intraurethral devices, and surgical interventions for SUI like anterior colporrhaphy and Burch colposuspension. The document also presents the Unani perspective on SUI, including causes, diagnosis, and treatments focused on addressing coldness, weakness of the bladder and its sphincters.

1. Presented by Fazly shakoor
Under guidance
Dr. wajeeha begm
HoD dept of OBG

2. Urinary incontinence
• Urinary incontinence is a condition in which involuntary loss of
urine is a social or hygienic problem and is objectively
demonstrable
• TYPES
True incontinence/continual
Urge incontinence- it is associated with strong desire to void
Stress incontinence-leaking on stress
Overflow incontinence-it is sequel of prolonged and neglected
retention

3. Prevalence
• After detailed assessment of data from 48 epidemiological
studies, conducted over apx, 40 years hampel at al found
that over all prevalence of UI ranged from 4.5-53%.
• SUI is most common type of urinary incontinence in
women, with 78% of incontinent women presenting with
the symptoms of SUI.
Urinary incontinence
p.no.9

4. Stress urinary incontinence
• Sir eardly holland 1n 1922 introduced the term SUI
• Stress urinary incontinence (SUI) is defined by the
international continence society (ICS) as the complaint of
involuntary leakage of urine on effort or exertion, or on
sneezing or coughing.

5. Genuine stress urinary incontinence
• Urinary loss which occurs with sudden elevation of the
intra abdominal pressure without detrusor contraction is
called stress urinary incontinence

6. Grading of SUI
• Grade 0
Incontinence without leakage
• Grade 1
Incontinence with only severe stress, such as coughing,
sneezing, and jogging
• Grade 2
Incontinence with moderate stress, such as fast walk, going up
and down the stairs
• Grade 3
Incontinence with mild stress such as standing

7. Types of SUI
• Type 1
Incontinence due to loss of posterior urethrovesical angle
alone
• Type 2
Incontinence due to loss of posterior urethrovesical angle as
well as urethral hypermobility
• Type 3
Incontinence due to ISD

8. Anatomical classification
Blaivis and Olsson, 1998
Based on urodynamic method

9. Types During Rest During Stress
Bladder base
position (IMPS)
Bladder neck &
Proximal urethra
Bladder base
position
Bladder neck &
Proximal urethra
Type 0 Normal position closed Rotational descent No leakage
Type 1 Normal position closed Descent
2cm
Open
leakage ve
Type 2A Normal position closed Rotational descent Open
Leakage
Type 2B At or below the closed Further descent Open
Leakage
Type 3 or ISD Normal position Open Not descent Open and leakage

11. • Pathophysiology

12. Anatomical theories
• Urethrocele is dislocation of urethra and it is the cause of
incontinence Mann’s American System of Gynecology 19 cent.
• Kelly invented cystoscope in 1914
The cystoscopic picture presents a gaping internal
sphincter orifice which closes sluggishly.
• Bonney attributed SUI to vesical neck funneling and he
hypothesised cause of this is loss of elasticity of urethral and
vesical sphincter.
• Incontinence caused by sagging of pubocervial muscle sheet which
interfere with the sphincter mechanism (bonney 1923)

13. • Kennedy 1923 suggested injury to the urethral
sphincter as the principal etiology of SUI
• Funneling of the bladder floor towards the urethra and
flattening of urethro vesical angle of the bladder showed
in sagittal image in cystogram (1937)
• SUI is now thought to be due to abnormality in urethra
On MRI of the pelvic floor SUI was associated with unequal
movement of anterior and posterior wall of bladder neck and
urethra in the presence of increased intra abdominal pressure
Urethral luemen pulled open as the posterior wall moved
away from the anterior wall
The Pathophysiology of Stress Urinary Incontinence: A Historical Perspective .2004

14. Pressure transmission theory
• Enhorning 1961
• Demonstrated the unequal pressure transmission
in bladder and urethra during increased intra
abdominal pressure in incontinent subjects
campbell walsh urology:expert consult

15. Hammock hypothesis
• In 1996, De Lancey proposed a consolidated theory of SUI
• He hypothesized that the pubocervical fascia provides
hammock like support for the vesical neck and there by creates
a backboard for the compression of proximal urethra during
increased intra abdominal pressure.
• Loss of this support would compromise equal transmission of
intra abdominal pressure.
campbell walsh urology:expert consult

16. Sphincteric Dysfunction Theory
• Agency for Health Care Policy and Research, 1992
• SUI the condition of “intrinsic sphincteric deficiencyʼʼ
In this condition, the urethral sphincter is unable to generate
enough resistance to retain urine in the bladder especially during
stress maneuver

17. Pathophysiology
• Urethral hypermobility
• Sphincter deficiency without descent (ISD)

18. Risk factor for ISD
Congenital CNS dysfunctions/lesions
Smooth muscle disorders
Striated muscle disorders
Acquired Childbirth
Prior pelvic surgery
Radiation therapy
CNS lesions
Peripheral neuropathies
Chronic catheter drainage
Other Hypoestrogenism
Aging

19. Aetiology
• Age
• Multiparity
• Obesity
• Smoking
• Prolapse
• Constipation
• Pregnancy and puerperium
• Atheletes
• Hereditary

21. Investigations
• Stress test
• Cotton swab test
• Marshall and bonneyʼs test
• Urethroscopy
• Urodynamic studies

22. Stress test
• Excellent method of demonstrating objectively the
presence of SUI
Steps
• Catheterisation
• Urine sample is sent for culture
• 250 ml warm saline instilled into the bladder
• Leakage noted in sitting and supine position
• Net weight gain of 2g or more is indicative of GSI

23. Q tip cotton test
• A Q tip cotton swab stick dipped in xylocain jelly is placed
in urethra
• Patient asked to strain or cough

25. Marshall and bonneyʼs test
• Bonney test
Absence of leakage of urine following bladder neck elevation
is indicative of beneficial outcomefollowing surgical repair
• Marshall test
vagina in the bladder neck is infiltrated with local
anaesthetic, and area elevated with an open allis clamp

26. Urethroscopy
Provides Information about the:
• Openning pressure
• Urethritis
• Diverticula
• Rigid urethra
• Urethrpvesical junction

27. Urodynamic studies
• Cystometry- measurement of pressure within
the bladder and urethra during artificial filling
• Uroflowmetry-urine flow rate and volume
• Micturition cystourethrography- for posterior
urethro vesical angle
• Uroproflowmetry – it measures the dynamic
urethral pressure it is gold standard in diagnosis
of GSI

28. • Ultrasound –for bladder volume and residual
urine
• Videocystourethrography-it combines the
pressure studies with video position of bladder
neck and urethrovesical angle
• MRI- to detect the defect in pelvic floor muscle
and supporting fasciae

29. Management
• Conservative
Fluid intake and voiding habits
Weight loss
Physiotherapy
Reduce caffein intake and smoking
Drugs
Intraurethral and vaginal devices
Electric stimulation
• Surgical

30. Conservative therapy
Fluid intake and voiding habits
• Trials have been demonstrated that increase in fluid intake
increases the episodes of incontinence thus decreasing the
fluid intake is helpful in for patient with high fluid
consumption
• Voiding prior to strenous activity beneficial in mild SUI

31. .
Pelvic floor exercises
• Kegel described the PFM exercises in 1948 for female UI
• Reported success rate is more than 80%
• Offer a trial of supervised pelvic floor muscle training of at
least 3 months' duration as first-line treatment to women
with stress or mixed UI. [2006]
• Pelvic floor muscle training programmes should comprise
at least 8 contractions performed 3 times per day for 3-6
month. [2006]

32. • Weight loss
Several studies shows association between obesity and
development of incontinence a study examining women who
had lost weight as a result of bariatric surgery found that there
was significant decrease in both subjective and objective SUI
and UUI

33. Medical therapy
Oestrogen
• Estrogen has tropical effects on urethral epithelium
subepithelial vascular plexus and connective tissues
• Fentl at al reviewed 23 articles and found patient had
subjective improvement but not there is no imrovement in
objective parameters

34. • Alpha-adrenoreceptor agonist
Ephedrine , Midorine, Methoximen
• Tricyclic antidepressant
Imipramine
2 studies with 75 mg BD
1st study shows subjective improvement in 70% and in 2nd
study shows objective improvement in 60% after 3month of
treatment

35. • Duloxetine
It is still in investigational phase
Phase 3rd studies appear promising
One study conduct in north america showed incontinence
episodes decreased by 50% in duloxetine group versus 27% in
placebo group
stress urinary incontinence
urology vol.13 part 1

36. Intraurethral and vaginal devices
• Ring pessary
• Contiform (silastic vaginal cone)
Electric stimulation
Tried if SUI is caused by denervation of pudendal nerve
during delivery
Useful in old women with weak pelvic floor muscles

37. • Artificial urinary sphincter
800 model used in neurological condition
Previous surgical failure
80% success rate
Disadvantages-
Expensive
Infection
mechanical failure

38. Surgical intervention
• Vaginal operation
Anterior colporrhaphy
Kellyʼs repair
Paceyʼs repair

39. • Abdominal approach
Retropubic colposuspension
Marshall-marchetti-krantz operation
Burch colposuspension
• Combined abdominal and vaginal operation

40. • Unani concept

41. • Ye wo marz hai jisme peshab be irada kharij ho jata
hai
Asbaab
• Masana ki baroodat
• Azla masana ka istarkha
• Masana ka zof ratoobat ki kasrat ki wajah se
• Mudirrarat, raqeeq sharab,kharbooza, aur dusre ratab
fawakiha ka kasrat se istemal
• Masana ki zyadti hararat
• Masana ka Zarab wa saqta

42. Diagnosis
• Bakasrat mudirrat ka istemaal kiya gya ho
• Pusht ka mohra apni jagah se jhat gya ho
• Hamal ho
• Amaa me bakasrat sufal ho
• Rehem me waram
• Qaarora – rang safaid, sozish aur tashunnagi na ho, sue
mizaj barid ki alaamate zahir ho to iska sabab masana aur
uske azla ki barodat, kamzori aur masana ka isterkha
• Agar qarora rangeen ho sozish ke sath ho, tashunnagi aur
mizaj me garmi ho,mariz ko garmi se nuqsan puhnche to
iska sabab masana ki zyadti hararat hogi

43. Treatment
• Marz masana ki sardi,azla ke isterkha aur unka zoaf ho to
Kundur ,mastagi, har 1 masha barik kar ke gulqand ya itrifal
saghir me mila kr de aur har qabiz dawain maslan kholanjan,
qust, waghaira barid qabiz wa mujafif adwiya maslan jaft
baloot,gulnar, habul aas ke sath murakkab kr ke den
Murakkab – majun baloota , majun kundur, majun falasafa

44. • Sabab hararat ki zyadti
Tabashir,gulnar, gile armani, tukhm khurfa,kahu,khashkhash
sab ka qurs bana kr khilaye
Agar sabab muhre ke zawal jiski wajah se masana ka ribat
toot gye ho to iska ilaj muhal hai lekin agar ribaat na toote ho
balki unme tamadud ho to iska ilaj ye hai ki muhre ko apni
jagah bithaye agar muhra ander ki janib hata ho to uski tadbir
ye hai ki sanghiya khichwaye ya zaft ka zimad kare

45. • Agar rehem ke waram ya ijtamae sufl ya hamal ki wajah se
ho to sabab ke zayl ho jane par khud hi rafa ho jata hai
• Agar mudirat ke zyada istemal se aariz ho to ise tark kare
• Agar buhrani ho to band na kare balki mudirat se aanat kare

46. Thank you