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