Uro gynacology- sui

STRESS URINARY
INCONTINENCE
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical
College
Chennai
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai 2

INCONTINENCE
The International Continence
Society (ICS) defines the
symptom of urinary incontinence
as “the complaint of any
involuntary loss of urine”
Chennai 3

stress urgency mixed
The symptom is the
complaint of
involuntary leakage
on exertion or on
sneezing or
coughing
The symptom is
the complaint of
an involuntary
leakage
accompanied by
or immediately
preceded by
urgency.
The complaint
of an
involuntary
leakage of
urine
associated
with urgency
and also with
exertion, effort,
sneezing, or
coughing
Chennai 4

stress urgency mixed
Urodynamic
stress
incontinence is
defined as the
involuntary
leakage of urine
during increases
in
abdominal
pressure in the
absence of a
detrusor
contraction
Detrusor
overactivity
incontinence is
incontinence
related to an
involuntary
detrusor
contraction
during
urodynamics.
Detrusor
contractions with
involuntary
leakage
Chennai 5

EPIDEMOLOGY OF URINARY
INCONTINENCE
• young adult life (20% to 30%)
• middle age (30% to 40%)
• elderly women (30% to 50%)
• In young and middle-aged women, stress incontinence
predominates
• and in older women mixed incontinence is most
common .
• stress incontinence is most common (49%)
• mixed incontinence (29%) and
• pure urge incontinence (21%)
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Risk factors
• age
• parity
• route of delivery
• obesity
• pregnancy
• Menopause
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Sphincteric Mechanism and Anatomic
Support
• the urethral sphincter is considered to be
composed of two components
• the internal sphincter which represents a
direct continuation of the detrusor smooth
muscle
• and the striated external sphincter
Chennai 8

The principles underlying the function of a
sphincter are
(1) watertight apposition of the urethral lumen
(2) compression of the wall around the lumen
(3) structural support to keep the proximal urethra
from moving during increases in pressure
(4) a means of compensating for abdominal
pressure changes (pressure transmission)
(5) neural control.
Thus, normal sphincteric function is the result of an
integrated interaction among all these factors
Chennai 9

DeLancey's theory of urethral support
hammock theory
Normally, with rises in intra-abdominal pressure,
the urethra is compressed against the
supporting structures, which act like a backboard
and prevent loss of urine
When the supporting structures fail, there can be
rotational descent of the bladder neck and
proximal urethra during increases in abdominal
pressure.
• If the urethra opens concomitantly, SUI ensues
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The causes of sphincteric dysfunction in
women
• from an anatomic viewpoint, urethral
hypermobility (urethral support defect),
• functional viewpoint, intrinsic sphincteric
insufficiency (ISD).
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Aetiology
Extrinsic
• Parity
• HRT
• Occupation
• obesity
• Menopause
• Trauma
• Previous surgery-
Hystrectomy
• Drugs-alpha blockers,
alpha methyl dopa
Intrinsic
• congenital weakness of
bladder neck-epispadias
• congenital weakness of
pelvic floor
• Defective collagen
• Genetic
• Ageing
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INVESTIGATIONS
AIM
• To confirm symptoms
• To confirm diagnosis
• To confirm cure
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Clinical examination
General – obesity- anemia
Local – abdominal – masses
• vaginal – descent, scarring - infection – dryness
• rectal – fecalimpaction, sphincter tone
Neurological - gentle tapping of the clitoris will produce a
reflex contraction of the anal sphincter (bulbocavernosus
reflex)
voluntary cough should cause a reflex contraction of the
anal sphincter
stroking the skin lateral to the anus contraction of the
external anal sphincter
Chennai 15

Investigations
Clinical examination (general & local
examination)
urine culture, urine cytology
Clinical test
stress test
stamey’s test
Q tip test
pad test(1hr,24hrs)
Imaging
ultrasound
MRI
urodynamic evaluation
Endoscopy Dept Of Urology, KMC and GRH,
Chennai 16

• To demonstrate stress incontinence the
woman should have a full bladder.
• The patient, is told to cough violently and
the escape of urine is noted – positive
stress test
• The index and middle finger of the
examiner’s hand should be inserted into
the vagina and the anterior vaginal wall
pressed against the sub-pubic angle but
without pressing on the urethra. If no leak-
stameys test positive
Chennai 17

Q-tip test
• The mobility of the urethra and bladder neck can be
evaluated by inserting a sterile, lubricated, Q-tip cotton
bud into the urethra to the level of the bladder neck.
• The patient is then asked to strain.
• The angle of the Q-tip is measured relative to the
horizontal
• The resting and straining angles are measured and the
difference between the two angles is calculated.
• A change of greater than 30 degrees is thought to
represent a hypermobile urethra.
Chennai 18

The voiding diary is an important tool in the
investigation of patients with lower urinary
tract symptoms and voiding dysfunction
Chennai 19

PAD TEST
It consists of the use of a perineal pad to document urinary
incontinence
The amount of lossis calculated by subtracting the weight of the pad
beforethe test from its weight at the end of the test.
Interpretation of urinary incontinence from the pad test weight
gain
• Category Weight gain (g)
• Dry <2
• Slight to moderate 2–10
• Severe 10–50
• Very severe >50
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pyridium test
• Phenazopyridine hydrochloride ingestion
results in the dye being excreted by the
kidney with consequent coloring (orange)
of the urine
Chennai 21

Urodynamic tests should be considered in
women:
• with mixed LUTS
• being considered for bladder neck surgery;
previous unsuccessful incontinence surgery
• neurogenic bladder disorders
• whom conservative and pharmacologic
measures have failed
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Urodynamics
• Single channel
• Multi channel
• Videourodynamics
• Ambulatory urodynamics
• Urethral pressure profilometry
• MULTICHANNEL URODYNAMICS GOLD
STANDARD
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Parameters monitored in urodynamics
• Qmax 12 and 30 ml/s
• Average flow 6 to 25 ml/s
• Voiding time 10–20 seconds
NORMAL CYSTOMETRY
• Residual urine of less than 50 ml;
• First desire to void between 150 and 200 ml;
• Capacity between 300 and 600 ml;
• no detrusor pressure rise on filling
• No leakage on coughing
• A maximum voiding detrusor pressure of less
than 50 cmH2O
Chennai 24

Lower urinary tract function according to clinical
diagnosis,detrusor and urethral action during the filling
and voiding cycles of micturition with possible urodynamic
diagnosis
Urodynamics
Filling phase Detrusor Urethra Diagnosis
normal Stable Competent Normal
• SUI Stable Incompetent USI
• OAB Overactive Competent DO
• OAB + SUI Overactive Incompetent DO + USI
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Urethral pressure profilometry
maximum urethral closure pressure (MUCP)
• is the highest pressure (relative to bladder
pressure) generated along the functional length
of the urethra.
• It usually corresponds to the striated sphincter in
the mid-urethra
• Cutoff value 20cm H2O
• Valsalva or cough leak point pressure dynamic
measure of urethral sphincter function.
• Cutoff values 60cm H2O
• Kinesiologic EMG
Chennai 26

Radiologic type of stress incontinence
TYPE0 Vesical neck and proximal urethra
• closed at rest and situated at or above the lower
end of the symphysis pubis.
• They descend during stress but incontinence is
not seen.
TYPEI Vesical neck closed at rest
• and is well above the inferior margin of the
symphysis.
• During stress the vesical neck and proximal
urethra open and descend <2 cm.
• Incontinence is seen.
Chennai 27

TYPEIIa Vesical neck closed at rest and is above
the inferior margin of the symphysis. During
stress the vesical neck and proximal urethra
open and descend >2 cm. Incontinence is seen.
TYPEIIb Vesical neck closed at rest and is at or
below the inferior margin of the symphysis.
During stress there may or may not be further
descent but as the proximal urethra opens
incontinence is seen.
TYPEIII Vesical neck and proximal urethra are
open at rest. The proximal urethra no longer
functions as a sphincter. There is obvious
urinary leakage with minimal increases in
intravesical pressure
Chennai 28

Cystourethroscopy
simple, minimally invasive approach.
• useful adjunct to multichannel urodynamics
• in women with possible ISD, urethral diverticula,
urogenital fistulae, foreign bodies or urothelial lesions
Chennai 29

RECOMMENDED ALGORITHM
• Life style modification
• Pelvic floor exercise
Absent or moderate bulking
agents (BA)
bladder neck mobility (BNM)
BA failure
POP mid urethral
sling
Major BNM
Recurrent SUI redo mid
urethral sling
BN fascial
sling
Major SUI,repeated artifical sphincter
procedures
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TREATMENT
CONSERVATIVE
Indications
• patient refusal
• unfit patient
• pregnancy
• further child bearing intended
• predominant urgency component
Chennai 31

• Catheters-simple end stage method
• Absorbent pads
• PFMT-pelvic floor muscle training
KEGEls
Vaginal cones-
Devices-bladder neck support prosthesis
Faradic stimulation of pelvic floor muscles
Chennai 32

• Bladder training (also referred to as
bladder drill, is a scheduled voiding
regimewith gradually progressive voiding
intervals.
• Timed voiding is a fixed voiding schedule
thatremains unchanged over the course of
treatment
• Habit training is a toileting s chedule that is
matched to the patient’s voiding pattern.
Chennai 33

Teaching pelvic floor muscle control
• The first step in training is to identify the pelvic floor
muscles properly and to contract and relax them
selectively (without increasing intra-abdominal pressure
on the bladder or pelvic floor).
• good results are generally achieved using 45–50
exercises per day
• To improve muscle strength, contractions should be
sustained for 2–10 seconds followed by 4secs rest
Chennai 34

PFMT is commonly used in combination with
other adjuncts such as
• biofeedback (BF),
• intra vaginal resistance devices (IVRD),
• electrical stimulation (ES),
• vaginal cones (VC)
• PFMT gives the best outcome among the
above measures
Chennai 35

The modified Oxford scale for the pelvic floor muscles (PFM)
Muscle grade External observation internal examination
0 No in drawing No activity detected
1 movement of the A mere flicker of activity
2 perineal body A weak contraction without PFM
lift
3 An in drawing A moderate PFM lift but without
movement of the resistance
4 perineal body A good capability to lift PFM
against some resistance
5 An ability to lift PFM against more
resistance with a strong grip of
examining digit
Chennai 36

Vaginal cone
Vaginal cone
Chennai 37

vaginal cone
• the appropriate weight of cone is
determined (the one that a woman can
retain in the vagina while walking for 1
minute),
• then the woman attempts to retain the
cone for increasing lengths of time and
increasing levels of activity.
Chennai 38

Urethral inserts are sterile inserts
placed into the urethra by the
patient and removed before a void
Chennai 39

Drugs
• α-Adrenergic agonists
• Tricyclic antidepressants
• β-Adrenergic antagonists
• Estrogens
• β-Adrenergic agonists
Chennai 40

α-Adrenergic agonists
• norfenefrine
• Phenylpropanolamine (PPA)
hydrochloride
• Midodrine
• Duloxetine
• Hormones- conjugated oestrogen
Chennai 41

SURGICAL TREATMENT
Indications
• patient requests
• failed conservative measures
Chennai 42

• In mixed incontinence patient has to be
cautioned about the outcome of surgery
• If stress is the predominant symptom
urgency is cured by the surgery
• But if urgency is the prime complaint it
gets worsened
Chennai 43

FAVOURABLE PARAMETERS
• Nonobese
• Young individual
• No comorbid illness
• Short duration of symptoms
• Primary surgery
• No associated urgency
Chennai 44

AIM OF SURGERY
• To elevate the bladder neck
• To enhance the urethral resistance
or Both
Chennai 45

BULKING AGENTS
• Injected trans urethral or periurethral
Indication
-to increase the success of primary surgery
Complication-
• Infection
• migration
• allergy
Chennai 46

Agents used
• -Bovine collagen,
• PTFE,
• Autologous fat,
• microparticulate silicon
• DurasphereTM pyrolytic carbon-coated
zirconium oxide beadsEthylene vinyl alcohol
co-polymer suspended in dimethyl sulfoxide
(DMSO) or Uryx® solution
• Calcium hydoxylapatite
• Zuidex™ – another biologic agent – consists of
dextranomer microspheres in a cross-linked
hyaluronic acid(HA) vehicle.
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Proximal urethral slings
Chennai 49

Mid urethral slings
Chennai 50

The autologous tissues used to increase bladderoutlet
resistance
• gracilis muscle
• pyrimidalis flaps
• levator ani
• rectus fascia slings are durable and safe and should be
considered the ‘gold standard’ of materials
• Allografts- lyophilized dura mater, cadaveric fascia lata
and acellular dermal grafts.
• Xenograft- Porcine small intestinal submucosa (SIS)
Chennai 51

synthetic sling materials.
• easily accessible,
• relatively inexpensive non-carcinogenic
• Due to the large pore size, monofilament
construction, and flexibility, Prolene is
currently the synthetic material of choice
for use in pelvic reconstructive surgery
Chennai 52

Pubo vaginal slings
indications
• vaginal wall atrophy
• Post RT
• Lack of urethral mobility
• Mixed incontinence with open bladder neck
• Failed procedures
• Concomitant urethral reconstruction
Complications
• Voiding dysfunction
Chennai 53

Abdominal incision. For most
patients a
short (6–8 cm) transverse
incision is made just above the
pubis below the pubic hairline
Chennai 54

A 2 cm wide graft is outlined,
keeping the
incision parallel to the direction
of the fascial fibers
Chennai 55

A plane is created between the fascia and
rectus muscle with Mayo scissors and an index
finger
places traction on the fascia as the incision is
extended
superolaterally to the point where the rectus
fascia divides to
pass around the external oblique muscle.
Chennai 56

Each end of the fascial graft is
transected
approximately 0.5 cm lateral to
the mattress suture
Chennai 57

A 4 cm transverse or slightly curved incision
is made in the anterior vaginal wall about 2 cm proximal
to the proximal edge of the Foley catheter balloon. This is the
approximate site of the vesical neck. The depth of this incision
extends just superficial to the pubocervical fascia
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COLPOSUSPENSION
Indications
• Urethral incompetance with or without
cystourethro coele with adequate vaginal
capacity and mobility
Contra indication
• previous bladder neck surgery
• low MUCP,<20CMH2O
• Severe urgency
• Significant descent
Chennai 61

COLPO SUSPENSION-
OPEN
LAPAROSCOPIC
First described by BURSH in 1961
Chennai 62

PRINCIPLE
• Bladder neck elevation increases the pressure
transmissionto over 100% to the proximal urethra
• Para vaginal tissues are elevated to the ilio pectineal
ligament-bow stringing
• Bursch colpo suspension is considered the gold
standard
Complications
Voiding dysfunction
Urgency
Pelvic organ prolapse
Chennai 63

Midurethral slings
• TRANS VAGINAL TAPE
• TRANS OBTURATOR TAPE
• TENSION FREE
• Day care procedure
• Done under local anaesthesia
• Possible to adjust the sling
Chennai 64

What does 'tension-free' mean?
• a synthetic transvaginal suburethral sling is
placed through the retropubic space without
using suspension sutures.
• Scar tissue later fixes the mesh, preventing
migration.
• Because the sling is not anchored to the pubic
bone, "free of tension."
• The result is a midcomplex urethral support that
limits urethral descent, i and reinforces support
of the backboard vaginal hammock.
Chennai 65

Indicated as a primary procedure
The sling made of polyproylene
Complication:
Injury to bladder ,bowel, blood vessels
Erosion
Extrusion
Infection
Retention
Chennai 66

TVT & TOT
• Goal to reinforce the pubourethral ligaments, .
Chennai 67

• The TVT device consists of an 11 mm wide × 40 cm long
tape of polypropylene,
• both ends attached to stainless steel, specially curved, 5
mm diameter insertion needles.
• The tape is covered by plastic sheets to protect it from
contamination and to facilitate its passage through the
tissues.
• A reusable handle fits to the needles and is used to
insert the needles.
• 18 Fr Foley catheter and helps to deflect the bladder
away from the path of needle insertion.
• The patient is placed in a lithotomy position
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three small incisions:
• two 1-cm wide suprapubic skin incisions
at the upper rim of the pubic bone, each
2–2.5 cm lateral to the midline,
• a vaginal midline incision 1.5 cm wide
starting 0.5 cm from the externalmeatus of
the urethra
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Chennai 71

• After the vaginal incision is made, careful
minimal blunt dissection, should be undertaken
paraurethrally between the vaginal mucosa and
the pubocervical fascia to a depth of not more
than 2 cm.
• The TVT needle is placed in its starting position
within the dissected paraurethral tunnel with the
needle tip between the index finger of the
surgeon’s hand in the vagina and the lower rim
of the pubic ramus.
• With slow controlled pressure, the needle is
brought through the urogenital diaphragm, the
space of Retzius, and the rectus muscle fascia
using the skin incision as a point of direction.
Chennai 72

• A, cystoscopy, is performed to confirm
bladder integrity.
• Once bladder integrity is confirmed, both
needles and the tape are brought through
and the final adjustment of the tape can
take place.
• The patient is asked to cough vigorously
while the tape is adjusted to a point when
leakage is only a drop of saline at the
urethral meatus
Chennai 73

The Transobturator Sling
• In France in 2001, Delorme introduced the
transobturator sling procedure.
Chennai 74

TOT Mimics Normal Anatomy
• The transobturator sling forms a
subfascial hammock of support under the
urethra.
• This mimics the normal position of the
pubourethral ligament .
Chennai 75

Step 1. Small incision is made under the urethra
Step 2. Vaginal epithelium is dissected free
Step 3. Area of groin incision located 1cm inferior
to adductor longus tendinous insertion (level of
clitoris)
Step4. Finger placed in vaginal incision to guide
needle.
• Needle placed in groin incision and passed
through the obturator membrane and muscles
and brought into the vaginal incision.
Chennai 76

Step 5. The needle is brought through the vaginal incision
and the tape is attached to the needle with the connector
Step 6. Connected tape is then brought back through the
groin incision
Step 7. Needle and tape is passed on the opposite side.
• Tape is then adjusted with an intra-operative cough test
and adjusted until no leakage occurs.
• Excess mesh is cut off at the groin incisions and these
are closed with steri-strips and vaginal incision is closed
with absorbable suture
Chennai 77

Advantages of Transobturator Approach
• -Safer, faster, more efficient
• -Decreased risk of:
• -Bowel Injury
• -Bladder Injury
• -Major Bleeding
• -No Retropubic Needle Passage
• -No Abdominal Incisions
• -More Anatomic Position of Tape
Chennai 78

Complications
• Bladder injury
• Vaginal erosion
• Voiding dysfunction
• Irritative symptoms
Obstructive symptoms
• Post operative perineal pain
• Infection
• Thigh abcess
• Infected obturator hematoma
• lower urinary tract infections
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Chennai 80

Artificial sphincter
• First made in 1973
• Consists of a graded silastic cuff ,
a reservoir and a pump
Indication
• redo surgeries
• Neuropathic bladder
• Congenital anomolies
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Artificial sphincter
Chennai 82

Contra indication
sepsis
severe physical disability
• UTI
• previous RT
• Severe detrusor instability
• voiding dysfunction
• previous urethral erosions
complicatiions
• Erosions
• Infection
• Late mechanical failure
• After7yrs only37% remained insitu
Chennai 83

RECURRENT INCONTINENCE
Causes
• Inappropriate surgery
• Inadequate surgery
• Urinary fistula
• Detrusor instability
• Poor tissues available
• Overflow with retention
Chennai 84

Procedures:
insufficient bladder neck elevation
pubo vaginal sling
colpo suspension
TVT hazardous because of
retropubic fibrosis
Insufficient urethral resistance :sling
artificial sphincter
• Continent diversion
Chennai 85

Procedure cure complication
Injectable bulking
agents
20%-70% 5%-13%
Midurethral
slings
80%-85% TVT5%-21%:
TOT-0.8-5%
Colposuspension 69%-88% 3%-18%
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Thank you
Chennai 93

Uro gynacology- sui

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