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Urinary incontinence2


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undergraduate, Urinary incontinence2

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Urinary incontinence2

  1. 1. Urology Department Under-graduate coursesUrinary Incontinence
  2. 2. Urinary IncontinenceDefinitioninvoluntary leakage of urine.Incidence• 14% in women and 13 % in men Types of IncontinenceStress urinary Urge Mixed Urinary Overflow Extra urethralincontinence incontinence Incontinence Incontinence Incontinence ©
  3. 3. Types of IncontinenceStress urinary Incontinence (SUI)• is the involuntary leakage of urine from the urethra in association with exertion or effort, such as coughing and sneezing.Urge urinary incontinence (UUI)• Leakage of urine associated with detrusor overactivity.• Detrusor overactivity is involuntary contraction of the bladder.• divided into neurogenic or non-neurogenic types. ©
  4. 4. Types of IncontinenceMixed urinary incontinence• It is the type of incontinence in which the patient has features of stress and urge incontinence, usually with one type being predominant.Overflow incontinence• It is the type of incontince which is caused by chronic retention of urine as a result of a non- painful bladder that is palpable on examination after voiding ©
  5. 5. Types of IncontinenceExtra-urethral incontinence• leakage of urine through a fistula or an ectopic ureter in which patients typically void normally and are incontinent between voids (also known as paradoxical incontinence). ©
  6. 6. Causes of IncontinenceCauses of Stress incontinence :• Weakness of pelvic floor muscles (often as a result of childbirth).• Intrinsic sphincter deficiency.• Damage of voluntary urethral sphincter (for example, after transurethral resection of prostate).• Collagen disorders.• Advancing age. ©
  7. 7. Causes of IncontinenceCauses of Neurogenic and non-neurogenicdetrusor overactivityNeurogenic causes Non-neurogenic causes• Spina bifida • Thought to be the result• Multiple sclerosis of intrinsic problems• Spinal cord injury within the bladder wall• Pelvic surgery ©
  8. 8. HistoryPresent History – Type of incontinence: Symptoms & duration – Severity: Number of pads required by day & night – Assessment of quality of lifePast history – Medical: Previous drug intake or Previous attacks of UTIs – Surgical: Parity or Previous pelvic surgery ( e.g. Hysterectomy) ©
  9. 9. Examination• Physical examination• Neurological examination• Abdominal examination – Palpable bladder – Scars of previous operations• Perineal examination (in Women) – Signs Atrophic vaginitis – Signs of pelvic floor prolapse (e.g.: cystocele, rectocele, vaginal vault prolapse, uterine prolapse). ©
  10. 10. Examination• P.V examination • asking the patient to contract the pelvic floor muscles while the examiner inserts two digits in the vagina • Pelvic floor strength is graded as weak, normal or strong• Stress test: • cough with full bladder to try to demonstrate SUI. ©
  11. 11. Examination• In men: – DRE ( Digital Rectal examination) to examine prostate – Genital examination: Signs of phimosis, urethral meatal stenosis ©
  12. 12. Investigations• Urine analysis Routine in all patients to exclude UTIs• Pad test• Uroflowmetry – With or without assessment of post micturition residual volume.• Urodynamics ©
  13. 13. Urodynamic studies• Urodynamic studies examine the physiological behavior of the bladder during filling and voiding. ©
  14. 14. Treatment of SUI & UUI• Non- surgical (conservative)  Pelvic floor training  Pharmacological treatment: Anti-muscarinic drugs for bladder overactivity.  Incontinece nurse practitioners• Surgical (different in SUI from UUI) ©
  15. 15. Surgical management of SUI• Bulking agents• Slings• Artificial urinary sphincter ©
  16. 16. Bulking agents injection– Submucosal into bladder neck or periurethral to increase urethral resistance. ©
  17. 17. Slings– TVT ( tension free vaginal tapes ) or TOT ( Transobturator tapes ) are available options with excelent results TOT TVT ©
  18. 18. Artificial urinary sphincter• This involves placing:1. inflatable cuff around the urethra2. reservoir of fluid3. pump system normally in the scrotum ©
  19. 19. Surgical management of UUI• Botox injection • Bladder augmentation. ©
  20. 20. Treatment of Overflow andExtraurethral incontinenceOverflow incontinence• Adequate bladder drainage.Extraurethral incontinence• Urinary fistulae need careful assessment followed by surgical repair ©
  21. 21. Vesicovaginal fistula• History – Previous history of gynaecological surgery (e.g, Vaginal or abdominal hysterectomy ) – Previous history of pelvic radiotherapy – Prevoius history of prolonged labour or trauma during childbirth ©
  22. 22. Vesicovaginal fistula• Symptoms  Urinary leakage from the vagina within 7-10 days after pelvic surgery  Presentation may range from watery vaginal discharge to total urinary incontince.• Examination:  Acute presentation • Area of inflamation & erythema in the vagina  Chronic presentation • May be seen as a small opening in the vaginal wall • Three Swab test may be usefull in diagnosis of Vesicovaginal fistula © 
  23. 23. 3 swab test• Three separate sponge swabs are placed into the vagina one above the other.• The bladder is then filled with a coloured agent such as methylene blue, and the swabs are removed after 10 minutes ©
  24. 24. Results of 3 swab test1. Discolouration of only the lowest swab suggests that urine has come down the vagina—as a result of a low urethral fistula or from back flow into the introitus.2. uppermost swab wetting but not discolouration suggest ureterovaginal fistula (urine come from ureter above the level of the bladder).3. Discoloration of topmost swab is caused by vesico-vaginal fistula. ©
  25. 25. Treatment of Vesicovaginal fistula• Conservative treatment (waiting for spontaneous rupture) by prolonged catheter is useful in small fistulas.• Surgical treatment (in most cases): by vaginal or abdominal approach ©
  26. 26. Thank You