This document discusses the definition, pharmacology, history taking, physical exam findings, investigations, and management of different types of urinary incontinence. It defines stress, urge, overflow, sensory, and bypass fistula incontinence. For each type, it describes the etiology, history, exam findings, investigation results, and management approaches including behavioral modifications, medications, injections, and surgeries. Key investigations discussed are urinalysis, bladder diary, urodynamic studies measuring post-void residual volume, uroflow, pressure flow studies, and cystometrogram. The goal of management is to treat any underlying causes and reduce symptoms through conservative or surgical methods depending on the incontinence type and severity.

1. Done by :
Yasmin Saidat
Mahmoud Ababneh
Supervised by :
Dr . Lama Al.Muhaisen
Jordan university of science and technology .

2. Defintion
 Involuntary loss of urine that is objectively
demonstrable and that is severe enough to constitute a
social or hygienic problem.

4. Pharmacology of incontinence
a.-Adrenergic receptors.
 found in urethra.
Stimulation cause contraction of urethral smooth
muscle, preventing micturition.
Drugs: ephedrine, imipramine, and estrogens.
a.-Adrenergic blockers or antagonists
 relaxthe urethra, enhancing micturition.
 Drugs: phenoxybenzamine .

5. β-Adrenergic receptors.
Found in detrusor muscle.
Stimulation cause relaxation of the bladder
wall, preventing micturition.
Drugs: flavoxate and progestins.

6. Cholinergic receptors.
Found in detrusor muscle
Stimulation cause contraction of the bladder
wall, enhancing micturition.
Chlinergic drugs: bethanecol and neostigmine .
Anticholinergic medications
block the receptors, inhibiting micturition.
Drugs: oxybutynin and propantheline .

8. History
P.P: Age, parity .
C.C:
Duration, frequency and amount of leakage
Precipitating factors:
 3 P’s
- Position of leakage (supine, sitting, standing)
- Protection (pads per day, wetness of pads)
- Problem (quality of life)
Progression – is it worsening?

9. Irritative:
 If Frequency: 10-12 x/day
OR urge incont.
 nocturia: 3-4 x/night.
 If no freq/nocturia  think of stress incont.
 Dysuria, hematuria, urgencyUTI urge incont.
 Recurrent Hx of UTI  urge
Obstructive:
 Hesitancy, dysuria, straining to void, poor or interrupted stream, retention of urine, incomplete
emptying, terminal dribbling.
 Volume of urine leakage – large amounts go with overflow incont.
 Stones, tumors
Lower urinary tract symptoms

10. Past obstetrics Hx: Mode of delivery, Birth Wt of her children .
Gyne. Hx: Symptoms of urogenital prolapse:
• Feeling of mass that goes down while urinating
 Worse towards the end of the day
 Dragging backache
Medical Hx: DM, HTN, Neurological problems,Disk prolapse
Pelvic Surgeries?
Trauma to the spine?
Drugs: diuretics, psychotropic agents, Ca-channel blockers, alpha-
blockers
Any alteration in bowel habit?
Smoker? Chronic cough?

11. Physical Exam.
1. General look of the pt *
2. Abdominal exam
3. Respiratory exam
4. Neurological exam *
5. Pelvic exam *
6. Asses pelvic floor muscle tone *
7. Rectal exam
8. Stress test *
9. Cotton swab (Q-tip) test urethral mobility *

12. Q-tip (cotton
swab) Test

13. Investigation

14. Investigation
 You MUST rule out UTI first !
 Midstream Urinalysis
 Blood test  KFT
 Bladder diary

15. Example Diary for Urge incontinence
Day Time Comments
Sunday, 5th of
March
7 am Woke up and needed to go to the toilet
7:30 Needed to go to the toilet again
8 am Breakfast – 300 ml grapefruit juice and
200 ml tea
8:15 am Passed about 100 ml
8:25 am Passed about 50 ml
9 am Pants a little damp, passed about 50 ml
9:15 am Dribbled a bit, changed pants
9:30 am Passed a few drops, bladder feels very
“jumpy”
and so on ….

16. Urodynamic studies
Parameters measured during
urodynamic evaluation 1,2,34
1. Post void residual volume (PVR)
2. Uroflow
3. Pressure flow study
4. Cystometrogram (CMG)
5. Abdominal Leak-Point Pressure (ALPP)
6. Video urodynamics

17. 1. Post void residual urine
Distinguish between:
 true incontinence (Residual urine < 50 mL).
 overflow incontinence (Residual urine >100 mL).

18. 2. Uroflow
Measurement of Urine Speed and Volume

20. 3. Pressure flow study
Bladder pressures are measured simultaneously with a
urinary flow rate during voiding .
This helps to differentiate true urethral obstruction
from detrusor failure.
Obstruction = detrusor pressure more than 50 cm
water and flow < 15 mL/s

22. 4. Cystometrogram
The pressure in the bladder and rectum/vagina is
measured during bladder filling. Intra-abdominal
pressure is subtracted from bladder pressure to give a
real indication of detrusorfunction.
Residual Volume <50mL
Sensation of fullness 200-225 mL
Urge to void 400-500 mL
No contractions are normal.

26. 5. Abdominal Leak-Point Pressure
Measurement of bladder pressure during coughing or
valsalva manoeuvre to determine the pressure in the
bladder required to induce leakage.
In hypermobility of the urethra, the ALPP will be more
than 60 cm water.
But with Intrinsic Sphincter Dysfunction, the ALPP is
less than 60 cm water and often less than 20 cm water.

28. 6.Video Urodynamics:
Urodynamic tests can be performed with equipment to
take pictures of the bladder during filling and
emptying. Contrast medium may be given via the
catheter.

29. Other invistigation
 Urethral Pressure Measurement
 Normal Urethral closure pressure (UCP) = 50-100 cm H₂O
 If < 20  stress incont
 If UCP is high  voiding difficulties, hesitancy and urinary retention
 Urethrocystoscopy
 Ultrasonography

30. Findings & results in each Type of
incontinence + management
 History
 Examination
 Investigation Findings

31. Stress Incontinence.
The most common form of urinary incontinence.
• Etiology. Rises in bladder pressure because of
intraabdominal pressure increases (e.g., coughing and
sneezing) are not transmitted to the proximal urethra
because it is no longer a pelvic structure owing to loss
of support from pelvic relaxation.
• History. Loss of urine occurs in small amounts
simultaneously with coughing or sneezing. It does not
take place when the patient is sleeping.

32. Examination.
 Pelvic examination may reveal a cystocele.
 Neurologic examination is normal.
 The Q-tip test is positive: when a lubricated cotton-tip
applicator is placed in the urethra and the patient increases
intraabdominal pressure, the Q-tip will rotate >30 degrees.
Investigative studies.
 Urinalysis and culture are normal.
 Cystometric studies are normal with no involuntary detrusor
contractions seen.

33. Management of stress incontinence
1. Conservative
 Stop smoking, cut down on alcohol, caffeine.
 Pelvic floor muscle exercises (Kegel exercise)
 Intravaginal device – large sized pessaries or cones used
to elevate and support bladder neck and urethra.
Success rate 70%.
2. Medical
Alpha agonists:
1. Pseudoephedrine
2. Phenylpropanolamine
 Enhance urethral closure and improve continence
 Do NOT give estrogen replacement unless she has atrophic vaginitis

34. Abdominal approach:
aims to elevate the urethral sphincter so that It is
again an intraabdominallocation (urethropexy). This is
done by attachment of the sphincter to the symphysis
pubis, using the Burch procedure as well as the
Marshall- Marchetti-Kranz (MMK) procedure.
 The success rate 85-90%
3. Surgery

35. Vaginal approach:
 Suburethral sling procedures  severe +
refractive cases
 Tension-free Vaginal Tape(TVT)
-A modification of the sling procedure  uses tension-free
synthetic (polypropylene) mesh placed at the level of mid
urethra (paraurethral).
-Minimally invasive
It does not elevate the urethra but forms a resistant platform
against intraabdominal pressure.
 periurethral bulking injections : (ovine collagen-
contigen or calcium hydroxylapatite)

37. TVT

38. Urge (Hypertonic) Incontinence
• Etiology. Involuntary rises in bladder pressure from
idiopathic detrusor contrac tions that cannot be voluntarily
suppressed.
• History. Loss of urine occurs in large amounts often without
warning. At day and night. The most common symptom is
urgency.

39. • Examination.
 Pelvic examination= normal anatomy.
 Neurologic examination Is normal.
• Investigative studies.
 Urinalysis and culture are normal
 . Cystometric studies show normal residual volume, but
involuntary detrusor contractions are present even with
small Volumes of urine in the bladder.

40. 1. Behavioral Modification:
 First line tt.
 Organize fluid intake habit: ↓ fluid intake & avoid liquids during evenings
 Gradually ↑ the interval btw voidings “Training”
 Kegel ex.
2. Medical Treatment to inhibit detrusor contractions
 Anticholinergic medications.
 NSAIDs to inhibit detrusor contractions.
 Tricyclic antid-dpressants.
 Calcium-channel blockers.
3. Functional Electrical Stimulation
Management of urge incontinence

41. Sensory Irritative Incontinence
• Etiology. detrusor contractions stimulated by irritation from
conditions: infection, stone, Tumor, or a foreign body.
• History. Loss of urine occurs with urgency, frequency, &
dysuria. At day or night.
• Examination.
 Suprapubic tenderness , but otherwise the pelvic
examination is unremarkable.

42. • Investigative studies.
 A urinalysis will show the following abnormalities: bacteria
and WBCs; suggest an infection, RBCs; suggest a stone,
Foreign body, or tumor.
 A urine culture is positive if an infection is present.
 Cystometric studies (which are usually unnecessary) would
reveal normal residual volume with involuntary detrusor
contractions present.
• Management. Infections are treated with antibiotics. Cytoscopy is
used to diagnose and remove stones, foreign bodies, and tumors

43. Overflow (Hypotonic) Incontinence
• Etiology. Rises in bladder pressure occur gradually from
an overdistended, hypotonic bladder. When the
bladder pressure exceeds the urethral pressure,
involuntary urine
loss occurs but only until the bladder pressure equals
urethral pressure. The bladder never empties. Then the
process begins all over. This may be caused by
denervated
bladder (e.g., diabetic neuropathy, multiple sclerosis)
or systemic medications (e.g.,ganglionic blockers,
anticholinergics).

44. • History. Loss of urine occurs intermittently in small
amounts. This can take place both
day and night. The patient may complain of pelvic
fullness
Exnmination.
 Pelvic examination may show normal anatomy.
 The neurologic examination will show decreased
pudendal nerve sensation.

45. • Investigative studies.
 Urinalysis and culture are usually normal, but may show an
infection.
 Cystometric studies show markedly increased residual
volume, but involuntary
detrusor contractions do not occur.
• Management. Intermittent self-catheterization may be
necessary. Discontinue the
offending systemic medications. Cholinergic medications to
stimulate bladder contractions and a-adrenergic blocker to
relax the bladder neck.

46. Bypass Fistula
• Etiology. The normal urethral-bladder mechanism is
intact, but is bypassed by urine Leaking out through a
fistula from the urinary tract.
• History. The patient usually has a history of either
radical pelvic surgery or pelvic radiation therapy. Loss
of urine occurs continually in small amounts. At day
and night.

47. • Examination.
 Pelvic examination may show normal anatomy.
 normal neurologic findings.
• Investigative studies.
 Urinalysis and culture are normal.
 An intravenous pyelogram (IVP) will demonstrate dye leakage
from a urinary tract fistula.
• Management. Surgical repair of the fistula

48. Prevention
1. Shortening of 2nd stage of labor
2. Reduce traumatic delivery
3. If menopause  consider HRT

49. The End