Dr.afroz Khizer MCPS Trainee

8/14/2019 Dr.afroz Khizer MCPS Trainee

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Dr.Afroz Khizer

MCPS Trainee



Defined as involuntary leakage of urineduring increased abdominal pressure in theabsence of detrusor contraction.

Bladder neck and proximal urethra areintraabdominal and supported bypubourethral ligaments.

Damage to pelvic floor musculature or

pubourethral ligament results in descent of the proximal urethra and result in leakageof urine per urethram during stress.



Vaginal delievry results in denervation of urethral sphincter mechanism.

“ Mid urethral theory” or “integraltheory” by Petros and Ulmstel.

“Damage to pubourethralligaments supporting the urethra,impairsupport of the anterior vaginal wall to themid urethra and weakend function of the

pubococcygeal muscles which insertsadjacent to the urethra are responisble forthe urinary stress incontinence.”



It is usually made by negative findingsrather than the positive ones.

If cystometry is normal and stressincontinence is observed a diagnosis of urodynamic stress incontinence can bemade.



CONSERVATIVE TREATMENT

MEDICAL TREATMENT

SURGICAL TREATMENT



Pelvic floor muscle exercises Perineometry Vaginal cones

Maximal electrical stimulations Vaginal devices



INDICATIONS: incontinence is mild.

patient is medically unfit for surgery.

woman who has not completed herfamily.



Pelvic floor muscle training

Perineometry

Weighted vaginal cones

Maximal electrical stimulation

Vaginal devices



It works in following ways:

1. Woman learns to consciously precontractthe pelvic floor muscles before and during

increases in abdominal pressure to preventleakage.

2. Strength training builds up long lastingmuscle volume and thus provides structural

support.3. Abdominal muscle training indirectly

strengthens the pelvic floor muscles.



Success of pelvic floor muscle trainingdepends upon :

a. Type and severity of incontinenceb. Instructions and follow up given

c. Compliance of the patient



It is a cylindrical vaginal device .

Used to assess the strength of pelvic floor

contraction.

Useful in detecting improvement followingpelvic floor exercises.

These devices are available for bothhospital and home usage.





Available as sets of 5 or 3,of same shapeand size but of increasing weights(20-90gms).

Cones stimulate the pelvic floor toprevent it from falling out and this provides“vaginal weight training”.

Success rate is 60 to 70 %.





Can be used at home.

Vaginal electrode is passed and woman is

able to adjust the strength of stimulusherself.

Device is instructed to use for twentyminutes daily initially for one month.





There are four types of devices.

1.Sanitary tampon

2.Sponge tampon

3.Conveen continence guard (CCG)

4.Contrelly continence tampon (CCT)





Various agents were used in past

1.alpha-1 adrenoreceptor agonist

2.Estrogens

3. Tricyclic antidepressants

Nowadays Duloxetine is the drug of choice.

It is a potent and balance serotonin (5-hydoxytryptamine) ,and nor adrenaline reuptakeinhibitor (SNRI) which enhances urethral striated

sphincter activity via centrally mediatedpathway.

Side-effects: nausea



It is the most effect way of curingurodynamic stress incontinence.

Aims of surgery are:

1. To elevate the bladder neck and proximal

urethra into an intra abdominal postion.

2. To support the bladder neck and align into the posterosuperior aspect of the pubic

symphysis.

3. To increase the out flow resistance.



It can be vaginally ,abdominally or combined.VAGINAL:-anterior colporrhaphy.-urethral bulking agents.-retropubic tape procedures-transobturator tape procedures

ABDOMINAL:-Marshall-Marchetti-Krantz procedure-Burch colposuspension

COMBINED:

-sling-endoscopic bladder neck suspenion



ANTERIOR COLPORRHAPHY:It is best used for cystourethrocele but

sometimes performed for stressincontinence.

MARSHALL-MARCHETTI-KRANTZ

PROCEDURE:It is a superopubic operation in which

the peraurethral tissue at the level of bladderneck is sutured to the periosteum and/orperichondrium of the posterior aspect of thepubic symphysis.

This procedure elevates the bladder

neck but cannot correct any cystocele.









COLPOSUSPENSION: It is the operation of choice in primary urodynamic stressincontinence because it corrects cystocele as well.

Procedure: 1. Low transverse suprapubic incision 2. bladder ,bladder neck and proximal urethra aredissected medially ,off the underlying paravaginal fascia andthree or four pairs of non absorbable sutures are insertedbetween the fascia and ipsilateral iliopectinel ligament.

3. sutures are tied thus elevating the bladder neck andbladder base.

4. post operatively a suction drain is left in retropubicspace and a suprapubic catheter is inserted into the bladder.Complications:

a.detrusor overactivity.b.voiding difficulties.c.rectoenterocele may be exacerbated by repositioning the

vagina.





It is minimal invasive surgery.

Two large randomized controlled trials havebeen reported from Australia and United

Kingdom,comparing laproscopic and opencolposuspension.

Both studies showed no significant differences

in cure rates or in patient’s satisfaction.



It is performed as secondary operation where there isscarring and narrowing of vagina.

Sling material can be organic(rectus fascia,porcinedermis) or inorganic(mersilene,marlex or silastic).

Sling can be inserted abdominally,vaginally or both.

It is used to elevate and support the bladder neck andproximal urethra.

COMPLICATIONS:a. difficult to decide strength of the sling.b. risk of infection,if material is inorganic.c. sling may errode into urethra or vagina.





RETROPUBIC TAPE PROCEDURES:

1. TENSION FREE VAGINAL TAPE:

- Introduced in 1996 and is commonly performed procedure in UK.-A knitted 11mm x 40 cm polypropylene mesh tape is insertedtransvaginally at the level of mid urethraursing two 5mm trochers.

-It can be performed under local.spinal or general anaesthesia.-Most women can go home the same day.

COMPLICATIONS:a. Voiding difficulties.

b. Bladder perforation.c. Urgencyd. Bleeding

2.SPARC-MID URETHRAL SLING SUSPENSION SYSTEM:

-It is a minimally invasive procedure.

-a knitted 10 m wide polypropylene mesh is placed at the level of the mid urethra by passing the needle via a suprapubic to vaginal approach.-it can be performed under local or general anaesthesia.- there were no significant differences in cure rates,bladder

perforation rates and urgency between sparc and tension free vaginal tape.-however a higher incidence of voiding difficulties and vaginal

erosions in sparc group seen.





It was first described in 2001. Can be performed under local,regional or

general anaesthesia. Has advantage of eliminating some of the

complications of retropubic route.

COMPLICATIONS: Damage to obturator nerve and vessels. Bladder injury.

Vaginal erosions.

APPROACHES:a. Inside out.b. Outside in.







It is performed endoscopically.

It is simple to perform but less effective thanopen suprapubic procedures and are now seldomused.

In this a long needle is used to insert a loop of nylon on each side of the bladder neck,this is tiedover the rectus sheath to elevate theurethrovesical junction.

Cystoscopy is used to detect any damage tothe bladder caused by the needle of the suture.



These are minimally invasive surgical procedures.

Useful in the elderly or those women who haveundergone previous operations and have fixed,scarred fibrosed urethra.

It is injected either periurethrally or transurethalyon either side of the bladder neck undercystoscopic control.

It is used to stop premature bladder neck openingwithout causing outflow obstructions.







It is employed when conventional surgery

fails. This is implanted and consists of fluid filled

inflatable cuff which is surgically placedaround the bladder neck.

DISADVANTAGES: Expensive

Surgery required to insert them iscomplicated.

Tissue around the bladder neck may beunsuitable for the implantation of the cuff.







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Dr.afroz Khizer MCPS Trainee