TYPICAL CASE SCENARIOTYPICAL CASE SCENARIO

• 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence.

involuntary U.I. Whenever she coughs or sneeze… wetting herself 2-3 times a week… socially embarrassing and unable to continue with her sport activity

She has asthma on medication and is trying to reduce her weight.

How would you approach this case?

TYPICAL CASE SCENARIOTYPICAL CASE SCENARIO

• 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence.

She goes to toilet every 30 minute to pass urine and if not near a toilet she might wet herself

She drinks 10 cups of tea and coffee per day

Medically she is diabetic and hypertensive on diuretic

How would you approach this case?

Facts:Facts:

• “ it is the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem”.

• It is very common among women of all ages– 15-44 5%– 45-64 10%– >65 20%– > 40% in institutionalized women

– Up to 30% post vaginal delivery,,,,,, temporarily.

• Female urethra 3-4 cm in length

Anatomy:

Innervation:

Parasympathetic. S2-4. stimulation of pelvic parasymp. Or adm of cholinergic drugs…. Bladder contract… anticholinergic drugs reduce the bladder pressure and increase the capacity

Sympathetic. T10-L2. β-fibers in detrusor muscle.. Relax urethra and detrusor muscle. Α-fiber in urethra.. Stimulation contracts the bladder neck and urethra and relaxes the detrusor

• Urethral causes:– Urethral sphincter incompetence{ genuine stress inc.}– Detrusor instability

• Neuropathic• Non-neuropathic

– Retention with overflow– Congenital– Misc

• Extra urethral:– Congenital– Fistula

• “ Involuntary loss of urine when the bladder pressure exceeds the maximum urethral pressure in the absence of any detrusor contraction”.

• Causes:– Abnormal descent of bladder neck and proximal urethra– Intraurethral pressure at rest lower than the intravesical,

scarring– Laxity of sub-urethral support

• Aetiology:– Damage to the nerve supplying pelvic floor and urethral

sphincter– Menopause– Congenital– Chronic causes, obesity, COPD,…..

• Symptoms:Leaking urine… feeling wet whenever

performing activities

Which raise the intra-abdominal pressure

Urgency, frequency and urge incontinence

Possible prolapse symptoms

• Examination: – General, chest, abdomen,

pelvic…… mass– Pelvic:

• Demonstrate incontinence• Cysto-urethrocele

• “ Involuntary loss of urine due to bladder contraction, either spontaneously or on provocation, despite the patient attempting to inhibit micturition”.

• Symptoms:– Urgency, urge incontinence, frequency{ 15-120 min},

nocturia, S.I., enuresis,,,, voiding difficulties

• Examination:– Non specific, but exclude masses…. prolapse

• Pathophysiology is poorly understood

• Poor toilet habit training and psychological factors have a role

• Idiopathic D.I. Is the commonest

• Possible causes: – Continence surgery, – outflow obstruction– Smoking and excessive tea and coffee intake

• History and examination may not be conclusive• The aim of urodynamic inv. Is to provide accurate DX

of disorders of micturition and investigating the L.U.T. and pelvic floor function

1. MSU

2. Urinary diary

3. Pad test

4. Dual channel subtracted cystometry

– Uroflowmetry

– Cystometry

5. Video-cysto-urethrography– Tertiary units

6. Ambulatory monitoring

7. Cysto-urethroscope

8. Imaging. MRI

1. PreventionI. Vaginal vs abdominal delivery

II. If vaginal, short second stage and less trauma

III. Weight reduction

IV. Chronic cough

V. Pelvic floor exercises

VI. ???? Hormone replacement therapy

2. Conservative:I. Physiotherapy. Mild to moderate cases.

Improvement in up to 40- 60%. Needs motivation

II. Prolapse correction. Ring pessaryIII. ?HRTIV. Biofeedback techniques. Weighted conesV. Maximal electrical stimulationVI. Continence devices

3. Medical : not effective. Duloxetine SSRI

4. Surgery..Treatment of choice….. Aims to 1) restores the urethra and

bladder neck to zone of intra-abdominal pressure 2) increase urethral resistance

Procedures:– Vaginal. Anterior colporrhaphy. Poor 5 years success

– Abdominal. Colposuspention. 80% 5 years f.u.

– Sling operation– TVT

Shortcut to TVT.lnk

• Surgery… cont.

When the defect is in the sphincteric mechanism producing a low resistance and poor functioning urethra….. Then:

– Artificial sphincter– Periurethral bulking:

• Collagen• macroplastiqua

1. Conservative:I. Bladder training. Effective 60-70% needs motivation

II. Biofeedback, hypnosis, TENS …etc

2. Medical:

I. Anticolenergics. Oxybutanin or tolterodine {side effects}

II. Imipramine { TCA} …. Enuresis

III. desmopressin {antidiuretic hormone a’gue}… Nocturea

3.Surgery.

Last resort.

Urinary diversion

Bladder augmentation

• Urinary incontinence is 20-30% prevalent among females• GSI & DI are the commonest• Physiotherapy is effective in mild to moderate GSI• Bladder training and Anticolenergics are most appropriate

treatment for DI

• UTI must always be excluded before any fancy investigation or treatment started,

• No incontinence surgery without urodynamic studies• Surgery for incontinence should be the patient’s decision

depending on how severe and findings