Urinary Incontinence Dr Engy Final 2014

8/13/2019 Urinary Incontinence Dr Engy Final 2014

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URINARY INCONTINENCE

BY

Professor Dr. Engy Taher


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The pelvis is a basin with 4 walls & floor.

Front wall:back of symphysis pubis.

Back wall: sacrum & pyriformis muscle.

2 side walls: obturator internus muscle.

Floor.


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Bony Pelvis:

bony pelvis consists of 2hip bones, fused tosacrum posteriorly and

to each other anteriorlyat symphysis pubis.

Each one composed of:

ilium,

ischium,

pubis.


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Numerous

projections andcontours provide

attachment sites

for ligaments,

muscles, and

fascial layers.


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Basic anatomy of lower urinary tract

Bladder

Urethra


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Anatomy of female pelvic floor

support


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Basic anatomy of pelvic floor

Pelvic floor Consists of 3 functional layers:

I. Muscle: (levator ani + coccygeus = pelvic

diaphragm)

II. Fascia: as endopelvic fascia

III. Perineal membrane(urogenital diaphragm)


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Muscular support of pelvic floor


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II- Urogenital diaphragm

Perineal body:

Pyramidal fibromuscular structure between

anus & vagina

3.5 cm

Responsible for closure of vaginal introitus.


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Urogenital Diaphragm


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Perineal body


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III- Fascial components of pelvic floor

Includes parietal& visceralfascia

visceral fascia termed endopelvic fascia

Uterosacral & cardinal ligaments arecondensations of endopelvic fascia


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Endopelvic fascia & connective tissue

supports:

3 compartments

Anterior

Middle

Posterior

Urethral supportBladder support

Vaginal supportUterine support

Rectal support


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Anterior supports:

Urethropelvicligament: The mostimportant support ofproximal urethra andbladder neck.

distal half of urethra issupported bypubourethral ligamentand levator

musculature. pubocervical fascia:

the main support ofbladder base.


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Posterior supports:

lateral rectal ligaments

is the fascial supports

for rectum.

Additional prerectaland pararectal fascial

elements.


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Normal Continence In Women


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Functions of urinary bladder:

1. Reservoirfor urine(resting phase).

2. contractile organ to actively expel the

contents (urine) to urethra (active phase)


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Micturition cycle :


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Principle of sphincter function is water tight

opposition of the urethral lumen,

compression of the wall around the lumen,

structural support to keep the proximalurethra from moving during increased

abdominal pressure and neural control.


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Functions of lower urinary tract:

Storage of urine (accomodation property). Expulsionmicturition.

Functions of pelvic floor:

Maintain continence. Prevent P.O.P.


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Neural control

I. Parasympathetic nerves (S2,3,4)

II. Sympathetic nerves (T10-L1)

III. Somatic motor.IV. Central control


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Continence

Urethral closure pressure must be greater

than bladder pressure both at rest and during

increase in intra abdominal pressure.


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During rest:

Tone of urethral muscles maintains a favorable

pressure relative to bladder pressure.

During activity:

dynamic process increases urethral closure

pressure to maintain continence


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Classification of incontinence

A. Genitourinary causes1. Urodynamic stress incontinence

2. Urge incontinence

3. Mixed incontinence

4. Overflow incontinence

5. Incontinence caused by fistula

6. Congenital causes

B. Non- Genitourinary Causes:-1. Neurological disorders

2. Medications.

3. Metabolic disorders


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Stress Incontinence


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Definition:

involuntaryescape of urine onlywith increase

in intra abdominalpressure withoutdetrusor

muscle contraction.


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Incidence & risk factors

Stress urinary

incontinence is the

most common type

of urinaryincontinence in

women.


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Risk factors for stress incontinence:

1. Being female.

2. Childbirth.

3. Coughingover a long period of time (aschronic bronchitis & asthma)

4. Getting older.

5. Obesity.

6. Smoking.


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Pathophysiology


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a)Urethral hypermobility (80-90%):

Due to loss of normal pelvic support of

bladderand urethradue to:

1-Trauma& stretchingof vaginal delivery.

2-Hysterectomy.

3-Hormonalchanges(menopause).

4-Pelvic denervation.5-Congenitalweakness


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Due to sphincter damage due to:

1-Multiple prior operations.

2-Trauma.3-Radiation.

4-Neurogenicdisorders including Diabetes

Mellitus.5-Atrophicchanges: lack of estrogen

B) Intrinsic Sphincter Dysfunction

(10 - 20% of patients):


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Degrees

I. Grade Iincontinence with severe stress

(sneezing, coughing, jogging).

II. Grade II incontinence with moderate

stress (rapid movement, waking up &

down stairs).

III. Grade IIIincontinence with mild stress

(standing up).


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Diagnosis & Treatment


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Diagnosis:


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History

Examination

investigations


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History

1. Durationof incontinence.

2. Frequencyand intensityof the incontinence.

3. Use of protectivepads.

4. Impactof symptoms on lifestyle.


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Physical examination

Abdominal examination.

Pelvic examination.


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Special tests:

1) Stress test

2) Bonneystest

3) Q-tip test

4) Pad test


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Treatment:

Conservative Surgical


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Conservative treatment:

1. Pelvic floor muscle exercises.

2. Biofeedback.

3. Lifestylechanges.


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Peri-urethral bulking injections

1. Collagen.

2. Teflon paste.


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4) Vaginal cones


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Surgical treatment:

Anterior vaginal repair (Kelly's plication)


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Abdominal retropubic cystourethropexy

(Marshall-Marchetti-

Krantzprocedure)

(Burchcolpo-suspension)


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Laparoscopic colpo-suspension:


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Suburethral sling procedure:


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URGE INCONTINENCE


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Definition:

Sudden involuntary

contractionsof muscular wall

of bladder, result in urgency

and immediate urge tourinate. And involuntary loss

of urine.


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Incidence

Urge incontinence is the 2nd mostcommon cause of incontinence. About 3 in 10 cases of incontinence are due to

urge incontinence.

It can occur at any age, but commonlyfirst startsin early adult life.

Women are more commonly affectedthan men.


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Causes:

In urinary incontinence, patient leaks urine as

bladder muscles contract at wrong times.

these contractionsoccurno matterhow much

urineis inthe bladder.


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Although there is no definite cause, Urgeincontinence may be resulted from:

1. - Nervous system disease (as multiple sclerosisor Parkinsonism).

2. - Nervous system injuries (as spinal cord injury

or stroke).3. - Infection(UTI).

4. - Bladder inflammation(Interstitial cystitis)

5. - Bladder outlet obstruction.

6. - Bladder stones.

7. - Bladder Cancer.


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Risk factors:

1. Elderly.2. Pregnant Women or whojust delivered.

3. C-sectionor other pelvic surgery.

4. Obese.5. Men had prostate surgery or prostateconditions, as enlarged prostateor prostatitis.

6. Nerve damage from conditions as diabetes,

stroke, or injury.7. Certain cancers, including bladderand prostate.

8. Urinary tract infections.


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Clinical Picture:

The main symptom is uncontrolled loss of urineassociated with sudden, strong desire to urinatethat cannot be postponed.

Women may describe sudden loss of urine in a

rush to reachthe toilet. Often, this occurs with certain triggering events,

as: fumbling with keys to open the door,

sound or sensation of running water, drinking much water, coffee or Alcohol

exposure to sudden cold.


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Treatment of Urge Incontinence


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THANKS

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Urinary Incontinence Dr Engy Final 2014