MENOPAUSE and

VOIDING TROUBLES

Prof . Abdel karim M. El Hemaly

MRCOG- FRCS

The most common voiding troubles in menopausal women are

• Increased frequency of micturition.

• Polyuria: undiagnosed, uncontrolled diabetes M.

• Dysuria. • Urgency and urgency incontinence .

• Stress urinary incontinence.• Mixed type of incontinence.

Less common voiding troubles

- True incontinence: from genitourinary fistula, resulting from malignancy and/or operative trauma.

- Urine retension and retention with overflow resulting from neurologic disease, drugs, pelvic surgery and incarcerated ovarian cyst.

- Haematuria: infection, stone, neoplasm.

MenopauseMarked drop of ovarian steroid hormones.

Cumulative effects of

trauma from

previous childbirth.

Increased total body

weight

Diabetes Mellitus and other metabolic

disorders Hypertension

General conditions

e.g.

Menopause

• Marked drop of ovarian steroid hormones will lead to:– loss of urogenital trophic support. – atrophy of urogenital tract.

– atrophy of collagenous tissue of the internal urethral sphincter leading to its weakness

– atrophy of urothelium, this will increase the chance of infection leading to more persistent, recurrent or chronic infection

Estrogen deficiency will lead to drop in the levels of:

Serotonin.

Neuro-peptides.

Nor-epinephrine.

Menopause

changes in the mood,

and Behavior

Decrease of the tone of the int, ureth, sphincter.

Menopause

Weakness of the

internalUrethral

sphincter

Voiding

troubles

Cumulative effects from previous childbirth trauma

Marked drop of ovarian Steroid

hormones

infection

Recently, In 1996 we put forwardIn 1996 we put forward a new a new concept, based on evidenceconcept, based on evidence explaining explaining the act of micturition and urinary the act of micturition and urinary continence.continence.

Micturition can be divided into 2 stages:

Stage-I: in Infancy before training of micturition.

Stage-II: in childhood after training of the act of micturition (how to control).

Micturition

• Stage-II : the mother starts to train her infant at the age of 18-24 months how to control micturition. This is gained by acquiring high alpha sympathetic tone at the internal sphincter closing it all the time except on need and /or desire.

Urinary continence depends on

• 1- An acquired behavior gained by learning in early childhood to keep a high alpha sympathetic tone in the internal urethral sphincter keeping it closed all the time except on need and/or desire.

• 2- An intact and strong internal urethral sphincter.

The structure of the The structure of the internal urethral internal urethral

sphincter sphincter -It is mainly a cylinder composed of compact collagenous tissue. It extends from the bladder neck down to the perineal membrane.

It is lined by urothelium. The muscle fibers intermingle with the collagenous fibers in the middle part; The muscle layer is controlled by alpha-sympathetic nerves T10-L2.

NORMAL INTERNAL URETHRAL SPHINCTER

3-D. ULTRASONOGRAPHY

U.B. U.B.

Closed urethradue to a strong,

intact int. u. sphincter

Closed lumen

Intact wall, compact sheet of collagenous tissue

with muscle fibers lie on and intermingle with

the collagen fibers In the

middle part of the cylinder

3D U.S.Cross section

Urethra

Vagina

Urethral lumen

Collag. tissue cylinder

Muscle layer

MRI picture of a normal continent woman

U.B.

Post. Wall of internal urethral sphincter.

Uterus

Vagina

MRI picture of a normal continent MRI picture of a normal continent womanwoman

• Collagen is the most abundant protein in humans.

• Collagen fibers are usually found in bundles of fibers and provide strength to the tissues.

• Each fiber is made up of fibrils, chemically it has a high content of hydroxy-proline and hydroxy-lysine,

• Many different types of collagen are identified on the basis of their molecular structure.

Type I is the most abundant being found in the dermis, bone, dentin, tendons, fascia, sclera, and organ capsules.

• In old age, the amount of intervening mucopolysacharide decrease.

• Also aging, with/ or without infection, cause fibrinoid necrosis of the collagen leading to its weakness

• In addition, marked drop of ovarian hormones leads to loss of urogenital trophic support.

• Important sites of collagen atrophy after menopause:

- bone osteoporosis

- urethra weakness – voiding troubles

- skin wrinkling

- fascia & organs loss of strength, form and shape.

• Collagen atrophy + mucosal thinning will lead to :–Frequency–Dysuria –Urgency–Cystitis–SUI–DI–Mixed type of incontinence.

• Weakness of the int. urethral sphincter will lead to:

– DI, overactive bladder , Urge and Urgency incontinence.

–SUI

– Mixed type of incontinence.

SUI, DI, and mixed incontinence are sequel of a torn weak internal

urethral sphincter.

• So, we innovated a new operation , trying to correct such types of urinary incontinence. Mending the torn edges of the internal urethral sphincter together by simple interrupted sutures, will restore the integrity of the internal urethral sphincter, and hence its strength. We called this operation

urethro-raphy.

References1. El Hemaly AKMA, Mousa LA. Micturition and Urinary Continence.

Int J Gynecol Obstet 1996:42, 291-2. 2. El Hemaly AKMA, Mousa LAE. Stress Urinary Incontinence, a New

Concept. Eur J Obstet Gynecol Reprod Biol 1996:68, 129-35. 3. El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and

Treatment. Int Urogynecol J Pelvic Floor Dysfunct 1998:9, 129-31. 4. Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.

Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.www.obgyn.net/urogynecology/urethroraphy

5. El hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction, Is SUI a puzzle?! www.obgyn.net/ PowerPoint presentations.

6. Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. Elmohamady. Evidence based Facts on the pathogenesis and management of SUI. www.obgyn.net/ PowerPoint presentations.

Authors • Abdel Karim M. El Hemaly*, Ibrahim

M.Kandil, and Bahaa E. El Mohamady M.

• Prof. Ob. Gyn. Faculty of medicine Al Azhar University, Cairo, Egypt.

• * corresponding author e mail m_hemaly@hotmail.com