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Ahmad Hafiz bin Ahmad Shafruddin Bangalore Baptist Hospital May 2012
Subtopics
Stress Urinary Incontinence Urge Incontinence Mixed Incontinence Functional and Transient Incontinence
Urinary Bladder
Mucosa Transitional epithelium Detrusor muscle - outer longitudinal, middle circular &
inner longitudinal Serosa Covers anterior and superior surface
Urethra
Inner Mucosa Proximal Transitional epithelium Distal Stratified squamous epithelium Outer Muscle Layer
Inner smooth muscle - Intrinsic sphincter Outer circular striated muscle Extrinsic sphincter Upper two-third Sphincter urethrae rhabdosphincter for urethral closure Lower one-third Levator ani additional force
Innervation
gambar
Urinary Incontinence: complaint of involuntary leakage of urine Stress Urinary Incontinence: complaint of involuntary leakage of urine with increased intra-abdominal pressure in the absence of detrusor contraction Most common Pathogenesis
Urethral Hypermobility
Intra-abdominal pressure weak support of levator ani & vaginal connective tissue to counter funneling gambar
Integrity maintained by
Epithelium Subepithelial vascular plexus Muscular layer Prior surgery Trauma of delivery denervation & scarring lead pipe or rigid urethra Ineffective closure leakage
Damage
Risk Factors
Age Multiparity Vaginal Delivery Obesity Menopause Chronic increase in intra-abdominal pressure Smoking Previous surgery
Clinical Evaluation
History
Is it a social problem?
Physical Examination
General Examination
Height, weight, BMI RS Neurological system Mass arising from the pelvis Excoriation of vulva Prolapse
Abdominal examination
External Genitalia
Speculum Examination
Investigations
Simple Tests Urine Microscopy and culture Q-tip test Postvoid residual urine measurement Office cystometry Voiding diary Stress test Exclude UTI Assess urethral hypermobility Exclude overdistended bladder Exclude overactive bladder Assess urinary output/frequency Assess urethral hypermobility
Q-tip test
gambar
Urodynamic Study Cystometry simple/multichannel Stress Incontinence Detrusor overactivity Bladder capacity Urethral function Voiding dysfunction Stress incontince Detrusor overactivity Bladder capacity Urethral closure Intrinsic sphincter deficiency Evaluate bladder
Uroflowmetry Cystometrography
Test of urethral function - Urethral pressure profilometry - Valsalva leak point pressure Cystourethroscopy
Management
Kegel's exercise Pessaries and urethral devices Medication imipramine, oestrogen, SSRI Vaginal Abdominal Laparoscopic
Surgical Management
Vaginal Procedure
In cystocoele also Plication of pubovesicocervical fascia Transverse stitches at the level of bladder neck Elevation of bladder neck
Combined procedures
Traditional sling procedure Endoscopic bladder neck suspension Proximal urethra and bladder neck to abdominal wall Bladder neck to rectus sheath
Urge Incontinence
Definition
Involuntary leakage or urine accompanied by or immediately preceded by urgency Urgency: Sudden, strong desire to pass urine that is difficult to defer Frequency: more than 8 voids per day
Symptoms of urgency with or without urge incontinence, usually with frequency and nocturia Detrusor activity, dx made after urodynamic testing Other causes: neurological, psychogenic, idiopathic
Management
Bladder drill void 30-60min, distration method, kegel Biofeedback behavioural therapy (visual, auditory or verbal feedback during muscle training) Medications anticholinergic
Mixed Incontinence
Both stress & urge Managed medically for detrusor overactivity If repeat urodynamic study shows stress incontince surgical intervention
Delirium Infection Atrophy Pharmacological Psychological Endocrinopathy Restricted mobility Stool impaction