URINARY INCONTINENCE ( UI )

Prof. Kamal Anwar

Mechanism of continence of urine: The proximal part of the urethra is intraabdominal ( above the levator ani ): When the intra abdominal pressure is increased ,it is transmitted equally to the bladder and proximal urethra The pubo-urethral ligament and levator ani keep the proximal part of the urethra intra-abdominal

Urethral muscular components: External urethral sphincter ( EUS )supplied by pudendal nerve: outer layer of striated muscle arranged in a circular pattern Internal urethral sphincter ( IUS ) : internal to EUS smooth muscle arranged in a longitudinal pattern Vascular plexus deep to these layers forms a watertight seal by coaptation of mucosal surface

Micturition cycle :
Bladder filling ( Sympathatic fibres from hypogastric plexus ) occurs with relaxation of detrusor muscle and contraction of IUS Bladder evacuation ( parasympathatic fibres from sacral plexus ): occurs with contraction of detrusor muscle

Nervous Control Bladder filling

Sympathetic nerves (T11-12) Inhibit detrusor contraction Increase sphincter tone Inhibit parasympathetic tone

Somatic nerves (S2-4) Maintain tone in pelvic floor musc

Urination
Parasympathetic nerves (S2-4) Contract the detrusor muscle Relax sphincter tone

Urinary incontinence is defined as involuntary leakage of urine Types of Urinary incontinence : 1-stress urinary incontinence ( genuine stress incontinence ) : It is the most common type of urinary incontinence , accounting for 50-70 % of cases It occurs when the abdominal pressure exceeds the bladder pressure

Stress incontinence is triggered by activities (coughing, sneezing, laughing, running, or lifting) that apply pressure to a full bladder. Childbirth and menopause increasing the risk for it Urethral hypermobility : Weakness of fibromuscular tissue that support the bladder neck and urethra Interinsic sphincter deficiency due to damage of uretheral sphincter resulting in failure to close the urethro-vesical junction
.

2-Overactive bladder (Urge urinary incontinence ) Involuntary leakage of urine immediately preceded by the urge to void due to involuntary detrusor contraction. patients complain of inability to reach the toilet in time Urge incontinence is marked by a need to urinate frequently. There are many causes of urge incontinence, including medical conditions, Parkinsons disease, multiple sclerosis, stroke, and spinal cord injuries), surgeries

3-Overflow incontinence occurs when the bladder cannot empty completely, which leads to dribbling. Bladder obstruction and inactive bladder muscle can cause overflow incontinence.

Overflow incontinence happens when the normal flow of urine is blocked and the bladder cannot empty completely

overflow incontinence can be due to a number of conditions: A partial obstruction. In this case the urine cannot flow completely out of the bladder, so it never fully empties : Tumors Scar tissue

An inactive bladder muscle. In contrast to urge incontinence (overactive bladder), with overflow incontinence the bladder is less active than normal. It cannot empty properly and so becomes distended, or swollen. Eventually this distention stretches the internal sphincter until it opens partially and leakage occurs. Certain medications and nerve damage increase the risk :

Certain medications (such as anticholinergics, antidepressants, antipsychotics, sedatives, narcotics, and alpha-adrenergic blockers) Nerve damage. When nerves in the bladder are damaged the body cannot feel when the bladder is full and the bladder does not contract. Nerve damage can be caused by spinal cord injuries, previous surgery in the colon or rectum, or pelvic fractures. Diabetes, multiple sclerosis also can cause this problem.

4-Functional incontinence Patients with functional incontinence have mental or physical disabilities that keep them from urinating normally ( impair a persons ability to use or get to the toilet ) although the urinary system itself is structurally intact. Conditions that can lead to functional incontinence include: Parkinson's disease Alzheimer's disease and other forms of dementia. Severe depression. In such cases, people may become incontinent because they have difficulty with self-control

5 -Mixed incontinence. Many people have more than one type of urinary incontinence.

Symptoms of both stress and urge incontinence may exist together

6- True incontinence or Bypass incontinence ( urogenital fistula ):

It is due to communication between urinary and genital tract Causes : Trauma during gynecologic surgery Obstetric injuries : Necrotic obstetric fistula Direct traumatic obstetric fistula: Forceps delivery Rupture uterus Others: radiation, genital malignancy

Risk factors for UI Parity Childbirth :Vaginal delivery causes damage to pelvic structure Medical conditions : diabetes, obesity, Chronically increased intra-abdominal pressure Estrogen deficiency Drugs Diuretics , caffeine and anticholinergics

Diagnosis of UI : Symptoms

Stress incontinence appears on stress as coughing Overactive bladder presents as urinary urgency with daytime frequency or nocturia Examination : Stress test : The bladder should not be empty Ask the patient to cough and inspect the urethra Involuntary leakage of urine from uretheral meatus indicates stress urinary incontinence

Neurological examination :
UI may be a symptom of neurological disease Evaluate the motor and sensory function of the lower limbs Pelvic examination : Assess pelvic floor including innervation , muscular and connective tissue support The strength of levator ani is assessed by placing 2 fingers in the vagina and ask the patient to squeeze

Q-tip test
It evaluate urethral support A cotton swab is placed in the urethra up to the bladder neck During straining ,the change of angle between the Q-tip and the horizantal plane is measured. If it is greater than 30 degrees ( abnormal ) , it indicates descent of the bladder neck due to urethral hypermobility

Investigations:
Urine analysis to exclude urinary tract infection Postvoid residual urine measurement : It aids in diagnosing overflow incontinence Normally , it should be less than 100 ml Cystourethroscopy : It assesses the anatomy and function of lower urinary tract

Cystourethrography :
Lateral view: loss of the posterior urethro-vesical angle Antero-posterior view : Funneling

Urodynamic study:
This is done to differentiate between stress incontinence and detrusor instability In detrusor instability ,there is abnormal contraction during filling In stress incontinence,there is decreased urethral closure pressure which is the difference between the pressure in the urethra and bladder

Treatment of Urinary Incontinence

Treatment options for urinary incontinence depend on the type of incontinence and the severity of the condition. Treatments include: Lifestyle Changes. Significant weight gain can weaken pelvic floor muscle tone, leading to urinary incontinence. Losing weight through healthy diet and exercise is important. Regulating the time you drink fluids and avoiding alcohol and caffeine are also helpful.

Treatment of stress urinary incontinence: Non- surgical :

Postmenopausal atrophy : Estrogen replacement therapy Pelvic muscle exercise( Kegel exercise ) for 36months Vaginal pessaries in case of pelvic organ prolapse

Surgical treatment of SUI:

A-Cystocele repair with Kelly suture for anterior vaginal prolapse Kelly suture: plication of pubo-urethral ligament around the bladder neck B-Colposuspension Indicated in hypermobile bladder neck Burch retropubic colposuspension: Permanent sutures are placed in the fibromuscular tissue lateral to the bladder neck and proximal urethra to be attached to iliopectineal line ( Cooper ligament ) Success rate over 80 %

Marshall- Marchetti Krantez operation: Similar to Burch but the stitches are placed through the periosteum of the symphysis pubis C-Suburethral sling : A sling is passed below the mid-urethra as a hammock providing stabilization of the urethra Tension-free vaginal tape ( TVT ) A mesh is placed without tension at the midurethra through retropubic space. Bladder perforation is the most common complication (5%)

Tension free obturator tape ( TOT ): TOT is passed through amid vaginal incision to obturator foramen

Treatment of overactive bladder

Medical treatment is the primary line Medications used inhibit involuntary detrusor contractions A- Anticholinergics : Oxybutynin ( Ditropan ) 5 10 mg / 8 hrs B- Tricyclic antidepressants : Imipramine 25 mg 1-4 times daily