Dr.

swati singh
Registrar
Introduction
Incidence
Anatomy / Physiology
Types of Incontinance
Aetiology
Management
Conclusion
 INTRO DUCTI ON
Cont ine nce i s th e abi li ty t o p as s uri ne or
fa ece s volu nt ar il y i n a s oci all y a cc ept abl e
.pl ace
:T he cont in ent pe rson can
reco gni ze t he need 
identi fy the co rrec t pl ace 
hol d on un ti l he r eaches the corr ec t p la ce 
to pa ss uri ne or fa ece s 
Inconti nenc e - i nvol unt ar y l oss of ur in e whi ch
is obje ct ively demons tra ble & it is s oci al
. and h ygi eni c p robl em
INCIDENCE
Urinary incontinence - not a recent
medical or social phenomena. Disorders
of urinary tract written in ancient times.
1 in 3 female age 55 or more complain of
incontinence.
1 in 10 women will have surgery for
prolapse or SI in life time. One third will
need further surgery.
Physiology of Micturition
• Bladder innervation:
somatic, parasympathetic (PSN) and
sympathetic (SNS)

• ~150-300 ml in bladder before the

brain
recognizes bladder fullness
Physiology of Micturition
 Physiology of Micturition
• Low bladder volumes: SNS is stimulated
and PNS is inhibited
• Bladder full: PNS stimulated (bladder
contracts) SNS inhibited (internal
sphincter relaxes)
• Intravesical pressure > resistance within
the urethra: urine flows
• Pudenal nerve innervates external
sphincter
Pudendal nerve is inhibited → external
PHYSIOLOGICAL
ANATOMY
The bladder neck and upper third or half of
the urethra are above the level of the pelvic
floor.

The internal urethral sphincter :Is an

involuntary muscle which surrounds the
bladder neck.
 PH YSIOLOG IC AL A NAT OMY
The external urethral sphincter :
is a voluntary muscle found between the
superficial and deep perineal membranes and
surrounds the middle part of the urethra
compessor urethrae muscle
 The external urethral sphincter
It empties the urethra after the act of
micturition,

Interrupts the flow of urine on desire

It acts as a secondary defensive

mechanism against escape of urine.
 PH YSIO LOG ICAL ANA TOMY
At rest the urethra makes an angle of 90-
100 degrees with the base of the urinary
bladder called the posterior
urethrovesical angle.

The urethra also makes an angle of less

than 30 degrees with the vertical line.
TYPES:
1. True incontinence.
2. False incontinence

3. Stress or
sphincter incontinence.

4. Urge incontinence
(precipitancy-detrusor
instability or detrusor
dyssynergia).

5. Nocturnal enuresis.
Incidence of Subtypes of
Urinary Incontinence in Women
Stress Incontinence
50%

Urge Incontinence
20%
STRESS INCONTINENCE
)SPHINCTER INCONTINENCE-GENUINE
STRESS INCONTINENCE

It is involuntary escape of few drops

of urine with increased intra-
abdominal pressure as during
straining, sneezing, coughing,
laughing ... etc.
DEGREES OF STRESS
INCONTINENCE

Grade I
Incontinence occurs only with severe
stress, such as coughing, sneezing, etc …
Grade II
Incontinence with moderate stress, such as
rapid movement or walking up and down
stairs
Grade III
Incontinence with mild stress, such as
TYPES OF STRESS INCONTINENCE
Type 1 : There is complete loss of the
posterior urethrovesical angle.

Type 2 : There is complete loss of the

posterior urethrovesical angle together
with increase in the angle between the
urethra and vertical line to be more than
30 degrees.
AETIOLOGY
Weakness of the internal urethral sphincter or
Descent of bladder neck below the level of the
pelvic floor.
Congenital weakness of the internal urethral
sphincter, seen in the young nullipara.
Congenital defects as:
Epispadias,
Short urethra (less than 1 cm),
Wide bladder neck, and
Separation of symphysis pubis.
 AE TIOLOG Y
3. Tr auma to the region of the bladder
neck due to vaginal delivery or operation.
In fact vaginal delivery is the commonest cause
of stress incontinence.

4. Pr egn an cy and continuous

administration of oestrogen-progestogen
preparation to induce psuedopregnancy
state to treat endometriosis.

The hormonal imbalance with increased progesterone

weakens the internal urethral sphincter.
 AE TIOLOG Y
5. Menopa use: Lack of oestrogen leads to
atrophy of bladder neck supports.

6. Genit al pro la ps e:

7. Orga nic ne rvous dis eases as disseminated

sclerosis.
Pathophysiology of Stress
Incontinence
The basic pathology is urethral incompetence.
This can be either due to:
Urethral hypermobility (80 -
90% of patients)

B) Intrinsic Sphincter Dysfunction

(10 - 20% of patients)
A) Urethral hypermobility (80 - 90% of patients)

 This results from loss of the normal

pelvic support mechanism of the bladder
and urethra due to:
2. Trauma and repeated vaginal delivery
3. Hysterectomy
4. Hormonal changes ( Menopause)
5. Pelvic denervation
6. Congenital weakness
Dysfunction (10 - 20% of
patients)
 This results from damage to the sphincter
due to:
Multiple prior operations
Trauma
Radiation
Neurogenic disorders including Diabetes
Mellitus
Atrophic changes: lack of estrogen.
1. A detailed history differentiates between the
different types of incontinence.
2. Stress incontinence and detrusor instability
frequently occur together.
3. Gradual onset after menopause suggests
oestrogen deficiency.
4. History of vaginal repair or operation in the
region of the bladder neck and history of any
neurologic disease.
Urinalysis and urine culture help to
diagnose urinary tract infection.

Bloo d tes t is required know the

compromised renal function, diabetes,
syphilis, or other systemic diseases are
suspected.
Stress Test
The bladder must be moderately full.
The patient in the lithotomy position, the two labia
are separated, and the patient is asked to cough.
If urine escapes, the patient is incontinent.
If no urine escapes, the test is repeated while the
index and middle fingers in the vagina press on the
perineum to abolish reflex contraction of the levator
ani muscles during straining.
If still no urine escapes, the test is repeated while
the patient is standing with the legs separated.
Bonney test
It is indicated in case of a positive stress
test associated with a cystocele.
To know if incontinence is due to descent
of bladder neck or weakness of the
sphincter.
The index and middle fingers are placed
on both sides of the urethra to elevate the
bladder neck upwards.
If no urine escapes on stress it means
that the incontinence is due to descent of
the bladder neck, but if urine still escapes
 You sef Tes t
Indicated in case of a negative stress test
associated with a large cystocele to diagnose
hidden stress incontinence.
The cystocele is reduced, the cervix is
grasped with a volsellum and pushed upward,
then the patient is asked to cough.
If urine escapes, it indicates that the patient
was continent because of kinking of the
urethra.
 The Cotton-Tip Applicator
(Q-Tip) Test
A sterile applicator with a small piece of cotton
at its tip is introduced to reach the bladder
neck.

The angle between the applicator and the

horizontal is measured.

The patient then strains maximally using the

Valsalva manoeuvre.

This causes descent of the bladder neck and

upward movement of the applicator producing a
(Q-Tip) Test
In normal patients the increase in
the angle is less than 30 degrees.

In stress incontinence the change is

more than 30 degrees indicating
poor support and abnormal descent
of bladder neck

The test is positive in more than

 Cy stou re throg raphy
A radio-opaque dye is injected by a
catheter into the bladder.

On straining, the lateral view will show

absence of the posterior urethrovesical
angle in more than 90% of cases.

Funneling of the bladder neck in the

antero-posterior view may be seen in
some cases.
 Urodynamics
1.Cystometrogram( most important
test), Filling Cystometry and Voiding
Cystometry
2. Electromyography
3. Uroflometry

4. Urethral pressure profile :

significant lowering of urethral
closure presure during strain
 Measurement of
Urethral Length
Stress incontinence
occurs if the length is
less than 1 cm.
 Transvaginal ultrasound
When damage affects the upper part of the
sphincter, the urethra appears "funnel-
shaped".

When damage affects the lower part, the

urethra appears "vase-shaped".

When damage affects the whole length of the

sphincter, the urethra appears short and
irregular.
 laboratory tests
Postvoid residual urine
After the patient voids, there
should be less than 50 ml of
urine in the bladder
( measurements greater than
100-200 ml) may have an
underlying neurologic
disorder.
Tests are most helpful in
differentiating between GSI and DI
Cy st ometr ogram
Cy st osc opy :
should be performed especially in patients with:
irritative bladder symptoms such as urgency,
frequency, and hematuria
To rule out:
5. inflammation,
6. tumors, or
7. anatomic deformities
1. During labour, the bladder should be kept empty.
2. Episiotomy is performed if necessary.
3. Physiotherapy.
Pelvic fl oor exercis es are started after
delivery.
These include repeated stoppage of the urinary
stream during micturition and repeated contractions
of the pelvic floor muscles.
 Conse rv ati ve (n on-su rgi cal )
Tre atmen t
Indications:
1.Mild stress incontinence
2.Patient is unfit for surgery or refuses
surgery.
3.When stress incontinence is combined
with detrusor instability.
Conservative treatment cures or
improves 50% of cases and include:
1.Physiotherapy: Kegal perineometer
may be used.
2. Faradic current stimulation of the
levator ani muscles to improve their tone.

3. Vaginal cones:
A set consists of 5 or 9 cones.
Weight ranges from 20 to 100 grams.
Patient inserts the cone in the vagina and
keeps it for 15 minutes twice daily.
If this succeeds she inserts the next cone.
This improves the tone of the pelvic floor
muscles.
4.Oestrogen therapy for menopausal
patients:
It causes thickening of the urethral
mucosa and engorgement of the
underlying blood vessels

5. Alpha-adrenergic stimulants: which

stimulate contraction of the internal
urethral sphincter, e.g. ephedrine.

6.Large vaginal diaphragms, Hodge

pessary to elevate ' and support the
7. Reduction of weight in obese
patients to reduce intra-abdominal
pressure.

8. Stop caffeine (to avoid diuresis)

and smoking (to avoid coughing)

9. Injection of Teflon or bovine

collagen in the submucosal layer in
the region of the bladder neck.
This leads to narrowing of the
urethral lumen and increased urethral
Surg ica l Treatmen t
Urethroplasty (Kelly,Kennedy,etc….)
Urethropexy (Retropubic
urethropexy e.g. Marshall-
Marchetti-Krantz, etc….)
Colposuspension (Burch operation,
Preyera)
Urethral slings (Aldridge operation,
etc)
Tension free Vaginal Tape (TVT)
 CONCLUSION:
• Urinary incontinence is a common problem, causes
distress to a large no of female population.

• Current diagnosis and management involves good

understanding of the condition.

• Therapy for UI is often long term and requires pt

explanation of pathology.

• In future, further understanding of pathophysiology

of condition may lead to further advances.