LOWER URINARY TRACT

(LUT) FUNCTION &

DYSFUNCTION

DR . JASSIM AL-HIJJI
CONSULTANT
OBS. & GYN.
UROGYNECOLOGY UNIT.
ADAN HOSPITAL

1
EMBRYOLOGY

2
EMBRYOLOGY AND
ANATOMY

3
LONGITUDINAL SECTION OF A 4-WEEK-
OLD EMBRYO

4
LONGITUDINAL SECTION OF A 5-WEEK-
OLD EMBRYO

5
LONGITUDINAL SECTION OF A 6-WEEK-
OLD EMBRYO

6
LONGITUDINAL SECTION OF A 8-WEEK-
OLD EMBRYO

7
Embryologic Contribution Of Various Structures Of
Female Urogenital System

8
ANATOMY

9
10
 BLADDER ANATOMY
•
• Body (or dome) and
Fundus :
 - supple, mobile and
highly distensible
-
capable of expanding
into abdomen,

 depending on
amount of urine stored


• Base of bladder not so

distensible holds
orifices (uretersand
urethra) in place
11
12
FEMALE URETHRA &
SURROUNDINGS

13
14
BLADDER MUSCLES
Main smooth muscle
layer includes:
(1) Detrusor and Trigone

It is the most important

 Muscle .A mesh of
smooth muscle
bundles, Collagen &
elastin.


(2) The Trigoneis a thin



smooth muscle lining

over the bladder base,
with a Collar around
ureteric orifices
– Actual function
still 15
 FEMALE URETHRA
•
Adult female urethra
4 cm in length, up to

6 cm Diameter
when distended
• Extends from
bladder neck
behind Symphysis
pubis
• Embedded in
anterior wall of 16
 FLOOR

• Smooth muscle extends

throughout Length of
urethra.
• No well-defined
sphincter at bladder
neck.
• Striated sphincter
(external sphincter)
Located along middle

third of urethra
Anatomically separate
from Pelvic floor
muscles.
Pelvic floor muscles help

keep urethra closed &

support bladder 17
 The parts of the urethral support and sphincteric mechanisms: the
proximal urethra and bladder neck are supported by the anterior
vaginal wall and its musculofascial attachments to the pelvic
diaphragm. Contraction of the levator anielevates the anterior
vagina and bladder neck and proximal urethra, contributing to
bladder neck closure. The sphincter urethrae, urethrovaginal
sphincter, and compressor urethrae are all parts of the striated
urogenital sphincter muscle.

18
The levator ani, seen from the side when the
ischium is removed. Arcus tendineus levatores ani
runs from the ischial spine to the pubic bone. Note
the perineal membrane that supports distal
portions of the urethra and vagina.

19
The levator ani, with patient in the
semirecumbent position. The muscle fibers
of the pelvic diaphragm form a broad,
anteriorly directed, U-Shaped muscle layer.
The pelvic organs pass within this U-Shaped
area, called the urogenital hiatus.

20
PHYSIOLOGY

21
 NORMAL MICTURITION
•
• Cycle begins with urine filling bladder through
ureters
• Pressure in bladder remains low during gradual
filling
• When bladder reaches certain distension, stretch
receptors in bladder wall send this information
to spinal cord; other nerves relay it to brain as
sensation of fullness
• If time and place are right, emptying takes place:
 - Urethral sphincter relaxes & urethral
pressure decreases
 - Detrusor muscle contracts & bladder
pressure rises
 - Bladder neck and urethra open
 - Urine flow begins and continues until
bladder is empty 22
 NEURAL PATHWAYS
• Motor pathways
from brain,
through spinal
 Cord to
sacrum, on to
bladder &
urethra
• Sensory nerve
fibers pass
information
back 23
24
PERIPHERAL INNERVATIONS

25
 Actions Of The Autonomic And Somatic Nervous
Systems During Bladder Filling / Storage And
Voiding
FILLING/STORAGE

• Inhibition of parasympathetics
• Stimulation of sympathetics
• alpha-contraction
• beta-relaxation
• Stimulation of somatic nerves
to striated
 urogenital sphincter
 VOIDING
•
• Stimulation of
parasympathetics


• Inhibition of sympathetics
• Inhibition of somatic nerves to
striated

26
• urogenital sphincter
27
28
 Urinary Incontinence
It is the involuntary leakage of


urine .It occurs when the pressure

in the bladder (expulsive force)
exceeds that within the urethra
(closure force)


 The ICS Definition



 A condition of involuntary
urine loss that is a social or
hygienic problem and is
objectively demonstrable. 29
 Genuine Stress
Incontinence(GSI)
Urodynamic stress
incontinence (previously
known as genuine stress
incontinence) is a solely
urodynamic diagnosis which

occurs when an
incompetent urethra allows
leakage of urine in the 30
 TYPES OF URINARY INCONTINENCE


• Stress Incontinence
Urine leakage occurs with increases in abdominal
pressure (hence, mechanical “stress”).


• Urge Incontinence
Often referred to as “overactive bladder.” an abrupt and
uncontrollable desire to void the bladder.


• Mixed Incontinence
When two or more causes contribute to urinary incontinence. Often
refers to the presence of both stress and urge incontinence.


• Overflow Incontinence
The involuntary loss of urine resulting from an overfilled bladder
without any corresponding feeling or urge to void.


• Functional Incontinence
Leakage (usually resulting from one or more causes) due to factors
impairing reaching the restroom in time because of physical
conditions (e.g., arthritis)
31
•
32
Urinary Incontinence

33
 PREVALENCE AND INCIDENCE
 An estimated 13 million adults of all ages
suffer from urinary incontinence – women
account for nearly 85 % of cases.


• SEX: 18% of Men 38% of Women



• AGE: The prevalence of urinary

incontinence appears to increase with
advancing age :
 4% of women aged 15 to 24
 16% of women aged 75 and greater.
 Reasons for the increase in prevalence
of urinary incontinence with age are
34
(Unknown).
voiding, bladder compliance and urinary
flow rate probably decrease with
ADVANCING AGE in both sexes.

Uninhibited bladder contractions and post

void residual urine volume increase with
age.

Maximal urethral closure pressure and

functional urethral length decrease in
women.
Changes in bladder and urethral function
probably are related directly to aging
process.

Another age related change is an

alteration in the pattern of fluid excretion.
35
36
 GENITOURINARY ETIOLOGY
Filling / Storage disorders


• Genuine stress incontinence

• Detrusor instability (Idiopathic)
• Detrusor hyperreglexia (Neurogenic)
• Mixed types
• Overflow incontinence
•
Fistula:


• Vesical
• Ureteral
• Urethral
• Congenital:
– Ectopic Ureter
– Epispadias

37
 Non genitourinary Etiology

• Functional
• Neurologic
• Cognitive
• Environmental
• Pharmacologic
• Metabolic
38 •
 Non-Urologic Causes of

Incontinence

• Behavioural problems
• Immobility
• Medication
• Diabetes.
•
• Race:
 Genital prolpse, enterocele and
stress incontinence are uncommon
in:
39
 Non-Urologic Causes of
Incontinence
• Child Birth:
 Child birth injury leading to pelvic support
abnormalities and stress incontinence


 Vaginal delivery directly damages pelvic

fascial supports and may cause partial
denervation of the pelvic floor and urethral
muscles.


• Menopause:-
 Vagina and urethra have similar epithelial
linings due to embryologic origin.Normal urethral
function in the female is affected by age and
estrogen status


• Smoking:-
 Significant association between cigarette 40
Non-Urologic causes of
Incontinence
• Obesity:
 Significantly more common in women with
GSI and D.I
•
• Psychologic Changes:
 U.T is a complex phenomenon with multiple
causes including psychogenic causes.The anxiety,
depression and other psychologic abnormalities may
be related .
•
• Sexual Changes:
 Sexual dysfunctionL U T dysfunction can effect
on sexual function.Leaking urine with intercourse
• Economic Issues:
 Costs of caring for elderly incontinence people
in nursing homes. 41
MEDICATIONS THAT CAN AFFECT LOWER URINARY TRACT
FUNCTION
LOW ER URIN ARY TRACT  TYPE OF M ED ICATION
EFFECTS
Polyu r ia ,  fr e q u e n cy u r g e n cy D iu r e t ics 

Ur in a r y r e t e n t ion ,  ov e r  f low   An t ich olin e r g ic a g e n t s 

in con t in e n ce

Se d a t ion ,  I m p a ir e d  m ob ilit y,   Alcoh ol 

d iu r e sis

An t ich olin e r g ic a ct ion s,   Psy ch ot r op ic a g e n t s

se d a t ion An t ich olin e r g ic a ct ion s.   AAn t id e p r e ssa n t s
se d a t ion Se d a t ion ,  m u scle   An t ip sych ot ics
r e la xa t ion ,  con f u sion Se d a t iv e s / H y p n ot ics

St r e ss in con t in e n ce Alp h a -a d r e n e r g ic b lock e rs

Ur in a r y r e t e n t ion Alp h a -a d r e n e r g ic a g on ist s
Ur in a r y r e t e n t ion Be t a -a d r e n e r g ic a g on ist s
Ur in a r y r e t e n t ion ,  ov e r f low   Ca lciu m -ch a n n e l b lock e r s 
in con t in e n ce  
42
43
 Evaluation of
Incontinence

• History
• Physical Examination
• Gynecologic
Examination
• Office Tests.
44
• Do you leak urine when you cough, sneeze , or laugh?
• Do you ever have such an uncomfortably strong need
to urinate that if you don't reach the toilet you will
leak?
• If " Yes" to No.2, do you ever leak before you reach the
toilet?
• How many times during the day do you urinate?
• How many times do you void during the night after
going to bed?
• Have you wet the bed in the past year?
• Do you develop an urgent need to urinate when you
are nervous, under stress, or in a hurry?
• Do you ever leak during or after sexual intercourse?
• Do you find it necessary to wear a pad because of your
leaking?
• How often do you leak ? 45
Questions in the Evaluation of Urinary
Incontinence

• Have you had bladder, urine, or

kidney infections?
• Are you troubled by pain or
discomfort when you urinate?
• Have you had blood in your urine?
• Do you find it hard to begin
urinating?
• Do you have a slow urinary stream?
• Do you have to strain to pass your
urine?
• After you urinate, do you have
dribbling or a feeling that your 46
The cotton-tipped applicator (Q-tip) test for the assessment
of urethral and bladder support. A: The resting angle of the
cotton-tipped applicator is normal. B: With straining, the
urethrovesical junction descends, causing the end of the stick
to rotate upward.

47
 Urodynamic Studies
A urodynamicstudy is a series of detailed
measurements that gives an idea of the
function of the bladder and urethra
•These tests can evaluate any problems
with storing urine or voiding urine from
the body.
• Accurate differentiation between types of
incontinence is vital . However,
empirical treatment without urodynamic
assessment can be commenced if
symptoms of idiopathic detrusor
overactivity are uncomplicated.
If treatment fails, or secondary adverse48
49
50
 Genuine stress
Incontinence
•
In intact L U T : Continence is maintained as long
as the pressure closing the urethra is greater
than the intra vesical pressure.
Etiology:

1.Lowered urethral pressure

2.Detrusor contractions
3.Greater transmission of intra-abdominal
pressure to the bladder than to the urethra
4.Passive increases in intra-vesical pressure due
to distention beyond the elastic limits of the
bladder
5.By passing of the continence mechanism due51 to
 Etiology Of GSI
Proposed Mechanisms:


• Anatomic decent of the proximal

urethra below its normal intra-
abdominal position during
stressful.


• Altered anatomic relationships

between the urethra and bladder.


• Failure of neuromuscular
components that reflexly increase
intraurethral pressure in response
52
 Genuine Stress Incontinence
(GSI)
• Anatomic S.I
• True S.I
• Urinary S.I
 It is the involuntary loss of urine through the urethra
occurring simultaneously with an increase in
intra-abdominal pressure in the absence of
detrusor muscle contraction.
• Continent at rest has intraurethral pressure greater
than the intra-vesical pressure.
• The pressure difference or urethral closure pressure
 (Total U.P – Intravesical P.) = Represents the
margin of continence.
• If the resting intravescial pressure + any increase in
pressure generated during stressful activities
exceeds the intraurethral Pressure at rest + any
increase in urethral pressure generated during
stressful activities, the urethral closure pressure will
53
 Treatment Of GSI
• Non Surgical Measures:
– Medical devices that block or capture
urine.
– Kegel exercises
– Medication to increase or decrease
the activity of the bladder muscle, or
medication to increase or relax the
closure of the bladder sphincter.
– Electrical stimulation to help return
injured muscles to fitness and
biofeedback to record progress in
strengthening treatments and
exercises.
– Magnetic Stimulation.
54
– Estrogen replacement
Pelvic Floor Muscle Training
It is the most recommended physical
therapy for women with stress urinary
incontinence. Adjuncts, as biofeedback or
electrical stimulation, are also commonly
used with pelvic floor muscle training.
Training regimens vary markedly from
area to area.
The inconsistency of intervention coupled

with different measures of success make

these trials difficult to compare. Results
show that an improvement can be
expected in 40–60% of women. 55
MAGNETIC STIMULATION

56
 DULOXITINE & GSI
A combined noradrenalin and serotonin
reuptak inhibitor,duloxetine,was used in
animal studies. In the cat model
duloxetine significantly increased
sphincteric activity and bladder capacity.
Duloxetinehas been trialled in a phase II

& III & a double-blind placebo controlled

study.
The effective dose was 40 mg twice daily.

This dose elicited significant

improvements with 50% of the women
experiencing a 64–100% reduction in 57
 SURGERY FOR STRESS
INCONTENENC
–
–Intraurethral injection
–Abdominal
procedures
–Vaginal procedure
–Classical Sling
procedure
58
Abdominal procedure to correct stress incontinence. A: anterior
vaginal wall has been mobilized. Two sutures have been placed on
either side and far lateral from the midline. Distal sutures are
opposite the mid urethra. Proximal sutures are at the end of the
vasicourethral junction. Sutures are attached to coopers ligament. B:
Cross section shows urethra free in retropubic space with anterior
vaginal wall lifting and supporting it.

59
ABDOMINAL BURCH
COLPOSUSPENSION.

60
 Sling Procedures:
There are two main types of sling


procedure: the classic open bladder neck

sling and the newer suburethral slings
such as TVT, TVT- O , TOT and TVT - S.


Success rates are approximately 80%, with



little diminution over time, and tend to be

higher with synthetic materials. However,
their use increases the risk of erosion and
sinus formation.


The risk of voiding disorder is in the region



of 10% and de novo detrusor overactivity

is variable, at approximately 14%.

61
TVT trocar in position behind the symphysis
pubis after the first pass

62
63
64
 Laparoscopic Colpo-
suspension
Laparoscopic surgery has the


presumed advantage of avoiding

a large incision, resulting in a
shorter hospital stay and a
quicker return to normal daily
activities. Large differences in
surgical techniques in this area
confound comparison. There are
few randomised controlled trials
and these have limited follow-up.
65
URGE URINARY INCONTINENCE
• It is the complaint of involuntary leakage
accompanied by, or immediately
preceded by, urgency.
• It is often associated with increased
frequency of micturition and nocturia.
Up to 15% of the population complain of
urgency although not all will be
incontinent.
• While urge urinary incontinence is a
symptom of many conditions ,
idiopathic detrusor overactivity
(formerly known as detrusor instability)
66
 Biofeedback
• It is a re-education or learning process in
which the patient is retrained using
information about usually unconscious
physiological responses.
• In the example of idiopathic detrusor
overactivity these would be unstable
bladder contractions.
• An auditory, visual or tactile signal is
relayed back to the patient so that she
can take action such as performing
relaxation techniques or tightening
certain muscle groups.
Although this has been shown to be 67
 Bladder Drill
• Bladder drill involves instructing the
patient to void at predetermined
intervals during the day. She must not
void between these times but instead
must either wait or be incontinent.
• The voiding interval is then increased
once the initial goal has been achieved.
• This process is continued until voiding can
be deferred to every 3-4 hours without
urgency or incontinence between these
times.
• A normal fluid intake should be
maintained (1.5 1/day). It is most
successful in young, well-motivated 68
 Drug Treatment
Changes to the central nervous system
have been implicated in pathology of
stress incontinence.
The suggestion is that the

neurotransmitters serotonin and

noradrenalin influence the contraction of
the urethral sphincter.
Abnormalities in their release can act alone

or in combination with local damage or

degeneration to the sphincteric
mechanisms. A strong association has
been found between depression and
idiopathic incontinence.


This suggests a common pathology


69
 Drug Treatment
• Urethra is mainly innervated by
alpha-adrenergic sympathetic
Nervous system.


• Elimination of medications that exert

ganglionic or alpha Adrenergic
blocking activity – Guanethidine,
Methyldopa and Prazosin for
improve urethral tone.


• Alpha- Adrenergic agonists may

improve G.S. 70
71
72
 DRUG TREATMENT OF OVERACTIVE
BLADDER
• Oxbutynin (Ditropan):
 2.5mg twice daily to 5mg 4 times a day
• Propantheline (Norpanth, Probanthine)
 7.5mg twice daily to 15mg 4 times a day
• Imipramine (Tofranil):
 25mg 2-3 times daily
• Flavoxate (Urispas):
 100mg twice daily to 200mg 4 times a day
• Hyoscyamine (Cystospaz, Levsin,):
 0.125-0.25mg 3- 4 times daily.


• Prostaglandin synthetase inhibitors

(nonsteroidal anti-inflammatory agents,
e.g Ibuprofen, Fenoprofen, Sulindac)
Advil, Clinoril, Naprosyn, 73
 OXYBUTYNIN (DETROPAN)
• It is a tertiary amine, and a highly
selective M1 and M3 muscarinic
receptor antagonist and a direct
muscle relaxant.
• It is the standard treatment against
which other drugs and therapies
have been tested.
• Its effectiveness in idiopathic
detrusor overactivity is well
documented but the incidence of
its main adverse effect, dry mouth,74
 TOLTERODINE (DETRUSITOL)
• Tolterodine is a muscarinic
receptor antagonist that
appears to target bladder
receptors over the salivary
glands. Several randomised,
double-blind, placebo-
controlled trials on patients
with idiopathic detrusor
instability have shown a
significant reduction in
incontinent episodes and 75
 IMIPRAMINE (TOFRANIL):
• Imipramine has systemic Anti
-cholinergic effects, which are
thought to improve the
symptoms of detrusor
overactivity.
• However, evidence of its
benefits is conflicting and it
should not be used as first-line
treatment.
• The benefits of its sedative
effects may be useful in 76
VASOPRESSIN (ANTI D URETIC
HORMONE)

77
 BOTULINUM TOXIN
LOCAL INTRAVESICAL INJECTION

78
 SURGERY FOR URGENCY
INCONTINENCE

• Augmentation cystoplasty


• Auto augmentation


• Sacral nerve stimulation

79