URINARY INCONTINENCEAnatomy of the lower UTThe bladder is a hollow muscular organ situated behind the pubic symphasis & covered superiorly & anteriorly by peritoneum.It is composed from a meshwork of smooth muscle fibers which is called detrusor muscle & those fibers are only recognized at the bladder outlet as 3 distinct layers ,the outer are longitudinal , middle circular & inner longtudinal.

In the adult female the urethra is a muscular tube 3-5 cm in length , lined proximally by transitional epithelium & distally by stratified sequamus non keratinized epithelium.

The second layer is a rich vascular plexus which contribute to the urethral pressure & it decreases with age.

The 3rd layer is the layer of longitudinally arranged smooth muscle fibers

The internal urethral sphincter Is a striated m. that surround the middle one

third of the urethra & is responsible for urethral closure of

The external urethral sphincter Is a striated m. fibers which is a part of

levator ani m. & is situated at the junction of the middle & lower one third of urethra & it is responsible for the additional closure pressure at time of physical effort.

The urethra is supported by 2 pubourethral ligaments that attach the urethra to the posterior aspect of symphasis pubis.

Innervations The lower UT is under the control of both

sympathetic & parasympathetic system. the parasympathetic fibers originate from the

spinal segments S2,3,4 & stimulation of those fibers will cause contraction of detrusor m.

stimulation of these fibers occur due to sensory impulses transmitted through strech receptors within the bladder wall & afferent impulses from the bladder will travel through pelvic hypogastric nerves to the sacral spinal segments

so cholinergic drugs stimulate & anticholinergic drugs inhibit detrusor contraction.

the sympathetic innervation is through fibers that originate from spinal cord segments T10-L2

the sympathetic system has α & β adrenergic component .

the β fibers terminate primerly in the detrusor m. whereas α fibers in the urethra.

α adrenergic stimulation contract the bladder neck & urethra & relaxes detrusor m. while β adrenergic stimulation relaxes the detrusor m. & urethra.

The intrinsic urethral sphincter m. is supplied by motor innervation through motor nerves from S2,3,4 via pelvic splanchnic nerves , while extrinsic urethral sphincter m. is supplied by the same sacral nerves roots but those travel through pudendal nerve.

Sensory supply the afferent impulses from the bladder wall &

proximal urethra travel through pelvic hypogastric nerves to the sacral segments S2,3,4.

the sensory nerves are stimulated when there is increase in the intravasical pressure or acute cystitis (radiation, infections…

Inhibitory impulses to those nerves travel through pudendal nerve which supply sensation to the vulva & perinael area & this is why pain in this area causes retention of urine.

Central nervous system During infancy , the storage & expulsion of

urine is under the direct sacral reflex arc, later on with training there will be a central control of this reflex arc & voiding will be under voluntary control.

This central control may be interrupted by organic diseases , social or mental disorders.

Continence control Normally the urine remain within the bladder

as long as the inravasical pressure is below the intraurethral pressure & whenever the intravasical pressure exceeds the intraurethral

pressure there will be incontinence of urine. The pubourethral ligaments & surrounding

fascia support the proximal urethra which is normally an intra abdominal organ, so any increase in the intra abdominal pressure would be transmitted equally to the bladder & urethra & the pressure gradient remain the same.

whenever there is physical effort that increase the intra abdominal pressure , there will be voluntary contractions of pelvic floor m. which add additional strength for urethral closure pressure.

incontinence It is the involuntary loss of urine According to symptomatology the types of

urinary incontinence are:1. Stress inco.2. Total inco.3. Urge inco.4. Overflow inco.

Causes Genuine stress inco. (GSI) due to urethral

sphincter incompetence. Detrusor instability (DI) Retention with overflow Fistulae: vasico-vaginal, uretro-vaginal,

urethro-vaginal Congenital abnormality as epispadias , ectopic

ureter , spina bifida Urethral diverticulum Temporary as in UTI immobility , feacal

impaction functional

Usually 90% of inco. In female are due to genuine stress inco. then detrusor instability

Urinary inco. Is a symtom or eve a sign but not a diagnosis so we need to reach to the final diagnosis or the cause

History: Ask about other urinary symptoms as irritative

symptoms (dysurea , frequency, urgency) or voiding problems (poor stream, straining during voiding, incomplete bladder evacuation) .

Ask about other gynecological symptoms or diseases as prolapse, menstrual disturbance , H/O fibroid , any gyn. operations vaginal wall repair

Obstetric history as delivery of large baby vaginaly.

If there is H/O recurrent UTI or acute retention of urine or nocturnal enuresis during childhood.

Ask about neurological symptoms & other medical disorder as multiple sclerosis or DM

Ask about drug intake as diuretic in old people , tricyclic antidepressant , major tranquilizer & β blocker.

examination Unfortunately clinical examination is not so

helpful in the diagnosis of female

SI can be demonstrated objectively but even that the diagnosis can not be made with sure because 98% of patient with GSI presented with SI , while 25% of patients with DI can be presented with such symptom

nevertheless the patient should be examined generally & for mental state

local pelvic examination include inspection of vulva to see any excoriation which indicate severity of the condition, any atrophic change

then inspection of the vaginal wall with Sims speculum for visualization of the anterior

vaginal wall & vasico-urethral junction & to see if there is any scarring or rigidity due to previous vaginal operation, & to see if there are atrophic changes of the vaginal wall & distal urethra.

During pelvic examination stress test should be performed that the patient in lithotimy with full bladder , then ask the patient to cough

GSI is suspected if there is a short spurt of urine per urethra with each cough , while if there is a delayed leakage or loss of a large volume of urine this may suggest DI.

If leakage of urine is not demonstrated in the lithotomy position , then the test is repeated while the patient in standing position.

if SI is demonstrated then GSI can be

suggested by performing Bonney’s test by inserting one finger on each side of the urethra at the bladder neck to elevate the bladder neck & proximal urethra , then if urine leakage is stopped this will suggest GSI

InvestigationsSimple types: Mid stream urine for culture & sensitivity ( the

presence of infections may affect the management )

Frequency-volume chart Pad weighing test for confirmation of inco.

Not for identification the cause Q tip test