INCONTINENCE OF URINE

Physiology of Micturition Bladder innervation: somatic, parasympathetic (PSN) and sympathetic (SNS) as urine fills the bladder, the detrusor stretches and allows the bladder to expand~300 ml in bladder before the brainrecognizes bladder fullness

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 sphincterPhysiology of Micturition

DEFINITION OF INCONTINENCE OF URINEIt is involuntary escape of urine

TYPES:1. True incontinence. 2. False incontinence 3. Stress or sphincter incontinence. 4. Urgency incontinence 5. Nocturnal enuresis.

Incidence of Subtypes of Urinary Incontinence in WomenStress Incontinence 50% Urge Incontinence 20% Mixed 30%

1. True (continuous) incontinenceIn this case, urine escapes continuously by day and by night. It is caused by: (a) Urinary fistulae as vesicovaginal fistula; (b) Ectopia vesica.

2. False incontinence (Overflow incontinence) It is involuntary loss of urine following overdistension of the bladder. Overflow incontinence, usually short-term, can occur after vaginal deliveryespecially if epidural anesthesia was used. Other causes include diabetes, neurological diseases, severe genital prolapse, and post surgical obstruction.

3. STRESS INCONTINENCEDefinition :It is involuntary escape of few drops of urine with increased intra-abdominal pressure as during straining, sneezing, coughing, laughing ... etc.

DEGREES OF STRESS INCONTINENCEGrade 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 stairsGrade III Incontinence with mild stress, such as standing. The patient is continent in the supine position

TYPES OF STRESS INCONTINENCEType 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. This type leads to severe stress incontinence

AETIOLOGYIt is due to either :Weakness of the internal urethral sphincter or Descent of bladder neck below the level of the pelvic floor.

AETIOLOGY1. Congenital weakness of the internal urethral sphincter, seen in the young nullipara.2. Congenital defects as:Epispadias, Short urethra (less than 1 cm), Wide bladder neck, and Separation of symphysis pubis.

3. Trauma to the region of the bladder neck due to vaginal delivery or operation. The incidence of stress incontinence increases with parity due to repeated birth trauma. AETIOLOGYIn fact vaginal delivery is the commonest cause of stress incontinence.

Pathophysiology of Stress IncontinenceThe basic pathology is urethral incompetence. This can be either due to:A) 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: Trauma and stretching of vaginal delivery Hysterectomy Hormonal changes ( Menopause) Pelvic denervation Congenital weakness

As the bladder neck support is weakened, the increase in intra-abdominal pressure is no longer transmitted equally to the bladder outlet, and therefore instantaneous leakage occurs.A) Urethral hypermobility (80 - 90% of patients)

B) Intrinsic Sphincter 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.

4. Urgency incontinence (precipitancy-detrusor instability or detrusor dyssynergia). The woman feels the desire to micturate but before she reaches the bathroom, urine passes involuntarily. It is due to irritability of the bladder muscle and so the patient cannot inhibit it. It is due to :emotional disturbance, neurologic diseases, and bladder diseases as cystitis, stone or tumour.

Detrusor instability (overactive bladder) is a condition in which the bladder contracts involuntarily in response to filling. It was called detrusor dys-synergia in the past. No cause is identified in more than 90% of these patients. Advancing age is an important risk factor. Detrusor instability (DI)

Detrusor instability caused by neurologic diseases such as cerebrovascular disease, multiple sclerosis, or spinal cord injury is called detrusor hyperreflexia. Irritation of the bladder by inflammation (such as urinary tract infection) or prior pelvic surgery can also cause detrusor instability.

Detrusor instability (DI)

Urge incontinence

5. NOCTURNAL ENURESISBedwettingDefinition : involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry.Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.

A. HistoryA detailed history differentiates between the different types of incontinence. Stress incontinence and detrusor instability frequently occur together.Gradual onset after menopause suggests oestrogen deficiency.History of vaginal repair or operation in the region of the bladder neck and history of any neurologic disease.

1. Stress Test2. Booney Test3. Yousef Test4. Urinalisis5. Cystourethroscopy6. Cystourethrography

I. Prophylactic Treatment1. During labour, the bladder should be kept empty.2. Episiotomy is performed if necessary.3. Physiotherapy. Pelvic floor exercises are started after delivery. These include repeated stoppage of the urinary stream during micturition and repeated contractions of the pelvic floor muscles.

Indications:1.Mild stress incontinence.2.Patient is unfit for surgery or refuses surgery.4.When stress incontinence is combined with detrusor instability.

II. Conservative (non-surgical) Treatment

Conservative treatment cures or improves 50% of cases and include:1. Physiotherapy: Kegl 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.

Conservative treatment cures or improves 50% of cases and include:4.Oestrogen therapy for menopausal patients: It causes thickening of the urethral mucosa and engorgement of the underlying blood vessels thus increasing the urethral pressure and resistance. Oestrogen is given orally or as vaginal cream.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 bladder neck.

4. Menopause: Lack of oestrogen leads to atrophy of bladder neck supports.5.Pregnancy 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.AETIOLOGY

6. Genital prolapse: If the bladder neck descends below the level of the pelvic floor, the increased intra-abdominal pressure will be transmitted to the bladder and not to the upper urethra leading to escape of urine.7. Organic nervous diseases as disseminated sclerosis.

AETIOLOGY