Urinary Incontinence

• Involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.

• Affects physical, psychological, social well being → Reduce quality of life

• Prevalence, ↑ with age • Common in institutionalized women, those in

residential nursing homes

Some definitions…• Stress incontinence is loss of urine on physical

effort• Urge Incontinence is an involuntary loss of urine

associated with a strong desire to void.• Overflow Incontinence occurs without any

detrusor effort when the bladder is over-distended.

• Urgency is a sudden desire to void• Frequency is passing of urine seven or more/day

or being awoken from sleep more than once a night to void.

Classification of IncontinenceURETHRAL CAUSES• Urethral Sphincter

Incompetence (Urodynamic stress Incontinence)

• Detrusor overactivity/Unstable bladder (Nueropathic or non-nueropathic)

• Retention with overflow• Congenital causes• Miscellaneous

EXTRA URETHRAL CAUSES

• Congenital causes• Fistula

1. URETHRAL CAUSES

1a : Urodynamic Stress Incontinence

• Involuntary leakage of urine during increased abdominal pressure in the absence of detrusor contraction.

• Symptoms: STRESS INCONTINENCE, urgency, frequency, urge incontinence, prolapse ±

• Examination: Stress incontinence when cough, look for prolapse, cystourethrocelesAlso asses her vaginal capacity and her ability to elevate

bladder neck.• Urodynamic studies will define cause of

incontinence

• Causes of USI– Damage to nerve supply of pelvic floor and urethral

sphincter caused by childbirth (Prolonged second stage, large babies, instrumental deliveries)

– Menopause +tissue atrophy, damage to pelvic floor, ineffective compression during stress, incontince

– Congenital cause (nulliparous women) – Connective tissue disorder esp collagen

– Chronic causes, Obesity, COPD, Raised Interabdominal pressure and constipation

1b: Detrusor Over-activity

• Involuntary detrusor contraction during the filing phase which may be spontaneous or provoked.

• Symptoms: Urgency, urge incontinence, frequency, nocturia, stress incontinence, enuresis, voiding difficulties

• Examination: Any mass that may compress bladder, prolapse TRO

• Causes: Idiopathic, Poor toilet habit training, psychological, Nueropathy, Incontinence surgery, outflow obstruction, smoking aw

1c: Retention with overflow• Insidious failure of bladder empting may lead to

chronic retention and finally, when normal voiding is ineffective, to overflow incontinence

• Caused by: LMN/UMN lesions, urethral obstructions, pharmacological

• Symptoms: poor stream, incomplete bladder emptying, straining to void, overflow stress incontinence

• Investigations: Cystometry (dx), bladder US, IV Urography to investigate state of upper urinary track and TRO reflux

1d: Congenital

• Epispadias: Faulty midline fusion of mesoderm causing wide bladder neck, short urethra, symphysial separation, imperfect sphincter control causing stress incontinence

• Rx with urethral reconstruction or artificial urinary sphincter

2. EXTRA URETHRAL CAUSES

2A: Congenital

• Bladder Exstrophy: Absence of anterior andominal wall and anterior bladder wall. Rx extensive reconstructive surgery in neonatal period

• Single/Bilateral Ectopic ureter with ectopic opening outside bladder (eg vagina, perineum). Rx exicion of ectopic ureter and and upper pole of kidney that it drains

2B: FISTULA

• Abnormal opening between the urinary track and outside.

• Obstetric cause: Obstructive labour with compression of bladder between presenting head and bony pelvis

• Gynecological cause: AW pelvic surgery, radiotherapy, pelvic malignancy

• Treated by primary closure or surgery

INVESTIGATIONS

• Urine C&S- tro Infections• Pad test• Measure Postvoidal Residual Volume by

bladder ultrasound or urethral catheter >100mL in more than one occasion→+

• Cough Stress Test. 250mL into bladder• Abdominal leak point pressure

• Urodynamic studies– Uroflowmetry. Bladder outlet obstruction– Cystometry. Detrusor activity, differentiate involuntary

detrusor contraction or increase intraabdominal pressure

• Cystogram– Stress incontinence, Cystocele, Sphincter activity,

fistula

• Cystoscopy– Tumors, stones

Treatment• Palliative – Fluid restriction, Protective perineal

pads, Bladder retraining, Pelvic Floor exercise (Kegel)

• Devices – Weighted vaginal cones, Vaginal pessaries, contraceptive diaphragms

• Surgery – to restore the proximal urethra and bladder neck to zone of intraabdominal pressure transmission and to increase urethral resistance

Colposuspension Operation, Artificial Sphincter