urinary incontinence ( ui )
TRANSCRIPT
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URINARY
INCONTINENCE( UI )
Prof. Kamal Anwar
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Mechanism of continence of urine:
The proximal part of the urethra is intra-
abdominal ( above the levator ani ):
When the intraabdominal pressure is
increased ,it is transmitted equally to the bladder
and proximal urethra
The pubo-urethral ligament and levator ani keepthe proximal part of the urethra intra-abdominal
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Urethral muscular components:
External urethral sphincter ( EUS )supplied by
pudendal nerve: outer layer of striated muscle
arranged in a circular pattern
Internal urethral sphincter ( IUS ) : internal to
EUS smooth muscle arranged in a longitudinal
pattern Vascular plexus deep to these layers forms
a watertight seal by coaptation of mucosal
surface
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Micturition cycle :
Bladder filling ( Sympathatic fibres from
hypogastric plexus ) occurs with relaxation of
detrusor muscle and contraction of IUS
Bladder evacuation ( parasympathatic fibres
from sacral plexus ): occurs with contraction of
detrusor muscle
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Sympathetic nerves (T11-12)
Inhibit detrusor contraction
Increase sphincter tone
Inhibit parasympathetic tone
Somatic nerves (S2-4)
Maintain tone in pelvic floor mus
Bladder filling
Urination
Parasympathetic nerves (S2-4)
Contract the detrusor muscle
Relax sphincter tone
Nervous Control
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Urinary incontinence is defined as involuntary
leakage of urine
Types of Urinary incontinence :
1-stress urinary incontinence ( genuine stressincontinence ) :
It is the most common type of urinary
incontinence , accounting for 50-70 % of cases It occurs when the abdominal pressure exceeds
the bladder pressure
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Stress incontinence is triggered by activities(coughing, sneezing, laughing, running, orlifting) that apply pressure to a full bladder.
Childbirth and menopause increasing the risk
for it Urethral hypermobility :
Weakness of fibromuscular tissue that support thebladder neck and urethra
Interinsic sphincter deficiency due to damageof uretheral sphincter resulting in failure to closethe urethro-vesical junction
.
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2-Overactive bladder (Urge urinaryincontinence )
Involuntary leakage of urine immediately
preceded by the urge to void due to involuntarydetrusor contraction.
patients complain of inability to reach the toilet
in time
Urge incontinence is marked by a need tourinate frequently. There are many causes of
urge incontinence, including medical conditions,
Parkinsons disease, multiple sclerosis, stroke,
and spinal cord injuries), surgeries
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3-Overf low incon t inenceoccurs when the
bladder cannot empty completely, which leads
to dribbling. Bladder obstruction and inactive
bladder muscle can cause overflowincontinence.
Overflow incontinence happens when the
normal flow of urine is blocked and thebladder cannot empty completely
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overflow incontinence can be due to a
number of conditions:
A partial obstruction. In this case the urine
cannot flow completely out of the bladder, soit never fully empties :
Tumors
Scar tissue
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An inactive bladder muscle. In contrast to
urge incontinence (overactive bladder), with
overflow incontinence the bladder is less
active than normal. It cannot empty properly and so becomes
distended, or swollen. Eventually this
distention stretches the internal sphincteruntil it opens partially and leakage occurs.
Certain medications and nerve damage
increase the risk :
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Certain medications (such as anticholinergics,
antidepressants, antipsychotics, sedatives,
narcotics, and alpha-adrenergic blockers)
Nerve damage. When nerves in the bladder aredamaged the body cannot feel when the bladder
is full and the bladder does not contract. Nerve
damage can be caused by spinal cord injuries,
previous surgery in the colon or rectum, orpelvic fractures. Diabetes, multiple sclerosis
also can cause this problem.
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4-Func t ional inco nt inence
Patients with functional incontinence have mentalor physical disabilities that keep them fromurinating normally ( impair a persons ability to use
or get to the toilet ) although the urinary systemitself is structurally intact.
Conditions that can lead to functionalincontinence include:
Parkinson's disease Alzheimer's disease and other forms of dementia.
Severe depression. In such cases, people maybecome incontinent because they have difficultywith self-control
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5 -Mixed incont inence. Many people have
more than one type of urinary incontinence.
Symptoms of both stress and urgeincontinence may exist together
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6- True incontinence or Bypass incontinence( urogenital fistula ):
It is due to communication between urinary andgenital tract
Causes : Trauma during gynecologic surgery
Obstetric injuries :
Necrotic obstetric fistula
Direct traumatic obstetric fistula:Forceps delivery
Rupture uterus
Others: radiation, genital malignancy
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Risk factors for UI
Parity
Childbirth :Vaginal delivery causes damage to
pelvic structure
Medical conditions : diabetes, obesity,
Chronically increased intra-abdominal
pressure Estrogen deficiency
Drugs Diuretics , caffeine and anticholinergics
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Diagnosis of UI :
Symptoms Stress incontinence appears on stress as
coughing Overactive bladder presents as urinary urgency
with daytime frequency or nocturia
Examination :
Stress test : The bladder should not be empty
Ask the patient to cough and inspect the urethra
Involuntary leakage of urine from uretheral
meatus indicates stress urinary incontinence
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Neurological examination :
UI may be a symptom of neurological disease
Evaluate the motor and sensory function of the
lower limbs
Pelvic examination :
Assess pelvic floor including innervation ,
muscular and connective tissue support The strength of levator ani is assessed by
placing 2 fingers in the vagina and ask the
patient to squeeze
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Q-tip test
It evaluate urethral support
A cotton swab is placed in the urethra up to the
bladder neck
During straining ,the change of angle between
the Q-tip and the horizantal plane is measured.
If it is greater than 30 degrees ( abnormal ) , itindicates descent of the bladder neck due to
urethral hypermobility
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Investigations:
Urine analysis to exclude urinary tract infection
Postvoid residual urine measurement :
It aids in diagnosing overflow incontinence
Normally , it should be less than 100 ml
Cystourethroscopy :
It assesses the anatomy and function of lower
urinary tract
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Cystourethrography : Lateral view: loss of the posterior urethro-vesical
angle
Antero-posterior view : Funneling
Urodynamic study: This is done to differentiate between stress
incontinence and detrusor instability
In detrusor instability ,there is abnormal
contraction during filling In stress incontinence,there is decreased
urethral closure pressure which is the differencebetween the pressure in the urethra and bladder
rea men o r nary
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rea men o r naryIncontinence
Treatment options for urinary incontinencedepend on the type of incontinence and the
severity of the condition. Treatments include: Lifestyle Changes. Significant weight gain can
weaken pelvic floor muscle tone, leading tourinary incontinence. Losing weight through
healthy diet and exercise is important.Regulating the time you drink fluids andavoiding alcohol and caffeine are also helpful.
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Treatment of stress urinary
incontinence:
Non- surgical :
Postmenopausal atrophy :
Estrogen replacement therapy
Pelvic muscle exercise( Kegel exercise ) for 3-
6months
Vaginal pessaries in case of pelvic organ
prolapse
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Surgical treatment of SUI:
A-Cystocele repairwith Kelly suture for anteriorvaginal prolapse
Kelly suture: plication of pubo-urethral ligament
around the bladder neck
B-Colposuspension
Indicated in hypermobile bladder neck
Burch retropubic colposuspension:
Permanent sutures are placed in thefibromuscular tissue lateral to the bladder neck
and proximal urethra to be attached to
iliopectineal line ( Cooper ligament )
Success rate over 80 %
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Marshall- Marchetti
Krantez operation:
Similar to Burch but the stitches are placedthrough the periosteum of the symphysis pubis
C-Suburethral sling :
A sling is passed below the mid-urethra as ahammock providing stabilization of the urethra
Tension-free vaginal tape ( TVT )
A mesh is placed without tension at the mid-
urethra through retropubic space. Bladder perforation is the most common
complication
( 5 % )
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Tension free obturator tape ( TOT ):
TOT is passed through amid vaginal incision to
obturator foramen
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Treatment of overactive bladder
Medical treatment is the primary line
Medications used inhibit involuntary detrusor
contractions
A- Anticholinergics :
Oxybutynin ( Ditropan ) 5 10 mg / 8 hrs
B- Tricyclic antidepressants :
Imipramine 25 mg 1-4 times daily
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