Debre Berhan University

Asrat Woldeyes Health

By: Mesfin T. (MSc)

30-Oct-24 By MT 2
Urinary incontinence (UI)
▪ Is involuntary leakage of urine so as to cause hygienic
and/or social inconvenience for day to day activity.
▪ The incidence increases with women age,
particularly after menopause and with increasing
degrees of pelvic relaxation.

30-Oct-24 By MT 3
Cont…
▪ Common, but only one in four women will seek
medical advice: underdiagnosed and undertreated.
▪ They feel ashamed and embarrassed,
▪ Lack of knowledge about availability of treatment
options, and/or fear of surgery,
▪ Limited health-care access, or
▪ Poor screening by healthcare providers

30-Oct-24 By MT 4
Epidemiology of UI
▪ In Western societies, 25 to 51% and even higher
among nursing home patients.
▪ Among ambulatory women with UI,
▪ SUI represents 29 to 75% of cases.
▪ Urgency urinary incontinence accounts for 33%.
▪ The remainder is attributable to mixed forms.
▪ The prevalence among non-pregnant women age 20
years and above has been reported at 10 to 17%.

30-Oct-24 By MT 5
Cont…
▪ Nearly 50% of all women experience occasional
urinary incontinence, and 20% of women over age 75
are affected daily.

30-Oct-24 By MT 6
Pathophysiology
▪ Continence requires the complex coordination of
multiple components that include: muscle
contraction and relaxation, appropriate connective
tissue support, and integrated innervation and
communication between these structures.
▪ Continence and micturition involve a balance
between urethral closure and detrusor muscle
activity.

30-Oct-24 By MT 7
Cont…
▪ When the urinary tract is intact, continence is
maintained as long as the pressure closing the
urethra is greater than the intravesical pressure.
▪ Urethral pressure rises and bladder pressure falls.
▪ Intraabdominal pressure increases (from coughing
and sneezing) are transmitted to both urethra and
bladder equally, leaving the pressure differential
unchanged, resulting in continence.

30-Oct-24 By MT 8
Cont…
▪ Basic pathology of incontinence is the rise of
intravesical pressure over that of maximum urethral
pressure.
▪ Pressure gradient is reversed, urine passes to the
urethra.
▪ The use of pads to protect against soiling
undergarments is the most common coping
mechanism.

30-Oct-24 By MT 9
Impacts
▪ Quality of life:
▪ Depression and anxiety, work impairment,
discomfort, embarrassment, and social isolation.
▪ Hospitalization due to skin breakdown and UTI
▪ Increased caregiver burden:
▪ Being a burden for caregivers, and also unable to
perform daily activities.
▪ Thus, increasing the need for caregiver assistance.
30-Oct-24 By MT 10
Cont…
▪ Sexual dysfunction:
▪ Upto one third of incontinent women
experience incontinence during sexual activity
(coital incontinence), and
▪ Fear of incontinence during sexual activity both
contribute to sexual dysfunction.
▪ Affects sexual desire, reducing sexual activity.

30-Oct-24 By MT 11
Cont…
▪ Morbidity:
▪ Perineal infections (e.g., candida or cellulitis) from
moisture and irritation as well as falls and
fractures that in turn increase overall morbidity,
mortality and health care costs.
▪ In older women with urge incontinence, falls are
1.5 to 2.3 times more common.
▪ Medical, social and economic burdens.

30-Oct-24 By MT 12
Risk factors
▪ Age
▪ Smoking
▪ Pregnancy and Childbirth
▪ Parity
▪ Trauma
▪ Genitourinary surgery, i.e., hysterectomy,
▪ Menopause/vaginal atrophy: hypoestrogenism
▪ Radiation
30-Oct-24 By MT 13
Cont…
▪ Mode of delivery: Vaginal delivery
▪ Obstructed labor, prolonged labor, macrosomia/>4kg
▪ Instrumental delivery and postpartum catheterization
▪ Chronically increased abdominal pressure;
▪ Obesity
▪ Chronic cough
▪ Constipation
▪ Occupational lifting
30-Oct-24 By MT 14
Cont…
▪ Cognitive and functional impairment
▪ Past medical history:
▪ "DIAPPERS": dementia/delirium, infection, atrophic
vaginitis, psychological, pharmacologic, endocrine,
restricted mobility (Physical handicaps, may not
have time to reach a toilet), and stool impaction.
▪ Genetic differences in connective tissue: relative
collagen deficiencies in the connective tissues of
incontinent patients.
30-Oct-24 By MT 15
Cont…
▪ Family history: higher in daughters and sisters of
incontinent women.
▪ Diabetes and Depression.
▪ Race: SUI common in Whites and UUI among
African-American women
▪ Sex: Urinary incontinence is two to three times
more common in women than men because of
shorter urethral length and the risk of connective
tissue, muscle, and nerve injury associated with birth.
30-Oct-24 By MT 16
Types of UI
▪ Primary types
1. Stress urinary incontinence (SUI),
2. Urgency urinary incontinence (UUI),
3. Mixed urinary incontinence, and
4. Overflow urinary incontinence.
▪ Other/ Non-classic forms:
1. Bypass incontinence, and
2. Functional incontinence.

30-Oct-24 By MT 17
1. Stress urinary incontinence
▪ Urine loss with physical exertion or straining
(coughing, laughing, sneezing, exercising).
▪ Associated with urine loss with increases in
intraabdominal pressure.
▪ Typically associated with urethral hypermobility
(see Q-tip test) or less commonly with intrinsic
sphincteric deficiency.
▪ No urine lost at night.

30-Oct-24 By MT 18
Cont…
▪ The most common incontinence in young women.
▪ In an ideally supported urogenital tract, increases in
intraabdominal pressure are equally transmitted
to the bladder, bladder base, and urethra and are
countered by supportive tissue tone provided by the
levator ani muscles and vaginal connective
tissue.

30-Oct-24 By MT 19
Cont…
▪ With loss of support, the ability of the urethra and
bladder neck to close against a firm supportive
"backboard" is diminished.
▪ This results in reduced urethral closing pressures, an
inability to resist increases in bladder pressure, and,
in turn, incontinence.

30-Oct-24 By MT 20
2. Urgency urinary incontinence
▪ Urine leakage due to involuntary, spontaneous, and
uninhibited bladder contractions.
▪ A related condition, detrusor overactivity/
overactive bladder describes urinary urgency with
or without incontinence.
▪ The leakage is accompanied or immediately preceded
by a perceived strong imminent need to void.

30-Oct-24 By MT 21
Cont…
▪ The patient has a strong urge/desire to void with an
inability to make it to the bathroom in time.
▪ Incontinence often occurs before reaching the toilet.
▪ Associated with frequent, small volume voids that
may keep the patient up at day and night/ nocturia.
▪ Common triggers of urge include hand washing,
running water, or exposure to cold.

30-Oct-24 By MT 22
Cont…
▪ Patients often describe "key in lock" syndrome.
▪ This is typically characterized by an uncontrollable
urge to void when unlocking the door after
returning from a trip out of the house.
▪ The first thing done upon return is to immediately
rush to the toilet or risk losing urine.

30-Oct-24 By MT 23
3. Mixed incontinence
▪ Urinary leakage with both stress and urgency
symptoms.
▪ Both stress incontinence and urge incontinence
occur simultaneously.

30-Oct-24 By MT 24
4. Overflow incontinence
▪ Is the involuntary loss of urine due to poor or absent
bladder contractions that lead to incomplete
voiding/bladder emptying, urinary retention, and
overdistension of the bladder.
▪ Detrusor underactivity/ hypotonic incontinence.
▪ Women were unable to empty their bladder well but
had involuntary, intermittent/continuous urinary
leakage/ dribbling with no warning or sensation both
day and night.
30-Oct-24 By MT 25
Cont…
▪ Suprapubic pressure or pain may be present.
▪ Patients will often note a sensation of a full bladder
and the need to strain in order to empty or apply
suprapubic pressure to void.
▪ This condition classically occurs in men who have
outlet obstruction secondary to prostatic
enlargement that progresses to urinary retention.

30-Oct-24 By MT 26
Cont…
▪ Relatively uncommon in women.
▪ But, when it does occur, it can be from increased
outlet resistance from advanced vaginal prolapse
(POP) causing a "kink" in the urethra, or
▪ After overcorrection with an anti-incontinence
procedure.

30-Oct-24 By MT 27
Cont…
Causes:
▪ Neurologic: Spinal cord trauma, Cerebral cortical
lesions, Diabetes neuropathy, and Multiple sclerosis.
▪ Infectious: Cystitis and Urethritis.
▪ Anatomic: Extrinsic compression (prolapse in
women) and Urethral mass.
▪ Pharmacologic: Anticholinergics and α-adrenergics.
▪ Iatrogenic: Surgery, Obstetric, and Anesthetic.
30-Oct-24 By MT 28
Summary
Stress Urge Detrusor
incontinence incontinence instability
Leakage of urine Unable to control The incontinence
coincides with the escape of urine, may occur abruptly
stress and no prior once there is urge even without a full
urge to void. to void. bladder.
Amount: Small Amount: Large Amount: Large
Patient: Fully aware Patient: Aware of Patient: Not aware
of it the urge of it
Micturition: Normal Urgency and Frequency and
frequency nocturia
30-Oct-24 By MT 29
Cont…
Other/ Non-classic forms:
Bypass incontinence:
▪ Involuntary, continuous urine leakage day and night
secondary to urinary tract fistula/anatomic deviation.
▪ The normal urethral-bladder mechanism is intact but
is bypassed by urine leaking out through a fistula
from the urinary tract.

30-Oct-24 By MT 30
Cont…
▪ Vesico-or-ureterovaginal are formed during poor
wound healing after traumatic insult e.g., from
obstetric laceration, pelvic surgery, perineal trauma,
or radiation exposure.
▪ Leakage due to fistulas may be elicited by positional
changes or stress-inducing activities.
▪ Evaluation should include a careful examination of
the vaginal walls for fistulas.

30-Oct-24 By MT 31
Cont…
▪ This can be facilitated by filling the bladder with milk
or dilute indigo carmine dye and looking for pooling
in the vaginal canal.
▪ Pad testing can be done by having the patient ingest
200 mg of oral phenazopyridine hydrochloride
(Pyridium) several hours before a examination.
▪ By placing a tampon in the vagina and on the
perineum, the diagnosis may be confirmed by
inspection of the pads after a period of time.
30-Oct-24 By MT 32
Cont…
Functional incontinence:
▪ The patient is unable to get to the toilet on time,
whether physically challenged (immobile or not
moving quickly enough out of a wheelchair due to
arthritis or Parkinson’s disease) or psychologically
challenged (inability to respond to voiding cues,
unclear thinking or communication due to
Alzheimer’s or dementia).
▪ Often seen in nursing home and geriatric patients.
30-Oct-24 By MT 33
Diagnosis
▪ History and physical examination can often
effectively diagnose the correct condition.

30-Oct-24 By MT 34
History
Patient questionnaires:
▪ Survey instruments can be filled out by patients to
facilitate diagnosis, determine the severity of
symptoms, and to follow impact of interventions.
▪ Surveys such as the;
▪ Urinary Distress Inventory (UDI-6),
▪ The Three Incontinence Questions (3IQ), and
▪ Incontinence Impact Questionnaire (IIQ-7).

30-Oct-24 By MT 35
Cont…
Voiding diary/ Urolog:
▪ A woman ideally completes a urinary diary.
▪ For a 24- to 48-hour (72-hour) period, the patient
records the;
▪ Volumes and type of each oral fluid intake,
▪ Volumes of urine with each void,
▪ Frequency and episodes of urinary leakage, and
▪ Triggers of incontinence episodes.
30-Oct-24 By MT 36
Cont…
▪ The women also record times of sleep and
awakening to document voluntary nocturnal voiding
patterns or enuresis.
▪ Reliable tool in the diagnosis and management of
urge incontinence and assist in clarifying home
voiding patterns, particularly in the elderly.
▪ Serve as a baseline for treatment interventions such
as behavioral training, bladder drills, and
pharmacologic therapy.
30-Oct-24 By MT 37
Cont…
▪ Voiding frequency is normally less than eight times
a day and once at night, and total volume voided in
24 hours is typically less than 1800 mL.

30-Oct-24 By MT 38
Urinary Symptoms
▪ Frequent voiding without increased oral fluid
intake may indicate overactive bladder.
▪ Urgency: Having a strong urge to urinate
▪ Nocturia: Walking from sleep to urinate
▪ May be noted in urgency urinary incontinence.
▪ Urinary retention or incomplete emptying can
be associated with either stress or urgency.
▪ Coital incontinence: leak during sexual intercourse.
30-Oct-24 By MT 39
Cont…
▪ Dou you wear a pad to protect your clothing?
▪ Dysuria: Painful urination
▪ Prior trauma or pelvic/vaginal surgery could scar or
obstruct the urethra
▪ Volume of urine lost:
▪ Large volume in urge UI and Small volume in SUI.
▪ Hypoestrogenism: At menopause may suggest
underlies genitourinary syndrome of menopause.

30-Oct-24 By MT 40
Physical Examination
▪ Perineum for evidence of atrophy.
▪ In postmenopausal patients, atrophy and change in
labial architecture may be due to estrogen deficiency.
▪ The presence of inflammation or irritation from
chronic moisture or pad usage should be noted.
▪ Any discharge should be noted, as it may mimic UI.
▪ Poor urethral support commonly accompanies pelvic
organ prolapse (POP).

30-Oct-24 By MT 41
Cont…
▪ Examination of the urethra with palpation of the
anterior vaginal wall under the urethra for
fluctuance, masses, or discharge may reveal signs of
urethral diverticulum, urethral infection, or rarely
carcinoma.
▪ Tenderness may point to urethral pain syndrome, a
condition marked by episodic urethral pain usually
with voiding, daytime frequency, and nocturia.
▪ Vaginal wall integrity must be assessed: Vaginal rugae,
or the folds in the epithelium.
30-Oct-24 By MT 42
Cont…
Neurologic examination:
▪ Mental status: testing orientation to place and time
and assessing speech and comprehension skills.
▪ Sensation: test at the dermatomes using light touch
and pinpricks over the perineum and thigh area.
▪ Deep tendon reflexes: tested at the patella, ankle,
and foot planus.

30-Oct-24 By MT 43
Cont…
▪ Bulbospongiosus reflex: by stroking one labium
majus with a cotton swab, both labia contract at the
same time.
▪ A normal circumferential anal sphincter
contraction, colloquially called an anal wink,
should follow cotton swab brushing of the perianal
skin.

30-Oct-24 By MT 44
Cont…
▪ Motor strength: is tested in the lower extremities
by assessing hip, knee, and ankle flexion, as well as
ankle eversion and inversion.
▪ Motor control may be diminished in focal brain or
cord lesions, most commonly Parkinson's disease,
multiple sclerosis, and cerebrovascular accidents.
▪ Clinically observed neurologic deficits should lead to
a neurologic consultation.

30-Oct-24 By MT 45
Cont…
Bimanual and Rectovaginal Examination:
▪ Bimanual examination may reveal a pelvic mass or a
uterus enlarged by leiomyomas or adenomyosis.
▪ These can create incontinence through increased
external pressure transmitted to the bladder.
▪ In addition, stool impaction is easily identified with
rectal examination.

30-Oct-24 By MT 46
Diagnostic tests
Urinalysis and culture:
▪ Many WBC and bacteria would suggest a UTI; do
urine culture for identification of bacteria and
antibiotic sensitivities.
▪ Microscopic hematuria would suggest a bladder
stone or foreign body and tumor.
▪ Do further work-up with cystoscopy.

30-Oct-24 By MT 47
Urodynamic studies
▪ A urodynamic study is any test that provides
objective dynamic information about lower urinary
tract function.
▪ Basic office cystometry begins with the patient
emptying the bladder as much as possible.
▪ A urinary catheter is first used to empty the bladder
and then left in place to infuse saline by gravity
retrograde assessing the following:

30-Oct-24 By MT 48
Cont…
▪ Post Void Residual urine (PVR):
▪ Residual volume: how much is left in bladder
after voiding (Normal <50 – 100mL).
▪ Measured by catheterization or U/S after 10
minutes of void.
▪ Inadequate emptying: >200mL (detrusor
weakness or bladder outlet obstruction).

30-Oct-24 By MT 49
Cont…
▪ Sensation-of-fullness volume:
▪ How much infusion (in mL) until patient senses
fluid in bladder (normal 200–225 mL).
▪ Urge-to-void volume:
▪ How much infusion (in mL) until patient feels the
need to empty bladder (normal 400–500 mL).

30-Oct-24 By MT 50
Cont…
▪ Involuntary bladder contractions:
▪ Detect involuntary detrusor contractions by
watching saline level in syringe rise or fall (absence
of contractions is normal)
▪ A cystometrogram can reveal an unstable bladder,
overflow incontinence, reduced bladder capacity, or
abnormalities of bladder sensation.

30-Oct-24 By MT 51
Clinical tests
Urinary cough stress test:
▪ Is done by instilling 300 ml of saline in the bladder
and the patient performs Valsalva maneuver/cough
vigorously 8 – 10 times while standing with feet
spread as wide as the shoulders and the perineum is
inspected for leakage of urine.
▪ Confirm stress and mixed incontinence
▪ The test is negative if no urine leaks.

30-Oct-24 By MT 52
Cont…
Pad test:
▪ Is done when the stress test is negative.
▪ In this procedure the patient wears preweighed
sanitary napkin, does some exercise and then the pad
will be reweighed to determine how much urine has
been lost.
▪ Positive pad test:
▪ Weight gain >1g/1 hour or >4g/24 hours.

30-Oct-24 By MT 53
Cont…
Cotton – tipped applicator (Q-tip) test:
▪ Used to predict stress urinary incontinence.
▪ A sterile (lubricated with 2% xylocaine jelly) cotton
tipped swab is introduced to the level of bladder
neck through the urethra.
▪ Then the patient is asked to sit and cough (Valsalva).
▪ If there is marked upward elevation (>30°) of the
cotton tipped swab, suggests urethral hypermobile.

30-Oct-24 By MT 54
Cont…
▪ An angle of
<15° shows
good anatomic
support.
▪ An angle of 15
– 30° is
considered
inconclusive.

30-Oct-24 By MT 55
Cont…
Bonney test:
▪ Assesses support of proximal urethra or if bladder
neck being pushed down too far by the stress in SUI.
▪ Done by putting the index and middle fingers in the
vagina, lifting the bladder base towards the pubic
bone and asking the woman to strain or cough.
▪ If there is no incontinence then the diagnosis of poor
urethral support is made and if there is incontinence
then other causes of SUI are looked for.
30-Oct-24 By MT 56
Cont…
Dye (cotton ball) test-
▪ This is a test to detect small vesicovaginal fistulas and
differentiate it from other types of urinary fistulas
(urethero-and-ureterovaginal fistula).
▪ It is done by putting three cotton balls into the
vagina and instilling diluted methylene blue into the
urinary bladder through a bladder catheter.

30-Oct-24 By MT 57
Cont…
▪ Vesicovaginal fistula: if
the middle swab stained
blue and others remain dry.
▪ Urethrovaginal fistula: if
the lower swab stained.
▪ Ureterovaginal fistula: If
the upper most swab
soaked with urine and the
lower two swabs remain dry
30-Oct-24 By MT 58
Cont…
▪ Fistulae in the urinary tract can be to the ureter
and/or bladder; this distinction is important for
considering treatment options.
▪ The source may be discerned in the clinic with a
double dye test.
▪ This is performed by administering an oral agent
such as phenazopyridine, which stains urine from the
kidneys orange, and

30-Oct-24 By MT 59
Cont…
▪ Placing a urethral catheter to fill the bladder with
blue dye such as methylene blue or indigo carmine.
▪ A tampon is placed in the vagina and the color of
drainage is examined upon removal.
▪ Orange staining suggests an ureterovaginal fistula,
whereas a blue stain indicates a vesicovaginal fistula.

30-Oct-24 By MT 60
Management
▪ Conservative Vs Surgical.
▪ It is appropriate to discuss that these issues are
not life threatening, but rather quality-of-life
threatening.
▪ It is prudent to counsel patients that "cure" may
not be achievable in many cases but that
improvement in symptoms should be the goal.

30-Oct-24 By MT 61
Conservative management
▪ Lifestyle / Behavioral modifications:
▪ Weight loss in overweight and obese women
▪ Dietary changes: reduce consumption of alcoholic,
caffeinated, carbonated beverages, and spicy foods.
▪ Fluid restriction
▪ Correct or avoid constipation and stool impaction
▪ Avoid smoking

30-Oct-24 By MT 62
Cont…
Pelvic floor muscle (Kegel) exercises:
▪ Also called active pelvic floor muscle training.
▪ Extremely helpful for mild to moderate forms of UI
▪ Focused, repetitive, voluntary contractions of the
levator ani muscles (pubococcygeus, coccygeus, and
iliococcygeus) where the patient contracts, or
"squeezes," the muscle as if to prevent the passage of
rectal gas is an effective therapy.

30-Oct-24 By MT 63
Cont…
▪ Effective for both stress and urgency incontinence.
▪ With SUI, pelvic floor strengthening attempts to
compensate for anatomic support defects (exert a
closing force on the urethra and increase muscular
support to the pelvic organs).
▪ For urgency urinary incontinence, it intensifies
pelvic floor muscle contractions to provide
temporary continence during waves of involuntary
bladder detrusor contraction.
30-Oct-24 By MT 64
Cont…
▪ A typical training begins with the contraction
duration a patient can sustain (e.g., 3 seconds) and
ask them to hold for this long and then relax for one
to two times this duration (e.g., 6 seconds).
▪ Patients should achieve a sustained pelvic floor
contraction of 10 seconds.
▪ This squeeze and release is repeated 10 to 15 times.

30-Oct-24 By MT 65
Cont…
▪ Three sets are performed throughout the day for a
total of approximately 45 – 100 repetitions.
▪ Should be done every day and continue for at least
15 to 20 weeks and results for improvement or
cure of bladder control can be up to 70%.

30-Oct-24 By MT 66
Cont…
Bladder training:
▪ It is an educational program that combines written
and verbal instruction to educate patients about the
mechanisms of normal bladder control with the
teaching of relaxation and distraction skills to resist
premature signals to urinate.
▪ Creating a voiding schedule by which the patient
urinates at preset intervals while attempting to
ignore the urge to urinate.
30-Oct-24 By MT 67
Cont…
▪ This may progressively lead to reestablishment of
cortical voluntary control over the micturition reflex.

30-Oct-24 By MT 68
Cont…
Scheduled/ timed voiding:
▪ It is a form of bladder retraining.
▪ Most effective for urgency incontinence.
▪ For stress incontinence only at higher bladder
volumes to keep bladder volumes below that where
stress incontinence occurs.
▪ Bladder training and Kegel exercises are often used in
combination with dietary and lifestyle modifications.

30-Oct-24 By MT 69
Cont…
▪ Bladder training starts with keeping a voiding diary to
identify their shortest voiding interval.
▪ The patient is instructed to void by the clock at
regular intervals while awake, using the shortest
interval.
▪ When the patient can avoid leakage for one day
using the initial urination interval, the time between
scheduled voids is increased by 15 minutes.

30-Oct-24 By MT 70
Cont…
▪ Urgency between voiding times is controlled with
either distraction or mental relaxation/distraction
techniques, e.g.,
▪ Performing mental math, and
▪ Deep breathing along with quick Kegel's exercise.
▪ The intervals are gradually increased until the patient
is voiding every three to four hours without
urinary incontinence or frequent urgency.

30-Oct-24 By MT 71
Cont…
Topical Vaginal Estrogen:
▪ For peri- or postmenopausal women with either
stress or urgency incontinence and vaginal atrophy.
▪ Enhance urethral blood flow, increase collagen
deposition, and increase α-adrenergic receptor
sensitivity.
▪ This thereby improves urethral coaptation and
urethral closure pressure.

30-Oct-24 By MT 72
Cont…
▪ Topical Estrogen cream 0.5 gm twice weekly OR
Estradiol tablet 10 mcg twice weekly.
▪ It is reasonable to treat with conservative therapies
for six weeks before considering subsequent
therapies.

30-Oct-24 By MT 73
Treatment of Stress incontinence
Pessaries:
▪ Designed to treat anatomic deficits associated with
incontinence and comorbid POP.
▪ Commonest traditional support devices and used
either as an adjunct or substitute for Kegel exercises.
▪ These "incontinence pessaries" are designed to
reduce downward excursion or funnelling of the
urethro-vesical junction.

30-Oct-24 By MT 74
Cont…
▪ This provides bladder neck and proximal urethral
support and thereby helps reduce incontinence
episodes.

30-Oct-24 By MT 75
Cont…
Electrical stimulation:
▪ Using intravaginal or transrectal electrodes with
stimulators, the pelvic muscles automatically contract
and are thereby artificially "trained."
▪ When used long term, weakened muscles are
strengthened and innervation reestablished with
activation.
▪ Used to help both SUI and mixed incontinence.

30-Oct-24 By MT 76
Cont…
Pharmacotherapy:
▪ α-adrenergic receptors:
▪ Imipramine: 10-25 mg one to four times daily.
▪ For mixed urinary incontinence, but provides only
mild symptomatic improvement.
▪ Cause contraction of urethral smooth muscle,
preventing micturition.

30-Oct-24 By MT 77
Cont…
Surgical management:
▪ For women who failed/don’t desire conservative
management, who desire more rapid and definitive
treatment, who are willing to accept risks of surgery
and for moderate to severe incontinence.
▪ The procedures prevent bladder neck and proximal
urethra descent during increases in intraabdominal
pressure by elevation of the urethrovesical junction.
▪ The cure rates ranges from 75 – 90%.
30-Oct-24 By MT 78
Cont…
Midurethral slings (MUS):
▪ A synthetic mesh is placed vaginally beneath the
midurethra and fixed to the lower anterior
abdominal wall.
▪ Used for stress and mixed incontinence and the
success rates: 86 – 99% with upto 10 years follow-up
▪ Sling procedures restore periurethral support
anatomy or create partial urethral obstruction to
enhance urethral integrity.
30-Oct-24 By MT 79
Cont…
▪ Classified according to the route of placement;
▪ A retropubic approach (B) or
▪ A transobturator approach (C).
▪ Have similar efficacy with respect to the treatment.

30-Oct-24 By MT 80
Cont…
▪ It does not elevate the
urethra but forms a
resistant platform
against intra-abdominal
pressure.
▪ The gold standard
first-line surgical
treatment for women
with SUI.

30-Oct-24 By MT 81
Cont…
Pubovaginal slings:
▪ A strip of a patient's own fascia harvested from the
leg (fascia lata) or rectus fascia or cadaveric fascia is
placed under the bladder neck and through the
retropubic space.
▪ The ends are secured at the level of the rectus
abdominis fascia.
▪ Cure rates of suburethral slings ranges from 70-95%.

30-Oct-24 By MT 82
Cont…
Retropubic urethropexy:
▪ Elevation and fixation of the urethra at the level of
urethrovaginal junction to the posterior aspect of
the symphysis pubis, using the
▪ Burch’s colposuspension procedure and
▪ Marshall-Marchetti-Krantz (MMK) procedure.
▪ They share the same mechanism of correction.

30-Oct-24 By MT 83
Cont…
▪ In the MMK procedure, the sutures are fixed to the
periosteum of the pubic symphysis, and in Burch's
procedure, the iliopectineal (Cooper's) ligament.
▪ The success rate of both procedures is 85–90%.
▪ But, Burch's procedure maintains high objective
and subjective cure rates of 92% after 1 year and
69% after 10 years of follow-up.

30-Oct-24 By MT 84
Cont…

30-Oct-24 By MT 85
Cont…
Transurethral Injection/Bulking:
▪ Injection of a bulking agent using cystoscopic
guidance into the urethrovesical junction to cause
narrowing or coaptation.
▪ Injected at evenly distributed locations, i.e., 3 and 9
o'clock; 12, 4, and 8 o'clock.
▪ This increases urethral resistance to involuntary
urine loss without changing resting urethral closure
pressure.
30-Oct-24 By MT 86
Cont…
▪ This procedure is generally reserved for SUI caused
by intrinsic sphincteric deficiency.
▪ Short-term improvement and cure rate is 53 – 66%.
▪ Durability is a major drawback of these procedures
as the coaptation tends to decrease over time due to
remodeling and flattening of the implanted material.
▪ Repeat injections are necessary for patients desiring
long-term continence with this method.

30-Oct-24 By MT 87
Cont…
Artificial Urethral Sphincters (AUS):
▪ Is an effective option for patients not amenable to
standard surgical treatment because of urethral
scarring or a tony.
▪ Best used in patients with incontinence due to poor
urethral sphincter function.

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Cont…
▪ The AUS obstructs the urethra by compressing the
bladder neck via a pressure-regulated balloon,
releasing the compression when the patient desires
to void and squeezes a pump most often implanted
in the labia majora.
▪ Manual dexterity is also required to properly operate
the device, which may be an issue for some patients.
▪ Reported success rates are up to 91%.

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Cont…
Paravaginal defect repair (PVDR)
▪ Is a surgical procedure that corrects lateral support
defects of the anterior vaginal wall.
▪ The technique involves suture attachment of the
lateral vaginal wall to the arcus tendineus fascia
pelvis.
▪ Currently, PVDR is primarily a prolapse-correcting
operation.

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Complications of surgery
▪ Retropubic suspension: bleeding, injury to the
bladder, urethra, ureter, pulmonary atelectasis and
infection, wound infection or dehiscence, abscess
formation, venous thrombosis or embolism,
postoperative voiding difficulty, detrusor overactivity,
and vaginal prolapse.
▪ Osteitis pubis symphysis (acute pubic pain) (MMK)

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Cont…
▪ Erosion of nonabsorbable cystourethropexy sutures
into the bladder lumen with stone formation and
significant bladder outlet obstruction secondary to
the positioning of the sutures into the endopelvic
fascia close to the bladder neck.
▪ Burch’s procedure: Injury to the bladder and
ureter, voiding dysfunction, and UTI.

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Cont…
▪ MUS include intraoperatively recognized bladder or
urethral perforation, postoperative functional
problems such as de novo urgency, urgency
incontinence, incomplete bladder emptying or
urinary retention, and vaginal mesh erosion.

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Urge incontinence
▪ Conservative management
▪ Pharmacotherapy:
A) Anticholinergic medications:
▪ Oxybutynin chloride 15–30 mg daily, or
▪ Fesoterodine fumarate 4–8 mg daily.
▪ Smooth muscle relaxant: Blunt detrusor
contractions to reduce the number of
incontinence episodes and volume lost with each.
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Cont…
▪ Beta-adrenergic agonists:
▪ Mirabegron 25 – 50 mg daily.
▪ Results in relaxation and inhibition of the detrusor
smooth muscle contraction, preventing
micturition and greater bladder capacity.
▪ NSAIDs to inhibit detrusor contractions;
▪ Tricyclic antidepressants; and
▪ Calcium-channel blockers.
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Cont…
Surgical management:
Injections of Botulinum Toxin A:
▪ Botulinum toxin is a naturally occurring chemical
produced by Clostridium botulinum bacteria.
▪ Is injected cystoscopically into the detrusor muscle.
▪ It blocks the release of acetylcholine from
presynaptic nerve terminals at the motor endplate,
thereby reducing the strength of muscle contractions.

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Cont…
Sacral neuromodulation (SNM):
▪ Focuses on the sensory nerve signals coming from
the bladder to reduce bladder activity.
▪ A thin wire is placed under the skin of the low back
and close to the nerve that controls the bladder.
▪ The wire is attached to a battery device placed
under the skin nearby.
▪ The device stimulates electrical nerve fibers by
sending a mild electrical signal through a wire.
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Mixed incontinence
▪ No single therapy works for everyone; options will
be directed by whether the stress or the urge
component is greater.
▪ Treatment should be based on the patient's worst
symptoms.

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Overflow incontinence
▪ Surgical treatment for obstruction.
▪ Intermittent self-catheterization,
▪ Discontinuation of the systemic medications,
▪ Cholinergic medications to stimulate bladder
contractions,
▪ α-adrenergic blocker, i.e., tamsulosin, to relax the
bladder neck.

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Cont…
▪ Timed voiding prevent accumulation of excess urine.
▪ In bladder areflexia, manual pressure on lower
abdomen (known as the Crede maneuver) or
abdominal splinting may facilitate emptying.

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Other/ Non-classic forms
▪ Bypass incontinence:
▪ Surgical repair of the fistula.
▪ Functional incontinence:
▪ Bedside commode;
▪ Treatment of the underlying medical condition;
▪ Possible bladder training, and
▪ Pelvic floor exercises (Kegel exercises).

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References
1. DC DUTTA’S Textbook of Gynecology including
contraception, 7th-ed, 2016.
2. Obstetrics and Gynecology For Health Science
Students, Lecture Note, 2006.
3. Up to date 2018.
4. Williams Gynecology, 4th-ed, 2022.
5. Current Diagnosis and Treatment. Obstetrics and
Gynecology, 12th edition, 2019.
6. KAPLAN Medical USMLE Step 2 Lecture Notes,
2020.
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