St Joseph University in Tanzania

Urinary Problems in gynecology.

Dr. Isaya Mhando
Department of Obstetrics and
Gynecology.
 Anatomy of the pelvic flow Muscles

The muscles of the pelvic floor, particularly the

levator ani muscles, provide support to the
pelvic visceral organs and play an integral role
in
 Urinary.
 Defecatory, and
 Sexual function.
The fusion of levator ani in the midline creates
the so-called "levator plate." The urogenital
hiatus is the space between the levator ani
musculature through which the urethra, vagina,
and rectum pass.
Puborectalis muscle — The puborectalis muscle
originates on the pubic bone, and its fibers
pass posterior, forming a sling around the
vagina, rectum and perineal body. This results
in the anorectal angle and promotes closure of
the urogenital hiatus.
Iliococcygeus muscle — The iliococcygeus
originates from the arcus tendineus levator ani
and inserts in the midline onto the
anococcygeal raphe and coccyx.
The fascia overlying the iliococcygeus muscle
can be used as a fixation point for suspension
of the vaginal apex in the treatment of vaginal
vault prolapse.
Within the deep perineal space lie the external
urethral sphincter and the urethrovaginalis,
compressor urethrae, and deep transverse
perineal muscles
The urethrovaginalis and compressor urethrae
muscles provide accessory sphincter function
to the urethra.
The urethrovaginalis muscles surround the distal
urethra and vagina without passing between
them, and therefore act as a sphincter to the
vagina as well the distal urethra.
Normal urethral function depends upon normal
support of the urethra, as well as its intrinsic
sphincter mechanism.
Dynamic interaction between the levator ani
muscle complex and the connective tissue
supports of the urethra is essential.
Levator ani nerve.
The levator ani nerve originates from S3, S4,
and/or S5 and innervates both the coccygeus
muscle and the levator ani muscle complex.
.
Pudendal neurovascular bundle The pudendal
nerve innervates the
Striated urethral.
Anal sphincters.
Deep and superficial perineal muscles and
provides sensory innervations to the external
genitalia. It originates from S2 to S4 (with S3
providing the largest contribution) sacral nerve
trunks.
 BLOOD SUPPLY

The internal pudendal artery is the main arterial

supply of the perineum. The pudendal artery
courses inferiorly from its origins in the
anterior trunk of the internal iliac artery.
Physiology of micturation
 DEFINITION

Urinary incontinence is the involuntary leakage

of urine.
Commonly undertreated.
It is estimated that nearly 50 percent of adult
women experience urinary incontinence, yet
only 25 to 61 percent of symptomatic
community-dwelling women seek care.
Quality of life – Urinary incontinence is
associated with depression and anxiety, work
impairment, and social isolation.
Sexual dysfunction – Urinary incontinence
during sexual activity (coital incontinence),
which may affect up to one-third of all
incontinent individuals.
Morbidity – Medical morbidities associated
with urinary incontinence include perineal
infections (eg, candida or cellulitis) from
moisture and irritation.
 EPIDEMIOLOGY

Overall prevalence of urinary incontinence

among non-pregnant women age 20 years and
above has been reported to range from 10 to
60.
However, Sedighe Batmani, in assessing the
prevalence and Factors associated with
Urinary incontinence from 2000-2020,
 EPIDEMIOLOGY
In 29 studies and the sample size of 518,465
people in the age range of 55–106 years,
urinary incontinence in older adults’ women in
the world based on a meta-analysis of 37.1%
(95% CI: 29.6–45.4%).
Continence depends upon both intact micturition
physiology (including lower urinary tract,
pelvic, and neurologic components.
 CLASSIFICATION

Urinary incontinence is divided into three

categories
 stress,
 urgency and
 Overflow.
Stress urinary incontinence (SUI) refers to the
leakage of urine due to increased intra-abdominal
pressure such as exercise and cough, which is due
to the poor functional urethra.
Reduction of anatomical support due to trauma,
vaginal delivery, obesity and increased intra-
abdominal pressure due to chronic constipation,
lifting heavy objects and exercise.
It is the most common type in younger women.
Mechanisms of SUI:
 Urethral hypermobility – Urethral
hypermobility is thought to stem from
insufficient support of the pelvic floor
musculature and vaginal connective tissue to
the urethra and bladder neck.
 Mechanisms of SUI
This causes the urethra and bladder neck to lose
the ability to completely close against the
anterior vaginal wall. With increases in intra-
abdominal pressure (eg, from coughing or
sneezing) the muscular tube of the urethra fails
to close, leading to urinary incontinence.
 Mechanisms of SUI
 Intrinsic sphincteric deficiency.
ISD can occur in the presence or absence of
urethral hypermobility and typically results in
severe urinary leakage even with minimal
increases in abdominal pressure.
 Urgency urinary incontinence.
It is believed to result from detrusor overactivity,
leading to uninhibited (involuntary) detrusor
muscle contractions during bladder filling.
Women with urgency urinary incontinence
experience the urge to void immediately
preceding or accompanied by involuntary
leakage of urine.
 Overflow urinary incontinence.
Overflow urinary incontinence typically
presents with continuous urinary leakage or
dribbling in the setting of incomplete bladder
emptying.
Overflow urinary incontinence is caused by
detrusor under activity or bladder outlet
obstruction.
 Overflow urinary incontinence
 Detrusor under activity – Detrusor under
activity may be caused by impaired
contractility of the detrusor muscle
 Overflow urinary incontinence
Etiologies of detrusor under activity include
 Fowler’s syndrome
 fibrosis
 Low estrogen state,
 Peripheral neuropathy (due to diabetes mellitus,
vitamin B12 deficiency, alcoholism)
 Damage to the spinal detrusor efferent nerves
pathologies affecting the spinal cord (eg, multiple
sclerosis, spinal stenosis
 Overflow urinary incontinence
Bladder outlet obstruction.
Bladder outlet obstruction in women is rare and
generally caused by external compression of
the urethra. This can occur with fibroids that
obstruct the urethra, advanced pelvic organ
prolapse (ie, beyond the hymen).
DIAGNOSIS
 TREATMENT.
Initial treatments for most types of incontinence
(stress, urgency, or mixed) include lifestyle
modifications and pelvic floor muscle exercise,
 TREATMENT.
Pads and protective garments – Pads designed
for incontinence are preferred.
Moisture-wicking catheters – External
moisture-wicking catheters remove urine as it
is voided with the goal of minimizing perineal
moisture and the associated skin breakdown
that can result.
Modifying contributory factors.
Weight loss in obese women.
Smoking cessation.
Pelvic floor muscle (Kegel) exercises.
Bladder training — Bladder training is most
effective for women with urgency incontinence
Topical vaginal estrogen vaginal estrogen
therapy for per- or postmenopausal women
with either stress or urgency incontinence.
Devices — Continence pessaries are the most
common, traditional form of support devices
and may be used for women with stress
incontinence either as an adjunct or substitute
for pelvic muscle exercises.
Surgery — Women without sufficient
improvement with initial treatment and/or
pessaries should be evaluated for surgical
therapy.
THANK YOU