STRESS URINARY
INCONTINENCE
Dr. Murad H. Assalya
URINARY INCONTINENCE
Definition: [as defined by International Continence Society (ICS)]
“The complaint of any involuntary loss of urine”
Types:
1. Stress urinary incontinence (SUI).
2. Urge urinary incontinence.
3. Mixed urinary incontinence.
4. Unconscious (unaware) incontinence.
5. Continuous urinary incontinence.
6. Nocturnal enuresis.
7. Post-micturation dribble.
8. Overflow incontinence.
9. Extraurethral incontinence.
“WHEN DESCRIBING INCONTINENCE, IT
IS RECOMMENDED TO SPECIFY
RELEVANT FACTORS SUCH AS:
Type,
Severity,
Precipitating factors,
Social impact,
Effect on hygiene and quality of life,
Measures used to contain the leakage.”
STRESS URINARY INCONTINENCE
Definition:
It is defined as:
Symptom: the complaint of involuntary leakage on
exertion or on sneezing or coughing.
Sign: the observation of involuntary urinary loss from
the urethra synchronous with exertion, sneezing or
coughing.
Urodynamic Stress incontinence:
involuntary leakage of urine during increase in
abdominal pressure in the absence of detrusor
contraction.
Etiology and Pathophysiology of
Incontinence
Urinary Incontinence
U reth ra l In co n t in en ce E x rt a -u reth ra l I n co n t in en ce
U reth ra l I n co n tin en ce E x rta - u ret h ra l I n co n tin en ce
Bladder
Bladder Bladder
Bladder Outlet
Outlet (Sphincter)
(Sphincter) Both
Both Fistula
Fistula Ectopic
Ectopic Urethra
Urethra
Stress
Incontinence
Sphincter
Abnormality
Women
)Classified in 2 ways ( Men
Anatomic
AnatomicViewpoint Functional
Viewpoint Functional Viewpoint
Viewpoint
:Most commonly●
Urethral
Urethral hypermobility
))Urethral
hypermobility
Urethral support
support defect
defect(( Intrinsic
Intrinsic Sphincteric
Sphincteric insufficiency
insufficiency (ISD)
(ISD)
.,Anatomic disruption after prostate surg
:Less commonly●
Causes: :Causes
Causes:
,Trauma
:Causes
Previous urethral or periurethral surg. (e.g. anti-continence surg.) .1
Previous urethral or periurethral surg. (e.g. anti-continence surg.) .1
1.
1. Pregnancy
Pregnancy & & vaginal
vaginal delivery.
delivery. :Neurologic insult .2
:Neurologic insult .2
:Sacral neurologic lesions, due to ●
2.
2. Pelvic
Pelvic surgery.
surgery. :Sacral neurologic lesions, due to ●
.Herniated disc, DM, Neuropathy, MS, spinal cord tumors
3.
3. Chronic abd, straining (e.g. chronic
Chronic
4.
abd,
4. Neurogenic
straining
Neurogenic injury
injury (e.g.
(e.g. chronic constipation)
(e.g. injury
injury to
constipation)
to pudendal
pudendal N.)
N.)
.Herniated disc, DM, Neuropathy, MS, spinal cord tumors
:.Extensive pelvic surg.: e.g ●
:.Extensive pelvic surg.: e.g ●
.Abdominoperineal resection of rectum, Radical hystrectomy
.Abdominoperineal resection of rectum, Radical hystrectomy
Pelvic radiation .3
Pelvic radiation .3
.Neurologic abnormality
DIAGNOSTIC EVALUATION OF UI
A. History Taking:
1. Frequency and severity of incontinence.
2. Degree of bothering.
3. Its effect on quality of life.
4. For Acute Symptoms:
Pattern of fluid intake and output,
Acute infection,
6. For chronic Symptoms:
History of congenital anomalies
Prior surgery,
7. Neurological conditions:
MS, DM, Myelodysplasia, Spinal cord injury, Stroke, Parkinson’s
8. History of prostate surgery, Vaginal surgery, or previous surgical repair of
incontinence.
9. Radiation therapy.
10. History of medications.
DIAGNOSTIC EVALUATION CONT.
B. Physical Examination:
1. Neurological examination.
2. Abdominal and flank examination.
3. Rectal examination including DRE.
4. Sacral innervations by assessing:
Anal sphincter tone and control.
Genital sensation.
Bulbocavernosus reflex.
5. Pelvic and vaginal examination.
6. Assessment of pelvic floor strength.
DIAGNOSTIC EVALUATION CONT.
C. Urinalysis (should be performed in all patients).
D. PVRU volume .
E. Micturation diary.
F. Pad testing.
G. Dye testing:
If there is doubt about the source of urine:
a. Phenazopyridine (Sedural).
H. Uroflowmetry.
I. Urodynamic Study.
TREATMENT OVERVIEW OF
SPHINCTERIC DYSFUNCTION (STRESS
INCONTINENCE)
A. Rehabilitation techniques.
B. Pharmacologic treatment:
1. α-adrenergic agents.
2. Tricyclic Antidepressant (TCAs): Imipramine.
3. Combined serotonin-norepinephrine reuptake
inhibitors: Duloxetine
4. Estrogens.
TREATMENT OVERVIEW CONT.
C. Urethral Bulking Agent.
D. Surgery of Stress Incontinence:
a. In Females:
o The goal:
To restore urethral support & create a proper backboard to
resist increase in abdominal pressure OR,
To restore the coaptative force of urethra OR,
Both
D. SURGERY OF STRESS INCONTINENCE CONT.:
Types of Procedures:
1. Suspension Procedures: (transvaginal or retropubic)
Consisted mainly of:
Marshal Marchetti Krantz urethropexy,
Burch colposuspension.
2. Sling procedures: mainly
Tension-free Vaginal Tape (TVT),
Trans-Obturator Tape (TOT).
3. Sphincter Prosthesis.
D. SURGERY OF STRESS INCONTINENCE CONT.:
The Choice of Procedure Depends Upon:
1. The underlying condition (degree of urethral motility &
leak point pressure).
2. Available outcome data on various procedures.
3. Surgeon preference and expertise.
4. Patients related factors as
- Age,
- Comorbid conditions,
- Desire for fast recovery,
- Avoidance of potential complications.
Retropubic Suspension Surgery
Specific Indications:
1. For patients undergoing a laparotomy for concomitant
abdominal surgery that can not be performed vaginally.
2. When there is limited vaginal access.
Retropubic Suspension Surgery Cont.
Potential contraindications:
1. If there is history of prior failed incontinence
procedure.
2. When SUI due to intrinsic sphincter deficiency.
3. In cases with a pan-pelvic floor weakness.
4. In cases of bladder neck hypermotility associated with
vaginal prolapse.
5. When there is an inadequate vaginal length or mobility.
FEMALE PELVIC ANATOMY
Burch Colposuspension
Pre-operation:
1. Broad-spectrum intravenous antibiotics are
administered (2 hour before op.).
BURCH COLPOSUSPENSION CONT.
Positioning:
The patient is placed in a modified lithotomy position
or in a supine position with the lower extremities in a
frog-leg position.
A Foley catheter is placed.
Incision:
A transverse suprapubic incision (Pfannenstiel skin
incision) or lower midline abdominal incision is made.
BURCH COLPOSUSPENSION CONT.
Dessection:
Separating the rectus muscles in the midline and sweeping
the anterior peritoneal reflection off the bladder.
Teasing away the retropubic fat and underlying retropubic
veins from the back of the pubic bone.
The bladder neck, anterior vaginal wall, and urethra are
then easy to identify, often facilitated by the presence of
the Foley balloon.
It is important to identify the lateral limits of the bladder as
it reflects off the vaginal wall because only in this manner
can one avoid inadvertent suturing of the bladder itself.
BURCH COLPOSUSPENSION CONT.
Suture:
Use Non-absorbable sutures (e.g. Nylon 0/2)
BURCH COLPOSUSPENSION CONT.
Technique:
Ask the assistant to make vaginal support (PV).
The most proximal suture is at the level of the bladder
neck and placed no closer than 2 cm lateral to it.
2 to 4 sutures are placed on each side, each suture taking
a good bite of fascia and vaginal wall, with care taken
not to pass through the vaginal mucosa.
Subsequent sutures are placed distal to the level of the
bladder neck, at about 1-cm intervals.
The sutures are then placed into corresponding sites in
Cooper's ligament, in Z-form.
BURCH COLPOSUSPENSION CONT.
Drain:
May be used (Ben-rose or Tube drain)
The highly vascular vaginal wall may bleed profusely
during suture placement, but most bleeding ceases once
the sutures are tied and the vagina is suspended.
BURCH COLPOSUSPENSION CONT.
Results:
Short- and medium-term outcomes with the Burch
procedure have been good.
overall cure rate between 85% to 90%.
This decreased to 70% at 5 years.
Time of Hospital Stay:
2 days.
COMPLICATIONS
A. Intra-operative:
1. Bleeding.
2. Vaginal mucosa suturing.
B. Post-operative:
1. Urine retention.
2. Wound infection.
Thank You
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