EVALUATION OF URINARY

INCONTINENCE IN FEMALES

Dr. Dereje Alemayehu

July, 2011.
 PHYSIOLOGY OF NORMAL
MICTURATION
• Bladder and urethra are under the control of
autonomic(symp & parasymp) and somatic
nervous systems and supraspinal reflex.
• Urethral smooth and striated muscles with
endopelvic fascia and pelvic muscles are
involved in urine storage and micturation
• Bladder wall has 3 but at trigone 2 muscular
layers.
• Extrinsic urethral sphincter is composed of
striated urethral & periurethral muscles.
 Physiology…
Sympathetic NS (T11-L2), noradrenergic induce
- contraction of urethral smooth muscle
- relaxation of detrusor muscle
╙
storage

Parasympathetic NS (S2-4), cholinergic

• Induce urethral smooth muscle relaxation
• Contraction of bladder smooth muscle.
╙
Voiding
 Physiology…
• Micturation reflex:
– Frontal lobe and basal ganglia provides
modulation with inhibitory signal i.e storage
►Supramedial portion of frontal lobes & genu of the
corpus callosum constitute cortical control of the
detrusor muscle.
– All CNS inputs integrated in the pontine
micturation center(PMC)
► The pons & mesencephalic reticular formation in
the brainstem constitute the micturation center.
– Supraspinal parasympathetic micturation reflex is
responsible for normal micturation.
 Physiology…
• Signal (detrusor) →peripheral nerve
→spinal cord→ PMC→ PNS→ [Link]
→Ach→ detrusor contraction.
• Inhibitory signal (PMC) to all storage
reflexes of bladder causing urethral
relaxation and urine flows.
 Urinary Incontinence
• Def is an involuntary loss of urine that is
social and hygienic problem to the patient &
demonstrable objectively (ICS).
• Affects women‘s social and sexual activities and
the quality of life.
• A common problem of women of all ages.
• Only <50% of women with UI seek help, why?
Social embarrassment
unaware of availability of services
• Women try to ameliorate symptoms by
frequent toilet visiting and fluid restriction.
• 2-4x common in women than men.
• increases with aging, b/c of ↓of smooth &
esp. striated urethral muscles
• Incidence 8-41% in women >65 yrs.
 Impacts on quality of life
• Social embarrassment
• Avoid physical activity & social interaction
• Lower self-esteem
• Sexual dysfunction (desire & activity)
• Anxiety
• Depression in 80%.
 Risk Factors
• Pregnancy • CHF
• Obesity • COPD
• ed parity • Smoking
• Vaginal delivery • DM
• ↓estrogen
• Stroke
• Pelvic surgery
(hysterectomy) • Impaired mobility
• Genetic d/c in CT
 Classification of UI
– Congenital anomalies – Stress urinary incontinence (SUI)
• Ectopic ureter Bladder neck displacement
• Bladder exstrophy Intrinsic sphincter dysfunction
• Episadias – Urge urinary incontinence (UUI)
– By pass incontinence Idiopathic
Ureterovaginal fistula Detrusor hyperreflexia
Vesicovaginal – Mixed urinary incontinence (MUI)
Urethrovaginal – Overflow incontinence
Combinations Eg obstruction
hyporreflexia
– Urethral diverticulum
 Classifications…
- Functional and transient incontinence
(DIAPPERS)
Delirium
Infection
Atrophic vaginitis, urethritis
Pharmacologic agents
Psychological
Excess urine production
Restricted mobility
Stool impaction
• Prevalence:
– SUI-50%
– MUI-30-40 %
– UUI-10-20%
• SUI is more common in young and middle
age groups.
• UUI is common in older women.
 Clinical evaluation of urinary
incontinence
• History:
- Urgency, dysuria, frequency (>7x/day)
- Leakage with intraabdominal pressure or
strong urge to void.
- Dribbling, incomplete voiding
- Nocturia >2x/day,bed wetting
 Clinical evaluation…..
- hesitancy, poor streaming, interrupted
voiding.
- Precipitants in the urine
- Coital incontinence.
- Giggle /exercise incontinence.
- running water / opening the door
incontinence
- “key in lock” syndrome.
 Clinical Evaluation….
Voiding diary (Frequency/Volume chart)
*Record over 24- 48 hrs
-all fluid intake
-volume & time of voiding
-time of incontinence, episodes &
events associated.
 Evaluation…
– Drugs
eg. Anticholinergics, sedatives, α-blockers,
Ca channel blockers, etc
– Medical illness
eg. CT disease, CLD, Parkinson’s disease, etc.
– Bowel habit
– Parity and gravidity
– Pelvic operation
– Duration & severity of the problem
 Clinical Evaluation….
• Physical examinations:
Gynecologic evaluation
-Evaluation of urethral support (D. lithotomy or
standing with full bladder).
- vag. walls(rugae, defects,mass)& pelvic
floor(anal sphincter)
- vulvar atrophy
 Clinical Evaluation….
- presence of inflammation or irritation from
moisture or pads
- vag. discharge (DDx for UI)
- uterine size
-Bladder distention.
-Rectal mass/fecal impaction
• Neurological evaluation
–Perianal sensation.
–Anal sphincter tone.
–Mental status
–Spina bifida
 Evaluation…

• Laboratory evaluation
• Urinalysis/ culture.
• Serum glucose level.
• Cystoscopy .
• Urine cytology (age >50, hematuria)
• RFT
 Evaluation…
• Other tests:
– Pad test
– Q-tip test →measure mobility at the level
of bladder neck with cotton swab
• Very crucial to Dx urethral hypermobility
• Angle of excursion <300 → normal support of
urethra & bladder
neck.
• Is very sensitive but less specific.
 Urodynamic tests
1) Bladder filling test
- urinate, catheterize (measure post void
volume), fill the bladder with N/S at a rate of
60-75 ml/min till functional capacity .
2) Cystometry – 2 types
Filling cystometry -- measures bladder
pressure while filling.
Voiding cystometry (pressure flow study)
-- bladder filled with saline, then measure
~ volume infused and pressure
~ point of leakage
~ » sensation to void
~ » strong desire to void
(cystometric capacity)
-- Do provocative maneuvres (coughing,
heel bouncing, sound of running water).
 Evaluation…
-- gives the detrusor pressure as a difference
of vesical and abdominal pressure

Pdet = Pves-Pabd

• In UUI contraction occur during filling.

• Leakage with out detrusor contraction is SUI
 Evaluation…
• Normal cystomerty values
– Residual volume <50 ml.
– First desire to void is b/n 150-250 ml.
– Strong desire to void be after 250 ml.
– Bladder capacity 400ml- 600 ml.
– No detrusor contraction on filling
phase.
– No leakage on coughing.
– No provoked detrusor contraction.
– Maximum detrusor pressure < 50
cmH2O.
– Maximum flow rate >15 ml/sec
 Stress urinary incontinence (SUI)
• Def: is leakage of urine that occurs when
intravesical pressure exceeds MUCP in
the absence of detrusor contraction
(sneezing, coughing, exercise).
• MUCP is difference of intravesical &
urethral pressures
• Causes:
– urethral hyper mobility.
– Intrinsic sphincter deficiency (ISD).
 SUI…
• Factors associated with SUI:
– Pelvic floor damage (denervation)
• Parturition.
• Pelvic surgery.
– Urethral damage
• Vaginal/urethral surgery.
• Uretherotomy.
– Increased intraabdominal pressure.
• Pregnancy.
• Chronic cough.
• Fecal impaction
• Pelvic mass, obesity, ascites.
 SUI…
• Diagnosis:
– history.
– Stress test.
– Q-tip test.
– Urodynamic study;
• Gold standard.
• Diagnose UUI, ISD, Overflow incontinence
Treatment
1) Non surgical→for mild & moderate cases
a) Avoid aggravating factors – decrease obesity, Rx of
cough, stop smoking, dietary modification, timed
voiding, etc.
b) Strengthen pelvic muscles
-Kegel exercise (pubococygeus m.)
-improve estrogen status
c) Vag pessaries
d) Urethral plug
e) Drugs – α-adrenergic drugs.
f) Electrical stimulation – experimental.
Urethral Plugs;
– Work as a mechanical barrier.
– Cure rate -80%.
– Needs changing after each void.
– In Ethiopia femsoft was used in two
cases.
2) Surgical treatment >130 procedures
a) anterior colporrhaphy:
long term success rate of 35- 65% → low.
b) Operations for urethral hypermobolity
-- Retropubic urethropexy
-- MMK (pubic symphysis)
-- Burch colposuspension (Cooper’s lig.)
long term success rate of 70 -90% → high.
--Trans vag urethropexy
eg Needle supension procedure
-currently out of favour
--Tension free vag tape
. needs both abdominal and vaginal
approach.
. Can be done under local anesthesia at out patient
level.
. Cure rate is b/n 90-92%.
. Is tension free b/c it forms a resistant platform rather
than elevating the urethra.
C) Operations for IUSD
1) Sling Operations
– Sub urethral sling;
• Is a hammock that support the urethra and
bladder neck.
• Needs both abdominal and vaginal incision.
• Cure rate of 70-90%.
• Materials used includes: Rectus fascia, proline
mesh
• Preferred for ISD with urethral hyper mobility.
 ISD…
c.2) Periurethral Injections
• Done at out patient level under local anesthesia.
• Works by ing urethral coaptation.
• Injected transurethral or periurethral.
• Materials:
– Glutaraldehyde cross linked bovine collagen (contigen).
• Needs repeat injection.
– Pyrolic carbon coated zirconium beads (Durasphere).
– Polytetrafluroethylene paste (Polytef).
 ISD…
c.3) Artificial sphincter
– For refractory cases.
– Is placing inflatable cuff around the
bladder neck and urethra.
– Pump placed in the vulva.
 Detrusor Over activity (DO)
Def (by ICS):
- it is spontaneous or provoked detrusor
contraction during filling phase of
bladder.
- is characterized by urge incontinence.
 DO…
• Treatment :behavioral modification &
medical therapy
– Bladder training
• Is to reestablish cortical control over detrusor.
• Patient will have scheduled voiding.
• Cure rate 47-90%.
– Timed voiding
– Pelvic floor exercise
 DO…
– Pharmacologic treatment
-Anticholinergics
eg Oxybutynin, Tolterodine, Imipramine,
Propantheline bromide.
-are smooth muscle relaxants.
• Estrogen
– Improves urethral mucosal seal, muscle tone.
– Improves ά-adrenergic receptor.
 DO…
– Functional electrical stimulation
• Intavaginal or perineal stimulation of sacral somatic
afferent can inhibit detrusor contraction.
→Cure rate is 52-77%.
• Implantation of electrode near s2 and [Link] neurogenic
bladder causing DO,
→ cure rate 76%.
– Surgery;
• If all other methods failed.
• Augmentaion enterocystoplaty can be done.
→Cure rate: DO- 75%.
Neurogenic bladder-78%.
• Last option is ileal conduit.
 Mixed incontinence (MUI)
• The predominant feature guides the line
of management. i.e SUI/UUI.
• Generally safer management is to treat
DO medically. Surgery is for failed cases.
 GENITOURINARY FISTULA
• Def is a hole in the tissue b/n bladder and vagina
and/or rectum.
• Etiology
– Congenital
– Acquired
• Child birth
esp. Obstructed labour
• Radiotherapy.
• Surgery
• Malignancy.
• Childhood
– Penetrating trauma.
– Foreign body.
– Surgery.
 Fistula…
• Predisposing factors to fistula are
– Poverty.
– Lack of skilled attendance at birth.
– Lack of emergency obstetric care .
– Lack of transportation.
– Poor integration of service.
 Fistula…
• Grave social consequence of fistula are
– divorce.
– depression.
– Poverty.
– Suicide.
 Fistula…
• Ethiopia
– WHO estimates 0.3% of labor in developing
country will have VVF.
– Ethiopia estimated to have 8900 cases/yr. with
total of 250,000 cases.
– 83.6% - marry before age of 20yrs.
– mean age at marriage & delivery is 14.7& 17.8yrs
respectively.
– Mean age affected is 18.9yr.
– 97% have still birth.
– 54-60% were divorced
– Urethral damage 28.6%, urethral loss 5%.
 Fistula…
• Clinical feature of VVF
– Continuous urine leakage vaginally.
– Usually occurs in the first 10 days of
procedures.
– Have foul ammoniac odor.
– Depression.
– Insomnia
– Disrupted sexual relationship.
– Lower self-esteem
 Fistula…
• Investigation
– Vaginal fluid analysis for urea.
– Urine culture
– Dye test (3-swab test).
– IVP (ureterovaginal fistula,
hydronephrosis).
– Cystourethroscopy.
 Fistula…
• Treatment
– Preoperative care
• Treat any infection or inflammation.
• Correct nutritional status.
• Perineal skin care
– Surgical technique
• It is mainstay of treatment,
• Approach: Vag or Abd
• Principles
– Wide mobilization of bladder
– Excise scar
– Tension fee closure
– Good homeostasis
– Minimize tissue trauma