Urinary Incontinence

ASTU
DEPT OF OBS/GYN
BY Wasihun A.
 Definition
• Urinary incontinence as defined by the
International Continence Society (ICS) is the
complaint of any involuntary leakage of urine.
• Incontinence can be, a symptom (patient
complaint), a sign or a condition diagnosed by
an examiner.
 Incidence
• The reported incidence of urinary
incontinence varies widely, up to 40% in
women over 65 years.
• Incontinence becomes more common as
women age, particularly after menopause.
 Risk Factors
1. Gender and Age
• Urinary incontinence is two to three times
more likely to occur in women than in men.
• Urinary incontinence increases with age
probably for striated muscle mass decreases
with aging.
 Risk…
2. Race
• Racial differences in the prevalence and type
of urinary incontinence have been reported
but remain poorly understood.
• Urinary incontinence prevalence is more
common in Caucasian women than African-
American women.
 Risk…

3. Childbirth
• Vaginal childbirth has been seen as the
leading inciting factor in the development of
urinary incontinence and pelvic floor
dysfunction.
• Strong associations have been made between
vaginal delivery and stress urinary
incontinence.
 Risk…

• The majority of the damage to the pelvic

tissues appears to occur with the first delivery.
• Other factors associated with increased risk
from vaginal delivery include forceps
deliveries, prolonged second stage, large birth
weight, and large head circumferences.
 Risk…

4. Smoking
• Women who are cigarette smokers or ex-
smokers are two to three times more likely to
have urinary incontinence than non-smokers.
• Whether this association is related to chronic
cough and increased abdominal pressure or
tissue damage from tobacco toxins is not
known.
 Risk…
5. Obesity
• Obesity has been shown to be more common
in women with both stress and urge
incontinence
• Morbidly obese women who lose weight have
shown objective as well as subjective cure of
their incontinence
Classification and Causes of
Urinary Incontinence
1. Genuine stress incontinence(GSI)
o Bladder neck displacement
o Intrinsic sphincter dysfunction
2. Detrusor instability/urge
incontinence
o Idiopathic
o Neurologic detrusor hyperreflexia
 Classification…
3. Mixed incontinence (genuine stress and detrusor
instability combined)
4. Overflow incontinence
o Obstruction
o Bladder hyporeflexia
5. Bypass incontinence
o Genitourinary fistulas
6. Functional and transient incontinence
o Infection
o Pharmacologic
o Dementia/delirium
History:
• The evaluation begins with more direct
questioning concerning the patient's
symptoms, timing, and severity of leak.
• An obstetric history including route of
delivery, episiotomy, lacerations, the use of
forceps or vacuum, birth weights, and the
length of the second stage.
 History…
• A history of pelvic cancer therapy should
included
• Other comorbid conditions affecting the lower
urinary tract: cigarette smoking, neurologic
and endocrine diseases, as well as family
history of urinary incontinence and pelvic
organ prolapse may direct the clinician toward
one type of urinary incontinence.
 History…
• Any functional components such as difficult
ambulation, declining cognition.
• Medications currently used should be
reviewed in detail as many medications have
adverse effects on the lower urinary tract eg
diuretics
EVALUATION…
Physical Examination

A general gynaecologic and neurologic examination

should be performed on all patients, with a focus
on the vaginal walls and pelvic floor.

An examination should be performed with the

patient in the lithotomy position.

The examination should begin with an assessment

of the vulvar & perineal area.
 P/E…
The presence of inflammation or
irritation from chronic moisture or
pad usage should be noted.

The presence of discharge should be

noted because this may mimic urinary
incontinence.

The position of the vaginal walls

should be noted in the lithotomy
position at rest and with
Valsalva/straining maneuver.
 P/E…

• A Sims' speculum or the lower blade of a Graves'

speculum allows easy visualization of either the
anterior or posterior vaginal wall.
 Neurologic Examination
• The sacral spinal cord nerve roots 2–4 contain vital
neurons controlling micturition.
• The anal wink reflex and the bulbocavernosus reflex
can confirm integrity of neurovisceral and urethral
reflex functions.
 P/E…

• Reflexes can be evoked by stroking the

perianal area and looking for an external anal
sphincter contraction, and by tapping the
clitoris and watching for contraction of the
bulbocavernosus muscle, respectively.
• Mental status, cranial nerves, motor & sensory
function, deep tendon reflexes, and sacral
spinal cord integrity should all be assessed.
 P/E…
• Motor control may be diminished in focal
brain or cord lesions, most commonly
Parkinson's disease, multiple sclerosis, and
cerebrovascular accident.
 Clinical tests
a. Urinary Stress Test
• Having the patient perform a Valsalva
maneuver or to cough forcefully multiple
times to reproduce urine loss.
• If no urine loss is exhibited, the patient is
asked to stand with legs shoulder width apart
and asked to cough.
• Immediate loss of urine suggests a diagnosis
of Stress Urinary Incontinence.
 Tests…
b. Cotton Swab or Q-tip test
• Quantifies mobility at the level of the bladder
neck with the use of a sterile cotton-tipped
swab.
• An angle greater than 30 degrees is
considered abnormal.
• The utility of this simple test is that an angle
greater than 30 degrees is certainly present in
the majority of women with genuine stress
incontinence.
 Tests…

A: Angle of the Q-tip at rest. B: Angle of the Q-tip with Valsalva maneuver or
cough
 Investigations
 Urinalysis
• Examination of the urine is an essential part of
the work-up of urinary incontinence for any
patient with LUTS.
• Infection is a common cause of urinary
complaints, including frequency, urgency, and
incontinence.
 Cystourethroscopy- Endoscopic evaluation
 Investigations …
 Urodynamics
• A urodynamic study is any test that provides
objective dynamic information about lower
urinary tract function.
 Imaging Tests
• These modalities are of limited use in the
evaluation of all but the most complex of
incontinent patients.
 1. Stress Urinary Incontinence

• The International Continence Society (ICS)

defines SUI as the complaint of involuntary
leakage on exertion, or on coughing or
sneezing.
• If intra-abdominal pressure increases as it
does with a cough, sneeze, or strain, and if this
pressure is not equally transmitted to the
urethra, then continence is not maintained
and leakage of urine occurs.
 Stress…

Causes:
 Bladder neck displacement
 Intrinsic sphincter dysfunction (ISD)
Treatment of Stress Urinary Incontinence
Bladder neck displacement
• Nonsurgical Measures
• Surgical Management
 Stress…
 Nonsurgical Measures
• Reduction in consumption of caffeinated
beverages and alcoholic drinks should be
encouraged.
• Fluid restriction in patients without chronic
medical problems.
• Timed voiding to prevent filling the bladder to
a capacity that causes urine loss
 Stress…
• Pelvic floor muscle exercises or Kegel exercises
found to be extremely helpful in patients with
mild to moderate forms of incontinence.
o Is focused repetitive voluntary contractions of
the levator ani muscles created by having the
patient contract or "squeeze" the muscle as if
to prevent the passage of rectal gas is an
effective therapy.
 Stress…

• Pessaries
o Are intra-vaginal devices to correct the anatomic
deficits associated with stress incontinence
 Surgical Management
• Surgical treatment should be offered for
moderate to severe incontinence.
For bladder neck displacement includes:
 Urethropexy
 Sling procedures
 Stress…
 Periurethral and Transurethral Injection -
Periurethral or transurethral injection of a
bulking agent into the submucosal space of
the bladder neck
Intrinsic sphincter dysfunction (ISD)
• Artificial Sphincters
 Urge urinary incontinence is the complaint of
involuntary leakage immediately preceded by
unbearable sense of voiding.
 Urge urinary incontinence is usually associated
with involuntary contractions of the bladder
or detrusor contractions.
 Also called detrusor instability or over active
bladder(OAB)
 Urge…
 Etiology
• Idiopathic
• Neurologic detrusor hyperreflexia
 Diagnosis
• Diagnosis of OAB is suggested by urinary frequency often
associated with a strong urge or a sense of impending urine
loss.
• Incontinence often occurs prior to reaching the toilet.
• Patients often describe "key in lock" syndrome, characterized
by an uncontrollable urge to void when unlocking the door
after returning from a trip out of the house.
 Urge…
 The first thing done upon return is to immediately
rush to the toilet or risk losing urine.
 Strictly speaking, detrusor instability (DI) is a
urodynamic definition and term.
 Treatment
o Behavioural Therapy
• Behavioural therapy includes bladder training, timed
voiding
o Pharmacologic Therapy: anticholinergics, have
become the mainstay of drug treatment
• Mixed incontinence occurs when both stress
incontinence and DI occur simultaneously.
• Patients may present with symptoms of both
types of incontinence.
• Dx and treatment targeting both
4. Overflow incontinence
• Overflow incontinence is defined as the
involuntary loss of urine associated with
bladder overdistention in the absence of
detrusor contraction.
• This condition classically occurs in men who
have outlet obstruction secondary to prostatic
enlargement that progresses to urinary
retention.
• In women this is a relatively uncommon cause
of urinary incontinence.
Overflow…
Diagnosis –witnessing involuntary loss of
urine associated with bladder over-distention
in the absence of detrusor contraction

Treatment

Bladder drainage to relieve retention is the

first priority followed by treatment of
underlying cause.
 5. Functional and
Transient Incontinence
o Causes
• Infection
• Pharmacologic
• Dementia/delirium
o Management
• Underlying cause
 6. Bypass Incontinence
• Bypass Incontinence is due to short communication
between urinary tracts and other systems.
• Usually presents as constant day and night dribbling
or dampness.
• Genitourinary fistulas (vesicovaginal or
ureterovaginal) are best examples.
• Genital fistula is a communication of the genital
organs (uterus, vagina) with the urinary tract
(urethra, bladder, ureter) and/or lower intestinal
tract (rectum, anus)
 Etiology of Genital Fistula
 Obstetric Causes
• Prolonged obstructed labor
• Operative delivery:
– Cesarean section
– Cesarean hysterectomy
– Instrumental delivery
– Symphysiotomy
– Destructive delivery
 Etiology…
 Non-Obstetric Causes
• Trauma:
– Post-coital
– Accidental fall
– Female genital cutting
• Pelvic surgical procedure
• Radiation
• Malignancy
• Congenital malformation
Pathogenesis of Obstetric Fistula
Prolonged obstructed labor

Pressure necrosis

Tissue slough

Fistula
 Management of
Genitourinary fistulas
Fistula
• Treat if there is infection
• Nutritional rehabilitation
• Physiotherapy
• Treat / prevent ammonical urine dermatitis
• Treat & Prevent urolithiasis & UTI by advising
to drink more fluid
• Psychological support
• Finally treat the fistula surgically
 Psychosocial
Consequences of Fistula
• Social isolation
• Divorce
• Depression
• Suicide
 Strategies
for Prevention of obs. Fistula
Primary Prevention Strategies
• Improve nutrition
• Ensure immunization and treatment of
childhood diseases
• Improve girl’s enrollment in school and
decrease dropout rates
• Improve access to information and service for
all components of reproductive health
services
 Primary Prevention…
• Educate to avoid early marriage
• Prevent harmful traditional practices
• Empower women
• Ensure availability and use of family planning
 Prevention…
Secondary Prevention Strategies
• Ensure access to and use of antenatal care
• Use partograph during labor
• Ensure presence of skilled attendant at
delivery
• Improve accessibility and availability of 24-
hour emergency obstetric care
• Improve the health delivery system
 Prevention…
Tertiary Prevention Strategies
• Catheterize in cases of obstructed labor and
small fistula
• Provide supportive care
• Ensure access to and availability of surgical
repair of fistula
Thank you!