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Female Urinary Incontienece

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FEMALE URINARY INCONTINENCE

DR MONA AHMED

FUNCTIONS OF URINARY SYSTEM

The urinary system’s functions include:

  • URINE
    • FORMATION
    • TRANSPORT
    • MICTURITION CYCLE
      • STORAGE PHASE
      • VOIDING PHASE

ANY DEFECT in these functions can lead to URINARY INCONTINENCE.

NORMAL MICTURITION CYCLE

URINARY INCONTINENCE

Urinary incontinence is demonstrable and is a social or hygienic problem.

  • TYPES
    • CONTINUOUS:
      • TOTAL
      • PARTIAL
    • INTERMITTENT:
      • STRESS (1ST)
      • URGE (2ND)
      • MIXED (3RD)
      • REFLEX
      • OVERFLOW
      • NOCTURNAL ENURESIS
      • FUNCTIONAL
      • VAGINAL ??

CONTINUOUS INCONTINENCE (PATIENT IS ALWAYS WET)

TypeTotalPartial
Cause- Vesicovaginal fistula
- Bilateral ureterovaginal F		- Unilateral Uterovaginal F
- Small, valvular or very high VVF
Micturition desireAbsentPresent but less than normal
Bladder distentionAbsentMay be distended

INTERMITTENT INCONTINENCE

(URINE PASSES INTERMITTENTLY AND PATIENT IS DRY IN BETWEEN)

INVOLUNTARY LOSS OF URINE: Z

  • STRESS : WHEN IVP EXCEEDS IUP DUE TO ↑IAP BY STRESS.

  • URGE: ASSOCIATED WITH STRONG DESIRE TO VOID DUE TO DETRUSOR INSTABILITY.*

  • REFLEX: DUE TO ABNORMAL REFLEX ACTIVITY IN SPINAL CORD (DUE TO BRAIN TUMOR & SPINAL CORD INJURY) USUALLY ASSOCIATED WITH STRONG DESIRE TO VOID.

  • OVERFLOW : WHEN IVP EXCEEDS IUP DUE TO EXCESSIVE BLADDER DISTENSION.

  • NOCTURNAL ENURESIS : DURING SLEEP E.G. SPINA BIFIDA, SMALL BLADDER CAPACITY, PSYCHOSOMATIC, & CHILDREN.

  • FUNCTIONAL : DUE TO IMMOBILITY OR COGNITIVE IMPAIRMENT HINDER TO GET TO TOILET.

  • MIXED

GENUINE STRESS INCONTINENCE

DEF: INVOLUNTARY LOSS OF A SPURT OF URINE SIMULTANEOUSLY WITH MANOEUVRES THAT INCREASE IAP WHICH ENDS ABRUPTLY WITH END OF ACT

DEGREE OF STRESS INCONTINENCE :

  1. GRADE I: INCONTINENCE OCCUR ONLY WITH SEVERE STRESS SUCH AS COUGHING, SNEEZING, ETC.
  2. GRADE II : INCONTINENCE WITH MODERATE STRESS SUCH AS RAPID MOVEMENT OR WALKING UP AND DOWN STAIRS
  3. GRADE III : INCONTINENCE WITH MILD STRESS, SUCH AS STANDING. THE PATIENT IS CONTINENT IN THE SUPINE POSITION

PATHOPHYSIOLOGY Y

  • AN INTERACTION BETWEEN BLADDER AND SPHINCTER

  • BLADDER ABNORMALITIES :

    • -DETRUSSOR OVERACTIVITY (IDIOPATHIC, NEUROGENIC)
    • -LOW BLADDER COMPLIANCE
    • SCI, INTERSTITIAL CYSTITIS, RADIATION CYSTITIS, HYSTERECTOMY

  • SPHINCTER ABNORMALITIES

    • EXTRINSIC : URETHRAL HYPERMOBILITY
      • WEAKNESS OF PELVIC FLOOR MUSCLE (URETHRAL SUPPORT)
    • INTRINSIC : INTRINSIC SPHINCTER DEFICIENCY (ISD)
      • URETHRAL MUSCULATURE, BLOOD FLOW, INNERVATION

AETIOLOGY OF GSI

  • CONGENITAL
  • TRAUMATIC: - OBSTETRICS - IATROGENIC (OPERATIONS) CAUSING SCARRING AT BLADDER NECK.
  • 3P - PREGNANCY - PROLAPSE - POSTMENOPAUSAL
  • SHORT URETHRA
  • OBESITY

CLINICAL EVALUATION

GENERAL EXAMINATION :

  • ABDOMINAL EXAMINATION: DISTENDED BLADDER, ABDOMINAL MASS/OBESITY.
  • CHEST EXAMINATION: FOR CHRONIC COUGH.
  • PELVIC EXAMINATION:
    • INSPECTION:
      • ATROPHIC VAGINITIS/ URETHRITIS.
      • PELVIC ORGAN PROLAPSE.
      • GENITOURINARY

EXAMINATION

  • RECTAL EXAMINATION : SKIN IRRITATION, ANAL SPHINCTER CONTROL, FAECAL IMPACTION
  • NEUROLOGIC EXAMINATION:
    • MENTAL STATUS.
    • PERINEAL SENSATION (S2, 3, 4)
    • SACRAL REFLEXES ASSESS (S2, 3, 4) CONTROLLING MICTURITION. A} ANAL REFLEX → SCRATCH PERINEUM WITH A PIN.

SPECIAL TESTS

SIGNS: SPECIAL TESTS (AIM, TECHNIQUE, RESULTS)

  1. STRESS TEST
  2. PERINEAL PAD TEST
  3. Q TIP TEST
  4. WATER BRIDGE TEST
  5. BLADDER NECK ELEVATION TEST

Q-TIP test

Bladder Diary (“Uro-Log”)

INVESTIGATIONS

  • URINE ANALYSIS
  • KIDNEY FUNCTION TESTS
  • US FOR:
    • RESIDUAL URINE
    • RENAL SIZE
    • BLADDER MASS, NECK AND URETHRAL ANATOMY.
  • CYSTOSCOPY
  • VOIDING CYSTOURETHROGRAPHY
  • URODYNAMIC STUDY

CYTOMETRY

NORMAL CYSTOMETROGRAM

TREATMENT

PROPHYLACTIC:

  1. TREATMENT OF PREDISPOSING FACTORS.
  2. GOOD OBSTETRIC CARE
  3. POSTNATAL PELVIC EXERCISES
  4. HRT IN POSTMENOPAUSAL WOMEN
  5. PROPER SURGICAL TECHNIQUE TO AVOID SCARING AT BLADDER NECK.

CONSERVATIVE TREATMENT

LIFE STYLE:

  • WEIGHT LOSS
  • STOP CAFFEINE & SMOKING
  • FLUID MANAGEMENT

MEDICAL:

  • ESTROGEN EITHER SYSTEMIC OR LOCAL IN POSTMENOPAUSAL WOMEN.
  • ALPHA-ADRENERGIC STIMULANTS
  • ANTICHOLINERGICS

PHYSIOTHERAPY:

  • PELVIC FLOOR EXERCISES
  • FARADIC CURRENT STIMULATION
  • MECHANICAL DEVICES: E.G. PESSARY, WEIGHTED CONES USED PREOPERATIVE OR WHEN PATIENT IS UNFIT FOR SURGERY

OTHERS:

  • IMPLANTED ARTIFICIAL SPHINCTER
  • PARAURETHRAL BULKING AGENTS : COLLAGEN, FAT

SURGICAL TREATMENT

A} VAGINAL URETHROPLASTY : PARAURETHRAL FASCIA ON EITHER SIDE OF BLADDER NECK BY 2-3 SUTURES.

B} ABDOMINAL URETHROCYSTOPEXY: SUTURE THE FRONT OF URINARY BLADDER TO THE BACK OF SYMPHYSIS PUBIS.

C} URETHRAL SLING PROCEDURES

D} MINIMAL INVASIVE SLING LIKE PROCEDURES:

  • TENSION FREE VAGINAL TAPE {TVT}
  • TRANSOBTURATOR TAPE {TOT}

TREATMENT OF URGE INCONTINENCE

Non surgicalSurgical
1) Reassurance 2) Physiotherapy
3) Medical treatment:
- Antibiotics for infections
- Anticholinergics
- Tricyclic antidepressants
- Antiprostaglandins
- Local Estrogen		-Infravesical nerve resection.
-Selective bladder denervation.
-Cystodistension.
Mixed type: treat DI first

mentoin generally, medical, physical, prophylactic - urinalaysis, indications for urodynamics? Z

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