DR/ADEL

DR/ADEL FAROUK M.D..

FAROUK M.D
ASSISTANT PROFFESOR of
ASSISTANT PROFFESOR of
Obstetrics
Obstetrics &&
Gynecology
Gynecology
Cairo
Cairo university
university
URINARY
URINARY INCONTINENCE
INCONTINENCE
IN
IN THE
THE FEMALE
FEMALE
 ANATOMY OF THE BLADDER
THE BLADDER is a hollow muscular organ
normally situated behind the pubis symphysis.
It is composed of a syncytium of smooth muscle
fibers known as the Detrusor muscle.
It is covered superiorly & anteriorly by peritoneum,
and is connected to the proximal urethra at the
bladder neck which rests on the urogenital
diaphragm.
The Detrusor muscle has a rich cholinergic
parasympathetic supply (S: 2,3,4).
Contraction of this meshwork of fibers results in
simultaneous reduction of the bladder in all its
diameters.
 ANATOMY OF THE URETHERA
THE URETHRA is 3-5 cm in length.
It is a thin-walled muscular tube that drains urine from the
bladder to outside the body.
The epithelium of the urethra is transitional near the
bladder, stratified squamous near the external opening and
pseudostratified columnar epithelium in between.
Beneath this thick epithelium is a rich vascular plexus
which contributes up to 1/3 the uretheral pressure.
The urethra has a minimal parasympathetic innervation
and its smooth muscles are innervated by sympathetic
fibres (T10,11,12).
Stimulation of these sympathetic fibres produce urethral
contraction via a-adrenergic receptors. b-adrenergic
receptors produce urethral and Detrusor muscle
relaxation.
 URETHERAL SPHINCTERS
The internal urethral sphincter (involuntary):
at the bladder-urethral junction, a thickening of
the detrusor muscle forms.
The external urethral sphincter (voluntary):
is skeletal muscle and surrounds the urethra
as it passes through the urogenital diaphragm.
N.B.: The urogenital diaphragm is part of the
pelvic diaphragm which is the muscular
portion of the pelvic floor that provides a
stable base on which the bladder neck and
proximal urethra rest.
ANATOMY OF THE BLADDER
AND THE URETHERA
 Mechanism of continence
The intera-urethral pressure at rest or with
the stress of increase intra-abdominal
pressure (I.A.P.) remains higher than intra-
vesical pressure by the following factors:
A- At rest:
- Urethral mucosal resistance.
- Periurethral vascular plexus pressure.
- Resting intra-abdominal pressure.
B- At stress of increased I.A.P.:
Kinking of the urethra.
Contraction of urogenital diaphragm ↑
pressure in lower urethra
 Mechanism of continence
Urinary continence is the ability to hold urine at all times
except during micturition. Continence control is
established via:
Intraurethral pressure is higher than the intravesical
pressure (neuromuscular).
Fascial support around the urethra (anatomical position) or
support of urethra at rest.
Submucosal vascularity.
Abrupt increases in intra-abdominal pressure (IAP) are
transmitted equally to the bladder and proximal urethra as
it lies above the pelvic diaphragm.
Increase IAP leads to kinking effect of the proximal urethra
because of strong support of pubocervical fascia posterior
to the urethra which stimulates contraction of the pelvic
diaphragm.
 Micturition
As urine accumulates, the bladder stretches
and stretch receptors are activated. This
causes a reflex that result in relaxation of the
detrusor muscle and contraction of the external
urethral sphincter.
When about 200 ml. of urine has accumulated,
impulses are sent to the brain and one begins
to feel the urge to urinate.
Activation of the micturition centre in the pons
signals parasympathetic neurons that stimulate
contraction of the detrusor and relaxation of the
sphincters.
 During micturition
1- Relaxation of pelvic striated muscle
(pudendal nerve inhibition).
2- Relaxation of the fascial support
(parasympathetic effect) leads to:
- Descent of bladder neck.
- Funnelling of the urethra.
- Increase of urethro-vesical angle → 180°
- Increase of urethral pubic angle → 45°
3- Contraction of detrusor muscle
(parasympathetic effect).
 Urinary incontinence
Urinary incontinence is the involuntary
loss of urine that is objectively
demonstrable and results in social and
hygienic problem.
 CLASSIFICATION OF URINARY
INCONTINENCE
A) Extraurethral incontinence: Fistula (vesicovaginal,
uretrovaginal, urethrovaginal)
B) Urethral incontinence:
Urodynamic stress incontinence (USI), also called
genuine stress incontinence (GSI).
Detrusor overactivity (DO), also called detrusor
instability (DI), or (urgency incontinence).
Mixed type (commonest).
Overflow incontinence (retention with overflow).
N.B.: Acute temporary incontinence may occur with child
birth, limited mobility, medication side effect or urinary
tract infection.
 Urinary incontinence
Common symptoms associated with
incontinence:
Urgency: a sudden desire to void.
Frequency: urination 7 or more times a day or
waking more than once at night to void.
Stress incontinence: loss of urine on physical
effort. It is not a diagnosis.
 I. URODYNAMIC STRESS
INCONTINENCE ((USI)
(Genuine Stress incontinence)
involuntary leakage of urine through the
urethra when the intravesical pressure
exceeds the maximal urethral pressure in
absence of detursor activity (Genuine type ). It
occurs during periods of increased intra-
abdominal pressure e.g. coughing, sneezing,
exercise. It results from incompetent closure
mechanisms at the urethra and the bladder
neck.
 Incidence
–Genuine stress incontinence occurs in about
20% of females at certain time of their life.
Prevalence and severity increase with age,
parity and obesity (5% before 45 years, 10%
between 45-60 years and 30% above 65 years).
 Etiology of stress incontinence
Stress incontinence occurs due to weakness of the
urethro-vesical junction resulting from
Weakness of the musculo-fascial support of this
region.
Descent of the urethro-vesical junction so that the
upper urethra is not situated above the
urogenital diaphragm and consequently it is not
compressed by the raised intra-abdominal
pressure at stress.
The bladder neck and proximal urethra are normally situated
in an intraabdominal position above the pelvic floor and are
supported by the pubourethral ligaments. This position
allows increases in IAP to be transmitted equally to the
bladder and proximal urethra maintaining urethral closure
and continence.
Damage to either the pelvic floor musculature (levator ani)
or pubourethral ligaments may result in descent of the
proximal urethra, and bladder neck, such that they will
become no longer intraabdominal organs. This descent
prevents transmission of IAP to the proximal urethra leading
to an increase in the intravesical pressure over the
intraurethral pressure during straining with a consequent
leakage of urine per urethra during stress.
This typically occurs in women that experience loss of
support in the anterior vaginal wall leading to prolapse and
descent of the bladder neck and urethra.
Reduction in the resting urethral closure pressure occurs
due to fibrosis, scarring or oestrogen deficiency, with
resultant weakness of the internal urethral sphincter.
 Etiology of stress incontinence
A) Predisposing Factors:
Congenital weakness “Racial and familial”.
Traumatic weakness:
Child birth trauma (overstretching of pelvic floor muscles
and ligaments).
Direct trauma (fracture pelvis).
Fibrosis of the urethra and periurethral support:
Secondary to bladder neck surgery or surgery for prolapse.
Secondary to radiotherapy
Postmenopausal atrophy that leads to further weakness of
the pelvic fascia as well as decrease the mucosal
resistance (due to oestrogen deficiency).
B) Precipitating Factors: Obesity, ascites, constipation,
chronic cough, pelvic mass.
Causes of stress incontinence
Congenital or developmental weakness of the
internal sphincter.
Traumatic: resulting from childbirth causing
overstretech and damage of the fascia around
the bladder neck.
Operative trauma: operations causing
excessive fibrosis around the bladder neck
Hormonal: postmenopausal atrophy of the
pelvic floor muscles, ligaments and fascia
around the sphincter.
Genital prolapse: due to descent of the
urethra and the bladder neck below the level
of the pelvic diaphragm and stretching of the
internal uretheral sphincter.
Descent of bladder neck

Descent of the urethro-vesical junction so that the upper urethra is not situated
above the urogenital diaphragm and consequently it is not compressed by the
raised intra-abdominal pressure at stress.
 Types of stress incontinence
–Genuine stress incontinence (anatomical
weakness of the bladder neck).it may be classified
into
–Grade I ( incontinence with severe stress),
–Grade II (with moderate stress rapid movement,
walking up or down stairs).
– Grade III (with mild stress as standing).
–Detreusor instability: involuntary contractions of
the detrusor muscles during filling. It may be due
to neurological lesions as DS (detrusor hyper-
reflexia) or urinary tract infection, it may lead to
incontinence.
 Diagnosis of stress incontinence
Symptoms:
Dribbling of urine with increases I.A.P.
(coughing-sneezing, laughing, walking or
other activities).
Loss of urine is brief, usually in spurts and
corresponds precisely to the period of
increase in I.A.P., limited to the upright or
sitting position and not associated with
desire to urinate
• Urgency, frequency may be present
• Awareness of prolapse especially in
multiparous women.
Stress incontinence can be demonstrated
when asking the patient to cough while the
bladder is full (better in erect position but
can be demonstrated more commonly in
lithotomy position).
Presence and degree of associated genital
prolapse
Examination of a case of stress
incontinence
Demonstrate the presence
of stress incontinence by
asking the patient to
cough. There should be
some urine in the bladder
before asking the patient to
cough to diagnose the
presence of stress
incontinence.
 Examination of a case of stress
incontinence
In some cases of stress incontinence loss of
urine may not appear (hidden stress
incontinence) this may be due to
The presence of large cystocele causing knick
•The
of the urethra (reexamination after elevation
of the cystocele) (Yossef test).
Empty bladder (the bladder should be half
•Empty
filled before demonstrating the presence of
stress incontinence.
Examination in recumbent position (so
•Examination
reexamination in the standing position might
be needed).
 Examination of a case of stress
incontinence
Try to find the cause:
Some degree of pelvic relaxation usually
exists (urethrocele or cystocele).
With straining excessive mobility of urethro-
vesical junction (detected by Q Tip test).
Examination of a case of stress
incontinence
The Q Tip test is done by
application of lubricated
applicator in the urethra and
asking the lady to strain;
normally the applicator moves
not more than 15º above the
horizontal plane excessive
mobility with the angle is up
to 50-70º indicates
detachment of the urethra
from the symphysis pubis.
Q Tip test
Bonney’s test:
The bladder neck is elevated by 2 fingers placed in
the vagina on each side of the urethra without
compressing it. The patient is asked to cough or
strain to produce an elevation in IAP. If no urine
escapes during coughing, then bladder neck
descent is the cause, and surgical repair will be
successful. If urine escapes on coughing then
weakness of bladder neck will be the cause.
Examination of a case of stress incontinence
• Bonney’s test: to detect the
etiology & to suggest
prognosis
 Bonney’s test
• Bonney’s test: If urine escapes from the urethra
on coughing, the test is repeated after elevation of the
bladder neck upwards (by 2 fingers in the vagina on
either side of the region of the bladder neck). If no
urine escapes on coughing, this means that the cause is
descent of the bladder neck treated by elevation of the
bladder neck region (uretheropexy), but if urine
escapes, this means that the cause is due to weakness of
the region of the bladder neck (not due to descent of the
bladder neck) (treated by uretheroplasty).
 Detrusor overactivity (DO)
• (previously called Detrusor instability) is a
urodynamic observation characterized by
involuntary Detrusor contractions during the
filling phase which may be spontaneous or
provoked.
• Incidence: It is the second most common cause
of female incontinence, after USI, and accounts
for 30-40% of cases.
 Detrusor overactivity (DO)
• Aetiology:
• Local bladder irritation (e.g. infection, stone, ulcer,
polyps, ....).
• In association with other evidence of neuropathy e.g. DM,
DS, spinal cord or brain lesions.
• Idiopathic (most common).
• Associated symptoms include; urgency, frequency, urgency
incontinence, nocturia, stress incontinence, voiding
difficulty and dysuria.
• Diagnosis:
• The diagnosis can only be made by urodynamic
investigation tests when there is failure to inhibit Detrusor
contractions during cystometry.
 III. OVERFLOW INCONTINENCE
Definition: Insidious failure of bladder emptying that
may lead to chronic urinary retention and overflow
incontinence.
Aetiology:
Hypotonic bladder; as in lower motor neurone
diseases, spinal cord injury or autonomic neuropathy
e.g. (D.M.)
Outflow obstruction: External or urethral (large cervical
myoma).
Acute retention with overflow e.g. postoperative,
postpartum or infection.
Iatrogenic e.g. anticholinergic and anticonvulsant
drugs
 OVERFLOW INCONTINENCE
Clinical presentation:
A) Symptoms: Patients usually present with various
symptoms including dribbling of urine, straining to void
with poor stream, and unawareness of urine loss.
B) Physical examination:
General examination: weight, gait, chronic chest
disease.
Abdominal examination: abdominal mass, hernia.
Pelvic examination: Atrophy, displacement, weak
perineal muscle.
Examination for neurologic disorder: Muscle
weakness, paralysis, deep tendon reflex.
 Investigations

Urine analysis, A midstream urine for
culture and sensitivity of urine to exclude
urinary tract infection
 Cystoscopy to exclude cystitis or any bladder
lesion.
 Rodiological studies: Cystourethrography:
 In cases of stress incontinence there is funneling
of the bladder neck in the antero-posterior view
and obliteration of the posterior urethro-vesical
angle in the lateral view.
 Investigations
Urodynamics study: these are group of tests
determine the pressure changes in the bladder
(cystometery) and in the urethra
(urethrometery), the functional length of the
urethra (the length of the urethra at which the
intra-uretheral pressure is higher than the intra-
vesical pressure) and pressure changes during
the act of micturition (Uroflwmetry).
Urodynamics are indicated to differentiate
genuine stress incontinence from detrusor
instability
 Urodynamics study
These are tests which are employed to determine bladder
function. They are indicated whenever multiple symptoms
are present, mixed types of incontinence suspected, or
where difficulties arise in differentiating USI from DO.
Cystometry: measures the pressure volume relationship
within the bladder. It can detect intravesical pressure and
intraurethral pressure during rest and voiding. Cystometry
can differentiate between USI and DO in the majority of
cases.
Uroflowmetry: rate of urine flow through urethra (N= 15
ml/sec.)
Urethral pressure profile: traces intraurethral pressure
along urethral length
DO: is diagnosed if there is rise of the bladder pressure
during the filling phase > 15 cm H2O.
USI: is diagnosed if leakage occurs as a result of increased
intra-abdominal pressure in the absence of rise in detrusor
pressure.
 Parameters of normal bladder
function
1) Residual volume < 50 ml.
2) First desire to void between 150-200 ml.
3) Capacity (strong desire between 400-600
ml.
4) Detrusal pressure during filling < 15 cm
H2O
5) Absence of systolic detrusor contraction.
6) No leakage on cough.
 MANAGEMENT OF URODYNAMIC
STRESS INCONTINENCE
A) Prophylactic measures:
Avoid prolonged 2nd stage of labour and
minimize child birth trauma.
Pelvic floor exercises especially in the
puerperium, or after pelvic surgery
Avoid marked obesity and overweight.
Proper treatment of chronic cough and
constipation especially in the post
menopausal period
 MANAGEMENT OF URODYNAMIC
STRESS INCONTINENCE
B) General measures and exercise:
Restrict fluid drinking to 1 litre / day
Weighed vaginal cones inserted in the vagina; to
stimulate pelvic floor muscle contractions, as a
sort of muscle exercise.
Maximum electrical stimulation
C) Medical treatment:
Oestrogen in cases of menopausal atrophy.
Alpha sympathomimetics (phenylpropanolamine)
Combination of both is the best.
 Treatment of stress incontinence
 1-Postmenopausal cases are treated by combined estrogen and
androgen preparations.
 2- Pelvic floor exercises by (Kegel’s) perinometer for 3-6 months
after labor may cure or improve some post-partum cases these
exercises strengthen the levator ani.
 3- ∝ adrenergic agonists as Ephedrine, impiramine these drugs
increase the tone of the bladder neck.
 4- Electrical stimulation therapy of the pelvic floor muscles.
 These measures are indicated in patients unfit for or refusing
surgery or cases with uncontrolled detrusor instability.
 5- Surgical treatment in patient fit for surgery.
Kegel’s perinometer
Kegel’s perinometer
 Surgical treatment of USI
Surgery is the gold standard in treatment of
USI, aiming at;
Restoration of the proximal urethra and the
bladder neck by their elevation to the region of
intraabdominal pressure transmission (i.e.,
elevation to a retropubic position).
Increase urethral resistance
 Surgical treatment of stress
incontinence
Basic operations can be grouped into
1. Colposuspension operations (e.g.:
Burch colposuspension)
2. The sling procedures.
3. Kelly’s placation with anterior
colporrhaphy
4. Periuretheral injection of collagen.
5. Needle suspension
1. Colposuspension operations
(e.g.: Burch colposuspension):
Attachment of the upper vagina on each
side to the Cooper’s or the pectineal
ligament at the inferior border of the pubic
arch by an abdominal approach.
Associated with the highest success rate
(95% after 1 year, & 75% after 15 years)
 Retropubic bladder neck
suspension (urethrocystopexy).
Burch operation:
Suturing the
paraurethral
tissues to the
pectineal part of
inguinal ligament.
Laparoscopic Bursh operation
 2. The sling procedures.
Autologous materials; using fascia and
rectus sheath.
Synthetic material (Tension free vaginal
tape- TVT). This has an advantage of
very high success rate, up to 90%,
shorter stay in the hospital as it is
performed under local anaesthesia. It is
considered now by many the treatment
of choice for stress incontinence.
Sling operations
Organic materials as
Aldridge operation
used in severe or
recurrent cases were a
fasial sling from the
anterior rectus sheath
is passed below the
neck of the bladder to
raise and tighten the
urethro-vesical
junction.
Synthetic materials.
TVT
TVT
TVT
TVT
T.O.T
3. Kelly’s placation with anterior
colporrhaphy
Indicated when repair of cystocoele is
planned by anterior colporrhaphy
Associated with 60-70% success rate
but fall to 30% after 5 years
Less morbidity than any other abdominal
procedure.
vaginal urethroplastic
techniques
Types of
urethroplastic
tenhniques are:
(Kelly’s sutures)
plication of the fascia
around the urethro-
vesical junction.
Kennedy, pacey’s and
Nichols operation.
Kelly’s sutures
 Other surgical procedures
4. Periuretheral injection of collagen.
This is a short term treatment, but long
term results are only 30% after 5 years
5. Needle suspension
Peyrera and Stamey procedures are not
used nowadays (30% cure rate after 5
years).
Needle suspension
procedures
Pereyra operation
and its modifications.
 Treatment of detrusor overactivity
1. Behavioural: Bladder retraining tend to increase the
interval between voids and inhibit symptoms of urgency.
However it is time consuming & require cooperative
patients
2. Medical treatment
a. Anticholinergic drugs: they reduce the vesical pressure
and increase the bladder volume.
- Oxybutinine 2.5mg twice daily
- Tolterodine or detrusitol (drug of choice) as it has less
side effects, 2mg twice daily
b. Imipramine often used for enuresis and
c. Antidiuretic hormone as Desmopressin often used for
nocturia