Download Urinary incontinence

Urinary incontinence
Urinary incontinence is the involuntary loss of urine
that is objectively demonstrated with social and
hygienic problem.
it result from failure to store the urine during filling
phase of bladder due to abnormality of the bladder
smooth muscle or the urethral sphincter
Classification of incontinence.
Anatomic or genuine urinary stress incont.
Urge incont.
Neuropathic incont.
Congenial incont.
Overflow incont.
Iatrogenic incont.
Fistulous incont.
Stress incontinence
 is an involuntary loss of urine that occurs during
increase intera abdominal pressure like during
coughing sneezing
Bet 15-30% of women over age of 65 have incont.
Mostly of stress type
30-50%of women with stress incont.have ergency
frequency and /or urge incont .so called mixed incont
Causes
. Classic or genuine stress incont. Is caused by
urethral hyper mobility or displacement of the urethra
and bladder neck from their normal anatomical
position
It can occur as result of intrinsic sphinctor deficiency
like due to surgery,estrogen deficincy ,truma
Anatomy
•The anatomic feaure is hypermobility or a lowering
of the position of the VU segment
•Normally movement of VU junction is about 2cm so
intra abdominal pressure diffuse on both bladder and
urethra ,but in incontinence there is hypermobility
causing movement accede 2 cm and bladder descend
more and pressure will press on bladder only
• angle of inclination is more than 30
•Posterior VU angle change
Risk Factors
1. Gender ; women more than men in men usually
post prostatectomy and transit
2. Genetic
3. Race ,culture and enverment white > blacks
4. Overweight
5. Pregnancy and childbirth it most important due to
baby weight, relaxing hormon,viginal delivery
causing stretching of pelvic floor nerves,tear or
episitomy had 3 time increasing risk
6. Smoking :due to chronic cough
7. Age :weeking of muscle making elderly people
susceptible to stress incontinence
8.Medication: like alpha blocker
Diagnostic evaluation
Causes of transit incontinence should role out due to
it treatable
1. Drug side effects
2. Delirium or hypoxia
3. Impaired mobility
4. UTI
5. Atrophic vigintis
6. Stool impiction
Evaluation
 History
 Examination
Urinalysis
Post void urine volume
Micturition diary
Pad test
Urodynamic evaluation
History :
Assess characteristic,severty and impact on life
Assess risk factores and/or transit causes
Examination
oNeurological exam :like gait,lumbosacral nerve root
assess
oAbdomenal and flank for destintation
oRectal exam :for prostate and anal tone.
oCough test bladder full in lithotomy position pat.
Ask to cough to reproduce incont.
oThe Q-Tip test: assess the degree of urethral
mobility straining angle more than 30
oVaginal exam anterior vaginal wall (cystocele)
posterior vaginal wall (enterocele)
oPelvic floor strength (urethra and trigone are
estrogens dependent
Urinalysis: for UTI
Residual urine volume: normally less than 50ml
Maturation Diary :Including time of maturation.
time and type of incont .and voided volume
Pad Test
A semi objective measurement of urine loss over a
given period of time
Weight gain sanitary towel of up to 8 gram is normal
Urethral pressure profilometery
Changes are
1. Low urethral closure pressure
2. Shorting of functional segment of urethra
3. Week response to stress
4. Fall in closure pressure in upright position
Treatment
Non surgical treatment
1. Alpha agonist
2. Oestrogen
3. Behaviour modification
4. Pelvic floor exercises
5. Biofeedback
6. Electrical stimulation
 Surgical treatment
 Urethral hypermobility then we do suspension of
the bladder neck and proximal urethra through
1. Reteropubic suspension (marshall-marchettikrantz and burch colposuspension
2. Transvaginal suspension
 Intrinsic sphenictor defect
1. Pubovaginal sling (TVT,TOT)
2. Periurethral injections
3. Sphincter prostheses
 Urge Incontinence
• Itis involuntary urine leakage accompanied by or
immediately preceded by sudden strong desire to
void
• The basic feature is detrusor instability and urine
loss while attempting to inhibit maturation
• There is overactive bladder with frequency
,ergency,and nocturia
•
over activity can result from bladder inflamination
obstruction or neurololgical trauma
• Any thing increase intravasical pressure lead to
urge incontinency
Urodynamic feeatures
• normal or high closure pressure
•Normal response to stress and filling
•Detrusor hyperirritability
 Treatment
•Bladder training
•Decrease fluid intake
Intravesical botulinun toxin
•Scheduled voiding
Surgery
Neuropathic incontinence
Active found in patients who have spastic lesion but
in whom the sphincteric mechanism, still exerts
adequate closure pressure.
Active incontinence is most often associated with
suprasegmental or upper motor neuron lesion .
 Passive neuropathic incontinence
occurs when the sphincteric mechanism is weakened
or completely lacking.
Passive incontinence is most often associated with
lesion involving the micturition center or more distal
lesion.
Classfication
A –failure of reservoir function
• can be caused by poor compliance of the urinary
bladder.
Intravesical pressure raised with minimal bladder
filling exceeding the outlet resistance & causing
urinary leakage.
B –failure of retention function (arflxia)
• total loss of smooth & striated sphincteric activity
due to complete lesion of the sacral segment or cauda
equina.
• The external sphincter offer minimal resistance.
• The bladder musculature is atonic & lax
Diagnosis.
A complete urologic & neurologic evaluation should
be done to determine whether the condition arise
from detrusor or sphincteric dysfunction.
History, physical examination, excretory urography,
cystourethrography, & urodynamic study are
recommended.
One must be alert to the possibility of overlapping
causes.
.
Treatment.
conservative management
1- failure of reservoir function.
Anticholinergic drugs like oxybutynin
Tricyclic antidepresent like Imipramine
Antihistaminic drugs
2-Failure of retention mechanism.
Clean intermittent catheterization
Drug less effective like alpha agonist.
 surgical management.
1- sphincterotomy.
4. diversion
2- Bladder augmentation.
5.Neurostimulation
3- Artificial sphincter.