Urinary incontinence is the involuntary loss of urine that negatively impacts quality of life. It affects women more than men and its prevalence increases with age. There are several types of incontinence with different causes, such as stress incontinence caused by weak pelvic floor muscles, urge incontinence due to an overactive bladder, and overflow incontinence from bladder retention. Diagnosing the type requires considering symptoms, patient history, and urodynamic tests like cystometry and uroflowmetry to evaluate bladder pressures and urine flow. Treatment depends on the underlying cause but can include pelvic floor exercises, medication, or surgery.

2. Urinary incontinence is defined as the involuntary loss of
urine that is objectively demonstrable and is a social or
hygienic problem.
It affects an individual's physical, psychological and social
well-being and is associated with a significant reduction in
quality Of life
.

3. The prevalence increases with age,
 approximately 5 per cent of women between 15
and 44 years of age being affected,
 rising 10 per cent of those aged between 45 and
64 years,
 approximately 20 per cent of those older than 65
years.
 It is even higher in women who are
institutionalized and may affect up to 40 per cent
of those in residential nursing homes

4. • Stress incontinence is a symptom and a sign and
means
loss of urine on physical effort. It is not a diagnosis .
• Urgency means a sudden desire to void.
• Urge incontinence is an involuntary loss of urine
associated with a strong desire to void.
.

5. • Overflow incontinence occurs without any detrusor
activity when the bladder is over-distended.
• Frequency is defined as the passing of urine seven
or more times a day, or being awoken from sleep
more than once a night to void

6. Urethral causes
• Urethral sphincter incompetence (urodynamic stress
incontinence)
• Detrusor over-activity or the unstable bladder - this is
either neuropathic or non-neuropathic
• Retention with overflow
• Congenital causes
• Miscellaneous
Extra-urethral causes
• Congenital causes
• Fistula

7.  Stress Incontinence
 Involuntary loss of urine due to increased intra-
abdominal pressure
 Coughing
 Sneezing
 Laughing
 Most common type in young women
 Due to pelvic floor muscle weakening resulting in
urethral hypermobility

8.  Urge Incontinence (OAB)
 “Overactive Bladder”, Detrusor overactivity
 A strong sense to void followed by involuntary
loss of urine
 Usually idiopathic, but can be due to infection,
bladder stones, bladder cancer

9.  Mixed Incontinence
 Most common in women overall
 Exact mechanism not well understood
 Characteristics of both Urge and Stress
Incontinence

10.  Overflow Incontinence
 Due to overdistension of the bladder
 Frequent or constant “dribbling”
 Either due to an outlet obstruction (prostate) or
detrusor underactivity (medications, spinal chord
injury, diabetic neuropathy, MS)
 Post void residual is often elevated

11.  Functional Incontinence
 Especially in the elderly
 Cognitive or Physical limitations
 Diagnosis of exclusion as other types might be
present in functionally limited individuals

12.  Incontinence due to secondary causes
 Medications
 Urinary Tract Infections
 Stool Impaction
 Hyperglycemia
 Heart Failure
 Interstitial Cystitis
 Bladder Malignancies

13.  Diuretics  Urge
 Caffeine  Urge
 Alcohol  Urge
 Anticholinergics  Overflow
 Alpha agonists  Overflow
 Beta agonists  Overflow
 Sedatives/Antidep  Overflow
ressants/Antipsych
otics

14.  Narcotics  Mixed
 Alpha blockers  Stress
 ACE  Stress
inhibitors(cough)

15. Urodynamic stress incontinence
Urodynamic stress incontinence (USI) , previously
called genuine stress incontinence, is noted during
filling cystometry, and is defined as the involuntary
leakage of urine during increased abdominal pressure
in the absence of a detrusor contraction.

16. The likely causes of USI are as follows.
• Abnormal descent of the bladder neck and proximal
urethra
• An intra-urethral pressure which at rest is lower than
the intravesical pressure; this may be due to urethral
scarring as a result of surgery or radiotherapy. It also
occurs in older women.
• Laxity of suburethral support normally provided by
the
vaginal wall, endopelvic fascia, arcus tendineus fascia
and levator ani muscles acting as a single unit results
in ineffective compression during stress and consequent
incontinence

17. The aetiology of USI is thought to be related to a number of
factors.
1-Damage to the nerve supply of the pelvic floor and
urethral sphincter caused by childbirth leads to progressive
changes in these structures, resulting in altered function.
2-Mechanical trauma to the pelvic floor musculature and
endopelvic fascia and ligaments occurs as a consequence of
vaginal delivery. Prolonged second stage, large babies and
instrumental deliveries cause the most damage.
3-Menopause and associated tissue atrophy may also damage to
the pelvic floor. cause
4- A congenital cause may be inferred, as some nulliparous
women suffer from incontinence. This may be due to altered
connective tissue, particularly collagen;
5-Chronic causes, such as obesity, chronic obstructive pulmonary
disease, raise intera-abdominall pressure and constipation may
also result in problems.-

19. Differential diagnosis
Normal Bladder OAB Stress
Incontinence

20. Detrusor over-activity, previously called detrusor
instability, is a urodynamic observation
characterized by involuntary detrusor contractions
during the filling phase which may be spontaneous
or provoked.

21. Detrusor over-activity
.
The largest group of women with this condition have
 an idiopathic variety.
 Neuropathy appears to be the most substantiated
factor.
 Incontinence surgery.
 Out flow obstruction and smoking are also
associated with detrusor over-activity.

22. Symptoms The presenting symptoms include
 Urgency.
 Urge incontinence.
 Frequency.
 Nocturia.
 Stress incontinence.
 Enuresis.
 Sometimes, voiding difficulties.

23. Retention with overflow
Insidious failure of bladder emptying may lead to
chronic retention and finally, when normal voiding
is ineffective, to overflow incontinence. The causes may be:
• Lower motor neurone or upper motor neurone lesions
• Urethral obstruction.
• Pharmacological.
.

24. Symptoms include :
 Poor stream.
 Incomplete bladder emptying .
 Straining to void.
 Overflow stress incontinence.
 Often there will be recurrent urinary tract
infection.
Cystometry is usually required to make the
diagnosis, and bladder ultrasonography or
intravenous urogram may be necessary to
investigate the state of the upper urinary tract to
exclude reflux.

25. Epispadias, which is due to faulty midline fusion of
mesoderm, results in a widened bladder
neck, shortened urethra, separation of the symphysis
pubis and imperfect sphincteric control.
The patient complains of stress incontinence which may
not be apparent when lying down but is noticeable
when standing up. The physical appearance of
epispadias is pathognomonic, and a plain X-ray of the
pelvis will show symphysial separation.
Management:
urethral reconstruction or an artificial urinary sphinter.

26.  Acute urinary tract infection.
 Faecal impaction in the elderly may lead to
temporary urinary incontinence.
 A urethral diverticulum may lead to post-
micturition dribble, as urine collects within the
diverticulum and escapes as the patient stands up.

27.  Bladder exstrophy and.
 In bladder exstrophy there is failure of mesodermal
migration with breakdown of ectoderm and
endoderm, resulting in absence of the anterior
abdominal wall and anterior bladder wall. Extensive
reconstructive surgery is necessary in the neonatal
period.
 Ectopic ureter
An ectopic ureter may be single or bilateral and presents
with incontinence only if the ectopic opening is outside
the bladder, when it may open within the vagina or
onto the perineum. The cure is excision of the ectopic
ureter and the upper pole of the kidney that it drains.

28. A urinary fistula is an abnormal opening between the urinary tract and the
outside .
Urinary fistulae have obstetric and gynaecological causes.
 The obstetric include
obstructive labour with compression of the bladder between the presenting
head and the bony wall of the pelvis.
 The gynaecological causes are associated with
 pelvic surgery .
 pelvic malignancy .
 radiotherapy.
Management
the fistula must be accurately localized. It can be treated by primary
closure or by surgery and can be delayed until tissue inflammation and
oedema have resolved at about 4 weeks. The surgical techniques involve
isolation and removal of the fistula tract, careful debridement, suture and
closure of each layer separately and without tension and, if necessary, the
interposition of omentum, which brings with it an additional blood
supply.

29. Urinary tract infection
Acute and chronic urinary infections are important
and-avoidable sources of ill-health among women.
 The short urethra, which is prone to entry of
bacteria during intercourse,
 Poor perineal hygiene
 The occasional inefficient voiding ability of the
patient .
 Unnecessary catheterizations are all contributory
factors.

30. A significant urinary infection is defined as the presence
of a bacterial count > 100 000 of the same
organism/mL of freshly plated urine. On microscopy
there are usually red blood cells and white blood cells.
The common organisms are Escherichia coli, Proteus
mirabilis, Klebsiella aerogenes, Pseudomonas
aeruginosa and Streptococcus faecalis. These gain
entry to the urinary tract by a direct extension from the
gut, lymphatic
spread via the bloodstream or transurethrally from the
perineum. Symptoms include dysuria, frequency and
occasionally haematuria. Loin pain and rigors and a
temperature above 38 C usually indicate that acute
pyelonephritis has developed.

31. A culture and sensitivity of mid-stream specimen of urine
is required.
Intravenous urography
renal ultrasonography
may be required in patients with recurrent infection to
define anatomical or functional abnormalities
With acute urinary infection, once a mid-stream urine
specimen has been sent for culture and sensitivity,
antimicrobial therapy can begin. If the patient is ill, the
treatment should not be delayed and an antimicrobia
drug regimen can be started immediately. The regimen
can be changed later according to the results of the
urine culture and sensitivity.

32. Commonly used drugs include trimethoprim 200 mg
twice daily or nitrofurantoin 100 mg four times
daily or a cephalosporin.
Recurrent urinary tract infection for which an
identifiable source has not been found may be
managed
by long-term low-dose antimicrobial therapy, such as
trimethoprim. Recently, ciprofloxacin and
norfloxacin
have proved effective.
It is important to treat urinary tract infections
effectively, especially in younger women.

34. INVESTIGATIONS
 An accurate and detailed history and examination provide a
framework for the diagnosis, but there is often a
discrepancy between the patient's symptoms and the
urodynamic findings.
 The aim of urodynamic investigations is to provide
accurate diagnosis of disorders of micturition and they
involve investigation of the lower urinary tract and pelvic
floor function.

35.  Mid-stream urine specimen
Urinary infection can produce a variety of urinary
symptoms, including incontinence.
A nitrate stick test can suggest infection, but a
diagnosis is made from a clean mid-stream
specimen. The presence of a raised level of white
blood cells alone suggests an infection and the test
should be repeated.
Invasive urodynamics can aggravate infection, and
test results are invalid when performed in the
presence of infection.

36.  Urinary diary
A urinary diary is a simple record of the patient's fluid
intake and output . Episodes of urgency and leakage and
precipitating events are also recorded.
There is no recommended period for diary keeping; a
suggested practice is 1 week. These diaries are more
accurate than patient recall and provide an assessment
of functional bladder capacity. In addition to altering
fluid intake, urinary diaries can be utilized to monitor
conservative treatment, e.g. bladder
re-education, electrical stimulation and drug therapy.

37. Pad test
Pad tests are used to verify and quantify urine loss.
The International Continence Society pad test takes
1 hour. The patient wears a pre-weighed sanitary
towel, drinks 500 mL of water and rests for 15
minutes. After a series of defined manoeuvres, the
pad is re-weighed; a urine loss of more than 1 g is
considered significant.

38. If indicated, methylene blue solution can be instilled
intravesically prior to the pad test to differentiate
between urine and other loss, e.g. insensible loss or
vaginal discharge. The popularity of 24-hour and
48-hour pad tests is increasing because they are
believed to be more representative. The woman
performs normal daily activities and the pad is re-
weighed after the preferred period.

39. Uroflowmetry
Uroflowmetry is the measurement of urine flow rate
and is a simple, non-invasive procedure that can be
performed in the outpatient department.
It provides an objective measurement of voiding
function and the patient can void in privicy.
Although uroflowmetry is performed as part of a
general urodynamic assessment, the main
indications are complaints of hesitancy or
difficulty voiding in patients with neuropathy or a
past history of urinary retention..

40.  It is also indicated prior to bladder neck or
radical pelvic cancer surgery to exclude voiding
problems that may deteriorate afterwards.
The normal flow curve is bell shaped. A flow
rate <15mL/s on more than one occasion is
considered abnormal in females

41. Cystometry
Cystometry involves the measurement of the
pressure volume relationship of the bladder. It is
still considered the most fundamental
investigation. It involves simultaneous abdominal
pressure recording in addition to intravesical
pressure monitoring during bladder filling and
voiding.
Electronic subtraction of abdominal from
intravesical pressure enables determination of the
detrusor pressure .

42. Cystometry is indicated for the following.
• Previous unsuccessful continence surgery.
• Multiple symptoms, i.e. urge incontinence, stress
incontinence and frequency.
• Voiding disorder.
• Neuropathic bladder.
• Prior to primary continence surgery

43. Prior to cystometry, the patient voids on the
flowmeter. A 12 French gauge catheter is inserted to
fill the bladder and any residual urine is recorded.
Intravesical pressure is measured using a 1 mm
diameter fluid-filled catheter, inserted with the
filling line, connected to an external pressure
transducer.

44. A fluid-filled 2 mm diameter catheter covered with a
rubber finger cot to prevent faecal blockage is
inserted into the rectum to measure
intra-abdominal pressure.
. The bladder is filled (in sitting and standing
positions) with a continuous infusion of normal
saline at room temperature.

45. The standard filling rate is between 10 and 100
mL/min and is provocative for detrusor instability.
During filling, the patient is asked to indicate her
first and maximal desire to void and these volumes
are noted. The presence of symptoms of urgency
and pain and systolic detrusor contractions are
noted.

46. At maximum capacity, the filling line is removed and the
patient stands. She is asked to cough and any leakage is
documented. The patient then transfers to the uroflowmeter
and voids with pressure lines in place.
Once urinary flow is established, she is asked to interrupt
the flow if possible.

47. The following are parameters of normal bladder
function.
• Residual urine of < 50 mL.
• First desire to void between 150 and 200 mL.
• Capacity between 400 and 600 mL.
• Detrusor pressure rise of <15 cmH20 during
filling and standing.
• Absence of systolic detrusor contractions.
• No leakage on coughing.
• A voiding detrusor pressure rise of < 70 cmH20
with a peak flow rate of> 15 mL/s for a
volume > 150 mL.

48. Detrusor over-activity is diagnosed when spontaneous
or provoked detrusor contractions occur which
the patient cannot suppress. Systolic detrusor over
activity is shown by phasic contractions, whereas low
compliance detrusor instability is diagnosed when
the pressure rise during filling is> 15 cmH20 and does
not settle when filling ceases. Urodynamic stress
incontinence is diagnosed if leakage occurs as a result
of coughing in the absence of a rise in detrusor
pressure.

49. Video -cystourethrography
representation of subtracted cystometry. If a radio-
opaque filling medium is used during
cystometry, the lower urinary tract can be
visualized by X-ray screening with an image
intensifier.).

50. Intravenous urography
This investigation provides little information about
the lower urinary tract but is indicated in cases of
haematuria, neuropathic bladder and suspected
uretero-vaginal fistula.

51. Ultrasound
Ultrasound is becoming more widely used in
urogynaecology.
Post-micturition urine residual estimation
can be performed without the need for urethral
catheterization and the associated risk of infection.
This is useful in the investigation of patients with
voiding difficulties, either idiopathic or following
postoperative catheter removal. Urethral cysts and
diverticula can also be examined using this
technique.

52. PVR < 50cc - Adequate bladder emptying
PVR > 150cc - Avoid bladder relaxing drugs
PVR > 200cc - Refer to Urology
PVR > 400cc - Overflow UI likely

53. Magnetic resonance imaging
Magnetic resonance imaging (MRI) produces
accurate anatomical pictures of the pelvic floor and
lower urinary tract and has been used to demarcate
compartmental prolapse.

54. Cystourethroscopy
Cystourethroscopy establishes the presence of
disease in the urethra or bladder. There are few
indications in
women with incontinence.
• Reduced bladder capacity.
• History of urgency and frequency.
• Suspected urethrovaginal or vesicovaginal fistula.
• Haematuria or abnormal cytology.
• Persistent urinary tract infection.

55. Urethral pressure profilometry
Urethral pressure profiles can be obtained
using a catheter tip dual sensor microtransducer.
Measurement of intraluminal pressure along the
urethra at rest or under stress (e.g. coughing) appears
to be of little clinical value because of a large
overlap between controls and women with USI.

56.  Simple measures such as exclusion of urinary tract
infection, restriction of fluid intake, modifying
medication (e.g. diuretics) and treating chronic
cough and constipation play an important role in
the management of most types of urinary
incontinence

57. Urodynamic stress incontinence
Prevention
 Shortening the second stage of delivery and
reducing
traumatic delivery may result in fewer women
developing
stress incontinence.
 The benefits of hormone replacement therapy have
not been substantiated.
 The role of pelvic floor exercises either before or
during pregnancy needs to be evaluated

58. Conservative management
Physiotherapy is the mainstay of the conservative
treatment of stress incontinence.
1- ( Kegel execise ).
With appropriate instruction and regular use,
between 40 and 60 per cent of women can derive
benefit from pelvic floor exercises to the point
where they decline any further intervention.

59. Premenopausal women appear to respond better
than their postmenopausal counterparts. Motivation
and good compliance are the key factors associated
with success.
2-The use of biofeedback techniques,
e.g. perineometry and weighted cones, can improve
success rates. Maximal electrical stimulation is
gaining popularity. A variety of devices have been
used but have not been very successful.

60. 3-Caregiver interventions
 Scheduled toileting
 Habit training
 Prompted voiding

61.  Surgery
For women seeking cure, the mainstay of treatment
is surgery.
The aims of surgery are:
restoration of the proximal urethra and bladder
neck to the zone of intra-abdominal pressure
transmission, to increase urethral resistance, a
combination of both.

62.  The choice of operation depends on the clinical
and urodynamic features of each patient, and the
route of approach.
1-The colposuspension operation is associated with
the highest success rates in the hands

63. 2-The artificial sphincter has been used since 1972.
It is used where conventional surgery has failed
and the patient is mentally alert and manually
dexterous.
3-Peri-urethral bulking has attracted considerable
interest because of the inherent simplicity of the of
most surgeons.

64. Silicon (Macroplastique) have all been
evaluated in the last decade. Subcutaneous fat,
although cheap, has poor efficacy and therefore has
lost popularity.
Contigen collagen is usually injected paraurethrally
and Macroplastique transurethrally. Most surgeons
inject collagen under local anaesthetic and
Macroplastique under general anaesthetic.

65. 4-Laparoscopic colposuspension may be
performed, and in the best hands gives equivalent
results to the open procedure but takes longer and
does not appear to offer advantages in terms of
postoperative recovery.

66. Surgery is reported to “cure” 4 out of 5
cases, but success rate drops to 50% after
10 years.
 Urethral Hypermotility
 Marshall-Marchetti-Kantz
procedure
 Needle neck suspension
 Intrinsic sphincter deficiency
 Sling procedure

67.  Pessaries
 Diapers or pads
 Chronic catheterization
 Periurethral or suprapubic
 Indwelling or intermittant

68.  Detrusor over-activity and voiding
difficulty
 Detrusor over-activity can be treateed by bladder
retraining, biofeedback or hypnosis, all of which
tend to increase the interval between voids and
inhibit the symptoms of urgency. These
methods'-are effective in between 60 and 70 per
cent of individuals. Anticholinergic agents such as
oxybutynin 2.5 mg twice daily or tolterodine 2 mg
twice daily can be equally as effective.

69. The latter has fewer side effects, mainly dry mouth
and constipation. Imipramine is often used for
enuresis and desmopressin (an antidiuretic
hormone analogue) is useful for nocturia.

70.  Neuropathic and non-neuropathic detrusor
instability can be treated with anticholinergic
drugs.
Bladder emptying can be achieved either by the use
of clean intermittent self-catheterization or by an
indwelling suprapubic or urethral catheter. Drug
therapy to encourage and aid detrusor contraction
or relax the urethral sphincter is relatively
ineffective.

71.  New developments
There is a wide variety of suburethral
tape operations now available and these are
currently
undergoing evaluation. The most novel of these
uses the obturator fossae as an approach route
to insert a tape.(TOT)
There are several new pharmaceutical agents
being evaluated for the treatment of urge
incontinence, and a new drug for stress
incontinence, duloxetine, will be launched soon.

72.  Urge Incontinence
 Oxybutynin (Ditropan)
 Propantheline (Pro-Banthine)
 Imipramine (Tofranil)
 Stress Incontinence
 Phenylpropanolamine (Ornade)
 Pseudo-Ephedrine (Sudafed)
 Estrogen (orally, transdermally or transvaginally)

73. Pessarie
s