Stress incontinence

1. Female Urinary Incontinence
Undergraduate
Dr/ Ahmed Walid Anwar Morad
Assistant professor of OB/GYN
Benha University
2017

2. Functions of urinary system
Urine
– Formation
– Transport
– Micturition cycle
• Storage phase
• Voiding phase
↓↓↓Any defect↓↓↓
Urinary Incontinence

3. Normal Micturition Cycle

4. Nerve control of the bladder

5. Pathophysiology of urinary
continence
Patient is continent as long
as
IUP > IVP
This depends on
1. Urethral Mechanism
2. Delancey level II support

6. Anatomy Involved in Maintaining
Urethral Closure and Continence
• Urethral Mechanism
– Intrinsic :
• 3 component
• Along whole length
• 2/3 UCP
– Extrinsic
• External urethral sphincter (1/3 UCP, mid/distal 1/3 of urethra)
• Position of bladder neck and proximal urethra above Urogenital
diaphragm.
• Delancey level II support
– Endopelvic fascia
• Pubocervical anteriorly
• Rectovaginal posteriorly
– Levator ani (through arcus tendineus fascia pelvis)

7. Theories Of Urinary Continence
1) Pressure transmission theory
During stress
• Continence is maintained by equal transmission of
increases in intra-abdominal pressure to the bladder and
the proximal urethra above diaphragm.
• Constant difference between IUP & IVP.

8. Theories Of Urinary Continence
2) Hammock theory

9. Theories Of Urinary Continence
Integral theory
• Continence is maintained at the level of
mid-urethra by the support of
pubouretheral ligament and anterior
vaginal wall.

10. Anatomic changes during
micturition
• Descent of bladder neck.
• Funneling of:
– Bladder neck
– Upper urethra.
• Increased posterior uretherovesical angle to 180
and increase pubouretheral angle.
Any of these changes is seen in true SI.

11. Urinary incontinence
• Def: Involuntary urine loss that is objectively
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 ??

12. Continuous incontinence
(patient is always wet)
Type Total Partial
Cause •Vesicovaginal
fistula
•Bilateral
uretrovaginal F
•Unilateral
Uterovaginal F
•Small , valvular
or very high
VVF
Micturation
desire
Absent Present but less
than normal
Bladder
distention
Absent May be
distended

13. Intermittent incontinence
(Urine passes intermittently and patient is dry in
between)
Involuntary loss of urine:
• 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.

14. Intermittent incontinence
(Urine passes intermittently and patient is dry in
between)
Involuntary loss of urine:
• 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.
• Vaginal: ???.
• Mixed

15. Genuine stress incontinence
Def: Involuntary loss of a spurt of urine
simultaneously with maneuvers that increase
IAP which ends abruptly with end of act,

17. Etiology of GSI
• Congenital
• Traumatic:
– Obstetrics
– Iatrogenic (operations) causing scarring at bladder neck.
• 3P
– Pregnancy
– Prolapse
– Postmenopausal
• Short urethra
• Obesity

18. Examination
• General examination :For anemia
• Abdominal examination: Distended bladder,
abdominal mass/obesity.
• Chest examination: For chronic cough.
• Pelvic Examination:
– Inspection:
-Atrophic
vaginitis/ urethritis.
-Pelvic organ
prolapse.
Clinical evaluation
Symptoms: ????

19. 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 micturation.
a} Anal reflex → scratch
perineum with a pin.

20. Special tests
• Signs: special tests (Aim, technique, results)
1. Stress test
2. Perineal pad test
3. Yousef test
4. Q tip test
5. Water bridge test
6. Bladder neck elevation test

23. Investigations
• Urine analysis
• Kidney function tests
• US for:
– Residual urine
– Renal size
– Bladder mass , neck and urethral anatomy.
• Cystoscopy
• Voiding cystourethrography
• Urodynamic study

24. Voiding cystourethrography
• A radiopaque dye is placed in the bladder
through a catheter {until the patient
urinates}.
• Radiographs (x-rays) {A-P, Oblique,
Lateral} views are usually taken before,
during, and after voiding.
• This test can reveal abnormalities of the
inside of the urethra and bladder.

25. GREEN CLASSIFICATION OF STRESS
INCONTINENCE
• Type 1 :
– There is complete loss of the posterior urethrovesical
angle.
– Success of vaginal surgery {90%}
• Type 2:
– There is complete loss of the posterior urethrovesical
angle + ↑ pubo-urethral angle(angle between the
urethra and vertical line) to be more than 30 degrees.
– Success of vaginal surgery {50%},abdominal
surgery{93%}

26. Urodynamics
• Def: dynamic study {physics
&Pathophysiology} of transport, storage,
and evacuation of urine by the urinary
tract.
• Indications:
– Doubtful diagnosis
– Complex symptoms
– Previous unsuccessful operation.

28. Cystometry

32. Urethral Pressure Profile

33. 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.

34. 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
– Parauretheral bulking agents : collagen, fat

35. Surgical Treatment
A} Vaginal Urehroplasty : e.g. Kelly suture: Plicate
Paraurethral fascia on either side of bladder neck by 2-3 {U-shaped,
mattress,/figure of 8 }sutures.
B} Abdominal Urethrocystopexy: e.g. William’s Operations:
suture the front of urinary bladder to periostium of the back of
symphysis pubis.
C} Urethral sling procedures
D} Minimal invasive sling like procedures:
• Tension Free Vaginal Tape {TVT}
• Transobturator Tape {TOT}
• TVT Secur sling

38. Treatment of urge incontinence

39. Thank You
Any Questions or
Comments?