1.
URINARY
INCONTINENCE
FARRUKH JAVEED
RESIDENT NEUROSURGERY JPMC

2.
GENERAL CONSIDERATIONS
• Urinary bladder is an important organ of our
body which stores and expels urine in a
coordinated and controlled fashion.

3.
BLADDER ANATOMY
• Bladder is divided into two parts; Detrussor
muscle and the Base.
• Base consists of the trigone and the bladder
neck.
• The bladder outlet is further divided into:
• Internal sphincter (smooth muscle); sphincter in the
bladder neck and proximal urethra
• External sphincter (striated muscle); sphincter of
the membranous urethra

4.
NERVE SUPPLY
• Coordinated activity of the bladder is
controlled by:
A. Central Nervous System
B. Somatic Peripheral Nervous System
i. Pudendal Nerve S2, S3, S4
C. Autonomic Peripheral Nervous System
i. Sympathetic: T11 - L2
ii. Parasympathetic: S2 S3, S4

5.
NORMAL MICTURITION
• Normal Micturition is primarily a spinal reflex
controlled by CNS (Brain, Pons and Sacral
spinal cord), which co-ordinates functions of
Urinary bladder and Urethral sphincter.

6.
Brain
• Frontal lobe of brain consists of
Micturition Control Centre (MCC).
• Primary activity of this area is to send
tonically inhibitory signals to Detrussor
Muscle via Pons to prevent Bladder
emptying, until socially acceptable place
is available.
• It helps in voluntary control of
micturition.
• Signals from Brain pass through Pons and
Sacral spinal cord, before reaching the
Urinary bladder.

7.
PONS
• Pons consists of Pontine Micturition
Centre (PMC).
• PMC is a relay centre between Brain
and Sacral spinal cord.
• PMC is responsible for co-ordinated
activities of Detrussor and Urethral
sphincter, so that they work in synergy
i.e. Detrussor contration and Sphincter
relaxation.
• PMC is affected by amotions, if
individual is excited or scared
sometimes can lead to urinary
incontinence.

8.
SPINAL CORD
• Functions as a communication
pathway between Pons and
Sacral spinal cord

9.
SACRAL SPINAL CORD
• It consists of Sacral Reflex Centre (SRC).
• It is a Primitive Micturition Centre.
• In infants upto 3-4 yrs of age, Micturition is
controlled directly by SRC.
• After 3-4 yrs of age due to Toilet training, Brain
takes over the control of Micturition.

10.
AUTONOMIC PNS
• IN Normal condition, Urinary Bladder and Internal
Urethral Sphincter are under the control of
Symphathetic Nervous System.
• When Sympathetic NS, is active Relaxation of
Detrussor and Contraction of Internal Urethral
Sphincter, causing inhibition of Micturition.
• When Parasympathetic NS is stimulated,
Contraction of Detrussor and relaxation of IUS
occur, causing Micturition.
• Sympathetic NS – Hypogastric Plexus (T11-L2)
• Parasympathetic NS – Pelvic Splanchnic Nerves
(S2-S4).

11.
SOMATIC PNS
• Is under direct control of Brain.
• Voluntary control of Micturition
occurs through Somatic PNS.
• Somatic PNS – Onuf nucleus (S2, S3,
S4) through Pudendal Nerve supplies
Pelvic musculature and External
Urethral Sphincer.

12.
PATHOPHYSIOLOGY
• Neurogenic Bladder can occur if any of the
before mentioned sites are affected.

13.
BRAIN LESIONS
• Lesions of the Brain above level of Pons destroy
Micturition Control Centre.
• Leads to Complete Loss of Voluntary control.
• Primitive Neonatal Micturition Reflex i.e.
Sacral Reflex centre and Pontine Micutrition
Centre remain intact.
• Loss of control over Primitive Neonatal
Micturition Reflex makes it Autonomous.
• Bladder empties too quickly and too often,
Storage capacity is lost.

14.
• Persistence of Pontine Micturition Centre
controls Synergistic functions between
Detrussor and Internal Urethral Sphincter.
• So, Urge Incontinence or Spastic Bladder or
Detrussor Hyper-reflexia
• E.g. Head injury, Cerebral Palsy, Stroke, SOL.

15.
SPINAL CORD LESIONS
• Injuries or Diseases of the Spinal cord
between Pons and Sacral spinal cord results
in Micturition control solely by Sacral Reflex
Centre.
• So, patients have Urge Incontinence or
Spastic Bladder or Detrussor Hyper-reflexia.
• But due to loss of control by PMC,
Synergistic function between Detrussor and
IUS is lost, leading to dys-synergia.

16.
SACRAL CORD INJURY
• Sacral cord injuries may prevent bladder from
emptying.
• Sensory Neurogenic Bladder – may not be able
to sense even when Bladder is full, due to
injury to Afferent fibres in Pelvic nerves.
• Motor Neurogenic Bladder – Bladder is full,
patient has sense, Detrussor may not contract,
due to injury to Efferent Parasympathetic
fibres in Pelvic Splanchnic nerves……Detrussor
Areflexia

17.
• Sacral cord injuries lead to Overflow
Incontinence.
• Other causes are Herniated Disc, Lumbar
Laminectomy, Pelvic Crush injuries, Sacral cord
tumors.

18.
PERIPHERAL NERVE LESIONS
• Pudendal Nerve Injury leads to weakness of
Pelvic floor muscles and External Urethral
sphincter.
• Voluntary control of Micturition is impaired.
• Stress Incontinence

19.
TYPES of NEUROGENIC
BLADDEER
1. Detrussor Hyper-reflexia
2. Detrussor Sphincter Dys-synergia with
Detrussor Hyper-reflexia (DSD-DH)
3. Detrussor Hyper-reflexia with impaired
Contractility (DHIC)
4. Detrussor Instability
5. Detrussor Areflexia

20.
DIAGNOSTIC PROCEDURES
• Post-void Residual Urine
• Uroflow rate
• Voiding Cystometrogram
• Filling Cystometrogram
• Electromyography
• Videourodynamics

21.
MANAGEMENT
• Absorbent Products
• Urethral Occlusive Devices
• Catheterization
• Pelvic Floor Exercises
• Electrical Stimulation – Stress and Urge
incontinence
• Bladder Training – Urge incontinence

22.
MEDICATION
• Estrogen derivatives
• Anticholinergic drugs
• Tricyclic antidepressants

23.
ESTROGEN DERIVATIVES
• Congenital Estrogen (Premarin)
• Upregulates Alpha-adrenergic receptors in neck
of the bladder.
• Useful in mild to moderate stress incontinence
• Mostly in Post-menopausal women
• In pre-menopausal women, its given along with
Progestin.

24.
ANTICHOLINERIC DRUGS
• Effective in Urge incontinence due to Detrussor
hyper-reflexia.
• Mechanism: inhibits parasympathetic activity
and decrease Detrussor contractility.
• E.g. SOAP-D
• Solefenacin, Oxybutynin, Atropine,
Propantheline, Dicyclomine

25.
TRI-CYCLIC ANTIDEPRESSANTS
• Imipramine has Alpha-adrenergic agonistic
activity.
• Increases the outlet resistance in the neck of
bladder in IUS.

26.
SURGICAL MANAGEMENT
• STRESS INCONTINENCE
• Peri-urethral bulking therapy
• Sling procedures
• Bladder neck suspension
• URGE INCONTINENCE
• Sacral neuromodulation
• Botulinum toxin
• Detrussor myomectomy

27.
THANK YOU..

28.
URINARY
INCONTINENCE
SCENARIOS

29.
Case 1
• A 45-year-old woman with insulin-dependent diabetes since
childhood is referred for urinary incontinence.
• On examination :
• Diabetic neuropathy.
• No history of urinary retention but states that she has had dribbling
urinary incontinence that is not associated with an urge to void.
• Urine examination: Normal
• Post-void residual volume 1500 mL of urine
• The patient states that she had no urge to void at that time.
• Video urodynamics demonstrate that the patient has a large
capacity, poorly sensitive bladder and impaired bladder contractility.

30.
SENSORY NEUROGENIC
BLADDER

31.
Case 2
• A 23-year-old man presents to the emergency department
with complaints of groin pain and urinary retention.
• He has a history of multiple sexually transmitted diseases,
including herpes simplex, gonorrhea, and chlamydia.
• He has been unable to void for 18 hours despite a strong urge
to void.
• Physical examination reveals an active herpetic infection with
multiple vesicular lesions at the base of the penile shaft.
• A catheter is placed with return of 1 L of clear urine.
• Cystoscopy reveals no obstructive lesions and a normal-
appearing bladder and urethra.
• Urodynamic testing demonstrates normal sensation and
capacity, but the patient is unable to generate any voiding
contractions.

32.
MOTOR NEUROGENIC
BLADDER

33.
Case 3
• A 45-year-old man is referred for urinary retention after recently
undergoing an abdominoperineal resection for rectal cancer.
• No significant past history of urinary symptoms
• A catheter was placed intraoperatively without difficulty, but the
patient was unable to void after the catheter was removed.
• After 12 hours, the catheter was replaced, with return of 600 mL of
urine.
• During that time, the patient was comfortable and had no sensation
of needing to void.
• Urodynamic testing demonstrates a normal capacity, compliant
bladder. The patient is unable to sense filling at any volume and is
also unable to generate any voiding contraction.

34.
AUTONOMOUS
BLADDER