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Urinary Incontinence

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Urinary Incontinence

  2. 2. GENERAL CONSIDERATIONS • Urinary bladder is an important organ of our body which stores and expels urine in a coordinated and controlled fashion.
  3. 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. 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. 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. 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. 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. 8. SPINAL CORD • Functions as a communication pathway between Pons and Sacral spinal cord
  9. 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. 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. 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. 12. PATHOPHYSIOLOGY • Neurogenic Bladder can occur if any of the before mentioned sites are affected.
  13. 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. 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. 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. 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. 17. • Sacral cord injuries lead to Overflow Incontinence. • Other causes are Herniated Disc, Lumbar Laminectomy, Pelvic Crush injuries, Sacral cord tumors.
  18. 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. 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. 20. DIAGNOSTIC PROCEDURES • Post-void Residual Urine • Uroflow rate • Voiding Cystometrogram • Filling Cystometrogram • Electromyography • Videourodynamics
  21. 21. MANAGEMENT • Absorbent Products • Urethral Occlusive Devices • Catheterization • Pelvic Floor Exercises • Electrical Stimulation – Stress and Urge incontinence • Bladder Training – Urge incontinence
  22. 22. MEDICATION • Estrogen derivatives • Anticholinergic drugs • Tricyclic antidepressants
  23. 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. 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. 25. TRI-CYCLIC ANTIDEPRESSANTS • Imipramine has Alpha-adrenergic agonistic activity. • Increases the outlet resistance in the neck of bladder in IUS.
  26. 26. SURGICAL MANAGEMENT • STRESS INCONTINENCE • Peri-urethral bulking therapy • Sling procedures • Bladder neck suspension • URGE INCONTINENCE • Sacral neuromodulation • Botulinum toxin • Detrussor myomectomy
  27. 27. THANK YOU..
  29. 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.
  31. 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.
  33. 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.

Notas do Editor

  • 1. UMN Lesion (Frontal lobe) 2. UMN Lesions (Pons or Infra-pontine) 3. Motor neurogenic bladder
    4. Overactive bladder without Neurologic impairment 5. LMN Lesion (Pudendal nerve)