6. EPIDEMIOLOGY
• COMMUNITY: 17% OLDER MEN, UP TO 30% OLDER WOMEN
• HOSPITAL: UP TO 50% OLDER MEN AND WOMEN
• ELDERLY (<65 Y): UP TO 10% IN MALE AND 15 % IN FEMALE
• F>M UNTIL AGE 80 YEARS, THEN M=F
7. ANATOMICAL STRUCTURES OF THE LOWER
URINARY TRACT SYSTEM
The bladder and bladder neck
The urethra and urethral sphincter mechanism
The pelvic floor musculature
8. THE BLADDER
• IS A HOLLOW MUSCULAR ORGAN
• LIES IN THE ANTERIOR PART OF THE
PELVIC CAVITY BEHIND THE SYMPHYSIS
PUBIS
• IT IS OUTSIDE THE PERITONEAL CAVITY
AND EXTENDS UPWARDS AS IT FILLS
• IT IS ANTERIOR TO THE RECTUM
9. THE BLADDER
• EMBRYOLOGICALLY, THE BLADDER IS
DERIVED FROM THE HINDGUT.
• EXTERNAL FEATURES ARE
THE APEX, BODY, FUNDUS AND NECK.
• TRIGONE – A TRIANGULAR AREA LOCATED
WITHIN THE FUNDUS
• IN ORDER TO CONTRACT DURING
MICTURITION, THE BLADDER WALL CONTAINS
SPECIALIZED SMOOTH MUSCLE, KNOWN
AS DETRUSOR MUSCLE.
10. NERVOUS SUPPLY OF BLADDER
o The sympathetic nervous system
o Hypogastric nerve (T12 – L2).
o It causes relaxation of the detrusor muscle.
o These functions promote urine retention.
o The parasympathetic nervous system
o Pelvic nerve(S2-S4).
o Increased signals from this nerve causes contraction of the detrusor muscle.
This stimulates micturition.
o The somatic nervous supply gives us voluntary control over micturition. It
innervates the external urethral sphincter, via the pudendal nerve (S2-S4). It can
cause it to constrict (storage phase) or relax (micturition).
11. Urethral Sphincters
Internal Urethral Sphincters
• Situated at the base of the
bladder neck.
• Circular smooth muscle layer
• Normally in a state of
contraction
• Involuntary control (under
autonomic control)
• It is thought to prevent
seminal regurgitation during
ejaculation.
External Urethral Sphincters
• Skeletal muscle
(Circular striated muscle
fibres)
• Reinforced by the pelvic floor
muscle
• Voluntary control
• During micturition, it relaxes
to allow urine flow.
12. FUNCTIONS OF THE PELVIC FLOOR
• PELVIC FLOOR FORMED BY LEVATOR ANI MUSCLES (LARGEST
COMPONENT), COCCYGEUS MUSCLE AND FASCIA
COVERINGS OF THE MUSCLES.
• FORMS A ‘SLING-LIKE’ SUPPORT FOR THE LOWER PELVIC
ORGANS
• CONTRIBUTES TO THE ACTION OF THE
EXTERNAL SPHINCTER IN MAINTAINING
URETHRAL CLOSURE.
• CONTRIBUTES TO THE ACTION OF
THE ANAL SPHINCTER IN MAINTAINING
FAECAL CONTINENCE.
14. AGING CHANGES
• Decreased bladder capacity
• Reduced voiding volume
• Reduced flow rates
• Increased urine production at night
• Detrusor over activity (20% of healthy
continent)
• BPH
15. REVERSIBLE CAUSES OF UI
- Delirium or Drugs
- Restricted mobility
- Infection, impaction
- Polyuria
I
P
R
D
16. CAUSES OF TRANSIENT (ACUTE)
INCONTINENCE
• D DELIRIUM
• I INFECTION
• A ATROPHIC VULVOVAGINITIS
• P PSYCHOLOGICAL
• P PHARMACOLOGIC AGENTS
• E ENDOCRINE, EXCESSIVE UO
• R RESTRICTED MOBILITY
• S STOOL IMPACTION
20. STRESS UI
Sudden increase in
abdominal pressure
Urethral pressure
-The complaint of
involuntary leakage with
effort or exertion or on
sneezing or coughing.
-Due to either:
1-poor pelvic floor.
2-weak urethral sphincter.
-Very common in women.
24. MAJOR POINTS
NONPHARMACOLOGICAL THERAPY:
PHARMACOLOGICAL THERAPY:
A. URGENCY INCONTINENCE:
B. CHOOSING MEDICATION:
C. STRESS INCONTINENCE:
D. ADJUNCTIVE MEASURES:
SURGICAL THERAPY:
I/ URGENCY INCONTINENCE:
II/ STRESS INCONTINENCE:
1)TRANSURETHRAL BULKING AGENTS:
2) PERINEAL SLINGS:
3) ARTIFICIAL URINARY SPHINCTER:
25. FIRST: NONPHARMACOLOGICAL THERAPY
• LIFESTYLE ADVICE (PARTICULARLY WEIGHT
LOSS AND DIETARY CHANGES).
• AVOIDANCE OF URETHRAL COMPRESSION
DURING VOIDING.
26. SECOND: PHARMACOLOGICAL THERAPY
A. URGENCY INCONTINENCE:
* “ANTIMUSCARINIC DRUGS” ARE THE MAIN
PHARMACOLOGICAL AGENTS AVAILABLE
FOR URGENCY INCONTINENCE, AND
“ALPHA BLOCKERS” ARE USED FOR MEN
WITH URGENCY INCONTINENCE WITH BPH.
27. CONT’ PHARMACOLOGICAL THERAPY
B. CHOOSING MEDICATION:
* DESPITE THE LACK OF EVIDENCE TO
GUIDE URGENCY INCONTINENCE THERAPY
IN MEN, IT’S REASONABLE TO INITIATE
PHARMACOLOGIC TREATMENT WITH ALPHA
BLOCKERS (WHY ?)
28. CONT’ PHARMACOLOGICAL THERAPY
C. STRESS INCONTINENCE:
* NO MEDICATIONS HAVE BEEN APPROVED
IN THE US FOR THE TREATMENT OF STRESS
INCONTINENCE.
* [DULOXETINE & SNRI] IS APPROVED FOR
THIS INDICATION IN MANY EUROPEAN
COUNTRIES.
29. CONT’ PHARMACOLOGICAL THERAPY
D. ADJUNCTIVE MEASURES:
* INCLUDE INCONTINENCE PADS,
INDWELLING CATHETERS, EXTERNAL
URINARY CATHETERS & PENILE
INCONTINENCE CLAMPS.
* THE TREATMENT OF URINARY
INCONTINENCE WITH AN INDWELLING
CATHETER IS USUALLY A POOR
MANAGEMENT CHOICE (WHY ?)
31. THIRD: SURGICAL THERAPY
I/ URGENCY INCONTINENCE:
- MOST COMMON SURGICAL TREATMENT FOR
URGENCY INCONTINENCE IS ----> SACRAL NERVE
STIMULATION.
- IN THE MINORITY OF PATIENTS IN WHOM MEDICAL
THERAPY IS INEFFECTIVE, TREATMENTS OPTIONS
INCLUDE: ELECTRICAL STIMULATION.
32. CONT’ SURGICAL THERAPY
II/ STRESS INCONTINENCE:
- MOST COMMONLY UTILIZED INTERVENTIONS FOR
MALE ARE TRANSURETHRAL BULKING AGENTS,
PERINEAL SLINGS & ARTIFICIAL URINARY
SPHINCTER.
