undergraduate, Urinary incontinence2

1. Urology Department
Under-graduate courses
Urinary Incontinence

2. Urinary Incontinence
Definition
involuntary leakage of urine.
Incidence
• 14% in women and 13 % in men
Types of Incontinence
Stress urinary Urge Mixed Urinary Overflow Extra urethral
incontinence incontinence Incontinence Incontinence Incontinence
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3. Types of Incontinence
Stress urinary Incontinence (SUI)
• is the involuntary leakage of urine from the urethra
in association with exertion or effort, such as
coughing and sneezing.
Urge urinary incontinence (UUI)
• Leakage of urine associated with detrusor
overactivity.
• Detrusor overactivity is involuntary contraction of the
bladder.
• divided into neurogenic or non-neurogenic types.
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4. Types of Incontinence
Mixed urinary incontinence
• It is the type of incontinence in which the patient
has features of stress and urge incontinence,
usually with one type being predominant.
Overflow incontinence
• It is the type of incontince which is caused by
chronic retention of urine as a result of a non-
painful bladder that is palpable on examination
after voiding
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5. Types of Incontinence
Extra-urethral incontinence
• leakage of urine through a fistula or an ectopic
ureter in which patients typically void normally
and are incontinent between voids (also known
as paradoxical incontinence).
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6. Causes of Incontinence
Causes of Stress incontinence :
• Weakness of pelvic floor muscles (often as a
result of childbirth).
• Intrinsic sphincter deficiency.
• Damage of voluntary urethral sphincter (for
example, after transurethral resection of
prostate).
• Collagen disorders.
• Advancing age.
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7. Causes of Incontinence
Causes of Neurogenic and non-neurogenic
detrusor overactivity
Neurogenic causes Non-neurogenic causes
• Spina bifida • Thought to be the result
• Multiple sclerosis of intrinsic problems
• Spinal cord injury within the bladder wall
• Pelvic surgery
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8. History
Present History
– Type of incontinence: Symptoms & duration
– Severity: Number of pads required by day & night
– Assessment of quality of life
Past history
– Medical: Previous drug intake or Previous attacks of
UTIs
– Surgical: Parity or Previous pelvic surgery ( e.g.
Hysterectomy)
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9. Examination
• Physical examination
• Neurological examination
• Abdominal examination
– Palpable bladder
– Scars of previous operations
• Perineal examination (in Women)
– Signs Atrophic vaginitis
– Signs of pelvic floor prolapse (e.g.: cystocele,
rectocele, vaginal vault prolapse, uterine prolapse).
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10. Examination
• P.V examination
• asking the patient to contract the
pelvic floor muscles while the
examiner inserts two digits in the
vagina
• Pelvic floor strength is graded as
weak, normal or strong
• Stress test:
• cough with full bladder to try to
demonstrate SUI.
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11. Examination
• In men:
– DRE ( Digital Rectal examination) to examine
prostate
– Genital examination: Signs of phimosis, urethral
meatal stenosis
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12. Investigations
• Urine analysis
Routine in all patients to exclude
UTIs
• Pad test
• Uroflowmetry
– With or without assessment of
post micturition residual volume.
• Urodynamics
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13. Urodynamic studies
• Urodynamic studies examine the
physiological behavior of the bladder
during filling and voiding.
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14. Treatment of SUI & UUI
• Non- surgical (conservative)
 Pelvic floor training
 Pharmacological treatment: Anti-muscarinic
drugs for bladder overactivity.
 Incontinece nurse practitioners
• Surgical (different in SUI from UUI)
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15. Surgical management of SUI
• Bulking agents
• Slings
• Artificial urinary sphincter
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16. Bulking agents injection
– Submucosal into bladder neck or periurethral
to increase urethral resistance.
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17. Slings
– TVT ( tension free vaginal tapes ) or TOT (
Transobturator tapes ) are available options
with excelent results
TOT TVT
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18. Artificial urinary sphincter
• This involves placing:
1. inflatable cuff around the urethra
2. reservoir of fluid
3. pump system normally in the scrotum
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19. Surgical management of UUI
• Botox injection • Bladder
augmentation.
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20. Treatment of Overflow and
Extraurethral incontinence
Overflow incontinence
• Adequate bladder drainage.
Extraurethral incontinence
• Urinary fistulae need careful assessment
followed by surgical repair
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21. Vesicovaginal fistula
• History
– Previous history of
gynaecological surgery
(e.g, Vaginal or abdominal
hysterectomy )
– Previous history of pelvic
radiotherapy
– Prevoius history of
prolonged labour or
trauma during childbirth
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22. Vesicovaginal fistula
• Symptoms
 Urinary leakage from the vagina within 7-10 days
after pelvic surgery
 Presentation may range from watery vaginal
discharge to total urinary incontince.
• Examination:
 Acute presentation
• Area of inflamation & erythema in the vagina
 Chronic presentation
• May be seen as a small opening in the vaginal wall
• Three Swab test may be usefull in diagnosis of
Vesicovaginal fistula
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23. 3 swab test
• Three separate sponge swabs are placed into
the vagina one above the other.
• The bladder is then filled with a coloured agent
such as methylene blue, and the swabs are
removed after 10 minutes
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24. Results of 3 swab test
1. Discolouration of only the
lowest swab suggests that urine
has come down the vagina—as a
result of a low urethral fistula or
from back flow into the introitus.
2. uppermost swab wetting but not
discolouration suggest
ureterovaginal fistula (urine come
from ureter above the level of the
bladder).
3. Discoloration of topmost swab
is caused by vesico-vaginal
fistula.
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25. Treatment of Vesicovaginal
fistula
• Conservative treatment (waiting for
spontaneous rupture) by prolonged
catheter is useful in small fistulas.
• Surgical treatment (in most cases): by
vaginal or abdominal approach
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26. Thank You