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INCONTINENCE INCONTINENCE OF URINEOF URINE

Dr .Ashraf Fouda

Damietta General Hospital

Physiology of Micturition

• Bladder innervation: somatic, parasympathetic (PSN) and

sympathetic (SNS)• As urine fills the bladder, the detrusor

stretches and allows the bladder to expand

• ~300 ml in bladder before the brainrecognizes bladder fullness

• Low bladder volumes: SNS is stimulated and PNS is inhibited

• Bladder full: PNS stimulated (bladder contracts) SNS inhibited (internal sphincter relaxes)

• Intravesical pressure > resistance within the urethra: urine flows

• Pudenal nerve innervates external sphincter


DEFINITION OF DEFINITION OF INCONTINENCE OF URINEINCONTINENCE OF URINE

It is involuntary It is involuntary escape of urineescape of urine

TYPES:TYPES:

11. True. True incontinence. incontinence.

22. False. False incontinence (ischuria incontinence (ischuria paradoxica). paradoxica).

3. 3. StressStress or sphincter incontinence. or sphincter incontinence.

4. 4. UrgencyUrgency incontinence incontinence

(precipitancy-detrusor instability or (precipitancy-detrusor instability or detrusor dyssynergia). detrusor dyssynergia).

5. 5. Nocturnal enuresisNocturnal enuresis..

1. True (continuous) incontinence1. True (continuous) incontinence

In this case, urine escapes In this case, urine escapes continuously by day and by night. continuously by day and by night.

It is caused by:It is caused by:

(a) Urinary fistulae as vesicovaginal (a) Urinary fistulae as vesicovaginal fistula; fistula;

(b) Ectopia vesica.(b) Ectopia vesica.

2. False incontinence 2. False incontinence ((Overflow incontinence)Overflow incontinence)

ItIt is involuntary loss of urine following is involuntary loss of urine following overdistension of the bladderoverdistension of the bladder. .

Overflow incontinence, usually short-term, Overflow incontinence, usually short-term, can occur can occur after vaginal deliveryafter vaginal delivery——especially especially if epidural anesthesia was used. if epidural anesthesia was used.

Other causes include Other causes include diabetes, neurological diabetes, neurological diseases, severe genital prolapse, and post diseases, severe genital prolapse, and post surgical obstruction.surgical obstruction.

4. Urgency incontinence 4. Urgency incontinence (precipitancy-detrusor instability or detrusor dyssynergia).(precipitancy-detrusor instability or detrusor dyssynergia).

The woman feels the desire to micturate but The woman feels the desire to micturate but before she reaches the bathroom, urine passes before she reaches the bathroom, urine passes involuntarily. involuntarily.

It is due to irritability of the bladder muscle and so It is due to irritability of the bladder muscle and so the patient cannot inhibit it. the patient cannot inhibit it.

It is due to :It is due to :

4.4. emotional disturbance, emotional disturbance,

5.5. neurologic diseases, and neurologic diseases, and

6.6. bladder diseases as cystitis, stone or tumour.bladder diseases as cystitis, stone or tumour.

Detrusor instability, also called Detrusor instability, also called overactive overactive bladderbladder, is a condition in which the bladder , is a condition in which the bladder contracts involuntarily in response to filling. contracts involuntarily in response to filling.

It was called It was called detrusor dys-synergiadetrusor dys-synergia in the past. in the past. It commonly presents as urge incontinence—It commonly presents as urge incontinence—

leakage of urine associated with a strong leakage of urine associated with a strong desire to void. desire to void.

No causeNo cause is identified in more than is identified in more than 90%90% of of these patients. these patients.

Advancing age is an important risk factorAdvancing age is an important risk factor. .

Detrusor instabilityDetrusor instability (DI) (DI)

Detrusor instability caused by neurologic Detrusor instability caused by neurologic diseases such as cerebrovascular disease, diseases such as cerebrovascular disease, multiple sclerosis, or spinal cord injury is multiple sclerosis, or spinal cord injury is called called detrusor hyperreflexia.detrusor hyperreflexia.

Irritation of the bladder by inflammation Irritation of the bladder by inflammation (such as urinary tract infection)(such as urinary tract infection) or prior or prior pelvic surgery can also cause detrusor pelvic surgery can also cause detrusor instability.instability.

Detrusor instabilityDetrusor instability (DI) (DI)

Urge incontinenceUrge incontinence

STRESS INCONTINENCESTRESS INCONTINENCE ))SPHINCTER INCONTINENCE-SPHINCTER INCONTINENCE-

GENUINE STRESS GENUINE STRESS INCONTINENCE)INCONTINENCE)

DEFINITIONDEFINITION

It is involuntary escape of few It is involuntary escape of few drops of urine with increased drops of urine with increased intra-abdominal pressure as intra-abdominal pressure as during straining, sneezing, during straining, sneezing, coughing, laughing ... etc.coughing, laughing ... etc.

DEGREES OF STRESS DEGREES OF STRESS INCONTINENCEINCONTINENCE

Grade IGrade I

Incontinence occurs only Incontinence occurs only with severe stresswith severe stress, such , such as coughing, sneezing, etc …as coughing, sneezing, etc …

Grade IIGrade II

Incontinence with Incontinence with moderate stressmoderate stress, such as rapid , such as rapid movement or walking up and down stairsmovement or walking up and down stairs

Grade IIIGrade III

Incontinence with Incontinence with mild stressmild stress, such as standing. , such as standing. The patient is continent in the supine positionThe patient is continent in the supine position

PHYSIOLOGICAL ANATOMYPHYSIOLOGICAL ANATOMY

The bladder neck and The bladder neck and upper third or half of the upper third or half of the

urethra are above the urethra are above the level of the pelvic floor. level of the pelvic floor.

With increased intra-With increased intra-abdominal pressure, abdominal pressure, the pressure is equally the pressure is equally

transmitted to the bladder transmitted to the bladder and upper urethra and and upper urethra and urine will not escapeurine will not escape

PHYSIOLOGICAL ANATOMY

Is an involuntary Is an involuntary muscle which muscle which

surrounds the bladder surrounds the bladder neck.neck.

The internal urethral sphincterThe internal urethral sphincter (= bladder sphincter)(= bladder sphincter)

The external urethral sphincterThe external urethral sphincter

is a voluntary muscle found is a voluntary muscle found between the superficial and between the superficial and

deep perineal membranes and deep perineal membranes and surrounds the middle part of surrounds the middle part of

the urethra the urethra (compessor urethrae muscle).(compessor urethrae muscle).

It empties the urethra after the It empties the urethra after the act of micturition, act of micturition,

Interrupts the flow of urine on Interrupts the flow of urine on desire desire and and

It acts as a secondary It acts as a secondary defensive mechanism against defensive mechanism against escape of urine.escape of urine.

The external urethral sphincter

At rest the urethra makes an angle At rest the urethra makes an angle of of 90-100 degrees90-100 degrees with the base of with the base of the urinary bladder called the : the urinary bladder called the : posterior posterior urethrovesical angleurethrovesical angle..

The urethra also makes The urethra also makes an angle of less than 30 degreesan angle of less than 30 degrees with the vertical line.with the vertical line.

During micturition the following changes During micturition the following changes occur:occur:

1. Descent of the bladder neck with complete loss of the 1. Descent of the bladder neck with complete loss of the posterior urethrovesical angle posterior urethrovesical angle (angle becomes 180 (angle becomes 180 degrees).degrees).

2. Opening 2. Opening (funneling)(funneling) of the bladder neck and upper of the bladder neck and upper urethra.urethra.

3. Descent of the urethra leading to increase in the angle 3. Descent of the urethra leading to increase in the angle between it and vertical line, so the angle becomes more between it and vertical line, so the angle becomes more than 30 degrees.than 30 degrees.

. . In stress incontinence, one or all of the above changes In stress incontinence, one or all of the above changes occur with increased intra-abdominal pressure.occur with increased intra-abdominal pressure.

Incidence of Subtypes of Urinary Incidence of Subtypes of Urinary Incontinence in WomenIncontinence in Women

Stress Incontinence Stress Incontinence 50%50% Urge Incontinence Urge Incontinence 20%20% Mixed Mixed 30%30%

TYPES OF STRESS INCONTINENCETYPES OF STRESS INCONTINENCE

Type 1 Type 1 :: There is complete loss of the There is complete loss of the posterior urethrovesical angle. posterior urethrovesical angle.

Type 2 Type 2 :: There is complete loss of the There is complete loss of the posterior urethrovesical angle together posterior urethrovesical angle together with increase in the angle between the with increase in the angle between the urethra and vertical line to be more than urethra and vertical line to be more than 30 degrees. 30 degrees.

This type leads to severe stress incontinenceThis type leads to severe stress incontinence

AETIOLOGYAETIOLOGY

It is due to either :It is due to either :Weakness of the internal Weakness of the internal

urethral sphincter or urethral sphincter or Descent of bladder neck below Descent of bladder neck below

the level of the pelvic floor.the level of the pelvic floor.

1. 1. Congenital weaknessCongenital weakness of the of the internal urethral sphincter, seen in internal urethral sphincter, seen in the young nullipara.the young nullipara.

2. 2. Congenital defectsCongenital defects as: as: Epispadias, Epispadias, Short urethra Short urethra (less than 1 cm),(less than 1 cm), Wide bladder neck, and Wide bladder neck, and Separation of symphysis pubis.Separation of symphysis pubis.

AETIOLOGYAETIOLOGY

3. 3. TraumaTrauma to the region of the bladder to the region of the bladder neck due to vaginal delivery or neck due to vaginal delivery or operation. operation.

The incidence of stress incontinence The incidence of stress incontinence increases with parity due to repeated increases with parity due to repeated birth trauma. birth trauma.

AETIOLOGY

In fact vaginal delivery is the In fact vaginal delivery is the commonest cause of stress commonest cause of stress

incontinence.incontinence.

4. 4. MenopauseMenopause:: Lack of oestrogen leads to Lack of oestrogen leads to atrophy of bladder neck supports.atrophy of bladder neck supports.

5.5.PregnancyPregnancy and continuous and continuous administration of oestrogen-progestogen administration of oestrogen-progestogen preparation to induce psuedopregnancy preparation to induce psuedopregnancy state to treat endometriosis. state to treat endometriosis.

The hormonal imbalance with increased The hormonal imbalance with increased progesterone weakens the internal progesterone weakens the internal

urethral sphincter.urethral sphincter.

AETIOLOGY

6.6. Genital prolapseGenital prolapse: :

If the bladder neck descends below the If the bladder neck descends below the level of the pelvic floor, the increased level of the pelvic floor, the increased

intra-abdominal pressure will be intra-abdominal pressure will be transmitted to the bladder and not to the transmitted to the bladder and not to the upper urethra leading to escape of urine.upper urethra leading to escape of urine.

7. 7. Organic nervous diseasesOrganic nervous diseases as disseminated sclerosis.as disseminated sclerosis.

AETIOLOGY

Pathophysiology of Stress Pathophysiology of Stress IncontinenceIncontinence

The basic pathology is urethral The basic pathology is urethral incompetence. incompetence.

This can be either due to:This can be either due to:A) A) Urethral hypermobilityUrethral hypermobility

(80 - 90% of patients)(80 - 90% of patients)B) B) Intrinsic Sphincter DysfunctionIntrinsic Sphincter Dysfunction

(10 - 20% of patients)(10 - 20% of patients)

A) Urethral hypermobility A) Urethral hypermobility (80 - 90% of patients)(80 - 90% of patients)

This results from loss of the normal This results from loss of the normal pelvic support mechanism of the bladder pelvic support mechanism of the bladder

and urethra due to:and urethra due to: 2.2. Trauma and stretching of vaginal Trauma and stretching of vaginal

delivery delivery 3.3. Hysterectomy Hysterectomy 4.4. Hormonal changes ( Menopause) Hormonal changes ( Menopause) 5.5. Pelvic denervation Pelvic denervation 6.6. Congenital weakness Congenital weakness

As the bladder neck support is As the bladder neck support is weakened, the increase in intra-weakened, the increase in intra-abdominal pressure is no longer abdominal pressure is no longer

transmitted equally to the transmitted equally to the bladder outlet, and therefore bladder outlet, and therefore

instantaneous leakage occurs.instantaneous leakage occurs.

A) Urethral hypermobility (80 - 90% of patients)

B) Intrinsic Sphincter Dysfunction B) Intrinsic Sphincter Dysfunction (10 - 20% of patients)(10 - 20% of patients)

This results from damage to the sphincter This results from damage to the sphincter due to:due to:

Multiple prior operations Multiple prior operations Trauma Trauma Radiation Radiation Neurogenic disorders including Diabetes Neurogenic disorders including Diabetes

Mellitus Mellitus Atrophic changes: lack of estrogen. Atrophic changes: lack of estrogen.

A. HistoryA. History1.1. A detailed history differentiates between the A detailed history differentiates between the

different types of incontinence. different types of incontinence.

2.2. Stress incontinence and detrusor instability Stress incontinence and detrusor instability frequently occur together.frequently occur together.

3.3. Gradual onset after menopause suggests Gradual onset after menopause suggests oestrogen deficiency.oestrogen deficiency.

4.4. History of vaginal repair or operation in the History of vaginal repair or operation in the region of the bladder neck and history of any region of the bladder neck and history of any neurologic disease.neurologic disease.

1. Stress Test1. Stress Test The bladder must be moderately full. The bladder must be moderately full. The patient in the lithotomy position, the two labia The patient in the lithotomy position, the two labia

are separated, and the patient is asked to cough. are separated, and the patient is asked to cough. If urine escapesIf urine escapes, the patient is incontinent. , the patient is incontinent. If no urine escapesIf no urine escapes, the test is repeated while the , the test is repeated while the

index and middle fingers in the vagina press on the index and middle fingers in the vagina press on the perineum to abolish reflex contraction of the levator perineum to abolish reflex contraction of the levator ani muscles during straining. ani muscles during straining.

If still no urine escapes, the test is repeated while If still no urine escapes, the test is repeated while the patient is standing with the legs separated.the patient is standing with the legs separated.

2. Bonney test2. Bonney test It is indicated in case of a positive stress test It is indicated in case of a positive stress test

associated with a cystocele. associated with a cystocele. To know if incontinence is due to descent of To know if incontinence is due to descent of

bladder neck or weakness of the sphincterbladder neck or weakness of the sphincter. . The index and middle fingers are placed on The index and middle fingers are placed on

both sides of the urethra to elevate the bladder both sides of the urethra to elevate the bladder neck upwards. neck upwards.

If no urine escapes on stressIf no urine escapes on stress it means that the it means that the incontinence is incontinence is due to descent of the bladder due to descent of the bladder neckneck, but if urine still escapes it means , but if urine still escapes it means weakness of the sphincter.weakness of the sphincter.

Indicated in case of a Indicated in case of a negative stress testnegative stress test associated with a large cystocele to diagnose associated with a large cystocele to diagnose hidden stress incontinence. hidden stress incontinence.

The cystocele is reduced, the cervix is The cystocele is reduced, the cervix is grasped with a volsellum and pushed upward, grasped with a volsellum and pushed upward, then the patient is asked to cough. then the patient is asked to cough.

If urine escapes, it indicates that the patient If urine escapes, it indicates that the patient was continent because of kinking of the was continent because of kinking of the urethra.urethra.

3. Yousef Test3. Yousef Test

4. Examination of Urine4. Examination of Urine

Urinalysis, culture and Urinalysis, culture and sensitivity to exclude sensitivity to exclude

cystitis.cystitis.

To exclude lesions in the urethra To exclude lesions in the urethra and bladder. and bladder.

The bladder neck is examined. The bladder neck is examined. It should close in response to It should close in response to

straining. straining. However, it opens in case of stress However, it opens in case of stress

incontinence.incontinence.

5. Cystourethroscopy5. Cystourethroscopy

A radio-opaque dye is injected by a catheter A radio-opaque dye is injected by a catheter into the bladder. into the bladder.

On straining, the lateral view will show On straining, the lateral view will show absence absence of the posterior urethrovesical angle in more of the posterior urethrovesical angle in more than 90% of cases. than 90% of cases.

Funneling of the bladder neckFunneling of the bladder neck in the antero- in the antero-posterior view may be seen in some cases. posterior view may be seen in some cases.

The procedure is recorded on video tape The procedure is recorded on video tape (video Cystourethrography)(video Cystourethrography) to facilitate to facilitate diagnosis and for education purposes.diagnosis and for education purposes.

6. Cystourethrography6. Cystourethrography

7. Urodynamics7. Urodynamics Medical science concerned with the study of Medical science concerned with the study of

urine transport from kidney to bladder as well urine transport from kidney to bladder as well as its storage and evacuationas its storage and evacuation

Classification:Classification:

1.Cystometrogram1.Cystometrogram( most important test), Filling ( most important test), Filling Cystometry and Voiding CystometryCystometry and Voiding Cystometry

2.Urethral pressure profile2.Urethral pressure profile

33..UroflowUroflow4.Electromyography4.Electromyography

To measure the intravesical To measure the intravesical pressure while the bladder is filled pressure while the bladder is filled with sterile water or carbon with sterile water or carbon dioxide gas. dioxide gas.

It diagnoses stress incontinence It diagnoses stress incontinence and detrusor instability. and detrusor instability.

The most important test.The most important test.

CystometrogramCystometrogram

CystometrogramCystometrogram Involves filling the bladder to measure Involves filling the bladder to measure

volume-pressure relationships. volume-pressure relationships. As the bladder is filled to its normal As the bladder is filled to its normal

capacity of capacity of 300-500 ml300-500 ml, the pressure , the pressure inside the bladder should remain low. inside the bladder should remain low.

The patient usually experiences the first The patient usually experiences the first urge to void at urge to void at 150-200 ml.150-200 ml.

Patients with DI often have Patients with DI often have reduced bladder capacity reduced bladder capacity

(< 300 ml)(< 300 ml) and demonstrate and demonstrate urinary incontinence that is urinary incontinence that is associated with involuntary associated with involuntary bladder contractions bladder contractions

(pressure increase above baseline)(pressure increase above baseline)

Cystometrogram

In patients with GSI, incontinence is In patients with GSI, incontinence is demonstrated when the patients coughs demonstrated when the patients coughs or strains (e.g., or strains (e.g., Valsalva maneuverValsalva maneuver). ).

The intravesical pressure at which The intravesical pressure at which leakage is noted leakage is noted (leak point pressure)(leak point pressure) is is generally generally < 60 cm< 60 cm of water pressure if of water pressure if intrinsic sphincter deficiency is present.intrinsic sphincter deficiency is present.

Cystometrogram

8. The Cotton-Tip Applicator 8. The Cotton-Tip Applicator (Q-Tip) Test(Q-Tip) Test

A sterile applicator with a small piece of cotton A sterile applicator with a small piece of cotton at its tip is introduced to reach the bladder at its tip is introduced to reach the bladder neck. neck.

The angle between the applicator and the The angle between the applicator and the horizontal is measured. horizontal is measured.

The patient then strains maximally using the The patient then strains maximally using the Valsalva manoeuvre. Valsalva manoeuvre.

This causes descent of the bladder neck and This causes descent of the bladder neck and upward movement of the applicator producing upward movement of the applicator producing a new angle with the horizontal. a new angle with the horizontal.

(Q-Tip) Test(Q-Tip) Test In normal patientsIn normal patients the increase in the the increase in the

angle is less than 30 degrees. angle is less than 30 degrees. In stress incontinenceIn stress incontinence the change is the change is

more than 30 degrees indicating poor more than 30 degrees indicating poor support and abnormal descent of support and abnormal descent of bladder neckbladder neck

The test is positive in more than The test is positive in more than 90%90% of cases with stress incontinenceof cases with stress incontinence..

To maintain continence, the urethral To maintain continence, the urethral pressure pressure (100-120 cm water)(100-120 cm water) must be must be higher than the intravesical pressure higher than the intravesical pressure (0-20 cm water). (0-20 cm water).

A special catheter; is used which A special catheter; is used which measures the intravesical and intra-measures the intravesical and intra-urethral pressure. urethral pressure.

9. Measurement of Urethral 9. Measurement of Urethral PressurePressure

The urethral closing pressureThe urethral closing pressure Equals the intraurethral pressure Equals the intraurethral pressure

minus the intravesical pressure minus the intravesical pressure (normally 90-100 cm water). (normally 90-100 cm water).

The length of the urethra along which The length of the urethra along which urethral pressure exceeds bladder urethral pressure exceeds bladder pressure is termed pressure is termed functional length functional length of the urethraof the urethra which is which is 3-4 cm3-4 cm. .

In stress incontinence the urethral In stress incontinence the urethral closing pressure is reducedclosing pressure is reduced..

Stress incontinence Stress incontinence occurs if the length is occurs if the length is

less than 1 cmless than 1 cm..

10. Measurement of 10. Measurement of Urethral LengthUrethral Length

It records the rate of urine flow It records the rate of urine flow through the urethra when the patient through the urethra when the patient is asked to void spontaneously while is asked to void spontaneously while sitting on uroflow chair. sitting on uroflow chair.

It is used to It is used to evaluate patientsevaluate patients with with stress incontinence stress incontinence before surgerybefore surgery to to exclude difficulty in voiding which exclude difficulty in voiding which may be increased by bladder neck may be increased by bladder neck surgery. surgery.

11. Uroflowmetry11. Uroflowmetry

The normal female voids The normal female voids by the rule of "20" by the rule of "20"

that is urine is passed at a that is urine is passed at a rate of 20 ml/second and rate of 20 ml/second and the bladder is emptied in the bladder is emptied in

less than 20 seconds.less than 20 seconds.

It gives information about It gives information about funneling of the bladder funneling of the bladder

neck, neck, both at rest and with both at rest and with Valsalva manoeuvre.Valsalva manoeuvre.

12. Sonographic12. Sonographic

By three-dimension transvaginal By three-dimension transvaginal ultrasoundultrasound

TheThe continent womencontinent women have a thick have a thick wall internal urethral sphincter which wall internal urethral sphincter which extends from the bladder neck and extends from the bladder neck and along 60-80% of the whole urethra. along 60-80% of the whole urethra.

In stress incontinenceIn stress incontinence, the sphincter is , the sphincter is torn as proved by appearance of torn as proved by appearance of areas of echolucency. areas of echolucency.

When rupture affects the When rupture affects the upper partupper part of the of the sphincter, the urethra appears sphincter, the urethra appears "funnel-shaped"."funnel-shaped".

When damage affects the When damage affects the lower partlower part, the , the urethra appears urethra appears "vase-shaped""vase-shaped"..

When rupture affects the When rupture affects the whole lengthwhole length of of the sphincter, the urethra appears the sphincter, the urethra appears short short and irregular.and irregular.

By three-dimension transvaginal By three-dimension transvaginal ultrasoundultrasound

What laboratory tests are helpful in What laboratory tests are helpful in evaluating incontinence?evaluating incontinence?

Postvoid residualPostvoid residual is an easy initial test to is an easy initial test to obtain. obtain.

After the patient voids, there should be less After the patient voids, there should be less than 50 ml of urine in the bladder. than 50 ml of urine in the bladder.

Postvoid residualPostvoid residual is measured by ultrasound is measured by ultrasound or catheterizing the patient in the office. or catheterizing the patient in the office.

A patient with A patient with an elevated Postvoid an elevated Postvoid residualresidual (repeat measurements greater than (repeat measurements greater than 100-200 ml) may have an underlying 100-200 ml) may have an underlying neurologic disorder. neurologic disorder.

Catheterization also provides a good Catheterization also provides a good opportunity to obtain urine for analysis and opportunity to obtain urine for analysis and culture.culture.

Urinalysis and urine cultureUrinalysis and urine culture help to diagnose help to diagnose urinary tract infection. urinary tract infection.

Blood workBlood work is required only if compromised is required only if compromised renal function, diabetes, syphilis, or other renal function, diabetes, syphilis, or other systemic diseases are suspected.systemic diseases are suspected.

What laboratory tests are helpful in evaluating incontinence?

Which tests are Which tests are mostmost helpful in helpful in differentiating between GSI and DI?differentiating between GSI and DI?

CystometrogramCystometrogram CystoscopyCystoscopy : :

should be performed especially in patients with: should be performed especially in patients with: irritative bladder symptoms such as urgency, irritative bladder symptoms such as urgency,

frequency, and hematuria frequency, and hematuria To rule out:To rule out:5.5. inflammation, inflammation, 6.6. tumors, or tumors, or 7.7. anatomic deformitiesanatomic deformities

I. Prophylactic TreatmentI. Prophylactic Treatment

1. During labour, the bladder should be kept 1. During labour, the bladder should be kept empty.empty.

2. Episiotomy is performed if necessary.2. Episiotomy is performed if necessary.

3. Physiotherapy. 3. Physiotherapy. Pelvic floor exercisesPelvic floor exercises are started after delivery. are started after delivery.

These include repeated stoppage of the urinary These include repeated stoppage of the urinary stream during micturition and repeated contractions stream during micturition and repeated contractions

of the pelvic floor muscles.of the pelvic floor muscles.

IndicationsIndications::

1.1.MildMild stress incontinence. stress incontinence.2.The patient not completed her family as vaginal 2.The patient not completed her family as vaginal

delivery may damage a bladder neck repairdelivery may damage a bladder neck repair

3.Patient is 3.Patient is unfit for surgeryunfit for surgery or refuses surgery. or refuses surgery.4.When stress incontinence is 4.When stress incontinence is combined with combined with

detrusor instability. detrusor instability. The latter should be treated at first before The latter should be treated at first before

surgery is done for stress incontinencesurgery is done for stress incontinence..

II. Conservative (non-surgical) II. Conservative (non-surgical) TreatmentTreatment

Conservative treatment cures or Conservative treatment cures or improves improves 50% of cases50% of cases and include: and include:

11. . Physiotherapy:Physiotherapy: Kegl perineometer may be used. Kegl perineometer may be used.22. . Faradic current stimulationFaradic current stimulation of the levator ani of the levator ani

muscles to improve their tone.muscles to improve their tone.33. . Vaginal cones:Vaginal cones: A set consists of 5 or 9 cones. A set consists of 5 or 9 cones. Weight ranges from 20 to 100 grams. Weight ranges from 20 to 100 grams. Patient inserts the cone in the vagina and keeps it for Patient inserts the cone in the vagina and keeps it for

15 minutes twice daily. 15 minutes twice daily. If this succeeds she inserts the next cone. If this succeeds she inserts the next cone. This improves the tone of the pelvic floor muscles.This improves the tone of the pelvic floor muscles.

4.4.Oestrogen therapy for menopausal Oestrogen therapy for menopausal patients:patients:

It causes thickening of the urethral mucosa and It causes thickening of the urethral mucosa and engorgement of the underlying blood vessels engorgement of the underlying blood vessels thus increasing the urethral pressure and thus increasing the urethral pressure and resistance. resistance.

Oestrogen is given orally or as vaginal cream.Oestrogen is given orally or as vaginal cream.5. 5. Alpha-adrenergic stimulants:Alpha-adrenergic stimulants:

which stimulate contraction of the internal which stimulate contraction of the internal urethral sphincter, e.g. ephedrine.urethral sphincter, e.g. ephedrine.

6.6.Large vaginal diaphragms, Hodge pessaryLarge vaginal diaphragms, Hodge pessary to elevate ' and support the bladder neck.to elevate ' and support the bladder neck.

Conservative treatment cures or Conservative treatment cures or improves 50% of cases and include:improves 50% of cases and include:

77. . Reduction of weightReduction of weight in obese patients in obese patients to reduce intra-abdominal pressure.to reduce intra-abdominal pressure.

88. . Stop caffeineStop caffeine (to avoid diuresis) (to avoid diuresis) and and smokingsmoking (to avoid coughing) (to avoid coughing)

99. . Injection of Teflon or bovine Injection of Teflon or bovine collagencollagen in the submucosal layer in the in the submucosal layer in the region of the bladder neck. region of the bladder neck.

This leads to narrowing of the urethral This leads to narrowing of the urethral lumen and increased urethral resistance.lumen and increased urethral resistance.

Conservative treatment cures or improves 50% of cases and include:

Il. Surgical TreatmentIl. Surgical Treatment

It is the primary treatment of It is the primary treatment of stress incontinence. stress incontinence.

The operation is done vaginally, The operation is done vaginally, abdominally, or abdominally, or abdominovaginally. abdominovaginally.

Almost 200 operations have been Almost 200 operations have been described.described.

UrehroplastyUrehroplasty (Kelly,Kennedy,etc….) (Kelly,Kennedy,etc….) UrethropexyUrethropexy (Retropubic (Retropubic

urethropexy e.g. Marchall-Marchitti-urethropexy e.g. Marchall-Marchitti-Krantz, etc….)Krantz, etc….)

ColposuspensionColposuspension ( Burch operation, ( Burch operation, Preyera , etc….)Preyera , etc….)

Urethral slingsUrethral slings (Aldridge operation, (Aldridge operation, etc…..)etc…..)

Tension free Vaginal TapeTension free Vaginal Tape (TVT) (TVT)

It consists of repair of cystocele and/or It consists of repair of cystocele and/or urethrocele. urethrocele.

Vertical mattress sutures are then placed to Vertical mattress sutures are then placed to plicate the whole urethra and bladder neck. plicate the whole urethra and bladder neck.

This gives support to the urethra and restores This gives support to the urethra and restores the normal posterior urethrovesical angle. the normal posterior urethrovesical angle.

Operation is done for mild and moderate cases Operation is done for mild and moderate cases of stress incontinence. of stress incontinence.

Long term success rate is 55-65%.Long term success rate is 55-65%.

1. 1. Kelly operationKelly operation 19141914

2. 2. El-Hemaly urethrorrhaphy El-Hemaly urethrorrhaphy operationoperation

A vertical incision is made in the anterior A vertical incision is made in the anterior vaginal wall. vaginal wall.

The torn edges of the internal urethral The torn edges of the internal urethral sphincter are sutured together to restore sphincter are sutured together to restore its integrity. its integrity.

The repair restores the normal The repair restores the normal urethrovesical angles seen in continent urethrovesical angles seen in continent women.women.

3. 3. Vaginal tape operation Vaginal tape operation (TVT)(TVT)19961996

The tape is made of prolene and has a curved needle at The tape is made of prolene and has a curved needle at each end. each end.

Operation is done using local infiltration anaesthesia. Operation is done using local infiltration anaesthesia. Two small transverse incisions 5 cm apart are made in Two small transverse incisions 5 cm apart are made in

the suprapubic area. the suprapubic area. A vertical incision is made in the anterior vaginal wall. A vertical incision is made in the anterior vaginal wall. The needles of the tape are passed upward behind the The needles of the tape are passed upward behind the

pubic bone and brought out through the suprapubic pubic bone and brought out through the suprapubic incisions. incisions.

The tape is made to surround the mid-urethra.The tape is made to surround the mid-urethra.

The cystoscope is used by the assistant to make sure that The cystoscope is used by the assistant to make sure that the bladder is not pierced by the needle. the bladder is not pierced by the needle.

The tape is adjusted by pulling on its ends, and The tape is adjusted by pulling on its ends, and continence is confirmed by asking the patient to cough. continence is confirmed by asking the patient to cough.

The ends of the tape are cut off and left free and not fixed The ends of the tape are cut off and left free and not fixed to the tissues, to the tissues,

Finally the vaginal and suprapubic incisions are closed.Finally the vaginal and suprapubic incisions are closed. When stress occurs ,the recti will contract and pull on the When stress occurs ,the recti will contract and pull on the

tape to support the urethra and prevent escape of urine tape to support the urethra and prevent escape of urine

3. Vaginal tape operation (TVT)

Simple, easy, relatively safeSimple, easy, relatively safe with short with short recovery & little pain.recovery & little pain.

Reported cure is 86% & improvement is Reported cure is 86% & improvement is 11%.11%.

Operation takes 20-30 minutes.Operation takes 20-30 minutes.Complications: urine retention, Complications: urine retention,

parautrethral & paravesical hemorrhage, parautrethral & paravesical hemorrhage, infection , bladder &bowel injury.infection , bladder &bowel injury.

Tension free Vaginal Tape (TVT)

The stitches are placed in the fascia on each The stitches are placed in the fascia on each side of the bladder neck and upper half of the side of the bladder neck and upper half of the urethra and are attached to the periosteum on urethra and are attached to the periosteum on the back of the symphysis pubis. the back of the symphysis pubis.

This restores the normal intra-abdominal This restores the normal intra-abdominal position of the urethra. position of the urethra.

Main complication is Main complication is osteitis pubis (0.5-5%).osteitis pubis (0.5-5%). Nonabsorpable (as mersilene) or delayed Nonabsorpable (as mersilene) or delayed

absorbable sutures (as Vicryl or Dexon) are absorbable sutures (as Vicryl or Dexon) are used.used.

1. 1. Mashall-Marchetti-Krantz Mashall-Marchetti-Krantz 19491949

2. 2. Burch Operation Burch Operation 19681968

Burch colposuspensionBurch colposuspension is the operation of choice is the operation of choice. . It corrects both stress incontinence and cystocele. It corrects both stress incontinence and cystocele. The stitches are placed in the fascia on each side The stitches are placed in the fascia on each side

of the bladder neck and the base of the bladder and of the bladder neck and the base of the bladder and are attached to the iliopectineal ligaments (Cooper are attached to the iliopectineal ligaments (Cooper Ligaments), Ligaments), ((The pectineal part of the inguinal ligament)The pectineal part of the inguinal ligament)

Nonabsorpable or delayed absorbable sutures are Nonabsorpable or delayed absorbable sutures are used. used.

Operation can be done through the laparoscope.Operation can be done through the laparoscope.

The success rate of The success rate of the above abdominal the above abdominal

operations is operations is 80-90%80-90%

1. Urethral Slings1. Urethral Slings In this condition, there is damage or paralysis In this condition, there is damage or paralysis

of the sphincteric unit which could even be in a of the sphincteric unit which could even be in a normal position. normal position.

The goal of surgery for Intrinsic Dysfunction is The goal of surgery for Intrinsic Dysfunction is coaptation, support, and compression of the coaptation, support, and compression of the damaged sphincteric unit. damaged sphincteric unit.

Simple suspension of the bladder neck is Simple suspension of the bladder neck is unlikely to correct the problem. unlikely to correct the problem.

Urethral Sling Procedures is the best to achieve Urethral Sling Procedures is the best to achieve the goal.the goal.

A sling is put around the urethra at A sling is put around the urethra at the bladder neck and either fixed the bladder neck and either fixed around the rectus muscles or to the around the rectus muscles or to the pubic bone.pubic bone.

- The sling could be taken from the - The sling could be taken from the rectus sheath rectus sheath "Aldridge operation"."Aldridge operation".

- A nylon sling may be used - A nylon sling may be used "Pereyra "Pereyra operation".operation".

Sling OperationsSling Operations

An incision is made in the vaginal wall to An incision is made in the vaginal wall to expose the bladder neck. expose the bladder neck.

A nylon suture is placed in the fascia on each A nylon suture is placed in the fascia on each side of the bladder neck. side of the bladder neck.

The two sutures are passed upward behind the The two sutures are passed upward behind the symphysis pubis and are attached to the symphysis pubis and are attached to the anterior rectus sheath. anterior rectus sheath.

The cystoscope is used to be sure that the The cystoscope is used to be sure that the needle does not pass through the bladder needle does not pass through the bladder (endoscopic needle bladder neck suspension).(endoscopic needle bladder neck suspension).

2. Needle Bladder Neck 2. Needle Bladder Neck Suspension OperationsSuspension Operations

An example is An example is Stamey operationStamey operation in which two Dacron in which two Dacron

tubes (1 cm) are tubes (1 cm) are used to give support used to give support to the bladder neck to the bladder neck

and to avoid the and to avoid the sutures cutting sutures cutting

through the tissues.through the tissues.

2. Needle Bladder Neck 2. Needle Bladder Neck Suspension OperationsSuspension Operations

ObTape transobturator slingObTape transobturator sling September 10, 2003September 10, 2003 new surgical implant for treatment of new surgical implant for treatment of

stress incontinence in women has been approved by the stress incontinence in women has been approved by the FDA. FDA.

It was pioneered in 1999 by Emmanuel Delorme in It was pioneered in 1999 by Emmanuel Delorme in France. France.

Soon became popular because the procedure is Soon became popular because the procedure is perceived to be simpler and faster, with less risk of perceived to be simpler and faster, with less risk of complications, than alternative procedures. complications, than alternative procedures.

In the last 2 years over 11,000 women have been In the last 2 years over 11,000 women have been successfully treated for stress incontinence with successfully treated for stress incontinence with transobturator sling. transobturator sling.

Indicated when surgery fails to correct Indicated when surgery fails to correct stress incontinence. stress incontinence.

The device consists of a cuff which is The device consists of a cuff which is placed around the bladder neck. placed around the bladder neck.

A balloon reservoir, containing fluid is A balloon reservoir, containing fluid is placed in the peritoneal cavity or under placed in the peritoneal cavity or under the anterior rectus sheath, and a small the anterior rectus sheath, and a small pump is situated in one labium major. pump is situated in one labium major.

D. Artificial Urinary SphincterD. Artificial Urinary Sphincter

Under normal conditions the cuff is Under normal conditions the cuff is full with fluid thus closing the bladder full with fluid thus closing the bladder neck. neck.

When voiding is desired the pump is When voiding is desired the pump is pressed to force the fluid in the cuff to pressed to force the fluid in the cuff to go back into the balloon reservoir so go back into the balloon reservoir so that voiding can occur. that voiding can occur.

The cuff then gradually refills over The cuff then gradually refills over the next few minutes.the next few minutes.

DETRUSOR INSTABILITYDETRUSOR INSTABILITY

The patient complains of urgency The patient complains of urgency incontinence, frequency and nocturia. incontinence, frequency and nocturia.

Involuntary loss of urine also occurs when Involuntary loss of urine also occurs when the women sits for a long time and stands the women sits for a long time and stands to go to the bathroom. to go to the bathroom.

She may pass urine with the She may pass urine with the sight or sight or soundsound of water of water

Women typically complain of Women typically complain of urgencyurgency followed by a large loss of followed by a large loss of urine.urine.

CystometryCystometry confirms the diagnosis. confirms the diagnosis. Involuntary detrusor contractions of Involuntary detrusor contractions of

15 cm of water or more occur 15 cm of water or more occur during filling of the bladder.during filling of the bladder.

DETRUSOR INSTABILITY (DI)

TREATMENT of (DI)TREATMENT of (DI)

Bladder retraining drillsBladder retraining drills: :

The patient is asked to pass urine The patient is asked to pass urine every hour during daytime and to every hour during daytime and to

increase the interval by 15 increase the interval by 15 minutes every week until she minutes every week until she passes urine every 2-3 hours.passes urine every 2-3 hours.

2. 2. DrugsDrugs : :Which inhibit the contractions of detrusor Which inhibit the contractions of detrusor

muscle as anticholinergic drugs, tricyclic muscle as anticholinergic drugs, tricyclic antidepressants, and ephedrine.antidepressants, and ephedrine.

EphedrineEphedrine stimulates alpha-adrenergic stimulates alpha-adrenergic receptors in the internal urethral sphincter receptors in the internal urethral sphincter leading to contraction, and stimulates beta-leading to contraction, and stimulates beta-adrenergic receptors in the detrusor muscle adrenergic receptors in the detrusor muscle leading to relaxation.leading to relaxation.

TREATMENT of (DI)

SURGICAL TREATMENT OFURODYNAMIC STRESS

INCONTINENCE

RCOG EVIDENCE BASED GUIDELINES RCOG EVIDENCE BASED GUIDELINES

OCTOBER 2003OCTOBER 2003

Surgery for stress Surgery for stress incontinence of urine incontinence of urine

has been performed on has been performed on women for over a women for over a

century.century.

The anterior vaginal repair The anterior vaginal repair was the most popular primary was the most popular primary

procedure for stress procedure for stress incontinence up to the incontinence up to the 1970s,1970s, but over the but over the last 20 yearslast 20 years the the operation has been criticized operation has been criticized because of high recurrence because of high recurrence

rates. rates.

More sustained More sustained results are obtained results are obtained

from retropubic from retropubic surgery.surgery.

Primary surgery Primary surgery should only be should only be

considered after considered after a period of conservative a period of conservative treatment from treatment from a specialist therapista specialist therapist

The literature on surgery The literature on surgery for stress incontinence for stress incontinence is extensive but is mainly is extensive but is mainly

based on based on case series rather case series rather than randomized trialsthan randomized trials. .

Overall, Overall, 83%83% of women of women reported improvement three reported improvement three

months after continence months after continence surgery, surgery, 5%5% had no change had no change

and and 8%8% reported a reported a worsening in their worsening in their

condition.condition.

Anterior vaginal repairAnterior vaginal repair

Anterior repair is less successful as Anterior repair is less successful as an operation for continence than an operation for continence than retropubic procedures and has been retropubic procedures and has been superseded by sling procedures.superseded by sling procedures.

Anterior repair still has a role in the Anterior repair still has a role in the treatment of prolapse without treatment of prolapse without incontinence.incontinence.

A

Meta-analyses of Meta-analyses of heterogeneous studies heterogeneous studies

suggest a continence rate suggest a continence rate of between of between 67.8–72.0%.67.8–72.0%.


A

The anterior colporrhaphy The anterior colporrhaphy procedure remains in use, largely procedure remains in use, largely because of the relatively because of the relatively

low morbiditylow morbidity of the procedure and of the procedure and its its familiarity familiarity for gynecologists as for gynecologists as

an operation for prolapse.an operation for prolapse.


A

The incidence of The incidence of long-term voiding long-term voiding disordersdisorders following this procedure following this procedure approaches approaches zerozero. .

Long-term results decrease with timeLong-term results decrease with time, , such that a 63% continence rate at one such that a 63% continence rate at one year of follow up fell to year of follow up fell to 37% at five years of follow up.37% at five years of follow up.


A

The view of the American Urological The view of the American Urological Association is that Association is that ‘anterior repairs‘anterior repairs are the least likely of the four major are the least likely of the four major

operative categories operative categories (anterior repair, (anterior repair, suburethral sling, colposuspension, suburethral sling, colposuspension,

long-needle suspension)long-needle suspension) to be to be efficacious in the long term’.efficacious in the long term’.


A

Burch colposuspension is the most Burch colposuspension is the most effective surgical procedure for stress effective surgical procedure for stress incontinence, with a continence rate incontinence, with a continence rate of 85–90% at one yearof 85–90% at one year. .

The continence rate falls to 70% at The continence rate falls to 70% at five years; this shows better longevity five years; this shows better longevity than other methods of treatment.than other methods of treatment.

Burch colposuspension

A

Voiding difficultyVoiding difficulty has been reported in a mean has been reported in a mean of 10.3% of women after colposuspension of 10.3% of women after colposuspension (range 2–27%). (range 2–27%).

De novo De novo detrusor overactivitydetrusor overactivity has been has been described in a mean of 17% women described in a mean of 17% women (range 8–27%).(range 8–27%).

Genitourinary prolapseGenitourinary prolapse (enterocele, rectocele) (enterocele, rectocele) has been reported in follow up at five years in has been reported in follow up at five years in an average of 13.6% women an average of 13.6% women (range 2.5–26.7%).(range 2.5–26.7%).


A

Ureteric damageUreteric damage has been reported. has been reported. There was There was no reported mortalityno reported mortality as a as a

direct consequence of the procedure.direct consequence of the procedure. The continence rate after Burch The continence rate after Burch

colposuspension falls if previous colposuspension falls if previous continence surgery has been performed. continence surgery has been performed.

In one study the continence rate fell from In one study the continence rate fell from 84% for a primary procedure to 63% for 84% for a primary procedure to 63% for secondary surgerysecondary surgery


A

A Cochrane review has examined the A Cochrane review has examined the place of Burch colposuspension place of Burch colposuspension

among other continence procedures among other continence procedures and concluded that : and concluded that :

open colposuspension is the most open colposuspension is the most effective surgical treatment for stress effective surgical treatment for stress incontinence, especially in the long incontinence, especially in the long

term. term.


A

Burch colposuspension is more Burch colposuspension is more effective than needle suspension effective than needle suspension and provides a similar subjective and provides a similar subjective continence rate to laparoscopic continence rate to laparoscopic

colposuspension (85–100% after colposuspension (85–100% after 6–18 months of follow-up).6–18 months of follow-up).


A

Alternative suprapubic surgeryAlternative suprapubic surgery

The role of other suprapubic The role of other suprapubic operations such as Marshall–operations such as Marshall–

Marchetti– Krantz , Marchetti– Krantz , paravaginal repair and paravaginal repair and

laparoscopic colposuspension, laparoscopic colposuspension, is unclear.is unclear.

B

(MMK) retropubic procedure was a (MMK) retropubic procedure was a common anti-incontinence procedure common anti-incontinence procedure

betweenbetween1950–90s1950–90s and Krantz and Krantz described a personal series of 3861 described a personal series of 3861 cases with a follow-up of up to 31 cases with a follow-up of up to 31

years and a years and a 96%96% subjective subjective continence rate.continence rate.

A

Marshall– Marchetti– Krantz (MMK)Marshall– Marchetti– Krantz (MMK)

The mortality was 0.2%, The mortality was 0.2%, with a 22% overall with a 22% overall complication rate.complication rate.

This operation has now This operation has now fallen into disuse. fallen into disuse.

Marshall–Marchetti–Krantz (MMK)Marshall–Marchetti–Krantz (MMK)

A

A characteristic complication of MMK A characteristic complication of MMK was was osteitis pubisosteitis pubis, which occurs in , which occurs in 2.5% of patients who undergo a MMK 2.5% of patients who undergo a MMK procedure. procedure.

The operation was less successful The operation was less successful than Burch colposuspension at than Burch colposuspension at correcting a cystocele. correcting a cystocele.

Marshall–Marchetti–Krantz (MMK)Marshall–Marchetti–Krantz (MMK)

A

Laparoscopic colposuspension has Laparoscopic colposuspension has been the subject of several case been the subject of several case series and cohort studies, which series and cohort studies, which show show similar continence rates similar continence rates

between laparoscopic and open between laparoscopic and open Burch colposuspensionBurch colposuspension..

Laparoscopic colposuspensionLaparoscopic colposuspension

A

There were no significant There were no significant differences for differences for

postoperative detrusor postoperative detrusor overactivity or voiding overactivity or voiding

difficulty.difficulty.

Laparoscopic colposuspensionLaparoscopic colposuspension

A

There were trends towards a:There were trends towards a: 2.2. higher complication rate and higher complication rate and

3.3. longer operative times, longer operative times,

4.4. lower intraoperative blood loss, lower intraoperative blood loss,

5.5. less postoperative pain, less postoperative pain,

6.6. shorter need for catheterization, shorter need for catheterization,

7.7. shorter hospital stay and shorter hospital stay and

8.8. earlier return to normal activitiesearlier return to normal activities

Laparoscopic colposuspension

A

Despite a quicker recovery, Despite a quicker recovery, the operation takes the operation takes longer to performlonger to perform, , is associated with is associated with more surgical more surgical complicationscomplications and is more and is more expensive. expensive.

It is likely to be performed by It is likely to be performed by surgeons highly skilledsurgeons highly skilled in both in both continence and laparoscopic continence and laparoscopic techniques.techniques.

Laparoscopic colposuspension

A

Needle suspension proceduresNeedle suspension procedures

Needle suspension procedures Needle suspension procedures should not be performedshould not be performed: : initial success rates are not initial success rates are not maintained with time andmaintained with time and

The risk of failure is higher than The risk of failure is higher than for retropubic suspension for retropubic suspension procedures.procedures.

A

Multiple suspension procedures have Multiple suspension procedures have been described in the past.been described in the past.

The first procedure was described by The first procedure was described by PeyreraPeyrera and numerous procedures and numerous procedures have subsequently evolved from this, have subsequently evolved from this, including the including the Stamey procedureStamey procedure, using , using suspending sutures and patch suspending sutures and patch materials. materials.


A

Long-term follow up of the Long-term follow up of the percutaneous needle procedurepercutaneous needle procedure was was

only:only:2.2. 5% cured , with 5% cured , with 3.3. 12% significantly improved and 12% significantly improved and 4.4. 83% considered the operation a 83% considered the operation a

failure. failure.


A

Needle suspensions were more likely to Needle suspensions were more likely to fail fail than open retropubic procedures and than open retropubic procedures and there were more perioperative there were more perioperative complications in the needle suspension complications in the needle suspension group group (48% compared with 30%).(48% compared with 30%).

Needle suspensions may be as effective as Needle suspensions may be as effective as anterior repair but carry a higher anterior repair but carry a higher morbiditymorbidity


A

Sling proceduresSling procedures

Suburethral sling procedures Suburethral sling procedures were developed initially in the were developed initially in the 1880s. 1880s.

Numerous authors have Numerous authors have subsequently modified these subsequently modified these procedures. procedures.

C

AldridgeAldridge used rectus sheath used rectus sheath strips , the strips , the success ratesuccess rate

recorded in the literature would recorded in the literature would appear to range between appear to range between 64% 64%

and 100%,and 100%, with a mean with a mean continence rate in the region of continence rate in the region of

86%.86%.

Sling procedures

C

Sling procedures, using Sling procedures, using autologous or autologous or synthetic materialssynthetic materials, produce a continence , produce a continence rate of approximately 80% and an rate of approximately 80% and an improvement rate of 90%, with little improvement rate of 90%, with little reduction in continence over time. reduction in continence over time.

Only one synthetic sling procedure Only one synthetic sling procedure (tension-free vaginal tape)(tension-free vaginal tape) has been has been subjected to randomized study to date.subjected to randomized study to date.

A


Numerous materials are available for Numerous materials are available for use in a suburethral sling. use in a suburethral sling.

As a generalization, As a generalization, autologous autologous material is associated with a greater material is associated with a greater continence rate and fewer continence rate and fewer complicationscomplications than either cadaveric than either cadaveric material or synthetic materials.material or synthetic materials.


A

Autologous rectus fascia Autologous rectus fascia and fascialata are and fascialata are probably the most probably the most

common materials in use. common materials in use.

Sling procedures

A

Synthetic material tends Synthetic material tends to be associated with a to be associated with a

risk of erosion and sinus risk of erosion and sinus formation.formation.

Sling procedures

A

Modifications designed to achieve Modifications designed to achieve greater stabilization, such as greater stabilization, such as

anchorage to the pubic boneanchorage to the pubic bone, are , are associated with good results in the associated with good results in the

short term but carry a long-term risk short term but carry a long-term risk of of osteomyelitisosteomyelitis at the site of at the site of

anchorage.anchorage.

Sling procedures

A

When compared with When compared with colposuspension colposuspension

procedures, the suburethral procedures, the suburethral sling carries a similar sling carries a similar

success rate.success rate.

Sling procedures

A

The intermediate and longer-term The intermediate and longer-term results for suburethral slings results for suburethral slings

suggest that the ten-year suggest that the ten-year continence rate is not dissimilar continence rate is not dissimilar from the one-year continence from the one-year continence

rate.rate.A

Sling procedures

The American Urological Association The American Urological Association considered that ‘considered that ‘Retropubic suspensions and Retropubic suspensions and slings are the most efficacious procedures for slings are the most efficacious procedures for long-term success based upon cure/dry ratelong-term success based upon cure/dry rate. .

However, retropubic suspensions and sling However, retropubic suspensions and sling procedures are associated with slightly higher procedures are associated with slightly higher complication rates, including postoperative complication rates, including postoperative voiding difficulty and longer convalescence. voiding difficulty and longer convalescence.

Sling procedures

A

The Second International The Second International Consultation on Incontinence Consultation on Incontinence

concluded that concluded that suburethral slings suburethral slings represented ‘an effective represented ‘an effective

procedure for genuine stress procedure for genuine stress incontinence in the presence of incontinence in the presence of

previous failed surgery.previous failed surgery.

Sling procedures

A

The Prolene® tension-free vaginal tape The Prolene® tension-free vaginal tape (TVT) is relatively new, although (TVT) is relatively new, although increasing numbers of cohort studies of its increasing numbers of cohort studies of its use are being reported.use are being reported.

The originator of the procedure reports The originator of the procedure reports that, at three years, that, at three years, 86%86% of women were of women were ‘completely cured,’‘completely cured,’ while a further while a further 11%11% were were ‘significantly improved’.‘significantly improved’.

TVT

A

The majority of women are potentially The majority of women are potentially treatable without general anaesthesia treatable without general anaesthesia and on a day-case basis.and on a day-case basis.

Between Between 3% and 15%3% and 15% of women of women developed symptoms compatible with developed symptoms compatible with the onset of the onset of de novo de novo detrusor detrusor overactivity.overactivity.

TVT

A

Short-term Short-term voiding disordervoiding disorder is is described in described in 4.3%4.3% of women, of women, although longer term voiding although longer term voiding disorder does not appear to disorder does not appear to

be a specific feature.be a specific feature.

TVT

A

There have been a few individual There have been a few individual case reports of urethral erosion, case reports of urethral erosion, sometimes several years after sometimes several years after surgery.surgery.

There is a need for long-term There is a need for long-term results for this procedure. results for this procedure.

TVT

A

Despite being more expensive Despite being more expensive than colposuspension, than colposuspension, the reduction in hospital stay the reduction in hospital stay makes the procedure makes the procedure

cost effectivecost effectiveA

TVT

Injectable agentsInjectable agentsInjectable agents have a Injectable agents have a lower lower

success rate than other success rate than other proceduresprocedures: a short-term : a short-term continence rate of 48% and an continence rate of 48% and an improvement rate of 76%.improvement rate of 76%.

Long term, there is a continued Long term, there is a continued decline in continence. decline in continence. B

The procedure has a The procedure has a low low morbiditymorbidity and may have a role and may have a role after other procedures have after other procedures have

failed, e.g. when a diagnosis of failed, e.g. when a diagnosis of intrinsic sphincter deficiency is intrinsic sphincter deficiency is

made.made.

Injectable agentsInjectable agents

C

The bulking agents (collagen, The bulking agents (collagen, Teflon fat, silicone, Durasphere ) Teflon fat, silicone, Durasphere ) are injected in a are injected in a retrograde (more retrograde (more common)common) or antegrade fashion in or antegrade fashion in the periurethral tissue around the the periurethral tissue around the

bladder neck and proximal bladder neck and proximal urethra. urethra.


C

Follow up was between three Follow up was between three months and two years, months and two years, (mean of (mean of 12 months).12 months).

The The cure ratecure rate, defined as , defined as completely dry, was completely dry, was 48%.48%.

The The success ratesuccess rate (defined as dry (defined as dry or improved) was or improved) was 76%.76%.


C

For For siliconesilicone Radley et al.Radley et al. showed showed cure or improvement in cure or improvement in 60%60% in a in a prospective cohort of women with prospective cohort of women with recurrent stress incontinencerecurrent stress incontinence on a on a 19-month follow-up. 19-month follow-up.

Detrusor overactivity was an Detrusor overactivity was an important important cause of failurescause of failures in this in this study. study.


C

RCTs are needed for bulking agents.RCTs are needed for bulking agents.The lack of morbidity associated with The lack of morbidity associated with

the bulking agents leads some people the bulking agents leads some people to believe that they should be more to believe that they should be more meaningfully compared with meaningfully compared with conservative therapy such as pelvic conservative therapy such as pelvic floor physiotherapy.floor physiotherapy.

Injectable agents

C

Artificial sphinctersArtificial sphincters

Artificial sphincters can be Artificial sphincters can be successfully used after previous successfully used after previous failed continence surgery but failed continence surgery but

have a have a high morbidity and need high morbidity and need for further surgery (17%).for further surgery (17%).

B

Preoperative managementPreoperative management

It is recommended that women It is recommended that women undergoing surgery for undergoing surgery for

urodynamic stress incontinence urodynamic stress incontinence should have urodynamic should have urodynamic investigations prior to investigations prior to

treatment treatment (including Cystometry).(including Cystometry).

Prior to performing assess Prior to performing assess objectively the type of objectively the type of

incontinence and the presence of incontinence and the presence of any complicating factors such as any complicating factors such as

voiding difficulty or detrusor voiding difficulty or detrusor overactivity, which may affect the overactivity, which may affect the

surgical decisionsurgical decision

Preoperative management

Surgery should be performed by a Surgery should be performed by a surgeon who has been trained in surgeon who has been trained in

the operation and who has a the operation and who has a caseload that enables him or her caseload that enables him or her

to provide a suitable level of to provide a suitable level of expertise, especially when any expertise, especially when any repeat surgery is considered.repeat surgery is considered.

Preoperative management

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