INCONTINENCE INCONTINENCE AND AND

GENITAL PROLAPSEGENITAL PROLAPSE

DR. IQBAL TURKISTANIDR. IQBAL TURKISTANIAsst. Prof. & ConsultantAsst. Prof. & Consultant

Ob/GynOb/Gyn

Basic Anatomy of the Lower Basic Anatomy of the Lower Urinary Tract (LUT) in womenUrinary Tract (LUT) in women

The LUT composed of the The LUT composed of the Bladder and UrethraBladder and Urethra in a in a functional unit serving the functional unit serving the two purposes of two purposes of storage storage and and voidingvoiding during the micturition during the micturition cycle.cycle.

These structures are supported These structures are supported by the by the pelvic floor.pelvic floor.

The Urinary Bladder:The Urinary Bladder:

-- Is a hollow, muscular Is a hollow, muscular organ which:organ which:

- acts as a compliant - acts as a compliant reservoir for urine reservoir for urine

- It comprises the - It comprises the Bladder Bladder wall & Bladder wall & Bladder cavity in cavity in which urine which urine collectscollects

The Bladder wall is composed The Bladder wall is composed of several layersof several layers

The Detrusor:The Detrusor:

Is a Is a complex network of complex network of smooth muscle fibers and smooth muscle fibers and elastic tissue elastic tissue which allows which allows the bladder to expand without the bladder to expand without pressure during bladder fillings pressure during bladder fillings and is and is responsible for bladder responsible for bladder contraction contraction during voiding.during voiding.

The The Trigone Trigone is a small muscular is a small muscular triangular area, lying at the triangular area, lying at the posterior wall of the bladder, next posterior wall of the bladder, next to the bladder neck.to the bladder neck. functions to prevent reflux of functions to prevent reflux of urine to the upper urinary tract urine to the upper urinary tract during voiding.during voiding.

the two ureters enter the the two ureters enter the bladder at the superior angles bladder at the superior angles of of the trigone.the trigone.

at the lower most apex of at the lower most apex of trigone is the opening of the trigone is the opening of the bladder through the bladder bladder through the bladder neck to the neck to the Urethra.Urethra.

2. Urothelium:2. Urothelium:

- The epithelial lining of the - The epithelial lining of the detrusordetrusor

-- Is smooth at trigone Is smooth at trigone and and folded into rugae on the folded into rugae on the

the rest of the bladder the rest of the bladder when emptywhen empty

II: II: The Urethra and The Urethra and SphinctersSphincters

The female urethra The female urethra is a fibro- muscular tube is a fibro- muscular tube 3.5 3.5

cm longcm long Consists of outer layer of Consists of outer layer of

striated muscle fibresstriated muscle fibres, and an , and an inner layer of inner layer of smooth musclesmooth muscle fibres, lined by the fibres, lined by the mucosa, mucosa, submucosal submucosal vessels and vessels and connectiveconnective tissues. tissues.

1.1. The Urethral Sphincters:The Urethral Sphincters:

Two mechanism to control urine Two mechanism to control urine flow in women:flow in women:A. A. The smooth muscleThe smooth muscle sphinctersphincter

(Bladder neck and (Bladder neck and proximal urethra)proximal urethra)

is a physiological but is a physiological but not not anatomical sphincteranatomical sphincter

Under involuntary Under involuntary controlcontrol

keeps the bladder and keeps the bladder and upper urethra closed upper urethra closed during the during the storage storage

phasephase

B. B. The Striated Sphincter:The Striated Sphincter:= Striated musculature, = Striated musculature,

which which is part of the outer is part of the outer wall of wall of proximal urethra proximal urethra (intrinsic(intrinsic sphinctersphincter) + bulky ) + bulky skeletal skeletal muscle group lateral muscle group lateral to the to the urethra at the level urethra at the level of the of the middle segment in middle segment in female female (extrinsic sphincter)(extrinsic sphincter)

2.2. Mucosa and submucosa:Mucosa and submucosa:Urothelium lining the urethraUrothelium lining the urethra-- beneath is a vascular pelxus beneath is a vascular pelxus helps form water tight seal helps form water tight seal

THE PELIV FLOORTHE PELIV FLOOR The pelvic organs are supported The pelvic organs are supported

and maintained in the correct and maintained in the correct position by the “Pelvic Floor”position by the “Pelvic Floor”-- This is mainly composed of This is mainly composed of

the the LEVATOR ANILEVATOR ANI group of group of musclesmuscles

-- Lined by the Lined by the Endopelvic Endopelvic fasciafascia ,which is a ,which is a continuous continuous mass of tissue mass of tissue with various with various thickened partsthickened parts-- the largest being the the largest being the arcus arcus

tendineus fascia pelvistendineus fascia pelvis-- the endopelvic fascia the endopelvic fascia attaches attaches the vagina to the pelvic the vagina to the pelvic

sidewallsidewall..

- Urogenital hiatusUrogenital hiatus = the opening = the opening within the levator ani muscles through within the levator ani muscles through which the urethra and vagina pass.which the urethra and vagina pass.

- The The constant activityconstant activity of levator ani of levator ani muscle (like that of postural muscle) muscle (like that of postural muscle) closes the lumen of the vagina closes the lumen of the vagina eleminting any opening within the pelvic eleminting any opening within the pelvic floor.floor.

- The interaction between the The interaction between the pelvic floorpelvic floor muscles and supportive muscles and supportive ligamentsligaments is is critical for pelvic organs supportcritical for pelvic organs support

- Although the ligaments can sustain the Although the ligaments can sustain the load of the pelvic organs for a short load of the pelvic organs for a short period of time, they ultimately fail to period of time, they ultimately fail to hold the vagina in place if they are not hold the vagina in place if they are not assisted by the pelvic floor muscle assisted by the pelvic floor muscle musculature.musculature.

- This happens when the muscles are This happens when the muscles are damaged or paralised.damaged or paralised.

::PHYSIOLOGY PHYSIOLOGY MICTURITIONMICTURITION CYCLECYCLEThe micturition cycle is composed and The micturition cycle is composed and

alternate between:alternate between: Storage phaseStorage phase Voiding phaseVoiding phase

- A normal micturition cycle requires a A normal micturition cycle requires a coordination and adequate interplay coordination and adequate interplay between the between the ReservoirReservoir and and Outlet Outlet FunctionsFunctions of the LUT structures of the LUT structures inlcuding:inlcuding:

The detrusor muscleThe detrusor muscle The urethral smooth muscleThe urethral smooth muscle The striated urethral sphincterThe striated urethral sphincter The pelvic floor muscles (PFM)The pelvic floor muscles (PFM)

Filling and Storage:Filling and Storage:Bladder accommodation during filling is Bladder accommodation during filling is primarily a passive phenomenonprimarily a passive phenomenon

- It depends on the Elastic Passive It depends on the Elastic Passive Phenomenon dependent on the Phenomenon dependent on the elasticelastic properties and visicoelastic properties properties and visicoelastic properties of the bladder wall and an increase in of the bladder wall and an increase in the outlet the outlet resistance resistance by the striated by the striated sphincter.sphincter.

- ContinenceContinence is maintained during is maintained during increases in intra abdominal pressure increases in intra abdominal pressure by the by the intrinsic competenceintrinsic competence of the of the bladder outelet (bladder neck and bladder outelet (bladder neck and proximal / mid urethra) and the pressure proximal / mid urethra) and the pressure transmission ratio to this area with transmission ratio to this area with respect to the intravesical contents.respect to the intravesical contents.

EMPTYINGEMPTYING AND VOIDINGAND VOIDING Can be voluntaryCan be voluntary

Or involuntaryOr involuntary Involves inhibition of the spinal Involves inhibition of the spinal somatic somatic and and

sympathetic reflexessympathetic reflexes and activation of the and activation of the vesical vesical parasympatheticparasympathetic pathways, the pathways, the organizational center (brain stem).organizational center (brain stem).

Initially there is Initially there is relaxation of the outletrelaxation of the outlet musculature mediated by cessation of somatic musculature mediated by cessation of somatic sympathetic spinal reflex.sympathetic spinal reflex.

ContractionContraction of the bulk of the bladder smooth of the bulk of the bladder smooth musculature occurs through a highly musculature occurs through a highly coordinated parasympathetic input.coordinated parasympathetic input.

With amplification and facilitation of the With amplification and facilitation of the detrusor contraction from other detrusor contraction from other peripheral peripheral reflexesreflexes and from spinal cord supraspinal and from spinal cord supraspinal sources and the absence of anatomical sources and the absence of anatomical obstruction between the bladder and the obstruction between the bladder and the urethral meatus urethral meatus Complete EmptyingComplete Emptying will will occur.occur.

URINARYURINARY INCONTINENCE (UI)INCONTINENCE (UI)

Definition:Definition:

Incontinence is the Incontinence is the involuntaryinvoluntary loss of urine. loss of urine.

Urine leakage(incontinence) Urine leakage(incontinence) occurs when the occurs when the pressure in pressure in the bladderthe bladder (expulsive force) (expulsive force) exceedsexceeds that that within the within the urethraurethra (closure force). (closure force).

CLASSIFICATION OF UI:CLASSIFICATION OF UI:

1.1. Urgency Urinary IncontinenceUrgency Urinary Incontinence (UUI)`~22%(UUI)`~22%== involuntary leakage occurs involuntary leakage occurs with a strong, sudden, and with a strong, sudden, and uncontrollable desire to urinate as uncontrollable desire to urinate as result of result of involuntary detrusor involuntary detrusor contraction.contraction.

2.2. Stress Urinary Incontinence (SUI): Stress Urinary Incontinence (SUI): (49%)(49%)== involuntary leakage on effort or involuntary leakage on effort or exertion or on sneezing or coughing, exertion or on sneezing or coughing, as a result of as a result of insufficient urethral insufficient urethral closure pressure.closure pressure.

3.3. Mixed Urinary Incontinence Mixed Urinary Incontinence 29% 29%== UUI + SUIUUI + SUI

The The symptomaticsymptomatic definitions can definitions can be supported by be supported by signssigns from from physical examination:physical examination:

e.g.- urine leakage during e.g.- urine leakage during stressstress / / cough testcough test

- - Urodynamic testingUrodynamic testing such as such as filling cystometry (e.g. filling cystometry (e.g. involuntary detrusor contractions involuntary detrusor contractions during the filling phase)during the filling phase)

OAB /OAB / Overactive bladderOveractive bladder::

== Symptoms of urgency with Symptoms of urgency with or without urgency incontior without urgency inconti --

nence usually with nence usually with frequency frequency and nocturia. and nocturia.

(frequency(frequency>> 8 mict day time) 8 mict day time)

(nocturia(nocturia>> 2mict at night) 2mict at night)

== UUI and mixed urinary UUI and mixed urinary incontinence are only part incontinence are only part of of the OABthe OAB

DETRUSOR OVERACTIVITYDETRUSOR OVERACTIVITY::

== Is a urodynamic observation Is a urodynamic observation characterized by involuntary characterized by involuntary detrusor contractions during detrusor contractions during

the filling phase. the filling phase.

N.B. -N.B. - Not all OAB patients Not all OAB patients show DO show DO

-- DO can be found on DO can be found on urodynamic studies urodynamic studies without complaints by without complaints by

the patient of OAB the patient of OAB symptomssymptoms

I. URGENCY INCONTINENCEI. URGENCY INCONTINENCE

1.1. Definition:Definition:= The complaint of involuntary = The complaint of involuntary

leakage, accompanied by / leakage, accompanied by / immediately preceeded by immediately preceeded by Urgency. Urgency.

== The symptoms are due to an The symptoms are due to an Overactive Detrusor muscle that Overactive Detrusor muscle that contracts inappropriately contracts inappropriately

during the filling phaseduring the filling phase== The symptoms caused by the The symptoms caused by the overactive bladder are typically:overactive bladder are typically:

FrequencyFrequency UrgencyUrgency Urge incontinence Urge incontinence

Frequency = emptying the Frequency = emptying the bladder more often than 8 bladder more often than 8 times a day.times a day.

Urgency = strong compelling Urgency = strong compelling desire to urinate which is desire to urinate which is difficult to defer.difficult to defer.

Nocturie = Night time Nocturie = Night time frequency which disrupts the frequency which disrupts the sleeping pattern, resulting in sleeping pattern, resulting in tiredness that may affect all tiredness that may affect all aspects of social life.aspects of social life.

2.2. AETIOLOGY:AETIOLOGY:Urge incontinence is mainly Urge incontinence is mainly secondary to OAB.secondary to OAB.

A. IDIOPATHIC DETRUSORA. IDIOPATHIC DETRUSOR OVERACTIVELYOVERACTIVELY

== Majority of casesMajority of cases == Pathophysiology of Pathophysiology of

DO DO is not fully is not fully understood / no objective understood / no objective causes are found.causes are found.

However several explanations have However several explanations have been proposed:been proposed:1.1. Supra pontine inhibition Supra pontine inhibition2.2. Afferent activity Afferent activity3.3. Sensitivity of detrusor Sensitivity of detrusor to to Acetyl choline Acetyl choline

B.B. Neurogenic detrusor Neurogenic detrusor overactivityoveractivity

In this case, there is an In this case, there is an objective evidence of objective evidence of neurological diseaseneurological disease

e.g. e.g. multiple sclerosis, multiple sclerosis, upper motor neuron lesions, upper motor neuron lesions, peripheral nerve lesions peripheral nerve lesions following pelvic surgeryfollowing pelvic surgery..

II: STRESS INCONTINENCE (SI)II: STRESS INCONTINENCE (SI)

1. 1. Definition:Definition:As a result of variable combination of:As a result of variable combination of:

intrinsic urethral sphincter intrinsic urethral sphincter muscle weaknessmuscle weakness

and anatomical defect in and anatomical defect in urethral support urethral support

leading to insufficient closure pressure in leading to insufficient closure pressure in the urethra during physical effort, e.g. the urethra during physical effort, e.g. lifting, coughing, sneezing, and lifting, coughing, sneezing, and runningrunning..

2.2. AETIOLOGY: AETIOLOGY: multifactorialmultifactoriali.i. Pregnancy Pregnancy Damage to the Damage to the pudendal npudendal n. .

during childbirth during childbirth contributing to~~~~~~contributing to~~~~~~

ii.ii. Vaginal delivery ~pelvic floor and sphincter Vaginal delivery ~pelvic floor and sphincter denervationdenervation

i.i. Pelvic surgery ~~Damage to the Pelvic surgery ~~Damage to the pelvic nervepelvic nerve (autonomic) during extensi(autonomic) during extensi

ii.ii. ve pelvic surgery can de-ve pelvic surgery can de-iii.iii. nervate the urethra.nervate the urethra.

iv.iv. Neurological ~~central or peripheral Neurological ~~central or peripheral causes causes neurological neurological problemproblems s

can can disrupt the continence disrupt the continence mechanism.mechanism.

v.v. Lifestyle ~~Lifestyle ~~ abdominal pressure abdominal pressure ~~ Stretching of perineal muscles ~~ Stretching of perineal muscles

vi.vi. Promoting causes~~Due to mainly aging and Promoting causes~~Due to mainly aging and

co-morbidities. co-morbidities.

III: MIXED INCONTINENCEIII: MIXED INCONTINENCE

The complaint of involuntary The complaint of involuntary leakage associated with leakage associated with urgencyurgency and also with and also with effort,effort, exertion, sneezing and exertion, sneezing and coughingcoughing

EVALUATIONEVALUATIONHistory:History: PersonalPersonal detaildetail

Urological Symptoms:Urological Symptoms:& incontinence symptoms& incontinence symptoms How often ?How often ? D/ND/N How much urine do you leak?How much urine do you leak? Stream / incomplete emptyingStream / incomplete emptying

Other associated symptoms:Other associated symptoms: Childhood enuresisChildhood enuresis Dysuria Dysuria Perineal discomfort / vaginal prolapsePerineal discomfort / vaginal prolapse Sexual problemSexual problem Rectal soilingRectal soiling

Quality of life assessmentQuality of life assessmentHow much does leakage of urine interferes with your How much does leakage of urine interferes with your everyday life! everyday life! 0 0 10 scales10 scalesNot at allNot at all a great deala great deal

OBS/GYN HISTORYOBS/GYN HISTORYMenstrual Menstrual Pelvic SurgeriesPelvic SurgeriesPregnancy Pregnancy DeliveryDeliveryPelvic radiotherapyPelvic radiotherapy

MEDICAL HISTORY:MEDICAL HISTORY:Chronic cough, constipationChronic cough, constipationCardiac problem / failureCardiac problem / failureRenal failureRenal failureEndocrine problemEndocrine problemNeurological problem (Parkinson, Neurological problem (Parkinson,

multiple) Sclerosis, spinal injury)multiple) Sclerosis, spinal injury)

DRUGS:DRUGS:

Sedatives , Diuretic,AnticholinergicsSedatives , Diuretic,Anticholinergics

Anxiolytics, Alcohol, Caffines,Anxiolytics, Alcohol, Caffines,

Tobacco…etcTobacco…etc

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

To check for aetiological conditions To check for aetiological conditions that may contribute to UI and that that may contribute to UI and that might affect the choice of might affect the choice of treatmenttreatment

I. I. General Exam:General Exam: Ht, & Wt Ht, & Wt BMI BMI

- Obesity, is a risk - Obesity, is a risk factor factor for UIfor UI Abdominal exam Abdominal exam

scars, distended scars, distended bladder, bladder, massesmasses Neurological examNeurological exam

Concentrating on Concentrating on sacral sacral segmentsegment

II.II. Perineal/Genital ExaminationPerineal/Genital Examination

1. Perineal skin for Excoriation and 1. Perineal skin for Excoriation and erythema due to incont.erythema due to incont.2. Stress test – 2. Stress test – coughcough3. Extra urethral incontinence3. Extra urethral incontinence

= urine leakage through = urine leakage through channels channels other than urethra other than urethra e.g. urogenital e.g. urogenital fistula (urethro-fistula (urethro-vaginal, vesico- vaginal, vesico- vaginal, vesico-uterine)vaginal, vesico-uterine)4. Assess bladder neck mobility, and 4. Assess bladder neck mobility, and

presence of pelvic organ presence of pelvic organ prolapse (POP) prolapse (POP) especially with especially with cough / straincough / strain5. Vaginal Exam:5. Vaginal Exam:

Assess pelvic muscle function for Assess pelvic muscle function for resting resting tone and pt’s ability to tone and pt’s ability to perform a pelvic perform a pelvic floor contraction floor contraction6. Rectal exam:6. Rectal exam:

Anal tone, pelvic floor function and Anal tone, pelvic floor function and the the consistency of stool. consistency of stool.

INVESTIGATIONS:INVESTIGATIONS:1.1. Standard Urine Analysis / reagent strip to R/O Standard Urine Analysis / reagent strip to R/O

UTI / microscopic heamaturiaUTI / microscopic heamaturia

2.2. Biochemical tests Biochemical tests Renal functionRenal function Prior to surgeryPrior to surgery

3 3 Postvoid Residue (PVR) Postvoid Residue (PVR) Ultrasound or catheterizationUltrasound or catheterization If > 30% of total bladder capacity (50-100 ml) = If > 30% of total bladder capacity (50-100 ml) =

significant significant

Pad testPad test 1 hr 1 hr / 24 h. test/ 24 h. test== Quantify urine lossQuantify urine loss

> 1 g> 1 g == +ve +ve 1 hr test1 hr test> 4 g> 4 g == +ve +ve 24 hr test24 hr test

URODYNAMICURODYNAMIC TESTTEST The only way to precisely define The only way to precisely define

bladder and urethral functionbladder and urethral function Allow characterization of Allow characterization of

pathophysiological aspects of the pathophysiological aspects of the various symptomsvarious symptoms

Help to determine the prognosis and Help to determine the prognosis and guide choice of therapeutic strategyguide choice of therapeutic strategy

1.1. UroflowmetryUroflowmetry::= measures urine flow rate= measures urine flow rate= Indicates outlet bladder obstruction= Indicates outlet bladder obstruction

2.2. CystometryCystometry ~~~~ FillingFilling~~~~ VoidingVoiding