Urinary incontinence in the female

1. Definition

2. Stress incontinence

3. Prevalence

4. Pathophysiology

5. Causes

6. Clinical presentation

7. Physical examination

8. Investigations

9. Management- Genuine stress

incontinence Detrusor instability

Definitions

Involuntary loss of urine which is objectively demonstrable & is a social or hygienic problem.

Stress incontinence: Involuntary expulsion of urine under conditions of stress like rise of intra-abdominal pressure due to coughing, sneezing , laughing or lifting weights.

Prevalence

Upto 57% in women 45-64 yrs.14% in general population.Common condition, but rarely life

threateningAdverse effect on quality of life Embarrassment and anxiety.

Pathophysiology of stress incontinence

1. Intravesical pressure exceeds urethral pressure because of weakness of urethral sphincter mechanism i.e. Genuine Stress Incontinence

2. Detrusor pressure excessively high i. e. Detrusor Instability or Hyper-reflexia of Bladder.

Causes of urinary incontinence

1. Genuine stress

incontinence- congenital weakness of bladder neck, denervation of sphincter mechanism of pelvic floor (during delivery), estrogen deficiency in menopause etc.

2. Detrusor instability

3. Retention with overflow incontinence

4. Urogenital fistula

5. Temporary – UTI, drugs-α-blockers.

6. Urethral diverticulum

Causes (contd…)

7. Congenital abnormalities- ectopic ureter, bladder exstrophy etc.

8. Functional /neurologic disorders- dementia, spinal lesions, space occupying lesions in brain etc.

Clinical presentation

Stress incontinence- most common.

Associated features- urgency, frequency, dysuria, urge incontinence, voiding difficulties- poor stream, straining, incomplete emptying.

Detail history- prolapse, obstetric history, recurrent UTI, episodes of retention etc.

H/O diabetes, drugs –diuretics, α-blockers etc.

Neurological symptom

Physical examination

With full bladder in stress incontinence. Local- excoriation of vulval skin. Atrophic changes, cystocele, prolapse. Bladder neck elevation test(Marchetti test)- To

see whether surgery will benefit or not. Mental state, developmental anomalies,

neurological examination.

Investigations

General

i. Urine- (MSU)Routine/microscopy, c/s

ii. Frequency/volume chart or urinary diary.

iii. Pad test.

Basic Urodynamics

i. Uroflowmetry- 15-25ml/sec

ii. Cystometry- differentiate betn GSI &DI- Intravesical pressure during filling , if > 15cm water after 250 ml DI

Investigations (contd…)

Residual urine- <5oml. First sensation of urge

~250ml. If earlierurge incontinence.

Bladder capacity- 500-600ml. If increasedneurologic disease.

Videocystourethrography Combines cystometry,

uroflowmetry & radiological screening of bladder & urethra.

Most informative, but expensive/time consuming.

Special investigations

Metallic bead chain urethrocystogram

Urethral pressure profilometry.

Cystourethroscopy. Micturition cystography

USG- position & excursion of bladder neck.

Electromyography of pudendal nerve.

Urethral electric conductance.

Management of GSI

Conservativea. Kegel’s exercises of pelvic floor muscles.b. Wt. Reduction in obese patients.c. Treat chronic cough, UTI.d. Faradism- interrupted current to stimulate

muscles & nerves.e. Drugs- Estrogen, α adrenergic agonists-

phenylpropanolamine.

Management (contd..)

Surgical 90% cure rate. Elevate bladder neck & proximal urethra into

intra-abdominal position, support the bladder neck.

a. Anterior colporrhaphy with Kelly suture.b. Marshall-Marchetti-Krantz operation-

suprapubic approach.

Surgical management (contd…)

c. Burch colposuspension.

d. Pereyra procedure.

e. Sling procedures- secondary- Stamey, Raz

f. Artificial sphincter implant.

g. GAX-collagen- periurethral injection.

h. Urinary diversion- Last.

Detrusor Instability

Spontaneous or provoked detrusor contractions during the filling phase when the pt. Is attempting to inhibit micturition.

Urgency, urge incontinence, enuresis, frequency.

No specific clinical signs.

Management of DI

1. Behavioral interventions.

2. Drugs- most widely used- anticholinergic agents- oxybutynin, propantheline., calcium channel blocker- terodiline, Tricyclic antidepressant-imipramine, αadrenergic stimulants., estrogen, synthetic vasopressin.

3. Denervation- phenol injection, bladder transection, vaginal denervation, sacral neurectomy.

4. Cystoplasty- clam ileocystoplasty.