Stress Incontinence

Dr. swati singh Registrar

Introduction Incidence Anatomy / Physiology Types of Incontinance Aetiology Management Conclusion

INTRO DUCTI ON Cont ine nce i s th e abi li ty t o p as s uri ne or fa ece s volu nt ar il y i n a s oci all y a cc ept abl e .pl ace :T he cont in ent pe rson can reco gni ze t he need

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identi fy the co rrec t pl ace  hol d on un ti l he r eaches the corr ec t p la ce

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to pa ss uri ne or fa ece s  Inconti nenc e - i nvol unt ar y l oss of ur in e whi ch is obje ct ively demons tra ble & it is s oci al . and h ygi eni c p robl em

INCIDENCE Urinary incontinence - not a recent

medical or social phenomena. Disorders of urinary tract written in ancient times. 1 in 3 female age 55 or more complain of incontinence. 1 in 10 women will have surgery for prolapse or SI in life time. One third will need further surgery.

Physiology of Micturition • Bladder innervation: somatic, parasympathetic (PSN) and sympathetic (SNS) • ~150-300 ml in bladder before the brain recognizes bladder fullness

Physiology of Micturition

Physiology of Micturition 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 Pudendal nerve is inhibited → external •

PHYSIOLOGICAL ANATOMY The bladder neck and upper third or half of

the urethra are above the level of the pelvic floor. The internal urethral sphincter :Is an

involuntary muscle which surrounds the bladder neck.

PH YSIOLOG IC AL A NAT OMY The external urethral sphincter :

is a voluntary muscle found between the superficial and deep perineal membranes and surrounds the middle part of the urethra compessor urethrae muscle

The external urethral sphincter It empties the urethra after the act of

micturition,

Interrupts the flow of urine on desire

It acts as a secondary defensive

mechanism against escape of urine.

PH YSIO LOG ICAL ANA TOMY

At rest the urethra makes an angle of 90-

100 degrees with the base of the urinary bladder called the posterior urethrovesical angle. The urethra also makes an angle of less than 30 degrees with the vertical line.

TYPES: 1. True incontinence. 2. False incontinence 3. Stress or sphincter incontinence. 4. Urge incontinence (precipitancy-detrusor

instability or detrusor dyssynergia).

5. Nocturnal enuresis.

Incidence of Subtypes of Urinary Incontinence in Women

Stress Incontinence

50% Urge Incontinence

20%

STRESS INCONTINENCE )SPHINCTER INCONTINENCE-GENUINE STRESS INCONTINENCE

It is involuntary escape of few drops

of urine with increased intraabdominal pressure as during straining, sneezing, coughing, laughing ... etc.

DEGREES OF STRESS INCONTINENCE Grade I Incontinence occurs only with severe stress, such as coughing, sneezing, etc … Grade II Incontinence with moderate stress, such as rapid movement or walking up and down stairs Grade III Incontinence with mild stress, such as

TYPES OF STRESS INCONTINENCE

Type 1 : There is complete loss of the posterior urethrovesical angle. Type 2 : There is complete loss of the posterior urethrovesical angle together with increase in the angle between the urethra and vertical line to be more than 30 degrees.

AETIOLOGY Weakness of the internal urethral sphincter or Descent of bladder neck below the level of the

pelvic floor. Congenital weakness of the internal urethral

sphincter, seen in the young nullipara. Congenital defects as:

Epispadias, Short urethra (less than 1 cm), Wide bladder neck, and Separation of symphysis pubis.

AE TIOLOG Y 3. Tr auma to the region of the bladder

neck due to vaginal delivery or operation. In fact vaginal delivery is the commonest cause of stress incontinence.

4. Pr egn an cy and continuous administration of oestrogen-progestogen preparation to induce psuedopregnancy state to treat endometriosis. The hormonal imbalance with increased progesterone weakens the internal urethral sphincter.

AE TIOLOG Y 5.

Menopa use: Lack of oestrogen leads to atrophy of bladder neck supports.

6. Genit al pro la ps e: 7. Orga nic ne rvous dis eases as disseminated sclerosis.

Pathophysiology of Stress Incontinence The basic pathology is urethral incompetence. This can be either due to:

Urethral hypermobility 90% of patients)

(80 -

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

A) Urethral hypermobility

(80 - 90% of patients)

 This results from loss of the normal 2. 3. 4. 5. 6.

pelvic support mechanism of the bladder and urethra due to: Trauma and repeated vaginal delivery Hysterectomy Hormonal changes ( Menopause) Pelvic denervation Congenital weakness

Dysfunction (10 - 20% of patients)  This results from damage to the sphincter

due to: Multiple prior operations Trauma Radiation Neurogenic disorders including Diabetes Mellitus Atrophic changes: lack of estrogen.

1. A detailed history differentiates between the

different types of incontinence. 2. Stress incontinence and detrusor instability frequently occur together. 3. Gradual onset after menopause suggests oestrogen deficiency. 4. History of vaginal repair or operation in the region of the bladder neck and history of any neurologic disease.

Urinalysis and urine culture help to

diagnose urinary tract infection. Bloo d tes t is required know the

compromised renal function, diabetes, syphilis, or other systemic diseases are suspected.

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

are separated, and the patient is asked to cough. If urine escapes, the patient is incontinent. If no urine escapes, the test is repeated while the index and middle fingers in the vagina press on the perineum to abolish reflex contraction of the levator ani muscles during straining. If still no urine escapes, the test is repeated while the patient is standing with the legs separated.

Bonney test It is indicated in case of a positive stress

test associated with a cystocele. To know if incontinence is due to descent of bladder neck or weakness of the sphincter. The index and middle fingers are placed on both sides of the urethra to elevate the bladder neck upwards. If no urine escapes on stress it means that the incontinence is due to descent of the bladder neck, but if urine still escapes

You sef Tes t Indicated in case of a negative stress test

associated with a large cystocele to diagnose hidden stress incontinence. The cystocele is reduced, the cervix is grasped with a volsellum and pushed upward, then the patient is asked to cough. If urine escapes, it indicates that the patient was continent because of kinking of the urethra.

The Cotton-Tip Applicator (Q-Tip) Test A sterile applicator with a small piece of cotton

at its tip is introduced to reach the bladder neck. The angle between the applicator and the

horizontal is measured. The patient then strains maximally using the

Valsalva manoeuvre. This causes descent of the bladder neck and

upward movement of the applicator producing a

(Q-Tip) Test

In normal patients the increase in

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

more than 30 degrees indicating poor support and abnormal descent of bladder neck The test is positive in more than

Cy stou re throg raphy A radio-opaque dye is injected by a

catheter into the bladder. On straining, the lateral view will show

absence of the posterior urethrovesical angle in more than 90% of cases. Funneling of the bladder neck in the

antero-posterior view may be seen in some cases.

Urodynamics 1.Cystometrogram( most important test), Filling Cystometry and Voiding Cystometry 2. Electromyography 3. Uroflometry 4. Urethral pressure profile : significant lowering of urethral closure presure during strain

Measurement of Urethral Length Stress incontinence

occurs if the length is less than 1 cm.

Transvaginal ultrasound When damage affects the upper part of the

sphincter, the urethra appears shaped".

"funnel-

When damage affects the lower part, the

urethra appears "vase-shaped".

When damage affects the whole length of the

sphincter, the urethra appears short and irregular.

laboratory tests Postvoid residual urine

After the patient voids, there should be less than 50 ml of urine in the bladder ( measurements greater than 100-200 ml) may have an underlying neurologic disorder.

Tests are most helpful in differentiating between GSI and DI

Cy st ometr ogram Cy st osc opy :

should be performed especially in patients with: irritative bladder symptoms such as urgency, frequency, and hematuria To rule out: 5. inflammation, 6. tumors, or 7. anatomic deformities

1. During labour, the bladder should be kept empty. 2. Episiotomy is performed if necessary. 3. Physiotherapy. Pelvic fl oor exercis es are started after delivery. These include repeated stoppage of the urinary stream during micturition and repeated contractions of the pelvic floor muscles.

Conse rv ati ve (n on-su rgi cal ) Tre atmen t Indications: 1.Mild stress incontinence 2.Patient is unfit for surgery or refuses surgery. 3.When stress incontinence is combined with detrusor instability. Conservative treatment cures or improves 50% of cases and include: 1.Physiotherapy: Kegal perineometer may be used.

2. Faradic current stimulation of the

levator ani muscles to improve their tone. 3. Vaginal cones: A set consists of 5 or 9 cones. Weight ranges from 20 to 100 grams. Patient inserts the cone in the vagina and keeps it for 15 minutes twice daily. If this succeeds she inserts the next cone. This improves the tone of the pelvic floor muscles.

4.Oestrogen therapy for menopausal patients: It causes thickening of the urethral mucosa and engorgement of the underlying blood vessels 5. Alpha-adrenergic stimulants: which stimulate contraction of the internal urethral sphincter, e.g. ephedrine. 6.Large vaginal diaphragms, Hodge pessary to elevate ' and support the

7. Reduction of weight in obese patients to reduce intra-abdominal pressure. 8. Stop caffeine (to avoid diuresis) and smoking (to avoid coughing) 9. Injection of Teflon or bovine collagen in the submucosal layer in the region of the bladder neck. This leads to narrowing of the

urethral lumen and increased urethral

Surg ica l Treatmen t Urethroplasty (Kelly,Kennedy,etc….) Urethropexy (Retropubic urethropexy e.g. MarshallMarchetti-Krantz, etc….) Colposuspension (Burch operation, Preyera) Urethral slings (Aldridge operation, etc) Tension free Vaginal Tape (TVT)

CONCLUSION: • Urinary incontinence is a common problem, causes

distress to a large no of female population.

• Current diagnosis and management involves good

understanding of the condition.

• Therapy for UI is often long term and requires pt

explanation of pathology.

• In future, further understanding of pathophysiology

of condition may lead to further advances.