Urinary incontinence aetiology and management.pptx

Urinary incontinence detailed explanation

1. Urinary Incontinence

2. Overall prevalence of female incontinence is reported at 38%, increasing with age from 20–30% during young adult life to almost 50% in the elderly It is estimated that 45.2%, 10.7%, 8.2%, and 21.5% of the 2008 worldwide population was affected by at least one lower urinary tract symptoms (LUTS), overactive bladder (OAB), urinary incontinence, and LUTS/bladder outlet obstruction (BOO), respectively.

3. The ICS defines the symptom of urinary incontinence as “the com- plaint of any involuntary loss of urine.” It is also recommended, when describing incontinence, to specify relevant factors such as Type, Severity, Precipitating factors, Social impact, Effect on hygiene and quality of life, Measures used to contain the leakage, and Whether or not the individual experiencing incontinence desires help.

4. Transient incontinence may occur after childbirth or during an acute lower urinary tract infection and usually resolved spontaneously. Chronic incontinence can result from a multitude of causes and is often persistent and progressive.

5. Scientific committee of the 4th International Consultation on Incontinence (Abrams et al, 2010). In principle, the committee recommends an initial management and a specialized management algorithm for all types of incontinence. The initial clinical assessment should include general, urinary, pelvic floor, symptom scores, quality of life, desire for treatment, physical examination, urinalysis, and postvoid residual urine. In initial assessment, one should identify the complicated incontinence group for specialized management. This includes recurrent or total incontinence, incontinence associated with pain, hematuria , recurrent infection, prostate irradiation, and radical pelvic surgery, suspected of fistula and significant postvoid residual.

6. The following groups are suitable for initial management: stress incontinence, urgency incontinence, and incontinence with mixed symptoms. The initial management consists of lifestyle intervention, bladder and pelvic floor muscle training, incontinence products and medications. Specialized management is recommended for patients who failed the above-mentioned managements or those with specialized conditions. The assessment includes imaging of urinary tracts, urodynamics, and cystourethroscopy, and more invasive treatments including surgery, neuromodulation, and prosthetics are recommended for these patients.

7. STRESS URINARY INCONTINENCE The ICS defines it as involuntary urine leakage on effort or exertion, or on sneezing or coughing. In men, stress incontinence is mostly due to surgery ( eg , after radical prostatec - tomy ) or trauma to the bladder neck/urethral sphincter. The causes of stress incontinence in women are more complicated and somewhat controversial. The vast majority of stress incontinence occurs in women after middle age (with repeated vaginal deliveries and obstructed labor ). It is usually a result of weakness/disruption of the pelvic floor muscle and ligaments leading to poor support of the vesicourethral sphincteric unit. An increase in urethral closure pressure is normally seen during bladder filling; when assuming an upright position; or in stressful events such as coughing, sneezing, or bearing down. During exertion, both passive pressure transmission from increased abdominal pressure and reflexic contraction of the sphincteric mechanism augment urethral resistance to prevent urine leakage.

8. Stress incontinence is thought to be caused by two major anatomical deficits: hypermobility of the sphincteric unit and intrinsic sphincter deficiency. In hypermobility, the assumption is that the intrinsic structure of the sphincter itself is intact. It loses closing efficiency because of excessive mobility and loss of support. Thus, the anatomic feature of stress incontinence is hypermobility or a lowering of the position of the vesicourethral segment (or a combination of the two factors). On the other hand, some women who have undergone multiple retropubic or urethral operations have a deficient intrinsic sphincteric mechanism characterized by an open bladder neck and proximal urethra at rest with minimal or no urethral descent during stress. Nevertheless, many women maintain normal continence with hypermobility, and a recent dynamic magnetic resonance imaging (MRI) study finds no correlation between perineal descent and patients’ symptoms of urinary incontinence ( Broekhuis et al, 2010). Therefore, contemporary opinion suggests that all women with stress incontinence have some degree of intrinsic sphincter deficiency.

9. Posterior vesicourethral angle. Axis of inclination, that is, the angle between the urethral line and the vertical plane. Relationship of the bladder base and the vesicourethral junction to the sacrococcygeal - inferior pubic point

10. Cystographic study (a lateral cystogram with a urethral catheter in place) is recommended. With the patient lying on the flat x-ray table, a lateral film is obtained, first at rest to determine the position of the vesicourethral segment in relation to the pubic bone and then with straining to ascertain its degree of mobility. Normally, the vesicourethral junction is opposite the lower third of the pubic bone and moves 0.5–1.5 cm with straining. This demonstration of abnormal position or excessive mobility of the vesicourethral segment is helpful in identifying the cause of existing urinary incontinence.

11. The urethral pressure profile is a measure of the activity of the external sphincter. A static profile demonstrates the resting tonus of both components of the sphincteric mechanism; a dynamic profile gives the responses of these sphincteric elements to various activities, such as an increase in bladder volume, assumption of the upright position, the prolonged stress of bearing down, or the sudden stress of coughing and sneezing. Normally, the urethral closure pressure—the net difference between the intraurethral and intravesical pressures—is maintained or augmented during stress. Electrical stimulation of the pelvic nerve induces contraction of the smooth muscle of the bladder and urethra while stimulation of the sacral nerve contracts smooth muscle of the bladder and urethra as well as striated muscle of the external sphincter

12. Petros and Ulmstem (1990) proposed that support of the anterior vaginal wall is provided by three separate but synergistic mechanisms: the anterior pubococcygeus muscle; the bladder neck; and the pelvic floor musculature, which acts like a hammock to help close the bladder neck during stress. Laxity of the anterior vaginal wall causes dissipation of all of three forces, resulting in stress incontinence. Delancey (1994) proposes that the stability of the supporting layer rather than the position of the urethra determines stress continence. During rises in intra-abdominal pressure, the urethra is compressed against the supporting structures, which act like a backboard and prevent loss of urine. The fact that both bladder neck and mid-urethral slings have been shown to be successful in treating stress incontinence supports the above-mentioned theories

13. A recent report of a clinical study concludes that low urethral closure pressure is the best predictor of SUI in women ( DeLancey et al, 2008). A MRI study also revealed that the striated urogenital sphincter in women with stress incontinence was 12.5% smaller than that in asymptomatic continent women (Morgen et al, 2009). A study on duloxetine, a serotonin and norepinephrine reuptake inhibitor, showed that it elevates both baseline urethral pressure (adrenergic innervation on the smooth muscle) and active pressure rise with sneezing ( Onuf ’ nucleus activated striated muscle contraction (Miyazato et al, 2008). These observations reaffirm the original observation by Tanagho that smooth muscle, striated muscle, and mucosa and submucosal vessels each contribute about one-third of the urethral closure pressure and all are important in sphincter function.

14. History Degree of leakage Relation to activity, position, and state of bladder fullness Timing of its onset Course of its progression. Knowledge of past surgical and obstetric history, Medications Dietary habits Systemic diseases ( eg , diabetes) Micturition diary that records the time of micturition, voided volume, and type of incontinence Pad test over 1 hour or 24 hours Degree of bother and effect on quality of life.

15. Physical examination Laxity of pelvic support Presence of any degree of prolapse, cystocele, rectocele, and mobility of the anterior vaginal wall. Neurologic examination should be done if neuropathy is suspected. The degree of hypermobility in women can also be assessed by a simple Q-tip test. This is done by inserting a well-lubricated sterile cotton-tipped applicator gently through the urethra into the bladder and then pulling it back to the level of the bladder neck. The angle from the horizontal at rest and after straining is recorded. Hypermobility is defined as a resting or straining angle >30° from the horizontal.

16. Urodynamic Characteristics The ICS defines urodynamic stress incontinence as the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction (Abrams et al, 2003). A. Urethral Pressure Profile Patients with stress incontinence have a low urethral pressure profile with reduced closure pressure. This factor varies with the severity of the sphincteric impairment. Not infrequently, this weakness of the pressure profile is not demonstrable when the bladder is relatively empty. It becomes more significant when the bladder has been distended. Also, the pressure profile may appear normal when the patient is in the resting (sitting) position; when he or she assumes the upright position in the dynamic pressure profile, the weakness becomes apparent.

17. B. Functional Urethral Length The anatomic length of the urethra is usually maintained, yet the functional length is shorter due to loss in the proximal urethral segment. Although it might not appear funneled on the cystogram, this segment has very low closure efficiency and its pressure is almost equal to intra- vesical pressure. The functional length, like the pressure profile, might appear normal when the bladder is not filled or the patient is in the sitting position.

18. C. Response to Stress With the sustained stress of bearing down or the sudden stress of coughing or sneezing, the net urethral closure pressure is reduced, depending on the degree of sphincteric weakness. In severe urinary stress incontinence, any strain or increase in intravesical pressure leads to urinary leakage. D. Voluntary Increase in Urethral Closure Pressure Patients with mild stress incontinence might be capable of activating their external sphincter maximally and generating a high urethral closure pressure. However, with progression of the anatomic problem and hypermobility, this voluntary increase progressively diminishes. E. Response to Bladder Distention and Change in Position The features might be normal in the resting position with minimal bladder filling, all of them can become aggravated with a full bladder or the upright position F. Abdominal Leak Point Pressure Abdominal leak point pressure (ALPP) is defined as the intravesical pressure at which urine leakage occurs because of increased abdominal pressure in the absence of a detrusor contraction (Abrams et al, 2003). This test assesses the intrinsic urethral function, and thus the lower the ALPP, the weaker the sphincter.

19. Treatment In mild and moderate cases, the ICS recommends Lifestyle interventions, such as weight loss caffeine reduction Pelvic floor muscle training Duloxetine (a serotonin and norepinephrine reuptake inhibitor). Electrical stimulation Urethral inserts and vaginal devices may also help some women.

20. If the initial management fails, the principal surgical treatment of female urinary stress incontinence is to provide proper support of the vesicourethral segment or the midurethra . The suprapubic approach - classic Marshall-Marchetti-Krantz (MMK) retropubic suspension described in 1949, in which periurethral tissue is attached to the back of the pubic symphysis. A modification was introduced by Burch in 1961, in which the anterior vaginal wall is fixed to Cooper’s ligament. The other approach is to suspend the bladder neck or support the midurethra with an abdominal or transobturator sling. Numerous sling materials are being used: for example, cadaveric fascia lata and various synthetic materials (TVT/TOT) Urethropexy- Pereyra , Stamey , Raz Colposuspension Injectable bulking agents – Collagen, Hyaluronic acid/ dextranomer gel, polydimethylsiloxane ( Macroplastique ), pyrolytic carbon-coated beads suspended in a water-based carrier gel ( Durasphere ®)