Urine incompet

Urinary incontinence simply means involuntary leaking of urine.

Incontinence can range from leaking just a few drops of urine to complete emptying of the bladder.

Social and hygienic problem.

1. Urinary ncontinence

2. Definition Urinary incontinence  simply means involuntary leaking of urine . Incontinence can range from leaking just a few drops of urine to complete emptying of the  bladder . Social and hygienic problem .

3. Prev ᵃ l e nce Incidence: increases with age: 4-8 % ultimately seek medical attention. One of three women over 60y has bladder control problems.

4. Mechanism Continence and urination involve balance between urethral closure and detrusor (bladder smooth muscle) activity. Urethral pressure normally exceed bladder pressure, resulting in urine remaining in the bladder. Intra-abdominal pressure increases (coughing, sneezing) normally are transmitted in both urethra and bladder equally, maintaining continence. Disruption of this balance leads to various types of incontinence.

5. causes Urinary tract infection (UTI) —UTIs sometimes cause leakage and are treated with  antibiotics . Diuretic  medications, caffeine, or alcohol—Incontinence may be a side effect of substances that cause your body to make more urine. Pelvic floor disorders —These disorders are caused by weakening of the muscles and tissues of the  pelvic floor  and include urinary incontinence,  accidental bowel leakage , and  pelvic organ prolapse . Constipation —Long-term constipation often is present in women with urinary incontinence, especially in older women. Neuromuscular problems —When nerve (neurologic) signals from the brain to the bladder and  urethra  are disrupted, the muscles that control those organs can malfunction, allowing urine to leak. Anatomical problems —The outlet of the bladder into the urethra can become blocked by bladder stones or other growths.

6. What other symptoms occur with urinary incontinence? It is common for other symptoms to occur along with urinary incontinence: Urgency !! — Having a strong urge to urinate Frequency —Urinating (also called voiding) more often than what is usual for the patient Dysuria —Painful urination Nocturia —Waking from sleep to urinate Nocturnal enuresis —Leaking urine while sleeping

7. Diagnosis (6 basis components) ▲ History - severity of symptoms, rule out medication cause, stress correlates with amount of urine loss . ▲ Physical examination; General examination Neurologic screening examination –reflexes Urogynecologic examination: may reveal severe vulvar excoriation from continual dampness. Vaginal tissue atrophy, stenosis.. The patient is asked to cough or Valsalva repeatedly with a full bladder in the lithotomy or standing position to induce urine leakage. ▲ Urinalysis and urine culture . To rule out inf before further evaluation. ▲ Residual urine volume after voiding. Catheterization ▲ Frecuency – volume bladder chart.,,, ▲ Urodynamics : Cystometry , Uroflowmetry , Complex urodynamic tests .

8. Urodynamics Simple cystometry involves placing a catheter and gradually filling the bladder with sterile water. Involuntary “ detrusor ” contractions are demonstrated by a rise in water level during filling due to back-pressure. Normally, the first sensation to void occurs at 150 mL and bladder capacity is typically 400–600 mL . Uroflowmetry is used to determine the urinary flow rate and flow time to screen for the presence of outflow obstruction and abnormal detrusor contractility. Normally, women achieve a peak flow rate of 15–20 mL /s with a voided volume of 150–200 mL . Complex urodynamic testing requires placement of an intravesical catheter to measure detrusor pressures and a vaginal or rectal catheter to indirectly measure intraabdominal pressures.

9. types of urinary incontinence Stress urinary incontinence (SUI) Urge incontinence Overflow incontinence

10. Stress urinary incontinence (SUI) Patients have loss of small amounts of urine with coughing, laughing, sneezing, exercising, or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder. Etiology Physical changes resulting from pregnancy, childbirth, and menopause often result in weaknesses in the pelvic floor, and urethral support structures and nerve damage

11. Stress urinary incontinence (SUI) Mechanism . If the fascial support is weakened, the urethra can move downward at times of increased abdominal pressure, causing bladder pressure to exceed urethral sphincter closure pressure (hyper- mobile urethra). Incomplete urethral closure may be due to scarring or neuromuscular damage, and cause a more severe form of stress urinary incontinence – intrinsic sphincter deficiency. Diagnosis . SUI is suggested by history, physical examination, and a positive stress test (demonstrable loss of urine while the patient is being examined ).

12. Non-surgical treatment . lifestyle changes Weight Loss; fluid intake Management; Limiting alcohol and caffeine; Bladder training. pelvic muscle ( Kegel ) exercises biofeed -back (pressure measurement device notifies the patient when correct muscle contraction is performed and reinforces correct technique) pessaries

13. pelvic muscle ( Kegel ) exercises Find the right muscles.  To identify your pelvic floor muscles, stop urination in midstream. If you succeed, you've got the right muscles. Once you've identified your pelvic floor muscles you can do the exercises in any position, although you might find it easiest to do them lying down at first. Perfect your technique.  Tighten your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds. Try it four or five times in a row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions. Maintain your focus.  For best results, focus on tightening only your pelvic floor muscles. Be careful not to flex the muscles in your abdomen, thighs or buttocks. Avoid holding your breath. Instead, breathe freely during the exercises. Repeat three times a day.  Aim for at least three sets of 10 repetitions a day.

14. Surgical treatment Tension-free transvaginal tape (TVT) or transobturator tape (TOT) are minimally invasive suburethral sling procedures that are rapidly becoming the “gold standard” Burch colposuspension Anterior colporrhaphy Collagen periurethral

15. Urge incontinence Patients experience involuntary leakage for no apparent reason while suddenly feeling an urgent need to urinate . This may be accompanied by urinary frequency and nocturia , and patients often describe their bladder as “spastic” or “overactive”. Etiology . Involuntary detrusor muscle contractions. Detrusor hyperactivity can be due to loss of central nervous system (CNS) inhibitory pathways, local irritants, or bladder outlet obstruction. Mechanism . Frequently idiopathic, but results from damage to the nerves of the bladder, the nervous system (spinal cord and brain), or the muscles themselves.

16. Urge incontinence Treatment . Behavior modification (bladder drills, biofeedback) and/or pharmacologic therapy ( oxybutynin chloride, imipramine , mirabegron ), injection of the detrusor muscle with botulinum toxin A, neuromodulation .

17. Overflow incontinence Patients experience continuous, unstoppable dribbling of urine , or continuing to dribble for some time after they have passed urine . Etiology . The bladder is always full and overflows, resulting in frequent or continuous urine leakage.

18. Overflow incontinence Mechanism . Weak bladder detrusor muscles, resulting in incomplete emptying, or a blocked urethra (outflow obstruction) due to pelvic organ prolapse , or after an anti-incontinence procedure that has overcorrected the problem. Treatment . Catheter drainage, followed by treatment of the underlying condition.

19. pelvic organ prolapse Descent of one or more pelvic organs (uterine cervix, vaginal apex, anterior vagina, posterior vagina, or cul de sac peritoneum) through the pelvic flor into the vaginal canal. ½ of parous women have prolapse on examination 10% will undergo surgery for prolapse or urinary incontinence in their lifetime Prolapse is the most common indication for hysterectomy in women after age 55.

20. Cystocele Surgical options Anterior colporrhaphy involves vaginally plicating the endopelvic fascia in the midline to provide support and raise the bladder to correct its anatomic position. Paravaginal repair replaces the anterolateral vaginal wall to its anatomic position. The McCall culdoplasty shortens the uterosacral ligaments and reattaches them to the vaginal apex.

21. Rectocele Surgical options Posterior colporrhaphy mimics the anterior procedure with a midline plication of endopelvic fascia. Perineorrhaphy is commonly required due to an attenuated perineal body or widened genital hiatus. Enterocele Surgical options As an enterocele is a true herniation of the peritoneal cavity at the pouch of Douglas which bulges into the rectovaginal septum, repair is usually performed at the same time as posterior colporrhaphy . The hernia sac is visualized as the vagina is separated from the rectum and it must be dissected free of underlying tissue. The neck of the hernia is then isolated and sutured. Fixing the uterosacral ligaments to the sac will help prevent recurrence.

22. Uterine procidentia ( Prolapse ) Surgical options TVH is common, but anterior and posterior colporrhaphy generally do not provide sufficient long-term apical support Sacrospinous ligament suspension (SSLS) may be concomitantly performed vaginally by suspending the fascia of the apex to one or both ligaments. Abdominal sacrocolpopexy with total abdominal hysterectomy (TAH) is another reasonable option that has less apical failure, post- operative dyspareunia , and stress incontinence than SSLS, but is associated with longer surgical time, longer patient recovery, and more short- and long-term complications. Laparoscopic and robotic-assisted techniques are the preferred option due to reduced recovery times. Colpocleisis ( Lefort procedure

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