Evidence Based Facts on the Pathogenesis and Management of Stress Urinary Incontinence

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Evidence Based Facts on the Pathogenesis and
Management of Stress Urinary Incontinence
Prof. Abdel Karim M. El Hemaly MRCOG - FRCS
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• SUI is still a vastly existing world wide tedious
  and ambiguous problem despite the many theories
  put, trying to explain the pathogenesis of the
  condition and the big efforts done for its
  treatment.

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• SUI involuntary escape of urine, through the
  urethra, on sudden increase of intra abdominal,
  intravesical pressure e.g. coughing, laughing,
  jumping.etc

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• This name SUI, was given by Sir Eardly Holland
  in1923.
• Prof. Abdel Fattah Yousef named the condition
  Sphincteric incontinence However the name did not
  gain popularity because of the lack of evedince
  that SUI is due to sphincteric defect .

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Detrusor instability DI
SUI
Genuine SUI

• However the 2 conditions overlap
• Also surgical correction of genuine SUI corrects
  DI in almost half the patients

Urethral Hypermobility
Genuine SUI
Intrinsic sphincter deficiency ISD
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Urinary Continence depends on

• 1- Presence of the bladder neck and upper part
  of the urethra above the pelvic floor,
• 2- The direct influence of intra abdominal
  pressure on the proximal segment of the urethra,
  intra abdominal part of the urethra
• 3- Urethro vesical angle
• 4- The shape of the urethra, with its lack of
  funnelling

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Cont.. Urinary Continence depends on

• 5- The length of the urethra
• 6- Neuro vascular factors ( natural tone of
  the urethra vascular pattern )
• 7- Mucous membrane coaptation
• 8- Pelvic floor muscles especially the levtor
  ani

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Cont.. Urinary Continence depends on

• 9- Urethral Sphincters
• ?int
• ?ext.
• ?3rd midurethral
  sphincter.
• 10- Perivesical and periurethral fasciae.
• 11- Petros theory of urinary continence.

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SUI is attributed to many factors e.g.

• 1 - descent of the bladder neck and upper part of
  the urethra below the pelvic floor.
• But,
• SUI can be present in absence of genital
  descent.
• there may be Genital descent with no SUI
• 2- Loss of urethro vesical angle
• But,
• SUI is absent in spite of the absence of the
  UV angle
• SUI is present in spite of good UV angle

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Cont.. SUI is attributed to many factors e.g.

• 3- Funnelling of the bladder neck
• But,
• SUI is present in spite of absence of
  funnelling
• No SUI is detected with funnelling of the
  bladder neck
• 4- Shortness of the urethra
• But,
• Amputation of distal half of the urethra e.g.
  radical valvectomy for cancer vulva gt does not
  lead to SUI.
• 5- Intrinsic sphincter defect. ISD

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Surgical correction of SUI

• Surgical correction of SUI aims at
• 1- Elevation of the upper part of the urethra
• 2- Elongation of the urethra
• 3 Angulation of the urethra
• 4- Plication of the funnelled bladder neck
• 5- Periurethral injection of different
  materials
• 6- Recently, Artificial sphincter

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Surgical Correction of SUI can be summarized

• 1- Plicatory Operations
• e.g. Kelly, Kelly Kennedy
• 2- Vesico urethropexy
• Marshall Marchetti Krantz MMK
• 3- Vesico urethro lysis
• Mulvany

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Cont.. Surgical Correction of SUI can be
summarized

• 4- ColpoSuspension Burch
• Abdominal
• Laparoscopic
• 5- Long Needle bladder Neck Suspension (LNBNS)
  With or without endoscopic guidance
• e.g. Peryra, Stamey
• 6- Sling operations
• e.g Aldridge, TVT, IVS,.etc..

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Cont.. Surgical Correction of SUI can be
summarized

• 7 - Peri urethral injections
• e.g. Teflon, Fat, Collagen,
• 8 - Artificial sphincter

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Recently, In 1996 we put forward a new concept,
based on evidence explaining the act of
micturition and urinary continence.
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Micturition can be divided into 2
stages Stage-I in Infancy before training of
micturition. Stage-II in childhood after
training of the act of micturition (how to
control).
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• Stage-II the mother starts to train her infant
  at the age of 18-24 months how to control
  micturition. This is gained by acquiring high
  alpha sympathetic tone at the inernal sphincter
  closing it all the time except on need and /or
  desire.

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Urinary continence depends on

• 1- An acquired behavior gained by learning in
  early childhood to keep a high alpha sympathetic
  tone in the internal urethral sphincter keeping
  it closed all the time except on need and/or
  desire.
• 2- An intact and strong internal urethral
  sphincter.

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The structure of the internal urethral sphincter

• It is mainly a cylinder composed of compact
  collagenous tissue. It extends from the bladder
  neck down to the external urethral meatus.

It is lined by urothelium. The muscle fibers
intermingle with the collagenous fibers in the
middle part The muscle layer is controlled by
alpha-sympathetic nerves T10-L2.
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Evidence Based Facts that prove the presence of a
high alpha sympathetic tone in the internal
urethral sphincter.
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Urethral pressure under basic conditions is 95 cm
water
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Urethral pressure 5 minutes after phentolamine,
alpha blocker (Regetine, Ciba- Geigy Switz )
dropped to 76 cm water.
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Urethral pressure after nor adrenaline
infusion (Levophed, Sanofi Wintrop UK) elevated
to 93 cm water
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Evidence Based Facts that Demonstrate the
Structure of the Internal Urethral Sphincter
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• Post mortem specimen of the int. u. sphincter and
  the vagina (MTC stain) (X40)

Pelvic floor m. External Urethral Sphincter
Vagina
Internal urethral sphincter
Collagenous tissue cylinder extending from
urothelium to the outside
Urethral Lumen
Smooth Muscle fibres overlying and intermengling
with the collagenous tissue cylinder
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• Post mortem specimen of the int. u. sphincter and
  the vagina (H E) (X40)

Vagina
Internal urethral sphincter
Collagenous tissue cylinder extending from
urothelium to the outside
Urethral Lumen
Smooth Muscle fibres overlying and intermengling
with the collagenous tissue cylinder
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NORMAL INTERNAL URETHRAL SPHINCTER
U.B.
U.B.
Closed urethra due to a strong, intact int. u.
sphincter
3-D. ULTRASONOGRAPHY
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3D U.S. Cross section
Closed lumen
Intact wall, compact sheet of collagenous tissue
with muscle fibers lie on and intermingle with
the collagen fibers In the middle part of the
sheet
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MRI picture of a normal continent woman
Urethra
Urethral lumen
Vagina
Muscle layer
Collag. tissue layer
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MRI picture of a normal continent woman
U.B.
Uterus
Post. Wall of Ureth.intimatelt relate to ant.
Vag. wall
Vagina
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• Accordingly voiding troubles could be better
  understood and treated e.g.
• - Nocturnal Enuresis
• - Detrusor Instability
• - SUI

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• Stress Uinary Incontinence is a result of a weak,
  damaged internal urethral sphincter.
• The damage affects mainly the collagenous tissue
  layer.
• The damage is mostly traumatic .

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TRAUMA
URETHRAL PRESSURE
RUPTURE
WEAKNESS
ATROPHY
CONFIGURATIONAL CHANAGES
1-INFECTION 2-HORMONE DEFICIENCY
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RUPTURE IN THE INTERNAL URETHRAL SPHINCTER
1-Affect the whole length Shortening of the
functional urethral length. Irregular in
shape. 2- Affect the upper part only loss of
urethro-vesical angle ( Funnelling). urethral
hypermobility. 3- Affect the lower part
only Flask-shape on 3-D ultrasound
SUI DI
SUI /or DI
Genuine SUI
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Evidence Based Facts that Prove The Pathogenesis
of SUI.
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Rupture Affect the whole length Irregularity and
shortening of the urethra
U.B.
Wide Urethral lumen with weak torn walls Of the
Int. U. Sphincter
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Urethral lumen wide and irregularly dilated.
Large defect, sonolucent areas.
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( A )
( B )
MRI of normal internal urethral sphincter A
compared to a torn internal sphincter in a
patient with SUI B
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MRI Picrure of a patient with SUI
Torn post wall of the int. U sphincter with the
ant. Vag. wall
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• Post mortem specimen of the int. u. sphincter and
  the vagina in a patient with SUI. (H E) (X4)

Vagina
Internal urethral sphincter
Urethral Lumen
Loose and torn collagenous tissue layer
Smooth Muscle fibres overlying and intermengling
with the collagenous tissue cylinder
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Comparison between Int. U. Sphincter in Normal
and SUI Patients (H E) (X40)
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Surgical specimens of Int. U. Sphincter (MCT
stain) (X40)
Compact collagenous tissue of a normal sphincter
Loose and torn collagenous tissue of an Int. U.
Sphincter in a patient with SUI
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Consequently, Urethro-raphy a new operation for
treatment of stress urinary incontinence was
innovated
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Low urethral pressure, 42 cm water in a patient
with SUI preoperative.
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Urethral pressure elevated to 76 cm water after
urethro-raphy
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CONCLUSION

• Evidence Based Facts prove that SUI is a sequel
  of a weak internal urethral sphincter, which
  cannot resist a sudden increase of intra
  abdominal pressure, and will lead to leakage of
  urine.
• This will initiate an immediate reactive
  sympathetic activity preventing further leakage
  of urine.

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• The weakness of the internal urethral sphincter
  is mostly caused by traumatic rupture of its
  wall.
• Urethro-raphy, aims at repairing the torn wall
  to restore the high wall tension and increase the
  urethral pressure, so it can resist sudden
  increase of intra abdominal pressure.
• This is achieved by demonstrating properly the
  torn wall and approximating the torn edges
  together by simple sutures using slowly
  absorbable material e.g. braided polyglycan.

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• There is no post operative voiding troubles, nor
  there is post voiding residual urine as seen
  after plicatory and sling operations.
• Urethro-raphy is a simple vaginal operation whish
  is completely different from Kelly and
  Kelly-kennedy operations in the aim of the
  operation, the pathogenesis of the condition, the
  operative technique and the post operative
  conditions and results.

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• Authors
• Abdel Karim M. El Hemaly, Nabil Abdel Maksoud,
  Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar,
  M. A. K El Hemaly and Bahaa E. El Mohamady M.
• Ob. Gyn. dept. Faculty of medicine Al Azhar
  University
• corresponding author e mail m_hemaly_at_hotmail.co
  m
• department of pathology

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ThankYou