Urinary Incontinence Khalid A. Yarouf 4MedStudents.com

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Urinary Incontinence

• Khalid A. Yarouf

4MedStudents.com
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Outline

• Anatomy of lower urinary tract.
• Factors influencing bladder behavior.
• Continence control.
• Classification of incontinence related issues
  for each type.
• Case.

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Anatomy of lower urinary tract

• Bladder detrusor muscle
• smooth muscle that appears as a meshwork of
  fibers.
• has 3 distinct layers outer longitudinal, middle
  circular inner longitudinal.
• Urethra in adult female
• Muscular tube 3-4 cm in length.
• Surrounded mainly by smooth muscle.
• Striated urethral sphincter
• surrounds middle third of urethra.
• contributes about 50 of total urethral
  resistance serves as 2º defense against
  incontinence.

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Cont Anatomy

• Innervation
• Parasympathetic fibers
• Originate in sacral spinal cord segments S2 thru
  S4.
• Stimulation / administration of cholinergic
  drugs
• ? detrusor muscle contraction.
• Anti-cholinergic drugs
• ? ? vesicle pressure ? bladder capacity.

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Cont Anatomy

• Sympathetic fibers
• Originate from thoraco-lumbar segments (T10 thru
  L2) of spinal cord.
• Have a ß-adrenergic components
• a-adrenergic stimulation
• ? contracts bladder neck urethra relaxes
  detrusor.
• ß-adrenergic stimulation
• ? relaxes urethra detrusor muscle.

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Factors influencing bladder behavior

• Sensory innervation
• Afferent impulses from bladder, trigone, proximal
  urethra ? pelvic hypogastric nerve ? S2 thru S4
  levels of spinal cord.
• Sensitivity of these nerve endings may be
  enhanced by
• Acute infection.
• Interstitial cystitis.
• Radiation cystitis.
• Intra-vesical pressure in
• Standing / bending forward position.
• a/w obesity, pregnancy, pelvic tumors.

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Cont

• Inhibitory impulses relayed by pudendal nerve ?
  also pass thru S2 thru S4 following mechanical
  stimulation of perineum anal canal.
• Their passage may explain why pain in this region
  can cause urinary retention.
• CNS Mental, environmental sociologic
  disturbances may profoundly alter micturition
  patterns.

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Continence control

• Normal bladder holds urine because intra-urethral
  pressure exceeds intra-vesical pressure.
• Pubo-urethral ligaments surrounding fascia
  support urethra so that abrupt ? in
  intra-abdominal pressure is transmitted equally
  to bladder proximal third of urethra ?
  maintaining a pressure gradient b/w the two. In
  addition, a reflex contraction of levator ani
  compresses mid-urethra.
• 50 of young, healthy women occasionally
  experience some degree of urinary incontinence.

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Definition of urinary incontinence

• Involuntary loss of urine that is objectively
  demonstrable is a social / hygienic problem.
• Affects 10-25 of women lt 65, 15-30 of
  non-institutionalized women gt 65 years, gt50 of
  nursing home residents.
• Pts often rely on absorbent pads / changes in
  their life style to cope with the condition.
  They become socially isolated as a result of
  restricting their interactions with friends
  family members.

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Classification of incontinence

• Stress
• Involuntary loss of drops of urine thru intact
  urethra, with sudden ? in intra-abdominal
  pressure in absence of bladder contraction.
• Causes
• Weakness of pelvic floor musculature (due to
  child bearing, previous abdominal/pelvic
  surgery).
• Damage / weakness of urethra or sphincter (e.g.
  hypo-estrogen of menopause, child bearing).

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Cont Classification (Stress)

• Mechanism
• Proximal urethra drops below pelvic floor because
  of pelvic relaxation defects ? ? intra-abdominal
  pressure is not transmitted equally to bladder
  proximal urethra i.e. bladder pressure gt
  abdo pressure.
• Degrees
• Grade I ? incontinence with severe stress
  (sneezing, coughing, jogging).
• Grade II ? incontinence with moderate stress
  (rapid movement, waking up down stairs).
• Grade III ? incontinence with mild stress
  (standing up).

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Cont Classification (Stress)

• Dx
• Hx age, PMHx (previous abdo/pelvic surgery),
  obstetric ( of deliveries).
• Pelvic exam
• Inspection of vaginal walls with Sims speculum ?
  allows visualization of anterior vaginal wall
  urethro-vesical junction.
• Scarring, tenderness, rigidity of urethra from
  previous vaginal surgeries / pelvic trauma may be
  reflected by scarred anterior vaginal wall.
• Because distal urethra is estrogen-dependent, pt
  with atrophic vaginitis also has atrophic
  urethritis.

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Cont Classification (Stress)

• Ix
• Stress test ? objective test
• Pt is examined with full bladder in lithotomy
  position. While physician observes urethral
  meatus, pt is asked to cough. (?????)
• Stress type is suggested if short spurts of urine
  escape simultaneously with each cough. If this is
  demonstrated, then elevate bladder neck with one
  finger on either side of urethra (Bonney test) or
  with partially opened Allis clamp
  (Marshall-Marachetti test) to prevent leakage of
  urine on coughing.
• Delayed leakage / loss of large volumes of urine
  ? suggests uninhibited bladder contractions.
• If not demonstrated ? repeat with pt in standing
  position.

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Cont Classification (Stress)

• US ? to check
• Inclination of urethra.
• Flatness of bladder base.
• Mobility funneling of urethra-vesical junction,
  both _at_ rest with Valsalva maneuver.
• Bladder / urethral diverticula.

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Cont Classification (Stress)

• Urethro-cystoscopy ? performed pre-operatively to
  observe
• Amount of residual urine.
• Bladder capacity (normal 400-500 mL of water).
• Appearance of urethral bladder urothelium,
  noting any inflammation, diverticula, or
  trabeculation.

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Cont Classification (Stress)

• Urodynamic studies
• Cystometrogram differentiates b/w stress
  uninhibited detrusor contraction
• Distend bladder with known volumes of H2O / CO2 ?
  observe pressure changes in bladder during
  filling.
• Pt is asked about sensation of bladder fullness ?
  indicates status of sensory innervation of
  bladder.
• Check for presence / absence of detrusor reflex
  a/w strong desire to void.
• Critical volume (400-500 mL) is capacity that
  bladder musculature tolerates before pt
  experiences a strong desire to urinate. At this
  point, if pt is asked to void, a terminal
  contraction may appear is seen as a sudden rise
  in intra-vesical pressure. At the peak of
  contraction, pt is asked to inhibit this reflex.
  Pts who cant inhibit it are referred to as
  (uninhibited detrusor contraction detrusor
  dyssynergia detrusor hyper-reflexia irritable
  / hypertonic / unstable bladder uninhibited
  neurogenic bladder).

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Cont Classification (Stress)

• Uroflowmetry
• Records rates of urine flow thru urethra when pt
  is asked to void spontaneously while sitting on
  uroflow chair.
• Normal female voids by the rule of 20s i.e.
  bladder is emptied in lt 20 sec _at_ a rate of 20
  mL/sec. For a flow rate to be significant, _at_
  least 200 mL of urine should be voided.
• Indication ? if signs outflow obstruction are
  present (pt has difficulty / hesitancy in
  voiding, incomplete bladder emptying, poor
  stream, urinary retention).

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Cont Classification (Stress)

• Voiding cysto-urethro-gram (VCUG) In this
  radiologic Ix, fluoroscopy is used to observe
• Bladder filling to know bladder size competency
  of its neck during coughing.
• Mobility of urethra bladder base.
• Bladder trabeculation, vesico-ureteral reflux
  during voiding, outflow obstruction.

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Cont Classification (Stress)

• Mx
• Non-medical
• Pads.
• Kegal exercises (pelvic diaphragm exercises)
• Improves / cures mild stress incontinence.
• Require diligence willingness to practice _at_
  home _at_ work.
• Drugs
• Estrogens
• ? sensory threshold for involuntary detrusor
  contractions.
• For atrophic urethritis ? improve urethral
  closing pressure, mucosal thickness possibly
  reflex urethral functions.
• a-adrenergic stimulants (Pseudoephedrine,
  Phenylephrine) ? enhances urethral closure
  improves continence.

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Cont Classification (Stress)

• Surgical
• Most commonly employed.
• Aim to correct pelvic relaxation defect to
  stabilize restore the normal intra-abdominal
  position of proximal urethra.
• Approach may be vaginal, abdominal, or combined
  abdomino-vaginal.

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Cont Classification (Total)

• Total
• Constant / periodic loss of urine without
  warning.
• Causes vesico-vaginal fistulas (95), or,
  uretro-vaginal fistulas.
• from previous pelvic surgery (abdo / vaginal
  hysterectomy) / radiation.
• Dx
• Hx painless continuous vaginal leakage of
  urine soon after surgery.

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Cont Classification (Total)

• Ix
• Instillation of methylene blue dye into bladder
  will discolor vaginal pack.
• IV indigo-carmine dye with leakage of dye into
  vaginal pack in presence of vesico-vaginal /
  uretero-vaginal fistula.
• Cysto-urethro-scopy determines site of
  fistulas.
• IVP / retrograde pyelogram localizes
  uterovaginal fistula.
• Mx most of obstetric fistulas can be repaired
  immediately on detection. For post-surgical
  fistulas, its usual to wait 3-6 months to allow
  inflammation to settle tissues to attain good
  vascularity and pliability.

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Cont Classification (Urge)

• Urge
• Urine loss due to uninhibited bladder
  contractions (detrusor instability).
• Causes
• Unknown in most cases.
• Local bladder irritation (e.g. cystitis, stone,
  tumor).
• CNS disorder.
• CFx urinary urgency, frequency, urge
  incontinence, nocturia.
• Dx
• Hx signs of cystitis (frequency, urgency), PMHx
  (CNS disorder).
• Systematic CNS exam.
• Urine C S ? exclude infection.
• Urodynamics (cystourethrogram) demonstrates
  uninhibited contractions if unstable bladder, or,
  small bladder capacity if irritable bladder.

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Cont Classification (Urge)

• Mx
• Drugs its reasonable to try several drugs,
  ?dose up to max. tolerated, until the most
  effective drug for a particular pt is found
• Anti-cholinergics most frequently employed
  agents ? (Oxybutinin / Pro-pantheline).
• ß-Sympathomimetics (Meta-protere-nol).
• Estrogens
• ? sensory threshold for involuntary detrusor
  contractions.
• For atrophic urethritis ? improve urethral
  closing pressure, mucosal thickness possibly
  reflex urethral functions.
• Smooth muscle depressant (Flavoxate).
• Diazepam (Valium)
• ? smooth muscle relaxant anti-cholinergic
  effect CNS sedation.
• TCAs (Imipramine) have anti-cholinergic action
  enhances continence by its a-adrenergic
  stimulation of urethra.

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Cont Classification (Urge)

• Bladder training Represents behavior
  modification designed to repeat process of toilet
  training. Aim is to ? bladder capacity day by
  day to prolong intervals b/w voiding.

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Cont Classification (Overflow)

• Overflow
• Urine loss when intra-vesical pressure exceeds
  urethral pressure.
• Causes
• Hypotonic bladder Detrusor-sphincter
  dyssynergia ? due to
• DM, autonomic neuropathy, LMN disease, spinal
  cord injuries.
• Outflow obstruction (e.g. stricture). Ask about
  straining to void, poor stream, urinary
  retention, incomplete emptying.
• Best Mx Self-catheterization.

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Cont Classification (Functional)

• Functional
• Urine loss caused by inability to reach toilet in
  time.
• Cause physical immobility.

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Case

• Mrs. Badria a 45-year old Lebanese Accountant,
  Para 5 1, requested a gynecological consultation
  because she was extremely worried about
  involuntary loss of urine during coughing,
  sneezing laughing. Her symptoms followed an
  attack of chest infection 6 months previously and
  are progressively getting worse. She is
  embarrassed to have sexual intercourse with her
  husband because of smell. This problem is also
  limiting her social activities such as shopping,
  visiting friends and walking. She was reluctant
  to seek medical care initially but is now
  concerned about the possibility of having a
  neurological problem causing involuntary
  urination.

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Cont Case

• All her deliveries were normal. Her LMP occurred
  2 weeks previously. She has recently gained 10
  Kg of body weight and smokes 20 cigarettes/ day.
  There were no other urinary symptoms. During
  vaginal examination in the lithotomy position,
  urine was seen spurting from urethra on straining
  but there were no other obvious abnormalities.
  In the left lateral position, no protrusion of
  vagina was demonstrated on straining.