Stress Urinary Incontinence SUI Facts and fiction'

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Stress Urinary Incontinence SUI Facts and
fiction.
SUI is it a Puzzle ?!

• Prof. Abdel Karim M. El Hemaly
• MRCOG - FRCS

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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 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
• Genuine SUI
• Urethral Hypermobility
• Intrinsic sphincter deficiency ISD

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Urinary Continence depends on

• 1- Presenc 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 urethra
• 3- Urethro vesical angle
• 4- The shape of the urethra, with its lack of
  funneling

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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 midureth sphinct.
• 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 inspite of the absence of the
  UV angle
• SUI is present inspite of good UV angle

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

• 3- Funneling of the bladder neck
• But,
• SUI is present inspite of absence of
  funneling
• No SUI is detected with funneling of the
  bladder neck
• 4- Shortness of the urethra
• But,
• Amputation of distal half of the urethra e.g.
  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 funneled 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 .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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However, recently, In 1996 we put forward a new
concept explaining micturation 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
  micturation. 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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• According to this new concept of micturation and
  its control, nocturnal enuresis pathogenesis and
  treatment can be understood.

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Thus Urinary Continence depends on- 1-An
acquired behavior gained by learning in early
childhood is how to keep a high alpha-sympathetic
tone, keeping the internal urethral sphincter
closed all the time, except on desire and/or in
need to void. 2-Strong, sound and intact
internal urethral sphincter. 3-the structure of
the internal urethral sphincter.
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THE INTERNAL URETHRAL SPHINCTER

• It is mainly a cylinder composed of compact
  collagenous tissue. It extends from the bladder
  neck down almost the entire urethral length.
• - It is lined by urothelium. The muscle bundle
  intermingle with the collagenous fibers in the
  middle part The muscle layer is controlled by
  alpha-sympathetic nerves T10-12.

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MRI picture of a normal continent woman
Urethra
Urethral lumen
Vagina
Muscle layer
Collag. tissue layer
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• According to this new concept, SUI is attributed
  to weakness of the internal urethral sphincter.
  The weakness is mostly due to traumatic rupture
  of the internal sphincter.

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WEAKNESS OF THE WALL OF THE INTERNAL URETHRAL
SPHINCTER
DROP OF THE URETHRAL PRESSURE
CONFIGURATIONAL CHANGES
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TRAUMA
URETHRAL PRESSURE
RUPTURE
WEAKNESS
ATROPHY
CONFIGUATIONAL 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 ( Funneling). 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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A
B
Comparison between normal Int. Sphincter (A), a
torn Int. Sphincter in a patient with SUI (B)
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• SUI results from a torn internal urethral
  sphincter as proven by pre- operative imaging (
  3D US MRI ), So we innovated a new operation
  for curing SUI by repairing the internal
  sphincter. This is achieved by approximating the
  torn edges together by simple sutures.

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Urethro-raphy is different from Kelly- Kelly
Kenndey operation in
1- Pathogenesis of the condition . 2- Aim of the
surgery. 3- Technique of the operation.
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• Co- authors of the work
• Ibrahim M. Kandil, M. M. Radwan, Asem Anwar, K.
  Elshikha, A. El Saban,M. Hesham, Bahaa E. El
  Mohamady and M. A. K. El Hemaly Jr.
• Correspending author
• A. K. El Hemaly
• E- Mail m_hemaly_at_hotmail.com