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INCONTINENCE OF URINE

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As urine fills the bladder, the detrusor stretches and allows ... 300 ml in bladder before the brain. recognizes bladder fullness. Physiology of Micturition ... – PowerPoint PPT presentation

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Title: INCONTINENCE OF URINE


1
INCONTINENCE OF URINE
Dr .Ashraf Fouda Damietta General Hospital
2
Physiology of Micturition
  • Bladder innervation
  • somatic, parasympathetic (PSN) and sympathetic
    (SNS)
  • As urine fills the bladder, the detrusor
    stretches and allows the bladder to expand
  • 300 ml in bladder before the brain
  • recognizes bladder fullness

3
Physiology of Micturition
4
Physiology of Micturition
  • Low bladder volumes SNS is stimulated and PNS
    is inhibited
  • Bladder full PNS stimulated (bladder
    contracts) SNS inhibited (internal sphincter
    relaxes)
  • Intravesical pressure gt resistance within the
    urethra urine flows
  • Pudenal nerve innervates external sphincter

5
DEFINITION OF INCONTINENCE OF URINE
  • It is involuntary escape of urine

6
TYPES
  • 1. True incontinence.
  • 2. False incontinence (ischuria paradoxica).
  • 3. Stress or sphincter incontinence.
  • 4. Urgency incontinence
  • (precipitancy-detrusor instability or detrusor
    dyssynergia).
  • 5. Nocturnal enuresis.

7
1. True (continuous) incontinence
  • In this case, urine escapes continuously by day
    and by night.
  • It is caused by
  • (a) Urinary fistulae as vesicovaginal fistula
  • (b) Ectopia vesica.

8
2. False incontinence (Overflow
incontinence)
  • It is involuntary loss of urine following
    overdistension of the bladder.
  • Overflow incontinence, usually short-term, can
    occur after vaginal deliveryespecially if
    epidural anesthesia was used.
  • Other causes include diabetes, neurological
    diseases, severe genital prolapse, and post
    surgical obstruction.

9
4. Urgency incontinence (precipitancy-detrusor
instability or detrusor dyssynergia).
  • The woman feels the desire to micturate but
    before she reaches the bathroom, urine passes
    involuntarily.
  • It is due to irritability of the bladder muscle
    and so the patient cannot inhibit it.
  • It is due to
  • emotional disturbance,
  • neurologic diseases, and
  • bladder diseases as cystitis, stone or tumour.

10
Detrusor instability (DI)
  • Detrusor instability, also called overactive
    bladder, is a condition in which the bladder
    contracts involuntarily in response to filling.
  • It was called detrusor dys-synergia in the past.
  • It commonly presents as urge incontinenceleakage
    of urine associated with a strong desire to void.
  • No cause is identified in more than 90 of these
    patients.
  • Advancing age is an important risk factor.

11
Detrusor instability (DI)
  • Detrusor instability caused by neurologic
    diseases such as cerebrovascular disease,
    multiple sclerosis, or spinal cord injury is
    called detrusor hyperreflexia.
  • Irritation of the bladder by inflammation (such
    as urinary tract infection) or prior pelvic
    surgery can also cause detrusor instability.

12
Urge incontinence
13
STRESS INCONTINENCE )SPHINCTER
INCONTINENCE-GENUINE STRESS INCONTINENCE)
14
DEFINITION
  • It is involuntary escape of few drops of urine
    with increased intra-abdominal pressure as during
    straining, sneezing, coughing, laughing ... etc.

15
DEGREES OF STRESS INCONTINENCE
  • Grade I
  • Incontinence occurs only with severe stress, such
    as coughing, sneezing, etc
  • Grade II
  • Incontinence with moderate stress, such as rapid
    movement or walking up and down stairs
  • Grade III
  • Incontinence with mild stress, such as standing.
    The patient is continent in the supine position

16
PHYSIOLOGICAL ANATOMY
  • The bladder neck and upper third or half of the
    urethra are above the level of the pelvic floor.

17
PHYSIOLOGICAL ANATOMY
  • With increased intra-abdominal pressure,
    the pressure is equally transmitted to the
    bladder and upper urethra and urine will not
    escape

18
The internal urethral sphincter (
bladder sphincter)
  • Is an involuntary muscle which surrounds the
    bladder neck.

19
The external urethral sphincter
  • is a voluntary muscle found between the
    superficial and deep perineal membranes and
    surrounds the middle part of the urethra
    (compessor urethrae muscle).

20
The external urethral sphincter
  • It empties the urethra after the act of
    micturition,
  • Interrupts the flow of urine on desire
    and
  • It acts as a secondary defensive mechanism
    against escape of urine.

21
  • At rest the urethra makes an angle of 90-100
    degrees with the base of the urinary bladder
    called the
    posterior urethrovesical angle.
  • The urethra also makes an angle of
    less than 30 degrees with the vertical line.

22
During micturition the following changes occur
  • 1. Descent of the bladder neck with complete loss
    of the posterior urethrovesical angle (angle
    becomes 180 degrees).
  • 2. Opening (funneling) of the bladder neck and
    upper urethra.
  • 3. Descent of the urethra leading to increase in
    the angle between it and vertical line, so the
    angle becomes more than 30 degrees.
  • . In stress incontinence, one or all of the above
    changes occur with increased intra-abdominal
    pressure.

23
Incidence of Subtypes of Urinary Incontinence in
Women
  • Stress Incontinence 50
  • Urge Incontinence 20
  • Mixed 30

24
TYPES OF STRESS INCONTINENCE
  • Type 1 There is complete loss of the posterior
    urethrovesical angle.
  • Type 2 There is complete loss of the posterior
    urethrovesical angle together with increase in
    the angle between the urethra and vertical line
    to be more than 30 degrees.
  • This type leads to severe stress incontinence

25
AETIOLOGY
  • It is due to either
  • Weakness of the internal urethral sphincter or
  • Descent of bladder neck below the level of the
    pelvic floor.

26
AETIOLOGY
  • 1. Congenital weakness of the internal urethral
    sphincter, seen in the young nullipara.
  • 2. Congenital defects as
  • Epispadias,
  • Short urethra (less than 1 cm),
  • Wide bladder neck, and
  • Separation of symphysis pubis.

27
AETIOLOGY
  • 3. Trauma to the region of the bladder neck due
    to vaginal delivery or operation.
  • The incidence of stress incontinence increases
    with parity due to repeated birth trauma.

In fact vaginal delivery is the commonest cause
of stress incontinence.
28
AETIOLOGY
  • 4. Menopause Lack of oestrogen leads to atrophy
    of bladder neck supports.
  • 5.Pregnancy and continuous administration of
    oestrogen-progestogen preparation to induce
    psuedopregnancy state to treat endometriosis.
  • The hormonal imbalance with increased
    progesterone weakens the internal urethral
    sphincter.

29
AETIOLOGY
  • 6. Genital prolapse
  • If the bladder neck descends below the level of
    the pelvic floor, the increased intra-abdominal
    pressure will be transmitted to the bladder and
    not to the upper urethra leading to escape of
    urine.
  • 7. Organic nervous diseases
    as disseminated sclerosis.

30
Pathophysiology of Stress Incontinence
  • The basic pathology is urethral incompetence.
  • This can be either due to
  • A) Urethral hypermobility (80 - 90 of
    patients)
  • B) Intrinsic Sphincter Dysfunction (10 - 20 of
    patients)

31
A) Urethral hypermobility (80 -
90 of patients)
  • This results from loss of the normal pelvic
    support mechanism of the bladder and urethra due
    to
  • Trauma and stretching of vaginal delivery
  • Hysterectomy
  • Hormonal changes ( Menopause)
  • Pelvic denervation
  • Congenital weakness

32
A) Urethral hypermobility (80 -
90 of patients)
  • As the bladder neck support is weakened, the
    increase in intra-abdominal pressure is no longer
    transmitted equally to the bladder outlet, and
    therefore instantaneous leakage occurs.

33
B) Intrinsic Sphincter Dysfunction (10 - 20 of
patients)
  • This results from damage to the sphincter due to
  • Multiple prior operations
  • Trauma
  • Radiation
  • Neurogenic disorders including Diabetes Mellitus
  • Atrophic changes lack of estrogen.  

34
Diagnosis
35
A. History
  • A detailed history differentiates between the
    different types of incontinence.
  • Stress incontinence and detrusor instability
    frequently occur together.
  • Gradual onset after menopause suggests oestrogen
    deficiency.
  • History of vaginal repair or operation in the
    region of the bladder neck and history of any
    neurologic disease.

36
B. Diagnostic Tests
37
1. Stress Test
  • The bladder must be moderately full.
  • The patient in the lithotomy position, the two
    labia are separated, and the patient is asked to
    cough.
  • If urine escapes, the patient is incontinent.
  • If no urine escapes, the test is repeated while
    the index and middle fingers in the vagina press
    on the perineum to abolish reflex contraction of
    the levator ani muscles during straining.
  • If still no urine escapes, the test is repeated
    while the patient is standing with the legs
    separated.

38
2. Bonney test
  • It is indicated in case of a positive stress test
    associated with a cystocele.
  • To know if incontinence is due to descent of
    bladder neck or weakness of the sphincter.
  • The index and middle fingers are placed on both
    sides of the urethra to elevate the bladder neck
    upwards.
  • If no urine escapes on stress it means that the
    incontinence is due to descent of the bladder
    neck, but if urine still escapes it means
    weakness of the sphincter.

39
3. Yousef Test
  • Indicated in case of a negative stress test
    associated with a large cystocele to diagnose
    hidden stress incontinence.
  • The cystocele is reduced, the cervix is grasped
    with a volsellum and pushed upward, then the
    patient is asked to cough.
  • If urine escapes, it indicates that the patient
    was continent because of kinking of the urethra.

40
4. Examination of Urine
  • Urinalysis, culture and sensitivity to exclude
    cystitis.

41
5. Cystourethroscopy
  • To exclude lesions in the urethra and bladder.
  • The bladder neck is examined.
  • It should close in response to straining.
  • However, it opens in case of stress incontinence.

42
6. Cystourethrography
  • A radio-opaque dye is injected by a catheter into
    the bladder.
  • On straining, the lateral view will show absence
    of the posterior urethrovesical angle in more
    than 90 of cases.
  • Funneling of the bladder neck in the
    antero-posterior view may be seen in some cases.
  • The procedure is recorded on video tape (video
    Cystourethrography) to facilitate diagnosis and
    for education purposes.

43
7. Urodynamics
  • Medical science concerned with the study of urine
    transport from kidney to bladder as well as its
    storage and evacuation
  • Classification
  • 1.Cystometrogram( most important test), Filling
    Cystometry and Voiding Cystometry
  • 2.Urethral pressure profile
  • 3.Uroflow
  • 4.Electromyography

44
Cystometrogram
  • To measure the intravesical pressure while the
    bladder is filled with sterile water or carbon
    dioxide gas.
  • It diagnoses stress incontinence and detrusor
    instability.
  • The most important test.

45
Cystometrogram
  • Involves filling the bladder to measure
    volume-pressure relationships.
  • As the bladder is filled to its normal capacity
    of 300-500 ml, the pressure inside the bladder
    should remain low.
  • The patient usually experiences the first urge to
    void at 150-200 ml.

46
Cystometrogram
  • Patients with DI often have reduced bladder
    capacity (lt 300 ml) and demonstrate
    urinary incontinence that is associated with
    involuntary bladder contractions
    (pressure increase above baseline)

47
Cystometrogram
  • In patients with GSI, incontinence is
    demonstrated when the patients coughs or strains
    (e.g., Valsalva maneuver).
  • The intravesical pressure at which leakage is
    noted (leak point pressure) is generally lt 60 cm
    of water pressure if intrinsic sphincter
    deficiency is present.

48
8. The Cotton-Tip Applicator (Q-Tip)
Test
  • A sterile applicator with a small piece of cotton
    at its tip is introduced to reach the bladder
    neck.
  • The angle between the applicator and the
    horizontal is measured.
  • The patient then strains maximally using the
    Valsalva manoeuvre.
  • This causes descent of the bladder neck and
    upward movement of the applicator producing a new
    angle with the horizontal.

49
(Q-Tip) Test
  • In normal patients the increase in the angle is
    less than 30 degrees.
  • In stress incontinence the change is more than 30
    degrees indicating poor support and abnormal
    descent of bladder neck
  • The test is positive in more than 90 of cases
    with stress incontinence.

50
9. Measurement of Urethral Pressure
  • To maintain continence, the urethral pressure
    (100-120 cm water) must be higher than the
    intravesical pressure (0-20 cm water).
  • A special catheter is used which measures the
    intravesical and intra-urethral pressure.

51
  • The urethral closing pressure
  • Equals the intraurethral pressure minus the
    intravesical pressure (normally 90-100 cm water).
  • The length of the urethra along which urethral
    pressure exceeds bladder pressure is termed
    functional length of the urethra which is 3-4 cm.
  • In stress incontinence the urethral closing
    pressure is reduced.

52
10. Measurement of Urethral Length
  • Stress incontinence occurs if the length is less
    than 1 cm.

53
11. Uroflowmetry
  • It records the rate of urine flow through the
    urethra when the patient is asked to void
    spontaneously while sitting on uroflow chair.
  • It is used to evaluate patients with stress
    incontinence before surgery to exclude difficulty
    in voiding which may be increased by bladder neck
    surgery.

54
  • The normal female voids by the rule of "20"
  • that is urine is passed at a rate of 20 ml/second
    and the bladder is emptied in less than 20
    seconds.

55
12. Sonographic
  • It gives information about funneling of the
    bladder neck, both at
    rest and with Valsalva manoeuvre.

56
By three-dimension transvaginal ultrasound
  • The continent women have a thick wall internal
    urethral sphincter which extends from the bladder
    neck and along 60-80 of the whole urethra.
  • In stress incontinence, the sphincter is torn as
    proved by appearance of areas of echolucency.

57
By three-dimension transvaginal ultrasound
  • When rupture affects the upper part of the
    sphincter, the urethra appears
    "funnel-shaped".
  • When damage affects the lower part, the urethra
    appears "vase-shaped".
  • When rupture affects the whole length of the
    sphincter, the urethra appears short and
    irregular.

58
What laboratory tests are helpful in evaluating
incontinence?
  • Postvoid residual is an easy initial test to
    obtain.
  • After the patient voids, there should be less
    than 50 ml of urine in the bladder.
  • Postvoid residual is measured by ultrasound or
    catheterizing the patient in the office.
  • A patient with an elevated Postvoid residual
    (repeat measurements greater than 100-200 ml) may
    have an underlying neurologic disorder.

59
What laboratory tests are helpful in evaluating
incontinence?
  • Catheterization also provides a good opportunity
    to obtain urine for analysis and culture.
  • Urinalysis and urine culture help to diagnose
    urinary tract infection.
  • Blood work is required only if compromised renal
    function, diabetes, syphilis, or other systemic
    diseases are suspected.

60
Which tests are most helpful in differentiating
between GSI and DI?
  • Cystometrogram
  • Cystoscopy
  • should be performed especially in patients with
    irritative bladder symptoms such as urgency,
    frequency, and hematuria
  • To rule out
  • inflammation,
  • tumors, or
  • anatomic deformities

61
TREATMENT
62
I. Prophylactic Treatment
  • 1. During labour, the bladder should be kept
    empty.
  • 2. Episiotomy is performed if necessary.
  • 3. Physiotherapy.
  • Pelvic floor exercises are started after
    delivery.
  • These include repeated stoppage of the urinary
    stream during micturition and repeated
    contractions of the pelvic floor muscles.

63
II. Conservative (non-surgical) Treatment
  • Indications
  • 1.Mild stress incontinence.
  • 2.The patient not completed her family as vaginal
    delivery may damage a bladder neck repair
  • 3.Patient is unfit for surgery or refuses
    surgery.
  • 4.When stress incontinence is combined with
    detrusor instability.
  • The latter should be treated at first before
    surgery is done for stress incontinence.

64
Conservative treatment cures or improves 50 of
cases and include
  • 1. Physiotherapy Kegl perineometer may be used.
  • 2. Faradic current stimulation of the levator ani
    muscles to improve their tone.
  • 3. Vaginal cones
  • A set consists of 5 or 9 cones.
  • Weight ranges from 20 to 100 grams.
  • Patient inserts the cone in the vagina and keeps
    it for 15 minutes twice daily.
  • If this succeeds she inserts the next cone.
  • This improves the tone of the pelvic floor
    muscles.

65
Conservative treatment cures or improves 50 of
cases and include
  • 4.Oestrogen therapy for menopausal patients
  • It causes thickening of the urethral mucosa and
    engorgement of the underlying blood vessels thus
    increasing the urethral pressure and resistance.
  • Oestrogen is given orally or as vaginal cream.
  • 5. Alpha-adrenergic stimulants
    which stimulate contraction of the internal
    urethral sphincter, e.g. ephedrine.
  • 6.Large vaginal diaphragms, Hodge pessary to
    elevate ' and support the bladder neck.

66
Conservative treatment cures or improves 50 of
cases and include
  • 7. Reduction of weight in obese patients to
    reduce intra-abdominal pressure.
  • 8. Stop caffeine (to avoid diuresis) and smoking
    (to avoid coughing)
  • 9. Injection of Teflon or bovine collagen in the
    submucosal layer in the region of the bladder
    neck.
  • This leads to narrowing of the urethral lumen and
    increased urethral resistance.

67
Il. Surgical Treatment
  • It is the primary treatment of stress
    incontinence.
  • The operation is done vaginally, abdominally, or
    abdominovaginally.
  • Almost 200 operations have been described.

68
  • Urehroplasty (Kelly,Kennedy,etc.)
  • Urethropexy (Retropubic urethropexy e.g.
    Marchall-Marchitti-Krantz, etc.)
  • Colposuspension ( Burch operation, Preyera ,
    etc.)
  • Urethral slings (Aldridge operation, etc..)
  • Tension free Vaginal Tape (TVT)

69
A. Vaginal Operations
70
1. Kelly operation 1914
  • It consists of repair of cystocele and/or
    urethrocele.
  • Vertical mattress sutures are then placed to
    plicate the whole urethra and bladder neck.
  • This gives support to the urethra and restores
    the normal posterior urethrovesical angle.
  • Operation is done for mild and moderate cases of
    stress incontinence.
  • Long term success rate is 55-65.

71
2. El-Hemaly urethrorrhaphy operation
  • A vertical incision is made in the anterior
    vaginal wall.
  • The torn edges of the internal urethral sphincter
    are sutured together to restore its integrity.
  • The repair restores the normal urethrovesical
    angles seen in continent women.

72
3. Vaginal tape operation (TVT)1996
  • The tape is made of prolene and has a curved
    needle at each end.
  • Operation is done using local infiltration
    anaesthesia.
  • Two small transverse incisions 5 cm apart are
    made in the suprapubic area.
  • A vertical incision is made in the anterior
    vaginal wall.
  • The needles of the tape are passed upward behind
    the pubic bone and brought out through the
    suprapubic incisions.
  • The tape is made to surround the mid-urethra.

73
3. Vaginal tape operation (TVT)
  • The cystoscope is used by the assistant to make
    sure that the bladder is not pierced by the
    needle.
  • The tape is adjusted by pulling on its ends, and
    continence is confirmed by asking the patient to
    cough.
  • The ends of the tape are cut off and left free
    and not fixed to the tissues,
  • Finally the vaginal and suprapubic incisions are
    closed.
  • When stress occurs ,the recti will contract and
    pull on the tape to support the urethra and
    prevent escape of urine

74
Tension free Vaginal Tape (TVT)
  • Simple, easy, relatively safe with short recovery
    little pain.
  • Reported cure is 86 improvement is 11.
  • Operation takes 20-30 minutes.
  • Complications urine retention, parautrethral
    paravesical hemorrhage, infection , bladder
    bowel injury.

75
B. Abdominal Operations
76
1. Mashall-Marchetti-Krantz 1949
  • The stitches are placed in the fascia on each
    side of the bladder neck and upper half of the
    urethra and are attached to the periosteum on the
    back of the symphysis pubis.
  • This restores the normal intra-abdominal position
    of the urethra.
  • Main complication is osteitis pubis (0.5-5).
  • Nonabsorpable (as mersilene) or delayed
    absorbable sutures (as Vicryl or Dexon) are used.

77
2. Burch Operation 1968
  • Burch colposuspension is the operation of choice.
  • It corrects both stress incontinence and
    cystocele.
  • The stitches are placed in the fascia on each
    side of the bladder neck and the base of the
    bladder and are attached to the iliopectineal
    ligaments (Cooper Ligaments),
    (The
    pectineal part of the inguinal ligament)
  • Nonabsorpable or delayed absorbable sutures are
    used.
  • Operation can be done through the laparoscope.

78
  • The success rate of the above abdominal
    operations is 80-90

79
C. Combined Abdomino vaginal Operations
80
1. Urethral Slings
  • In this condition, there is damage or paralysis
    of the sphincteric unit which could even be in a
    normal position.
  • The goal of surgery for Intrinsic Dysfunction is
    coaptation, support, and compression of the
    damaged sphincteric unit.
  • Simple suspension of the bladder neck is unlikely
    to correct the problem.
  • Urethral Sling Procedures is the best to achieve
    the goal.

81
Sling Operations
  • A sling is put around the urethra at the bladder
    neck and either fixed around the rectus muscles
    or to the pubic bone.
  • - The sling could be taken from the rectus sheath
    "Aldridge operation".
  • - A nylon sling may be used "Pereyra operation".

82
2. Needle Bladder Neck
Suspension Operations
  • An incision is made in the vaginal wall to expose
    the bladder neck.
  • A nylon suture is placed in the fascia on each
    side of the bladder neck.
  • The two sutures are passed upward behind the
    symphysis pubis and are attached to the anterior
    rectus sheath.
  • The cystoscope is used to be sure that the needle
    does not pass through the bladder (endoscopic
    needle bladder neck suspension).

83
2. Needle Bladder Neck
Suspension Operations
  • An example is Stamey operation in which two
    Dacron tubes (1 cm) are used to give support to
    the bladder neck and to avoid the sutures cutting
    through the tissues.

84
ObTape transobturator sling
  • September 10, 2003 new surgical implant for
    treatment of stress incontinence in women has
    been approved by the FDA.
  • It was pioneered in 1999 by Emmanuel Delorme in
    France.
  • Soon became popular because the procedure is
    perceived to be simpler and faster, with less
    risk of complications, than alternative
    procedures.
  • In the last 2 years over 11,000 women have been
    successfully treated for stress incontinence with
    transobturator sling.

85
D. Artificial Urinary Sphincter
86
D. Artificial Urinary Sphincter
  • Indicated when surgery fails to correct stress
    incontinence.
  • The device consists of a cuff which is placed
    around the bladder neck.
  • A balloon reservoir, containing fluid is placed
    in the peritoneal cavity or under the anterior
    rectus sheath, and a small pump is situated in
    one labium major.

87
  • Under normal conditions the cuff is full with
    fluid thus closing the bladder neck.
  • When voiding is desired the pump is pressed to
    force the fluid in the cuff to go back into the
    balloon reservoir so that voiding can occur.
  • The cuff then gradually refills over the next few
    minutes.

88
DETRUSOR INSTABILITY (DI)
89
DETRUSOR INSTABILITY
  • The patient complains of urgency incontinence,
    frequency and nocturia.
  • Involuntary loss of urine also occurs when the
    women sits for a long time and stands to go to
    the bathroom.
  • She may pass urine with the sight or sound of
    water

90
DETRUSOR INSTABILITY (DI)
  • Women typically complain of urgency followed by a
    large loss of urine.
  • Cystometry confirms the diagnosis.
  • Involuntary detrusor contractions of 15 cm of
    water or more occur during filling of the bladder.

91
TREATMENT of (DI)
  • Bladder retraining drills
  • The patient is asked to pass urine every hour
    during daytime and to increase the interval by 15
    minutes every week until she passes urine every
    2-3 hours.

92
TREATMENT of (DI)
  • 2. Drugs
  • Which inhibit the contractions of detrusor muscle
    as anticholinergic drugs, tricyclic
    antidepressants, and ephedrine.
  • Ephedrine stimulates alpha-adrenergic receptors
    in the internal urethral sphincter leading to
    contraction, and stimulates beta-adrenergic
    receptors in the detrusor muscle leading to
    relaxation.

93
SURGICAL TREATMENT OFURODYNAMIC STRESS
INCONTINENCE
  • RCOG EVIDENCE BASED GUIDELINES
  • OCTOBER 2003

94
  • Surgery for stress incontinence of urine has been
    performed on women for over a century.

95
  • The anterior vaginal repair was the most popular
    primary procedure for stress incontinence up to
    the 1970s, but over the last 20 years the
    operation has been criticized because of high
    recurrence rates.

96
  • More sustained results are obtained from
    retropubic surgery.

97
  • Primary surgery should only be considered after
    a period of conservative treatment from
    a specialist therapist

98
  • The literature on surgery for stress incontinence
    is extensive but is mainly based on case
    series rather than randomized trials.

99
  • Overall, 83 of women reported improvement three
    months after continence surgery, 5 had no change
    and 8 reported a worsening in their condition.

100
Surgical procedures
101
Anterior vaginal repair
  • Anterior repair is less successful as an
    operation for continence than retropubic
    procedures and has been superseded by sling
    procedures.
  • Anterior repair still has a role in the treatment
    of prolapse without incontinence.

A
102
Anterior vaginal repair
  • Meta-analyses of heterogeneous studies suggest a
    continence rate of between 67.872.0.

A
103
Anterior vaginal repair
  • The anterior colporrhaphy procedure remains in
    use, largely because of the relatively
    low morbidity of the procedure and its
    familiarity for gynecologists as an operation for
    prolapse.

A
104
Anterior vaginal repair
  • The incidence of long-term voiding disorders
    following this procedure approaches zero.
  • Long-term results decrease with time, such that a
    63 continence rate at one year of follow up fell
    to 37 at five years of
    follow up.

A
105
Anterior vaginal repair
  • The view of the American Urological Association
    is that anterior repairs are the least likely of
    the four major operative categories (anterior
    repair, suburethral sling, colposuspension,
    long-needle suspension) to be efficacious in the
    long term.

A
106
Burch colposuspension
  • Burch colposuspension is the most effective
    surgical procedure for stress incontinence, with
    a continence rate of 8590 at one year.
  • The continence rate falls to 70 at five years
    this shows better longevity than other methods of
    treatment.

A
107
Burch colposuspension
  • Voiding difficulty has been reported in a mean of
    10.3 of women after colposuspension (range
    227).
  • De novo detrusor overactivity has been described
    in a mean of 17 women (range 827).
  • Genitourinary prolapse (enterocele, rectocele)
    has been reported in follow up at five years in
    an average of 13.6 women
    (range 2.526.7).

A
108
Burch colposuspension
  • Ureteric damage has been reported.
  • There was no reported mortality as a direct
    consequence of the procedure.
  • The continence rate after Burch colposuspension
    falls if previous continence surgery has been
    performed.
  • In one study the continence rate fell from 84
    for a primary procedure to 63 for secondary
    surgery

A
109
Burch colposuspension
  • A Cochrane review has examined the place of Burch
    colposuspension among other continence procedures
    and concluded that
  • open colposuspension is the most effective
    surgical treatment for stress incontinence,
    especially in the long term.

A
110
Burch colposuspension
  • Burch colposuspension is more effective than
    needle suspension and provides a similar
    subjective continence rate to laparoscopic
    colposuspension (85100 after 618 months of
    follow-up).

A
111
Alternative suprapubic surgery
  • The role of other suprapubic operations such as
    MarshallMarchetti Krantz , paravaginal repair
    and laparoscopic colposuspension, is unclear.

B
112
Marshall Marchetti Krantz (MMK)
  • (MMK) retropubic procedure was a common
    anti-incontinence procedure between195090s and
    Krantz described a personal series of 3861 cases
    with a follow-up of up to 31 years and a 96
    subjective continence rate.

A
113
MarshallMarchettiKrantz (MMK)
  • The mortality was 0.2, with a 22 overall
    complication rate.
  • This operation has now fallen into disuse.

A
114
MarshallMarchettiKrantz (MMK)
  • A characteristic complication of MMK was osteitis
    pubis, which occurs in 2.5 of patients who
    undergo a MMK procedure.
  • The operation was less successful than Burch
    colposuspension at correcting a cystocele.

A
115
Laparoscopic colposuspension
  • Laparoscopic colposuspension has been the subject
    of several case series and cohort studies, which
    show similar continence rates between
    laparoscopic and open Burch colposuspension.

A
116
Laparoscopic colposuspension
  • There were no significant differences for
    postoperative detrusor overactivity or voiding
    difficulty.

A
117
Laparoscopic colposuspension
  • There were trends towards a
  • higher complication rate and
  • longer operative times,
  • lower intraoperative blood loss,
  • less postoperative pain,
  • shorter need for catheterization,
  • shorter hospital stay and
  • earlier return to normal activities

A
118
Laparoscopic colposuspension
  • Despite a quicker recovery, the
    operation takes longer to perform, is associated
    with more surgical complications and is more
    expensive.
  • It is likely to be performed by surgeons highly
    skilled in both continence and laparoscopic
    techniques.

A
119
Needle suspension procedures
  • Needle suspension procedures should not be
    performed initial success rates are not
    maintained with time and
  • The risk of failure is higher than for retropubic
    suspension procedures.

A
120
Needle suspension procedures
  • Multiple suspension procedures have been
    described in the past.
  • The first procedure was described by Peyrera and
    numerous procedures have subsequently evolved
    from this, including the Stamey procedure, using
    suspending sutures and patch materials.

A
121
Needle suspension procedures
  • Long-term follow up of the percutaneous needle
    procedure was only
  • 5 cured , with
  • 12 significantly improved and
  • 83 considered the operation a failure.

A
122
Needle suspension procedures
  • Needle suspensions were more likely to fail than
    open retropubic procedures and there were more
    perioperative complications in the needle
    suspension group (48 compared with 30).
  • Needle suspensions may be as effective as
    anterior repair but carry a higher morbidity

A
123
Sling procedures
  • Suburethral sling procedures were developed
    initially in the 1880s.
  • Numerous authors have subsequently modified these
    procedures.

C
124
Sling procedures
  • Aldridge used rectus sheath strips , the success
    rate recorded in the literature would appear to
    range between 64 and 100, with a mean
    continence rate in the region of 86.

C
125
Sling procedures
  • Sling procedures, using autologous or synthetic
    materials, produce a continence rate of
    approximately 80 and an improvement rate of 90,
    with little reduction in continence over time.
  • Only one synthetic sling procedure (tension-free
    vaginal tape) has been subjected to randomized
    study to date.

A
126
Sling procedures
  • Numerous materials are available for use in a
    suburethral sling.
  • As a generalization, autologous material is
    associated with a greater continence rate and
    fewer complications than either cadaveric
    material or synthetic materials.

A
127
Sling procedures
  • Autologous rectus fascia and fascialata are
    probably the most common materials in use.

A
128
Sling procedures
  • Synthetic material tends to be associated with a
    risk of erosion and sinus formation.

A
129
Sling procedures
  • Modifications designed to achieve greater
    stabilization, such as anchorage to the pubic
    bone, are associated with good results in the
    short term but carry a long-term risk of
    osteomyelitis at the site of anchorage.

A
130
Sling procedures
  • When compared with colposuspension procedures,
    the suburethral sling carries a similar success
    rate.

A
131
Sling procedures
  • The intermediate and longer-term results for
    suburethral slings suggest that the ten-year
    continence rate is not dissimilar from the
    one-year continence rate.

A
132
Sling procedures
  • The American Urological Association considered
    that Retropubic suspensions and slings are the
    most efficacious procedures for long-term success
    based upon cure/dry rate.
  • However, retropubic suspensions and sling
    procedures are associated with slightly higher
    complication rates, including postoperative
    voiding difficulty and longer convalescence.

A
133
Sling procedures
  • The Second International Consultation on
    Incontinence concluded that suburethral slings
    represented an effective procedure for genuine
    stress incontinence in the presence of previous
    failed surgery.

A
134
TVT
  • The Prolene tension-free vaginal tape (TVT) is
    relatively new, although increasing numbers of
    cohort studies of its use are being reported.
  • The originator of the procedure reports that, at
    three years, 86 of women were completely
    cured, while a further 11 were significantly
    improved.

A
135
TVT
  • The majority of women are potentially treatable
    without general anaesthesia and on a day-case
    basis.
  • Between 3 and 15 of women developed symptoms
    compatible with the onset of de novo detrusor
    overactivity.

A
136
TVT
  • Short-term voiding disorder is described in 4.3
    of women, although longer term voiding disorder
    does not appear to be a specific feature.

A
137
TVT
  • There have been a few individual case reports of
    urethral erosion, sometimes several years after
    surgery.
  • There is a need for long-term results for this
    procedure.

A
138
TVT
  • Despite being more expensive than
    colposuspension, the reduction in
    hospital stay makes the procedure cost
    effective

A
139
Injectable agents
  • Injectable agents have a lower success rate than
    other procedures a short-term continence rate of
    48 and an improvement rate of 76.
  • Long term, there is a continued decline in
    continence.

B
140
Injectable agents
  • The procedure has a low morbidity and may have a
    role after other procedures have failed, e.g.
    when a diagnosis of intrinsic sphincter
    deficiency is made.

C
141
Injectable agents
  • The bulking agents (collagen, Teflon fat,
    silicone, Durasphere ) are injected in a
    retrograde (more common) or antegrade fashion in
    the periurethral tissue around the bladder neck
    and proximal urethra.

C
142
Injectable agents
  • Follow up was between three months and two years,
    (mean of 12 months).
  • The cure rate, defined as completely dry, was
    48.
  • The success rate (defined as dry or improved) was
    76.

C
143
Injectable agents
  • For silicone Radley et al. showed cure or
    improvement in 60 in a prospective cohort of
    women with recurrent stress incontinence on a
    19-month follow-up.
  • Detrusor overactivity was an important cause of
    failures in this study.

C
144
Injectable agents
  • RCTs are needed for bulking agents.
  • The lack of morbidity associated with the bulking
    agents leads some people to believe that they
    should be more meaningfully compared with
    conservative therapy such as pelvic floor
    physiotherapy.

C
145
Artificial sphincters
  • Artificial sphincters can be successfully used
    after previous failed continence surgery but have
    a high morbidity and need for further surgery
    (17).

B
146
Preoperative management
  • It is recommended that women undergoing surgery
    for urodynamic stress incontinence should have
    urodynamic investigations prior to treatment
    (including Cystometry).

147
Preoperative management
  • Prior to performing assess objectively the type
    of incontinence and the presence of any
    complicating factors such as voiding difficulty
    or detrusor overactivity, which may affect the
    surgical decision

148
Preoperative management
  • Surgery should be performed by a surgeon who has
    been trained in the operation and who has a
    caseload that enables him or her to provide a
    suitable level of expertise, especially when any
    repeat surgery is considered.

149
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