Control of Micturition, Urinary Incontinences, stress incontinence and other abnormalities

Involuntary loss of urine when the intravesical pressure exceeds the maximum urethral pressure, but in the absence of detrusor activity. It occurs when there is increase in intra-abdominal pressure.

In genuine stress incontinence there is weakness of one or more of the components of the urethral sphincter mechanism

Commonest cause of incontinence in women

The bladder neck and proximal urethra are normally situated in the abdomen above the pelvic floor

Damage to the pelvic floor muscles and pubourethral ligaments result in descent of the proximal urethra and results in GSI

Predisposing factors

• Vaginal delivery is associated with denervation of the urethral sphincter mechanism and pelvic floor denervation
• High parity
• Prolonged second stage of labor
• Instrumental delivery
• Genital prolapse
• Menopausal atrophy
• Previous bladder neck surgery

Clinical presentation

• Stress incontinence
• +/- Frequency
• Urgency
• Urge incontinence

• Stress incontinence may be demonstrated

Treatment

Conservative treatment

• Recommended for mild incontinence, patient unfit for surgery or who refuse surgery.
• Pelvic floor exercise (kegel exercise)
• Perineometry: insertion of a cylindrical vaginal devise (perineometer) into the vagina, which helps to contract pelvic floor muscle and also assesses the strength of pelvic floor muscles.
• Vaginal cones: when inserted into vagina it stimulates the pelvic floor to contract to prevent cone from falling out and provides 'vagina weight training'
• Vagina pessaries
• Maximum electrical stimulation: using vaginal electrode
• Estrogen: no evidence to suggest that estrogen alone is useful but estrogen reduces urinary incontinence when combined with alpha-adrenergic agonists (phenylpropanolamine)
• Incontinence devices
• Tampon (sanitary or sponge)
• Contiguard
• Introl
• Femassist
• Reliance insert

Surgical treatments

• Anterior colporrhaphy.
• Marshall-Marchetti-kranz procedure
• Burch colposuspension.
• Vagina (mid urethral slings = MUS) Slings procedures
• Tension free vaginal tape (TVT)
• Trans-obturator vaginal tape (TOT)
• Single incision mini sling
• Urethral bulking procedures
• Artificial urinary sphincter (AUS)

It is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked

Often causing the intravesical pressure to exceed the urethral pressure resulting in incontinence

The second commonest cause of UI in women

Etiology

• The actual cause is unknown and in majority of cases it is idiopathic
• May be emotional, psychosocial, or neurological (upper motor neurone lesion in multiple sclerosis and referred to as detrusor hyperreflexia)
• It may also be caused by intake of caffeine, carbonated drinks, cigarette smoking and alcohol ingestion.

Clinical presentation

• Most patients with unstable bladder presents with multiple symptoms such as
• Urgency
• Urge incontinence
• Enuresis
• Frequency
• Nocturia
• Sometimes incontinence during sexual intercourse.
• Has no specific clinical sign

Diagnosis

• Made during urodynamic study
• Detrusor contraction occurs during filling phase when patient is attempting to inhibit micturition (there is failure to inhibit detrusor contraction during cystometry).

Treatment

Aim: is re-establish central control or to alter peripheral control via bladder innervation.

Behavioral intervention (habit retraining/ bladder retraining / bladder drill) for idiopathic detrusor instability

Medical- drug treatment is the most widely employed treatment

Anticholinergic-oxybutynin, Tolterodine

Surgery-

• Denervation procedures- injection of aqueous phenol into bladder base
• For patients with severe detrusor instability which is not amenable to simple medical treatment, CLAM ileocystoplasty is the current treatment of choice

Presence of both urethral sphincter incompetence and detrusor instability.

Many patients present with both stress and urge incontinence but only about 5% truly have mixed incontinence.

Treatment

• Patient should be managed medically first with anticholinergic
• If she still leaks urine without significant detrusor activity and her main complaint is stress incontinence, recourse to bladder neck surgery

This is as a result of retention of urine from any cause especially in elderly patients with loss of bladder sensation, when the bladder becomes grossly distended urine may dribble away

Causes

Can be nervous or mechanical

• Nervous causes:
• Few days of puerperium
• After abdominal or pelvic surgery due to nervous or spasm of levator ani
• Lesions of CNS e.g. Multiple sclerosis, disease of the cord, hysteria
• Mechanical causes:
• Impacted pelvic mass/tumor (fibroid, ovarian mass)
• Retroverted gravid uterus
• Fetal head

Treatment

• To relieve retention by catheterization
• Treat the cause