Urinary incontinence

Urogynaecological conditions include: urinary incontinence, voiding difficulties, Pelvic organ

prolapse, frequency and urgency, urinary tract infection and urinary fistulae.
Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and
is a social or hygienic problem, remains undetected and undertreated worldwide despite its substantial
impact on affected individuals.
The prevalence increases with age and in women, in older women, the prevalence of urinary
incontinence is 17-55%.

Anatomy of the urinary system:

Normal Urethral Closure
Normal urethral closure is maintained by a combination of intrinsic & extrinsic factors that maintain
the intraurethral pressure at rest higher than the intravesical pressure(detrusal + Abdominal pressure):
Look to the next figures

The extrinsic factors:

The levator ani muscles mainly, the endopelvic fascia, & their attachments to the pelvic
sidewalls & the urethra

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The intrinsic factors includes:

the striated muscle of the urethral wall

vascular congestion of the submucosal venous plexus

the smooth muscle of the urethral wall & associated blood vessels

the epithelial coaptation of the folds of the urethral lining

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The Bladder : is a low-pressure system that expands to accommodate increasing volumes of urine
without an appreciable rise in pressure (good compliance).

Normal Micturition:
During bladder filling, there is an accompanying increase in muscle fiber recruitment of the pelvic
floor & urethra increase in outlet resistance. The bladder muscle (the detrusor) should remain
inactive during bladder filling, without involuntary contractions
When the bladder has filled to a certain volume, fullness is registered by tension-stretch receptors,
which signal the brain to initiate a micturition reflex this reflex is permitted or not permitted by
cortical control mechanisms, depending on the social circumstances & the state of the patient's
nervous system.
Normal voiding is accomplished by voluntary relaxation of the pelvic floor & urethra, accompanied
by sustained contraction of the detrusor muscle, leading to complete bladder emptying.

Innervations
- The lower urinary tract receives its innervation from three sources:

Sympathetic nervous system

Parasympathetic nervous system

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The neurons of the somatic nervous system (external urethral sphincter)

The sympathetic nervous system: Originates in the thoraco-lumbar spinal cord, principally T11
through L2-L3
- Acts on two types of receptors:

Alpha-receptors (important in Rx) in the urethra & bladder neck increases urethral tone &
thus promotes closure

Beta-receptors in the bladder body decreases tone in the bladder body

The parasympathetic nervous system: Originates in the sacral spinal cord, primarily in S2 to S4 ,
Controls bladder motor function bladder contraction & bladder emptying (in Urge incontinence we
use Antimuscarinic drugs to inhibit the early contraction)
The somatic nervous system: The somatic innervation of the pelvic floor, urethra, & external anal
sphincter originates in the sacral spinal cord, primarily in S2 to S4 .

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Common symptoms associated with incontinence:

Stress incontinence: is a symptom and a sign and means loss of urine on physical effort.
Urgency: means a sudden desire to void
Urge incontinence: is an involuntary loss of urine associated with a strong desire to void
Overflow incontinence: occurs without any detrusor activity when the bladder is overdistended
Frequency: is defined as the passing of urine seven or more times a day, or being awoken from
sleep more than once a night to void
So The four main types of urinary incontinence are urge, stress, mixed(Urge + stress), and
overflow incontinence.
Urinary incontinence is classified according to pathophysiological concepts: "according to Gynaecology
by Ten Teachers "

1 - Urethral causes:
A - Urodynamic stress incontinence (USI)
B - Detrusor overactivity or the unstable bladder this is either neurogenic or non-neurogenic
C - Retention with overflow
D- Congenital

2 Extra-urethral causes of incontinence

A Congenital (Bladder exstrophy and ectopic ureter )
B Fistula
C - Frequency and urgency
D - Voiding difficulties
E - Urinary tract infection
1 - Urethral causes:
A - Urodynamic stress incontinence (USI)
This is The most common type defied as the involuntary leakage of urine during increased
abdominal pressure in the absence of a detrusor contraction. may be provoked by minimal or no
activity when there is severe sphincter dysfunction
Symptoms:
Stress incontinence is the usual symptom, but urgency, frequency and urge incontinence may be
present. There may also be an awareness of prolapse.
On clinical examination stress incontinence may be demonstrated when the patient coughs.
Also can be noted during filling cystometry, as Urodynamic studies will define the cause of
incontinence
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Vaginal examination: looking for ( prolapse ,

cystourethrocele )
Pathophysiology
suburethral support normally provided by the vaginal
wall, endopelvic fascia, arcus tendineus fascia and
levator ani muscles acting as a single unit , 90% of
cases any Laxity by trauma or scaring .. Results in
ineffective compression during physical stress and
consequent incontinence.
An intraurethral pressure which at rest is lower than
the intravesical pressure; this may be due to urethral
scarring as a result of surgery or radiotherapy It also
occurs in older women due to estrogen deficiency
(cause stress or urge).

Etiology:
Vaginal delivery can Damage to the nerve supply of the pelvic floor and urethral sphincter, or a
direct mechanical trauma to the pelvic floor muscles and ligaments. Noted that prolonged second
stage, large babies and instrumental deliveries cause the most damage.
Menopause and associated tissue atrophy may also cause damage to the pelvic floor.
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A congenital cause due to altered connective tissue,particularly collagen. Stress incontinence is

much less common in black women and differences in connective tissue are thought to be responsible.
Chronic causes, such as obesity and chronic obstructive pulmonary disease, raise intrabdominal
pressure, and constipation and associated straining may also result in problems.
It's mainly structural problem so mostly need surgical intervention

B - Detrusor overactivity "idiopathic Urge incontinence" :

Is an urodynamic observation characterized by involuntary detrusor contractions during the filling
phase which may be spontaneous or provoked.
Pathophysiology:
Poor toilet habit training, psychological factors ,urinary tract infection but still mostly idiopathic,
Childhood enuresis increases the likelihood of developing symptoms of overactivity, Neuropathy
appears to be the most substantiated factor, Incontinence surgery, outflow obstruction and smoking
are also associated with detrusor overactivity.
Symptoms:
urgency, frequency and nocturia is termed the overactive bladder (OAB) syndrome with (OAB wet)
urgency incontinence or without (OAB dry) "urgency", in the absence of urinary tract infection or other
obvious pathology.
Common triggers include running water, hand washing, and cold weather exposure.
Examination:
Exclude other causes like masses, prolapse, stress incontinence, fistula.

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C - Retention with overflow "Overflow incontinence" :

More common in males, Insidious failure of bladder emptying may lead to chronic retention and,
finally, when normal voiding is ineffective, to overflow incontinence.
The causes:
- lower motor neuron or upper motor neuron lesions
- urethral obstruction
- pharmacological
Symptoms:
poor stream, incomplete bladder emptying and straining to void, together with overflow stress
incontinence. Often, there will be recurrent urinary tract infection.
Investigations:
Cystometry is usually required to make the diagnosis, and bladder ultrasonography or intravenous
or CT (computed tomography) urogram may be necessary to investigate the state of the upper urinary
tract to exclude reflux.
D Congenital:
Epispadias results in a widened bladder neck shortened urethra, separation of the symphysis pubis
and imperfect sphincteric control. The patient complains of stress incontinence,
E- Miscellaneous:
Acute urinary tract infection or fecal impaction in the elderly may lead to temporary urinary
incontinence.
A urethral diverticulum may lead to post-micturition dribble, as urine collects within the diverticulum
and escapes as the patient stands up.

2 - Extraurethral causes of incontinence:

A Congenital : Bladder exstrophy and ectopic ureter
In bladder exstrophy, there is failure of mesodermal migration with breakdown of ectoderm and
endoderm, resulting in absence of the anterior abdominal wall and anterior bladder wall. Extensive
reconstructive surgery is necessary in the neonatal period.
An ectopic ureter may be single or bilateral and presents with incontinence only if the ectopic opening
is outside the bladder, when it may open within the vagina or onto the perineum. The cure is excision
of the ectopic ureter and the upper pole of the kidney that it drains.

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B Fistula:
Present with continuous urine leakage, Urinary fistulae have
obstetric and gynaecological causes. The former include
obstructive labour with compression of the bladder between
the presenting head and the bony wall of the pelvis. The
gynaecological causes are associated with pelvic surgery or
pelvic malignancy or radiotherapy.
The fistula must be accurately localized. It can be treated by
primary closure or by surgery.
C - Frequency and urgency:
Approximately 1520 % of women have frequency and
urgency.
Clinical examination and investigation directed towards the common causes. These include masses
that cause compression, prolapsed, infection, stones and malignancy. Increased fluid intake or
evidence of ingestion of too much caffeine
and help to diagnose possible diabetes insipidus or mellitus.
D - Voiding difficulties:
Is either failure of detrusor contraction or sphincteric relaxation, or urethral
obstruction, and this may be due to causes such as stricture and impacted retroverted gravid uterus.
also occur after bladder overdistension, such as after pelvic surgery or traumatic vaginal delivery, any
masses and prolapse must be excluded.
Symptoms:
poor stream, incomplete emptying and straining to void, Incontinence may follow, and chronic
retention and overflow.
Investigations: include uroflowmetry, cystometry and a lumbar sacral spine magnetic resonance
imaging (MRI).
E - Urinary tract infection:
The common organisms are Escherichia coli, Proteus mirabilis, Klebsiella aerogenes, Pseudomonas
aeruginosa and Streptococcus faecalis. These gain entry to the urinary tract by a direct extension from
the gut, lymphatic spread via the bloodstream or
transurethral from the perineum.
Symptoms include dysuria, frequency and occasionally haematuria. Loin pain and rigors and a
temperature above 38C usually indicate that acute pyelonephritis has developed.
With acute urinary infection, once a midstream urine specimen has been sent for culture and
sensitivity, antimicrobial therapy can begin.
Commonly used drugs include trimethoprim 200 mg twice daily or nitrofurantoin 100 mg four times
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daily or a cephalosporin.
Intravenous or CT urography or renal ultrasonography may be required in patients with recurrent
infection to define anatomical or functional abnormalities.

Overall EVALUATION and investigations :

History:
- Patients urinary symptoms (volume, onset of incontinence, timing, severity, hesitancy, precipitating
triggers, nocturia, intermittent or slow stream, incomplete emptying, continuous urine leakage, and
straining to void)
Voiding (bladder) diaries " look to figure " are sometimes useful for assessing incontinence
frequency, severity, and volume of urine loss during incontinent episodes

- Severity of symptoms & degree of bother and effect on quality of life

Urinary incontinence has profound effects on quality of life and is associated with depression and
anxiety, work impairment, social isolation, and sexual dysfunction
- If there is indications to evaluate for underlying serious causes (malignancy , neurological " MS " ) or
potentially reversible conditions. Alarm symptoms on history include:
Sudden onset of incontinence (Neurological .. )
the presence of abdominal or pelvic pain
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 Hematuria (cervical CA .. )
changes in gait or new lower extremity weakness
cardiopulmonary or neurologic symptoms
mental status changes
- Other: drug history, constipation, caffeine intake etc.
Keep in mind the suspected causes:
Genitourinary
In older women, several physiologic changes occur in the lower urinary tract that can cause
incontinence:

Involuntary detrusor contractions or overactivity

Decreased detrusor contractility

Low estrogen levels

Decrease in urethral closure pressure

Others:

Urogenital fistulas

Interstitial cystitis (painful bladder syndrome

Pelvic organ prolapse (e.g., cystocele)

Systemic conditions

Neurologic disorders: e.g. stroke, multiple sclerosis, Parkinson disease, disc herniation, spinal
cord injury

Diabetes mellitus: overflow incontinence and poor urinary stream can be present in patients
with diabetic autonomic neuropathy

Cancers

Potentially reversible causes

Medications (e.g., alpha blockers)

Decreased mobility (e.g., post-surgery)

Change in cognitive or mental status (e.g., sedation from medications)

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Stool impaction

Alcohol and caffeine intake

Physical examination
- All women presenting with incontinence need a pelvic examination. In addition, a comprehensive
examination is often necessary to detect potentially reversible factors and underlying serious
conditions
- The detailed pelvic examination in women includes:

Inspect the vaginal mucosa for signs of atrophy "estrogen deficiency" (thinning, pallor, loss of
rugae), and inflammation ( Candidal infection .. )

Palpate bimanually to evaluate for masses (fibroid ...) or tenderness.

Assess for pelvic organ prolapse: hold the blade (Simms speculum) firmly against the posterior
vaginal wall. Ask the woman to cough once, looking for urethral leakage &/or cystocele.

Bladder stress test is performed by asking the patient, with a full bladder, to stand, relax,
and give a single vigorous cough

Investigations:

Urine analysis

Postvoid residual volume (PVR) In general, a PVR of < 50 mL is considered adequate

emptying, and a PVR > 200 mL is considered inadequate and suggestive of either detrusor
weakness or bladder outlet obstruction

Urodynamic testing

Urodynamic testing
Urodynamics refers to a group of tests used to assess function of the urinary tract. Some specific types
of urodynamic testing are:

Cystometry (or cystometrogram) evaluates bladder function by measuring pressure and

volume of fluid in the bladder during filling, storage, and voiding.

Uroflowmetry measures the rate of urine flow.

Clinical evaluation with urodynamics may lead to a more accurate diagnosis of incontinence type

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Cystometry is indicated for the following:

Previous unsuccessful continence surgery.
Multiple symptoms, i.e. urge incontinence, stress incontinence and frequency.
Voiding disorder.
Neurogenic bladder.
Normal observations and results The normal bladder should not have involuntary phasic
contractions during filling despite provocation. It should initially expand without resistance or
increased intraluminal pressure. The urethral sphincter should relax and open when the patient wants
to initiate voiding, accompanied by detrusor contractions. During voiding, detrusor contraction should
be smooth and lead to a steady urine stream.
Technique " look to figures next page"

The patient begins by emptying her bladder as much as possible

A catheter is inserted into the bladder ( measure PVR)

Intravesical & rectal catheters are placed to measure detrusor and abdominal pressure

Water or normal saline is used to fill the bladder, The standard filing rate is between 10 and
100 mL/min and is provocative for detrusor instability.

The woman is asked to describe sensations during filling, including when the first feeling of
bladder fullness occurs.

At maximum capacity, the filing line is removed and the patient stands. She is asked to cough
and any leakage is documented. Provocative maneuvers, such as coughing, Valsalva, listening
to running water are helpful for determining if they cause leakage and whether the leakage is
related to uninhibited detrusor contractions or stress incontinence

Once the bladder is completely full, the woman is asked to begin voiding in the uroflowmeter,
and measurements are made of pressure, volume, and flow rate.

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- Approximate of normal cystometric values for women are:

Residual urine < 50 mL

First desire to void occur between 150 & 250 mL

Strong desire to void doesnt occur until > 250 mL ??

Bladder compliance between 400 & 600 mL

No uninhibited destructor contraction during filling, despite provocation

No stress or urge incontinence

Voiding occurs because of voluntarily initiated & sustained detrusor contraction

Flow rate during voiding is > 15 mL / sec with detrusor pressure of < 50 cm H2O

Overactive bladder Detrusor overactivity can be diagnosed if there is urgency or leakage with
a detrusor contraction that the patient cannot suppress

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Stress urinary incontinence is characterized by leakage that occurs with an increase in

abdominal pressure, such as coughing or Valsalva, without a rise in true detrusor pressure

Uroflowmetry : the measurement of urine flow rate

The normal flow curve is bell shaped. A flow
rate <15 mL/second on more than one
occasion is considered abnormal in females.
The voided volume should be >150 mL, as flow
rates with smaller volumes are not reliable. A
low peak flow rate and a prolonged voiding
time suggest a voiding disorder. Straining can
give abnormal flow patterns with interrupted
flow. Uroflowmetry alone cannot diagnose the
cause of impaired voiding; simultaneous
measurement of voiding pressure allows a
more detailed assessment.

Videocystourethrography:
radio-opaque filing medium is used during
cystometry the lower urinary tract can be
visualized by x-ray screening with an image
intensifier. During bladder filing, vesicoureteric
reflux can be seen. During voiding,
vesicoureteric reflux, trabeculation and bladder
urethral diverticulae can be noted

and

Intravenous urography: If suspected

ureterovaginal fistula.
Ultrasound : For Post-micturition urine residual estimation , Urethral cysts and diverticula .
Magnetic resonance imaging : show detailed anatomy .
Cystourethroscopy: indicated in women with incontinence when:
Reduced bladder capacity.
Short history (less than two years) of urgency and frequency.
Suspected urethrovaginal or vesicovaginal fistula.
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 Haematuria or abnormal cytology.

Persistent urinary tract infection.
Urethral pressure profiometry : measure urethral pressure which to maintain continence, must
remain higher than the intravesical pressure

Prevention

Behavioral and lifestyle changes: weight loss for obesity, smoking cessation, increasing physical
activity/exercise, improving dietetc.

Pelvic floor muscle exercises are effective in preventing and reversing some urinary
incontinence in the first year after vaginal delivery or following pelvic surgery

Management of conditions associated with incontinence (e.g., diabetes, constipationetc)

Specific medications and surgical procedures may adversely affect continence, and clinicians
should include these risks in discussing treatment choice with patients

Treatment
Stress incontinence , Mainly surgical
Non-surgical Treatment

Reduce factors that worsen the problem obesity, smoking, medication, excessive fluid
intakeetc

Pelvic floor exercise & biofeedback

Estrogen therapy (in postmenopausal women with urogenital atrophy)

Electrical stimulation of pelvic floor muscle

Surgical Management : For women seeking cure,

The aims of surgery are:
to provide suburethral support
restoration of the proximal urethra and bladder neck to the zone of intra-abdominal pressure
transmission;
to increase urethral resistance;
a combination of both.
Types used: just know them according to Doctor

Anterior vaginal colporrhaphy

Retropubic bladder neck suspension operations

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Tension-free vaginal tape

Sling operations

Periurethral injections

Urge incontinence

Conservative measure:

Cut down volume of fluid consumed should consume between 1 & 1.5 liters a day
Avoid caffeine based drinks

Bladder training: the patient is instructed to void on a timed schedule, starting with a relatively
frequent interval

If Conservative didn't work start on Medications:

Antimuscarinic drugs (e.g. tolterodine and oxybutynin)

Estrogen

Intra-vesical therapy (capsaicin, Botulinum toxin)

Sacral nerve root neuromodulation

Surgery (cystoplasty, urinary diversion) in refractory cases

Overflow incontinence:

Medical therapy to enhance bladder emptying provided there is no obstruction e.g.

Bethanechol (used rarely)

Treatment of the underlying cause of obstruction e.g. myomectomy or hysterectomy in the

case of fibroid, removal of the urethral stricture etc.

Intermittent self catheterization (every 4 hours )

The End
Resources : Gynaecology by Ten Teachers, 19th Edition , Doctor Rawan's slides and lecture
Done by :

Nour J. Al-khasieb
Hope group , 2015

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