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LOWER

LOWER URINARY

URINARY TRACT

TRACT

(LUT)

(LUT) FUNCTION

FUNCTION &&

DYSFUNCTION

DYSFUNCTION

DRDR

..

JASSIM

JASSIM AL-HIJJI

AL-HIJJI

CONSULTANT

CONSULTANT

OBS. && GYN.

OBS.

GYN.

UROGYNECOLOGY

UROGYNECOLOGY UNIT.

UNIT.

ADAN HOSPITAL

ADAN

HOSPITAL

EMBRYOLOGY

EMBRYOLOGY

EMBRYOLOGY

EMBRYOLOGY AND

AND

ANATOMY

ANATOMY

LONGITUDINAL SECTION

LONGITUDINAL

SECTION OFOF AA 4-WEEK-

4-WEEK-

OLD EMBRYO

OLD

EMBRYO

4
4

LONGITUDINAL SECTION

LONGITUDINAL

SECTION OFOF AA 5-WEEK-

5-WEEK-

OLD EMBRYO

OLD

EMBRYO

LONGITUDINAL SECTION

LONGITUDINAL

SECTION OFOF AA 6-WEEK-

6-WEEK-

OLD EMBRYO

OLD

EMBRYO

LONGITUDINAL SECTION

LONGITUDINAL

SECTION OFOF AA 8-WEEK-

8-WEEK-

OLD EMBRYO

OLD

EMBRYO

Embryologic Contribution

Embryologic

Contribution Of

Of Various

Various Structures

Structures Of

Of

Female Urogenital

Female

Urogenital System

System

ANATOMY

ANATOMY

BLADDER ANATOMY

BLADDER

ANATOMY

Body (or dome) and

Fundus :

- supple, mobile and

highly distensible

-

capable of expanding

into abdomen,

depending on

amount of urine stored

Base of bladder not so

distensible holds

orifices (uretersand

urethra) in place

BLADDER ANATOMY BLADDER ANATOMY • Body (or dome) and Fundus :  - supple, mobile and

11

FEMALE URETHRA

FEMALE

URETHRA &&

SURROUNDINGS

SURROUNDINGS

BLADDER MUSCLES

BLADDER

MUSCLES

Main smooth muscle

layer includes:

(1) Detrusor and Trigone

It is the most important

Muscle .A mesh of

smooth muscle

bundles, Collagen &

elastin.

(2) The Trigoneis a thin

smooth muscle lining

over the bladder base,

with a Collar around

ureteric orifices

Actual function

still

ntr

r

i

l

15

FEMALE URETHRA

FEMALE

URETHRA

Adult female urethra

4 cm in length, up to

6 cm Diameter

when distended

Extends from

bladder neck

behind Symphysis

pubis

Embedded in

anterior wall of

16

FLOOR

FLOOR

Smooth muscle extends

throughout Length of

urethra.

No well-defined

sphincter at bladder

neck.

Striated sphincter

(external sphincter)

Located along middle

third of urethra

Anatomically separate

from Pelvic floor

muscles.

Pelvic floor muscles help

keep urethra closed &

support bladder

FLOOR FLOOR Smooth muscle extends throughout Length of urethra. No well-defined sphincter at bladder neck. Striated

17

The

The parts

parts of

of the

the urethral

urethral support

support and

and sphincteric

sphincteric mechanisms:

mechanisms: the

the

proximal urethra

proximal

urethra and

and bladder

bladder neck

neck are

are supported

supported byby the

the anterior

anterior

vaginal wall

vaginal

wall and

and its

its musculofascial

musculofascial attachments

attachments toto the

the pelvic

pelvic

diaphragm. Contraction

diaphragm.

Contraction of

of the

the levator

levator anielevates

anielevates the

the anterior

anterior

vagina and

vagina

and bladder

bladder neck

neck and

and proximal

proximal urethra,

urethra, contributing

contributing toto

bladder neck

bladder

neck closure.

closure. The

The sphincter

sphincter urethrae,

urethrae, urethrovaginal

urethrovaginal

sphincter, and

sphincter,

and compressor

compressor urethrae

urethrae are

are all

all parts

parts of

of the

the striated

striated

urogenital sphincter

urogenital

sphincter muscle.

muscle.

The levator

The

levator ani,

ani, seen

seen from

from the

the side

side when

when the

the

ischium isis removed.

ischium

removed. Arcus

Arcus tendineus

tendineus levatores

levatores ani

ani

runs from

runs

from the

the ischial

ischial spine

spine toto the

the pubic

pubic bone.

bone. Note

Note

the perineal

the

perineal membrane

membrane that

that supports

supports distal

distal

portions of

portions

of the

the urethra

urethra and

and vagina.

vagina.

The levator

The

levator ani,

ani, with

with patient

patient inin the

the

semirecumbent position.

semirecumbent

position. The

The muscle

muscle fibers

fibers

of the

of

the pelvic

pelvic diaphragm

diaphragm form

form aa broad,

broad,

anteriorly directed,

anteriorly

directed, U-Shaped

U-Shaped muscle

muscle layer.

layer.

The pelvic

The

pelvic organs

pass within

within this

this U-Shaped

U-Shaped

organs pass

area, called

area,

called the

the urogenital

urogenital hiatus.

hiatus.

PHYSIOLOGY

PHYSIOLOGY

NORMAL MICTURITION

NORMAL

MICTURITION

Cycle begins with urine filling bladder through

ureters

Pressure in bladder remains low during gradual

filling

When bladder reaches certain distension, stretch

receptors in bladder wall send this information

to spinal cord; other nerves relay it to brain as

sensation of fullness

If time and place are right, emptying takes place:

  • - Urethral sphincter relaxes & urethral

pressure decreases

- Detrusor muscle contracts & bladder

pressure rises

- Bladder neck and urethra open

  • - Urine flow begins and continues until

bladder is empty

U

th

l

hi

t

t

t

22

NEURAL PATHWAYS

NEURAL

PATHWAYS

Motor pathways

from brain,

through spinal

Cord to

sacrum, on to

bladder &

urethra

Sensory nerve

fibers pass

information

back

23

PERIPHERAL INNERVATIONS

PERIPHERAL

INNERVATIONS

Actions Of

Actions

Of The

The Autonomic

Autonomic And

And Somatic

Somatic Nervous

Nervous

Systems During

Systems

During Bladder

Bladder Filling

Filling // Storage

Storage And

And

Voiding

Voiding

FILLING/STORAGE

Inhibition of parasympathetics

Stimulation of sympathetics

alpha-contraction

beta-relaxation

Stimulation of somatic nerves

to striated

urogenital sphincter

VOIDING

Stimulation of

parasympathetics

Inhibition of sympathetics

Inhibition of somatic nerves to

striated

urogenital sphincter

26

Urinary Incontinence

Urinary

Incontinence

It is the involuntary leakage of

urine .It occurs when the pressure

in the bladder (expulsive force)

exceeds that within the urethra

(closure force)

The ICS Definition

A condition of involuntary

urine loss that is a social or

hygienic problem and is

objectively demonstrable.

29

Incontinence(GSI)

Incontinence(GSI)

Urodynamic stress

incontinence (previously

known as genuine stress

incontinence) is a solely

urodynamic diagnosis which

occurs when an

incompetent urethra allows

leakage of urine in the

30

TYPES OFOF URINARY

TYPES

URINARY INCONTINENCE

INCONTINENCE

Stress Incontinence

Urine leakage occurs with increases in abdominal

pressure (hence, mechanical stress).

Urge Incontinence Often referred to as overactive bladder.an abrupt and uncontrollable desire to void the bladder.

Mixed Incontinence

When two or more causes contribute to urinary incontinence. Often refers to the presence of both stress and urge incontinence.

Overflow Incontinence

The involuntary loss of urine resulting from an overfilled bladder

without any corresponding feeling or urge to void.

Functional Incontinence

Leakage (usually resulting from one or more causes) due to factors impairing reaching the restroom in time because of physical conditions (e.g., arthritis)

31

Urinary Incontinence

Urinary

Incontinence

33

PREVALENCE

PREVALENCE AND

AND INCIDENCE

INCIDENCE

An estimated 13 million adults of all ages

suffer from urinary incontinence women

account for nearly 85 % of cases.

SEX: 18%

of Men

38% of Women

AGE: The prevalence of urinary

incontinence appears to increase with

advancing age :

4% of women aged 15 to 24

16% of women aged 75 and greater.

Reasons for the increase in prevalence

of urinary incontinence with age are

(Unknown).

34

voiding, bladder

voiding,

bladder compliance

compliance and

and urinary

urinary

flow

flow rate

rate probably

probably decrease

decrease with

with

ADVANCING AGE

ADVANCING

AGE inin both

both sexes.

sexes.

Uninhibited bladder

Uninhibited

bladder contractions

contractions and

and post

post

void residual

void

residual urine

urine volume

volume increase

increase with

with

age.

age.

Maximal urethral

Maximal

urethral closure

closure pressure

pressure and

and

functional urethral

functional

urethral length

length decrease

decrease inin

women.

women.

Changes inin bladder

Changes

bladder and

and urethral

urethral function

function

probably

probably are

are related

related directly

directly toto aging

aging

process. process.

Another

Another

age related

age

related change

change isis anan

alteration inin the

alteration

the pattern

pattern of

of fluid

fluid excretion.

35

excretion.

GENITOURINARY

GENITOURINARY

ETIOLOGY

ETIOLOGY

Filling / Storage disorders

Genuine stress incontinence

Detrusor instability (Idiopathic)

Detrusor hyperreglexia (Neurogenic)

Mixed types

Overflow incontinence

Fistula:

Vesical

Ureteral

Urethral

Congenital:

Ectopic Ureter

Epispadias

Non genitourinary

Non

genitourinary Etiology

Etiology

Functional

Neurologic

Cognitive

Environmental

Pharmacologic

Metabolic

Non-Urologic

Non-Urologic Causes

Causes of

of

Incontinence

Incontinence

Behavioural problems

Immobility

Medication

Diabetes.

Race:

Genital prolpse, enterocele and

stress incontinence are uncommon

in:

Chinese

- Eskimo

39

- Black

Non-Urologic

Non-Urologic Causes

Causes of

of

Child Birth:

Incontinence

Incontinence

Child birth injury leading to pelvic support

abnormalities and stress incontinence

Vaginal delivery directly damages pelvic

fascial supports and may cause partial

denervation of the pelvic floor and urethral

muscles.

Menopause:-

Vagina and urethra have similar epithelial

linings due to embryologic origin.Normal urethral

function in the female is affected by age and

estrogen status

Smoking:-

Significant association between cigarette

40

smoking and development of all forms of urinary

Non-Urologic

Non-Urologic causes

causes of

of

Incontinence

Incontinence

Obesity:

Significantly more common in women with

GSI and D.I

Psychologic Changes:

U.T is a complex phenomenon with multiple

causes

including psychogenic causes.The anxiety,

depression and other psychologic abnormalities may

be related .

Sexual Changes:

Sexual dysfunctionL U T dysfunction can effect

on sexual function.Leaking urine with intercourse

Economic Issues:

in

Costs of caring for elderly incontinence people

41

nursing homes.

MEDICATIONS THAT

MEDICATIONS

THAT CAN

CAN AFFECT

AFFECT LOWER

LOWER URINARY

URINARY TRACT

TRACT

FUNCTION

FUNCTION

LOW

LOWERER URINARY

URINARY TRACT

TRACT

EFFECTS

EFFECTS

TYPE OF

TYPE

OF MMEDICATION

EDICATION

Polyuria,

Polyu

ria, ffrereque

quency

ncy uurge

rgency

ncy

Diurerettics ics

Diu

Urinaryry reretteennttion,

Urina

ion, ove

overr flow

flow

inconttine

incon

inence

nce

AnAntticholine

icholinergic

rgic age

agennttss

SeSedadattion, ion, ImImpaire pairedd mmobilit obility, y,

Alcohol

Alcohol

diu diureresis sis

AnAntticholine icholinergic rgic aact ctions, ions,

sesedadattionAn ionAntticholine icholinergic rgic aact ctions. ions.

Psychotropic

Psychot

ropic age

agennttss

AAn AAnttide ideppreressan ssanttss

sesedadattionSe ionSedadattion, ion, mmuscle uscle

relaxaxattion,

rela

ion, con

confusion

fusion

AnAnttipsychot ipsychotics ics

SeSedadattive ivess // HHypnot ypnotics ics

St Streressss incon

inconttine

inence

nce

Urinaryry reretteennttion

Urina

ion

Urinaryry reretteennttion

Urina

ion

Alpha-ad

Alpha

-adrerenenergic

rgic blocke

blockersrs

Alpha-ad

Alpha

-adrerenenergic

rgic aagonist

gonistss

Be Bettaa-a-addrerenenergic

rgic agonist

agonistss

Urina Urinaryry reretteennttion, ion, ove overrflow flow

incon inconttine inence nce

Calcium

Calcium-channel

-channel blocke

blockersrs

va ua

o

o

Incontinence

Incontinence

History Physical Examination

Gynecologic

Examination

Office Tests.

44

Do you leak urine when you cough, sneeze , or laugh?

Do you ever have such an uncomfortably strong need

to urinate that if you don't reach the toilet you will

 

leak?

If " Yes" to No.2, do you ever leak before you reach the

toilet?

How many times during the day do you urinate?

How many times do you void during the night after

going to bed?

Have you wet the bed in the past year?

Do you develop an urgent need to urinate when you

are nervous, under stress,

or in a hurry?

Do you ever leak during or after sexual intercourse?

Do you find it necessary to wear a pad because of your

leaking?

How often do you leak ?

45

Incontinence

Incontinence

Have you had bladder, urine, or

kidney infections?

Are you troubled by pain or

discomfort when you urinate?

Have you had blood in your urine?

Do you find it hard to begin

urinating?

Do you have a slow urinary stream?

Do you have to strain to pass your

urine?

After you urinate, do you have

dribbling or a feeling that your

46

The cotton-tipped

The

cotton-tipped applicator

applicator (Q-tip)

(Q-tip) test

test for

for the

the assessment

assessment

of urethral

of

urethral and

and bladder

bladder support.

support. A:

A: The

The resting

resting angle

angle of

of the

the

cotton-tipped applicator

cotton-tipped

applicator isis normal.

normal. B:

B: With

With straining,

straining, the

the

urethrovesical junction

urethrovesical

junction descends,

descends, causing

causing the

the end

end of

of the

the stick

stick

toto rotate

rotate upward.

upward.

Urodynamic Studies

Urodynamic

Studies

A urodynamicstudy is a series of detailed

measurements that gives

an idea of the

function of the bladder and urethra

These tests can

evaluate any problems

with storing urine or voiding

urine from

the body.

Accurate differentiation between types of

incontinence is vital . However,

empirical treatment without urodynamic

assessment can be commenced if

symptoms of idiopathic detrusor

overactivity are uncomplicated.

48

If treatment fails, or secondary adverse

Genuine

Genuine stress

stress

Incontinence

Incontinence

In intact L U T : Continence is maintained as long

as the pressure closing the urethra is greater

than the intra vesical pressure.

Etiology:

1.Lowered urethral pressure

2.Detrusor contractions

3.Greater transmission of intra-abdominal

pressure to the bladder than to the urethra

4.Passive increases in intra-vesical pressure due

to distention beyond the elastic limits of the

bladder

5.By passing of the continence mechanism due to

51

fistula or ecto ic ureter

Etiology Of

Etiology

Of GSI

GSI

Proposed Mechanisms:

Anatomic decent of the proximal

urethra below its normal intra-

abdominal position during

stressful.

Altered anatomic relationships

between the urethra and bladder.

Failure of neuromuscular

components that reflexly increase

intraurethral pressure in response

i

i

i

bd

i

l

52

Anatomic

S.I

True S.I

Urinary S.I

(GSI)

(GSI)

It is the involuntary loss of urine through the urethra

occurring

simultaneously with an increase in

intra-abdominal pressure in the absence of

detrusor muscle contraction.

Continent at rest has intraurethral pressure greater

than the intra-vesical pressure.

The pressure difference or urethral closure pressure

(Total U.P Intravesical P.) = Represents the

margin of continence.

If the resting intravescial pressure + any increase in

pressure generated during stressful activities

exceeds the intraurethral Pressure at rest + any

increase in urethral pressure generated during

stressful activities, the urethral closure pressure will

53

  • d t

Z

G S I

ill

lt

Treatment Of

Treatment

Of GSI

GSI

Non Surgical Measures:

Medical

Medical devices

devices that block or capture

urine.

Kegel exercises

Medication

Medication to increase or decrease

the activity of the bladder muscle, or

medication to increase or relax the

closure of the bladder sphincter.

Electrical

Electrical stimulation

stimulation to help return

injured muscles to fitness and

biofeedback to record progress in

strengthening treatments and

exercises.

Magnetic

Magnetic Stimulation.

Stimulation.

Estrogen replacement

54

Pelvic Floor

Pelvic

Floor Muscle

Muscle Training

Training

It is the most recommended physical

therapy for women with stress urinary

incontinence. Adjuncts, as biofeedback or

electrical stimulation, are also commonly

used with pelvic floor muscle training.

Training regimens vary markedly from

area to area.

The inconsistency of intervention coupled

with different measures of success make

these trials difficult to compare. Results

show that an improvement can be

MAGNETIC STIMULATION

MAGNETIC

STIMULATION

DULOXITINE && GSI

DULOXITINE

GSI

A combined noradrenalin and serotonin

reuptak inhibitor,duloxetine,was used in

animal studies. In the cat model

duloxetine significantly increased

sphincteric activity and bladder capacity.

Duloxetinehas been trialled in a phase II

& III

& a double-blind placebo controlled

study.

The effective dose was 40 mg twice daily.

This dose elicited significant

improvements with 50% of the women

experiencing a 64100% reduction in

57

SURGERY FOR

SURGERY

FOR STRESS

STRESS

INCONTENENC

INCONTENENC

Intraurethral injection

Abdominal

procedures

Vaginal procedure

Classical Sling

procedure

omom nana

proce ure

proce

ure too correc

correct sstress

ress ncon

ncont nence.

nence.

:: ananter

er or

or

vaginal wall

vaginal

wall has

has been

been mobilized.

mobilized. Two

Two sutures

sutures have

have been

been placed

placed onon

either side

either

side and

and far

far lateral

lateral from

from the

the midline.

midline. Distal

Distal sutures

sutures are

are

opposite the

opposite

the mid

mid urethra.

urethra. Proximal

Proximal sutures

sutures are

are at

at the

the end

end of

of the

the

vasicourethral junction.

vasicourethral

junction. Sutures

Sutures are

are attached

attached toto coopers

coopers ligament.

ligament. B:

B:

Cross section

Cross

section shows

shows urethra

urethra free

free inin retropubic

retropubic space

space with

with anterior

anterior

vaginal wall

vaginal

wall lifting

lifting and

and supporting

supporting it.

it.

ABDOMINAL

ABDOMINAL

BURCH

BURCH

COLPOSUSPENSION

COLPOSUSPENSION..

Sling Procedures:

Sling

Procedures:

There are two main types of sling

procedure: the classic open bladder neck

sling and the newer suburethral slings

such as TVT, TVT- O , TOT and

TVT - S.

Success rates are approximately 80%, with

little diminution over time, and tend to be

higher with synthetic materials. However,

their use increases the risk of erosion and

sinus formation.

The risk of voiding disorder is in the region

of 10% and de novo detrusor overactivity

is variable, at approximately 14%.

TVT

TVT trocar

trocar inin position

position behind

behind the

the symphysis

symphysis

pubis after

pubis

after the

the first

first pass

pass

pp

pp

suspension

suspension

pp

Laparoscopic surgery has the

presumed advantage of avoiding

a large incision, resulting in a

shorter hospital stay and a

quicker return to normal daily

activities. Large differences in

surgical techniques in this area

confound comparison. There are

few randomised controlled trials

and these have limited follow-up.

65

URGE URINARY

URGE

URINARY INCONTINENCE

INCONTINENCE

It is the complaint of involuntary leakage

accompanied by, or immediately

preceded by, urgency.

It is often associated with increased

frequency of micturition and nocturia.

Up to 15% of the population complain of

urgency although not all will be

incontinent.

While urge urinary incontinence is a

symptom of many conditions ,

idiopathic detrusor overactivity

(formerly known as detrusor instability)

66

Biofeedback

Biofeedback

It is a re-education or learning process in

which the patient is retrained using

information about usually unconscious

physiological responses.

In the example of idiopathic detrusor

overactivity these would be unstable

bladder contractions.

An auditory, visual or tactile signal is

relayed back to the patient so that she

can take action such as performing

relaxation techniques or tightening

certain muscle groups.

Although this has been shown to be

67

Bladder Drill

Bladder

Drill

Bladder drill involves instructing the

patient to void at predetermined

intervals during the day. She must not

void between these times but instead

must either wait or be incontinent.

The voiding interval is then increased

once the initial goal has been achieved.

This process is continued until voiding can

be deferred to every 3-4 hours without

urgency or incontinence between these

times.

A normal fluid intake should be

maintained (1.5 1/day). It is most

successful in young, well-motivated

68

Drug Treatment

Drug

Treatment

Changes to the central nervous system

have been implicated in pathology of

stress incontinence.

The suggestion is that the

neurotransmitters serotonin and

noradrenalin influence the contraction of

the urethral sphincter.

Abnormalities in their release can act alone

or in combination with local damage or

degeneration to the sphincteric

mechanisms. A strong association has

been found between depression and

idiopathic incontinence.

This suggests a common pathology

i

l

i

t

i

Th

f

th

69

Drug Treatment

Drug

Treatment

Urethra is mainly innervated by

alpha-adrenergic sympathetic

Nervous system.

Elimination of medications that exert

ganglionic or alpha Adrenergic

blocking activity Guanethidine,

Methyldopa and Prazosin for

improve urethral tone.

Alpha- Adrenergic agonists may

improve G.S.

70

DRUG

DRUG TREATMENT

TREATMENT OFOF OVERACTIVE

OVERACTIVE

BLADDER

BLADDER

Oxbutynin (Ditropan):

2.5mg twice daily to 5mg 4 times a day

Propantheline (Norpanth, Probanthine)

7.5mg twice daily to 15mg 4 times a day

Imipramine (Tofranil):

25mg 2-3 times daily

Flavoxate (Urispas):

100mg twice daily to 200mg 4 times a day

Hyoscyamine (Cystospaz, Levsin,):

0.125-0.25mg 3- 4 times daily.

Prostaglandin synthetase inhibitors

(nonsteroidal anti-inflammatory agents,

e.g Ibuprofen, Fenoprofen, Sulindac)

Advil, Clinoril, Naprosyn,

73

OXYBUTYNIN (DETROPAN)

OXYBUTYNIN

(DETROPAN)

It is a tertiary amine, and a highly

selective M1 and M3 muscarinic

receptor antagonist and a direct

muscle relaxant.

It is the standard treatment against

which other drugs and therapies

have been tested.

Its effectiveness in idiopathic

detrusor overactivity is well

documented but the incidence of

its main adverse effect, dry mouth,

74

i

80%

TOLTERODINE (DETRUSITOL)

TOLTERODINE

(DETRUSITOL)

Tolterodine is a muscarinic

receptor antagonist that

appears to target bladder

receptors over the salivary

glands. Several randomised,

double-blind, placebo-

controlled trials on patients

with idiopathic detrusor

instability have shown a

significant reduction in

incontinent episodes and

75

IMIPRAMINE (TOFRANIL):

IMIPRAMINE

(TOFRANIL):

Imipramine has systemic Anti

-cholinergic effects, which are

thought to improve the

symptoms of detrusor

overactivity.

However, evidence of its

benefits is conflicting and it

should not be used as first-line

treatment.

The benefits of its sedative

VASOPRESSIN (ANTI

VASOPRESSIN

(ANTI DD URETIC

URETIC

HORMONE)

HORMONE)

BOTULINUM TOXIN

BOTULINUM

TOXIN

LOCAL INTRAVESICAL

LOCAL

INTRAVESICAL INJECTION

INJECTION

SURGERY FOR

SURGERY

FOR URGENCY

URGENCY

INCONTINENCE

INCONTINENCE

Augmentation cystoplasty

Auto augmentation

Sacral nerve stimulation