Urine Incontinence

‫بسم اهلل الرحمن الرحيم‬ ‫‪WWW.SMSO.NET‬‬ Stress Incontinence Of Urine In Females WWW.SMSO.NET Introduction. Incidence.  Cost effectiveness.  Quality of life.  WWW.SMSO.NET Epidemiologic Survey Stress urinary incontinence is more common in women aged 30 to 60 years (29%) than in women younger than 30 years (16%).  Stress incontinence (78%) is more common than urge incontinence (51%).  Hampel C, Weinhold N, Eggersmann C, Thuroff JW: Definition of overactive bladder and epidemiology of urinary incontinence. Urology 50 (Suppl 6A): 4 14, 1997. WWW.SMSO.NET  Can a woman express properly whether she has stress incontinence or urge incontinence? WWW.SMSO.NET Definitions Epidemiological Definitions.  Clinical Definitions  WWW.SMSO.NET Clinical Definitions More than one definition adopted by the International Continence Society (Abrams et al, 2001).  Multiple definitions are in accordance with the heterogeneous character of female urinary incontinence.  Definitions are based on symptoms, signs or urodynamic findings.  Abrams P, Cardozo L, Fall M et al: The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 61: 37 – 49, 2001. WWW.SMSO.NET Definition Based on “Symptoms”  Stress incontinence: complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Urge incontinence: complaint of involuntary leakage accompanied by or immediately preceded by urgency. WWW.SMSO.NET  Definition Based on “Signs”  Stress incontinence: the observation of involuntary leakage of urine from the urethra on effort or exertion, or on sneezing or coughing. Urge incontinence: there is no specific definition for urge incontinence based on signs.  WWW.SMSO.NET Definition Based on “Urodynamic Findings”  Stress incontinence: involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction. Urge incontinence: involuntary leakage of urine during a detrusor contraction.  WWW.SMSO.NET Are Urodynamic Studies Always Required?   Not required if the complaint is mild, and treatment is non surgical. Required if the complaint is considerable, with failure of medical treatment and plan for surgical correction. WWW.SMSO.NET Symptoms Versus Urodynamics   Among 950 patients with incontinence, diagnosis as having stress incontinence was 30% based on “symptoms”, and 62% based on urodynamic studies. Conclusion: urodynamic diagnosis of stress incontinence is more predictable. Diagnosis based on symptoms alone can be misleading. Can a woman express properly whether she has stress incontinence or urge incontinence? Abrams P, Cardozo L, Fall M et al: The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 61: 37 – 49, 2001.  WWW.SMSO.NET Risk Factors Aging  Obesity  Smoking  Pregnancy and childbirth  WWW.SMSO.NET Stress Incontinence Today and 100 Years Ago How does it develop? A historical review on the Pathophysiology of stress urine incontinence: WWW.SMSO.NET Kelly HA, Dumm WM: Urinary Incontinence in Women, Without Manifest Injury of the Bladder. Surg Gynecol Obstet 18: 444, 1914.   The first study that attempted to explain the pathophysiology of stress incontinence based on the use of a new instrument called “cystoscope”. Cystoscopy revealed: a gaping internal sphincter orifice, probably resulting from “vesical neck funneling” (caused by loss of elasticity or normal tone of the urethral and vesical sphincter. Sphincteric dysfunction was attributed to loss of anterior vaginal wall support). WWW.SMSO.NET Boney V: On Diurnal Incontinence of Urine in Women. J Obstet Gynecol Br Emp 30: 358, 1923.    Mechanism of incontinence: The front part of the pubo-cervical muscle-sheet becomes lax. This muscle yields under sudden pressure. The bladder slips down behind the symphysis pubis below the sub-pubic angle. WWW.SMSO.NET Stevens WE, Smith SP: Roentgenological Examination of the Female Urethra. J Urol 37: 194, 1937.    The first study that attempted to explain the pathophysiology of stress incontinence based on the use of x-ray findings. Bead chain that showed “funneling of the bladder floor towards the urethra” and flattening of the urethrovesical angle in sagittal images. This anatomic abnormality was explained by presence of a weak sphincter. WWW.SMSO.NET Enhorning G: Simultaneous Recording of intravesical and Intraurethral Pressure: a Study on Urethral Closure in Normal and Stress Incontinent Women. Acta Chir Scand Suppl 276: 1, 1961.    First study on simultaneous measurment of vesical and urethral pressures, using a urethral catheter with 2 pressure transducers 5 cm apart. In continent subjects: urethral pressure exceeded vesical pressure, both at rest and during increase in intra-abdominal pressure. In stress incontinence: upper part of the urethra becomes relaxed into a funnel and functionally becomes part of the bladder  short functional urethral length   maximum urethral closure pressure. WWW.SMSO.NET Smith AR, Hosker GL, Warrell DW: The Role of pudendal Nerve Damage in the Etiology of Genuine Stress Incontinence in Women. Br J Obstet Gynaecol 96: 29, 1989.  First study to show that denervation injury to both the striated urethral muscle and the pelvic floor musculature is the underlying mechanism of stress incontinence. WWW.SMSO.NET Urinary Incontinence Guideline Panel: Urinary Incontinence in Adults. Clinical Practice Guidelines, Rockville, Md: Agency for Health Care Policy and Research. US Dept of Health and Human Services, 1992.      Stress incontinence is caused by “intrinsic sphincteric deficiency”. The urethral sphincter is unable to generate enough resistance to retain urine in the bladder, especially during stress maneuvers. Urethral closure pressure  20 cm H2O. Retropubic urethropexy fails to correct stress incontinence because it cannot correct sphincteric incompetence. This dysfunction is predisposed by 2 risk factors: aging or prior pelvic surgery. WWW.SMSO.NET Blaivas JG, Olsson CA: Stress Incontinence: Classification and Surgical Approach. J Urol 139: 727, 1988.   They modified a classification system of stress urinary incontinence proposed by McGuire et al in 1976. This classification was based on fluoroscopic images of the bladder and urethra during rest and during coughing. WWW.SMSO.NET WWW.SMSO.NET Surgical Implication of Blaivas & Olsson Classification   Retropubic urethropexy is the best treatment for types 0 to II stress urinary incontinence (urethral support failure). Suburethral sling is the best treatment for type III stress urinary incontinence (sphincteric failure). WWW.SMSO.NET External Urethral Sphincter (Two Components)   Sphincter urethra: a circumferential skeletal muscle that surrounds the proximal two thirds of the urethra. Urethrovaginal sphincter & compressor urethra: both originate from the vaginal wall and ischiopubic ramus. They envelop the distal third of the urethra. WWW.SMSO.NET WWW.SMSO.NET Neurophysiology  Efferent spinal Pathways: sympathetic. parasympathetic. Somatic Efferent supraspinal Pathways:  WWW.SMSO.NET Sphincteric Mechanism (Three Components)    Internal urethral sphincter (autonomic innervation). External urethral sphincter (somatic + serotonin innervation). Nonmuscular component (vascular plexus + mucosal coaptation).   Each of these components normally contributes roughly one third of urethral closure pressure. Urethral sphincteric dysfunction can result from compromise of one or more of these 3 components. WWW.SMSO.NET Mechanism of Stress Urinary Incontinence    Loss of urethral support. Compromised sphincteric function. Both (commonest). WWW.SMSO.NET Treatment of Stress Urinary Incontinence   Choice of treatment, whether non-surgical or surgical should be made by the patient, and not her doctor. Her choice is based on how much she is bothered with her incontinence problem. WWW.SMSO.NET Non-surgical Treatment of Stress Urinary Incontinence     Behavioral therapy: control of water intake; voiding interval. Pelvic floor muscle training: therapeutic; preventive. Electrical stimulation: external application of electrical current to the pelvic floor through an anal or vaginal probe. Medications: phenylpropalonamine (selective -adrenergic agonist); imipramine (-adrenergic & serotonin agonist + anticholinergic + antidepressant); duloxetine (-adrenergic & serotonin agonist); estrogen (-adrenergic agonist + vascular & mucosal support for the urethral wall). WWW.SMSO.NET Surgical Treatment of Stress Urinary Incontinence WWW.SMSO.NET Selection of the Surgical Procedure  Stress incontinence caused by anatomical loss of bladder base & urethral support: surgical re-positioning and stabilization of the bladder base and urethral support (retropubic vesicourethropexy).  Stress incontinence caused by intrinsic sphincter dysfunction: augmentation of urethral resistance by surgical coaptation or compression of the urethral lumen (sling operations or periurethral injectable bulking agents). WWW.SMSO.NET Popular Surgical Procedures     Anterior Repair:  Kelly plication (1914). Retropubic suspension:  Marshall-Marchetti-Krantz procedure (1949).  Burch colposuspension (1961). Sling Operations:  Rectus fascia and fascia lata.  Tension-free vaginal tape (TVT, 1993). Bulking agents:  Collagen.  Teflon. WWW.SMSO.NET Anterior Repair  Kelly plication (1914):   Midline incision in the anterior vaginal wall. Plication of the endopelvic fascia at the level of the bladder neck. This serves as a buttress to support the urethra. Easy to perform, but long-term success is relatively poor.  WWW.SMSO.NET WWW.SMSO.NET Retropubic Suspension  Marshall-Marchetti-Krantz procedure (1949): • Periurethral fascia on either sides is sutured to posterior periostium of the symphysis pubis (2-3 sutures from midurethra to the bladder neck). • Complication: osteitis pubis (2.5%).  Burch colposuspension (1961): • Paravaginal fascia on either sides of the bladder neck is sutured to the ipsilateral cooper’s ligament (ileopectineal ligament). • Cure rate: over 80% at 4 years follow up. WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET Sling Operations  Tension-free vaginal tape (TVT, 1993): • A long thin strip of polypropylene tapes is inserted on either side of the urethra. Each strip is passed from a small incision in the vaginal wall overlying the midurethra to a small incision in the lower abdominal wall by using a special trocar system. • Procedure is minimally invasive, performed under local or regional anesthesia and done in an outpatient setting. • Five year cure rate (84.7%). • Complications are rare (bladder perforation in recurrent cases).  Rectus fascia and fascia lata: • Major surgical procedure. WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET Bulking Agents  e.g. Collagen and Teflon agents:     Injected in a retrograde fashion under direct cystoscopic guidance. Continence is achieved through the obstructive or sealing effect on the urethral lumen. Procedure is minimally invasive, performed under local or regional anesthesia and done in an outpatient setting. Short-term results are promising, but long-term results are not as good, probably because of biologic reabsorption or particle migration. WWW.SMSO.NET WWW.SMSO.NET Summery of Expected Outcomes. Outcomes Cure rate % of patients Success rate % of patients injectable 30- 78 40-86 TVT 66-91 94 sling procedures 73-95 64-100 Bruch colposuspension 73-92 81-96 Post op. complications,% Voiding dysfunction De novo detrusor overactivity Follow up ,years 3-5 3-9 0.5-3 1-4 6-14 0.25-3 2-27 8-27 0.75-10 0.25-2 WWW.SMSO.NET 1. Stress Urinary Incontinence should not be viewed inevitable or shameful. 2. Stress Urinary Incontinence should be viewed as treatable. 3. It is the time to change our role in management of SUI. WWW.SMSO.NET Thank You WWW.SMSO.NET