Anatomy of male continence
INTACT BLADDER: Capacity Compliance Instability INTACT SPHINCTERS
Anatomy of male continence Proximal mechanism:
Bladder neck. Prostate. Supramontanal urethra.
Anatomy of male Continence
Distal mechanism: Mucosal folding. Rhabdosphincter. Para-urethral skeletal muscles.
Anatomy of male continence
URETHRAL MECHANISMS
• a. b. c. d. e. • • Wall tension and external compression. Smooth and striated muscle tone Phasic contractions. Vesicoelastic property. Abdominal pressure transmission. Anatomic support of posterior urethal wall. Inner wall softness. Mucosal folds.
Definition
Involuntary or unconscious loss of urine Per urethra
Classification of incontinence
Types Total
False
Under-active Bladder
Partial
Stress Urge
Over-active Bladder
True
Obstruction
Sphincteric
Sphincteric
Diagnosis of incontinence
• History:
A. Character and severity of incontinence. B. Neurologic conditions. C. Medications. Alpha-blockers-------Stress incontinence Tricyclic antidepressants----Overflow Diuretics------------aggravate incontinence
Diagnosis of incontinence
Examination
• a. b. c. d. Neurologic examination: Gait. Genital sensations. Anal sphincter tone and contraction. Bulbocavernosus reflex.
Diagnosis of incontinence
• Distended bladder. • Digital rectal examination. • PV examination for pelvic organ prolapse or Full bladder. • Demonstration of incontinence in supine and standing positions.
Diagnosis of incontinence
Micturition Diary:
• Frequency charts (may be enough). • Frequency-Volume charts. • Urinary diaries additions.
Diagnosis of incontinence
Pad Test
• One hour test. • 24 hour test. • 72 hour test. One gram= One ml urine. 8 grams/24 hour are accepted (Sweating).
Diagnosis of incontinence
Uroflowmetry:
Obstructed curve = Impaired bladder contractility Or Infra-vesical obstruction
Diagnosis of incontinence
Residual urine:
• < 50 ml-----------Normal. • > 200 ml----------Abnormal. • 50-200 ml--------Require clinical correlation.
Diagnosis of incontinence
Urodynamic evaluation:
• Video/multichannel (the best). • Multichannel (the least). • Valsalva and detrusor leak point pressure. • UPP (less important value). • Ambulatory urodynamics (more physiologic).
Diagnosis of incontinence
Cystoscopy:
• Should be routine. • Detect lower urinary tract abnormality. • Which to be done first?
Treatment of incontinence
I. Non-Surgical Treatment 1. Medical treatment:
• • Antichlonergic agents: Tolterodine (Detrol). Oxybutinin (Ditropan).
Treatment of incontinence
Tricycles antidepressants: (Tofranil). dual action, additive action with antichlonergics. Botulinium A toxin.
Treatment of incontinence
2. Behavior modification:
Both for bladder and sphincter defects. In the form of: Oral fluid intake. Pelvic floor exercises. Relaxation techniques. Timed voiding.
Treatment of incontinence
3. Electrical stimulation:
High frequency stimulation. Low frequency stimulation. Dual stimulation.
Treatment of incontinence
4. Biofeedback:
Training the patient to control body function by providing him with information
Treatment of incontinence
II. Surgical management: A. Bladder dysfunction
1. Sacral root neuromodulation. 2. Augmentation entero-cystoplasty. 3. Bladder Auto-augmentation.
Treatment of incontinence
B. Sphincter dysfunction.
1. 2. 3. 4. 5. Bladder flap operations. Sling procedures. Injection therapy. Artificial Sphincter. Urinary diversion.
Post-prostatectomy incontinence
Incidence
• 1-3% after TURP or open
prostatectomy • 2.5-87% after radical prostatectomy
Post-prostatectomy incontinence
Pathogenesis
A. Bladder Instability With obstruction (53%-80%). Age dependant without obstruction. After surgery: Bladder denervation after radical prostatectomy. Resection of the trigone with TURP.
Post-prostatectomy incontinence
B. Sphincter dysfunction:
Direct injury. (TURP or Open). Injury to neural structures. Previous injury (radiation).
Post-prostatectomy incontinence
Treatment: Pelvic floor exercises and Biofeedback (needs controlled studies). Pharmacotherapy is of limited benefit. Injection therapy: Success rates with collagen 36%-69% Silicon particles high initial success
Post-prostatectomy incontinence
• Artificial sphincter (most effective-long-term) • Bulbo-Urethral sling procedures. • Diversion: (continent stoma) In difficult cases.
Geriatric incontinence
• Incidence:
15%-30% of older people.
• Predispose to:
1. 2. 3. 4. Perineal rashes and ulcers. UTI. Falls and fractures. Depression.
Geriatric incontinence
Continence depends on: • Integrity of LUT function. • Adequate mentation. • Mobility. • Manual dexterity.
Geriatric incontinence
Urinary tract changes with aging:
1. Decreased bladder capacity and contractility in both sexes. 2. Increased involuntary contractions and residual urine in both sexes. 3. Decreased MUCP & FUL in women. 4. Prostatic enlargement in male. 5. Nocturia associated with sleep disorders.
Geriatric incontinence
• Geriatric incontinence usually due to extra-urinary disorders. • Age related LUT changes do not cause but predispose to incontinence.
Geriatric incontinence
Causes of Transient incontinence:
1. Delerium. 2. Infection. 3. Atrophic urethritis and vaginitis (in demented). 4. Pharmaceuticals. 5. Excess urine output. 6. Stool impaction.
Geriatric incontinence
Causes of established incontinence:
1. Detrusor overactivity is the most common. 2. Stress incontinence 2nd most common in females. 3. Outlet obstruction is 2nd most common in males. 4. Detrusor underactivity.
Artificial Sphincter
Selection:
• Poor urethral function with Normal compliance No detrusor hyperreflexia No urethral abnormality (Stricture or diverticulum)
Artificial Sphincter
Site
• Bulbar urethra. • Bladder neck.
Artificial Sphincter
Artificial Sphincter
Complications:
• Erosion. • Infection. • Proximal obstruction.
Injection therapy
Indications:
• Poor urethral function with: Normal baldder capacity and compliance. Good anatomic support.
Injection therapy
Site:
• Above the external sphincter. • At the bladder neck.
Injection therapy
Injection therapy
Injection therapy
Material:
• Polytetrafluoroethylene (PTFE): Particle migration • Glutaraldehyde cross-linked Bovine collagen: Safe, no migration. Biodegradable replaced by connective tissue • Durasphere: Carbon beads. No migration, no antigenicity
Injection therapy
• Autologous injectables (fat): less effective due to rapid loss (defective vascularity). • Silicon polymers: (Macroplastique & Bioplastique): Although large particles still migration can occur