URINARY INCONTINENCE Objectives: 1-To outline different types of urinary incontinence 2-To enumerate the lines of treatment of urinary incontinence. DEFINITION: It is involuntary loss of urine per urethra. N.B: this definition exclude urinary fistula.
NORMAL URINARY CONTROL: 1) Bladder: low intravesical pressure during filling phase 2) Urethra: a)-adequate sphincter activity. b)-intra-abdominal position of urethra. C-mucosal factor. d)-length of urethra. * ANATOMY OF BLADDER & URETHRAL SPHINCTER: -The bladder composed of single mesh like muscle layer called detrusor muscle. -The urethral has two sphincters: a) Proximal sphincter (situated at bladder neck & composed only of smooth muscles). b) Distal sphincter (situated at the membranous urethra & it has two parts: 1- Intrinsic (smooth muscle only) 2- Extrinsic (skeletal muscle) which merge with pelvic floor muscle. NORMAL BLADDER & URETHRAL FUNCTION: -The bladder has two functions: a) Storage of urine (bladder act as reservoir). b) Evacuation of urine.
BLADDER & URETHRAL INNERVATION:
-The bladder muscle has stretch receptors in between muscles cells connect to afferent parasympathetic nerve --- sacral spinal center S2,3,4 (situated behind body of 1st lumbar vertebra) ---efferent parasympathetic nerve --- detrusor muscle. -The urethral sphincter: 1-proximal: is supplied by the efferent sympathetic fibers. 2-distal: intrinsic smooth muscle & extrinsic skeletal muscle supplied by the pudendal nerve S2, 3, 4 -The sacral micturation center is primitive & autonomous. After the age of 3 years a higher center in the pons & cerebral cortex take the upper hand in urinary control. A sample of the impulses reaching the spinal center ascends in spinal cord white matter to these high centers. These high centers always send inhibitory impulses to the sacral center during voiding.
Vesical pressure Maximum urethral closure pressure Urethral sphincterPMG
Storage phase Low 0-10 cm.H2O High 80-100 cm.H2O contracted
Evacuation phase High 40-60 cm.H2O Low 0 cm.H2O relaxed
INVESTIGATION: 1- Urine analysis: pus cell → cystitis. 2- CBC: anemia → RF. 3- Renal function: inc. blood urea → RF. 4- Radiological: plain X-ray & IVU. 5- U/S 6- Urodynamic study: flowmetry, cystometry, urethral pressure & RMG.
CLINICAL TYPES: A) True. B) False. C) Stress. D) Urge.
E) Enuresis. Type True Overflow Stress Urge Bladder Empty, normal Full, atonic Normal Uninhibited contraction Urethral sphincter Both inactive. Normal + Obstruction. Both are weak + Lax pelvic floor. Normal
DIAGNOSIS 1- History: a) Trauma. b) Operation (perineal prostatectomy, TURP) c) Obstetric. d) Drugs. 2- Investigation. 3- Clinical picture.
TREATMENT: According to clinical type: a) Neurogenic incontinence: - uninhibited bladder→ parasympatholytic (probanthine,cetipren). - atonic bladder→ parasympathomimetics. b) True incontinence: - artificial sphincter - Collagen injection - Corporal approximation. (All aim at urethral compression). c) False incontinence: - congenital reconstruction of bladder neck & urethra. d) Stress incontinence: - the objective is to restore the bladder neck & urethra into the pelvic cavity. - The operation is called Colposuspention: 1) - Open surgery: Marshall Marquette (the para urethral tissue is sutured to back of the symposia & cooper's ligament. 2) – Needle suspension