Evidence Based Facts on the Pathogenesis and Management of Stress

Evidence Based Facts on the Pathogenesis and Management of Stress Urinary Incontinence Prof. Abdel Karim M. El Hemaly MRCOG - FRCS  SUI is still a vastly existing world wide tedious and ambiguous problem despite the many theories put, trying to explain the pathogenesis of the condition and the big efforts done for its treatment.  SUI = involuntary escape of urine, through the urethra, on sudden increase of intra abdominal, intravesical pressure e.g. coughing, laughing, jumping ….etc  This name SUI, was given by Sir Eardly Holland in1923. Prof. Abdel Fattah Yousef named the condition Sphincteric incontinence However the name did not gain popularity because of the lack of evedince that SUI is due to sphincteric defect .  SUI Detrusor instability Genuine DI SUI However the 2 conditions overlap  Also surgical correction of genuine SUI corrects DI in almost half the patients  Urethral Hypermobility Genuine SUI Intrinsic sphincter deficiency ISD Urinary Continence depends on 1- Presence of the bladder neck and upper part of the urethra above the pelvic floor, 2- The direct influence of intra – abdominal pressure on the proximal segment of the urethra, intra – abdominal part of the urethra 3- Urethro – vesical angle 4- The shape of the urethra, with its lack of funnelling Cont.. Urinary Continence depends on 5- The length of the urethra 6- Neuro – vascular factors ( natural tone of the urethra & vascular pattern ) 7- Mucous membrane coaptation 8- Pelvic floor muscles especially the levtor ani Cont.. Urinary Continence depends on 9- Urethral Sphincters ?int ?ext. ?3rd midurethral sphincter. 10- Perivesical and periurethral fasciae. 11- Petro`s theory of urinary continence. SUI is attributed to many factors e.g. 1 - descent of the bladder neck and upper part of the urethra below the pelvic floor. But, * SUI can be present in absence of genital descent. * there may be Genital descent with no SUI 2- Loss of urethro – vesical angle But, * SUI is absent in spite of the absence of the UV angle * SUI is present in spite of good UV angle Cont.. SUI is attributed to many factors e.g. 3- Funnelling of the bladder neck But, * SUI is present in spite of absence of funnelling * No SUI is detected with funnelling of the bladder neck 4- Shortness of the urethra But, Amputation of distal half of the urethra e.g. radical valvectomy for cancer vulva > does not lead to SUI. 5- Intrinsic sphincter defect. ISD Surgical correction of SUI Surgical correction of SUI aims at : 1- Elevation of the upper part of the urethra 2- Elongation of the urethra 3 –Angulation of the urethra 4- Plication of the funnelled bladder neck 5- Periurethral injection of different materials 6- Recently, Artificial sphincter Surgical Correction of SUI can be summarized 1- Plicatory Operations e.g. Kelly, Kelly – Kennedy 2- Vesico – urethropexy Marshall – Marchetti – Krantz MMK 3- Vesico – urethro lysis Mulvany Cont….. Surgical Correction of SUI can be summarized 4- ColpoSuspension Burch Abdominal Laparoscopic 5- Long – Needle bladder Neck Suspension (LNBNS) With or without endoscopic guidance e.g. Peryra, Stamey 6- Sling operations e.g Aldridge, TVT, IVS,….etc.. Cont….. Surgical Correction of SUI can be summarized 7 - Peri – urethral injections e.g. Teflon, Fat, Collagen,… 8 - Artificial sphincter Recently, In 1996 we put forward a new concept, based on evidence explaining the act of micturition and urinary continence. Micturition can be divided into 2 stages: Stage-I: in Infancy before training of micturition. Stage-II: in childhood after training of the act of micturition (how to control).  Stage-II : the mother starts to train her infant at the age of 18-24 months how to control micturition. This is gained by acquiring high alpha sympathetic tone at the inernal sphincter closing it all the time except on need and /or desire. Urinary continence depends on 1- An acquired behavior gained by learning in early childhood to keep a high alpha sympathetic tone in the internal urethral sphincter keeping it closed all the time except on need and/or desire.  2- An intact and strong internal urethral sphincter.  The structure of the internal urethral sphincter -It is mainly a cylinder composed of compact collagenous tissue. It extends from the bladder neck down to the external urethral meatus. It is lined by urothelium. The muscle fibers intermingle with the collagenous fibers in the middle part; The muscle layer is controlled by alpha-sympathetic nerves T10-L2. Evidence Based Facts that prove the presence of a high alpha sympathetic tone in the internal urethral sphincter. Urethral pressure under basic conditions is 95 cm water Urethral pressure 5 minutes after phentolamine, alpha blocker (Regetine, Ciba- Geigy Switz ) dropped to 76 cm water. Urethral pressure after nor adrenaline infusion (Levophed, Sanofi Wintrop UK) elevated to 93 cm water Evidence Based Facts that Demonstrate the Structure of the Internal Urethral Sphincter  Post mortem specimen of the int. u. sphincter and the vagina (MTC stain) (X40) Pelvic floor m. & External Urethral Sphincter Internal urethral sphincter Vagina Urethral Lumen Smooth Muscle fibres overlying and intermengling with the collagenous tissue cylinder Collagenous tissue cylinder extending from urothelium to the outside  Post mortem specimen of the int. u. sphincter and the vagina (H & E) (X40) Internal urethral sphincter Vagina Urethral Lumen Smooth Muscle fibres overlying and intermengling with the collagenous tissue cylinder Collagenous tissue cylinder extending from urothelium to the outside NORMAL INTERNAL URETHRAL SPHINCTER U.B. U.B. Closed urethra due to a strong, intact int. u. sphincter 3-D. ULTRASONOGRAPHY 3D U.S. Cross section Closed lumen Intact wall, compact sheet of collagenous tissue with muscle fibers lie on and intermingle with the collagen fibers In the middle part of the sheet MRI picture of a normal continent woman Urethra Urethral lumen Muscle layer Vagina Collag. tissue layer U.B. Post. Wall of Ureth.i ntimate lt relate to ant. Vag. wall MRI picture of a normal continent woman Uterus Vagina  Accordingly voiding troubles could be better understood and treated e.g. - Nocturnal Enuresis - Detrusor Instability - SUI Stress Uinary Incontinence is a result of a weak, damaged internal urethral sphincter.  The damage affects mainly the collagenous tissue layer.  The damage is mostly traumatic . TRAUMA RUPTURE URETHRAL PRESSURE WEAKNESS ATROPHY CONFIGURATIONAL CHANAGES 1-INFECTION 2-HORMONE DEFICIENCY RUPTURE IN THE INTERNAL URETHRAL SPHINCTER 1-Affect the whole length : Shortening of the functional urethral length. Irregular in shape. 2- Affect the upper part only: loss of urethro-vesical angle ( Funnelling). urethral hypermobility. SUI + DI SUI &/or DI Genuine SUI 3- Affect the lower part only: Flask-shape on 3-D ultrasound Evidence Based Facts that Prove The Pathogenesis of SUI. Rupture Affect the whole length Irregularity and shortening of the urethra U.B. Wide Urethral lumen with weak torn walls Of the Int. U. Sphincter Urethral lumen wide and irregularly dilated. Large defect, sonolucent areas. (A) (B) MRI of normal internal urethral sphincter “A” compared to a torn internal sphincter in a patient with SUI “B” MRI Picrure of a patient with SUI Torn post wall of the int. U sphincter with the ant. Vag. wall  Post mortem specimen of the int. u. sphincter and the vagina in a patient with SUI. (H & E) (X4) Internal urethral sphincter Vagina Urethral Lumen Smooth Muscle fibres overlying and intermengling with the collagenous tissue cylinder Loose and torn collagenous tissue layer Comparison between Int. U. Sphincter in Normal and SUI Patients (H & E) (X40) Surgical specimens of Int. U. Sphincter (MCT stain) (X40) Loose and torn collagenous tissue of an Int. U. Sphincter in a patient with SUI Compact collagenous tissue of a normal sphincter Consequently, Urethro-raphy a new operation for treatment of stress urinary incontinence was innovated Low urethral pressure, 42 cm water in a patient with SUI preoperative. Urethral pressure elevated to 76 cm water after urethro-raphy CONCLUSION  Evidence Based Facts prove that SUI is a sequel of a weak internal urethral sphincter, which cannot resist a sudden increase of intra abdominal pressure, and will lead to leakage of urine. This will initiate an immediate reactive sympathetic activity preventing further leakage of urine.     The weakness of the internal urethral sphincter is mostly caused by traumatic rupture of its wall. Urethro-raphy, aims at repairing the torn wall to restore the high wall tension and increase the urethral pressure, so it can resist sudden increase of intra abdominal pressure. This is achieved by demonstrating properly the torn wall and approximating the torn edges together by simple sutures using slowly absorbable material e.g. braided polyglycan.   There is no post operative voiding troubles, nor there is post voiding residual urine as seen after plicatory and sling operations. Urethro-raphy is a simple vaginal operation whish is completely different from Kelly and Kelly-kennedy operations in the aim of the operation, the pathogenesis of the condition, the operative technique and the post operative conditions and results. Authors  Abdel Karim M. El Hemaly*, Nabil Abdel Maksoud, Laila A. Mousa**, Ibrahim M. Kandil, Asem Anwar, M. A. K El Hemaly and Bahaa E. El Mohamady M. Ob. Gyn. dept. Faculty of medicine Al Azhar University * corresponding author e mail    m_hemaly@hotmail.com ** department of pathology