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Evidence Based Facts on the Pathogenesis _ Management of Stress Urinary Incontinence

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Evidence Based Facts on the Pathogenesis _ Management of Stress Urinary Incontinence Powered By Docstoc
					Evidence Based Facts on
 the Pathogenesis and
 Management of Stress
 Urinary Incontinence
   Prof. Abdel Karim M. El Hemaly
           MRCOG - FRCS
 SUIis 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 .
               Detrusor instability     DI
    SUI
               Genuine                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   Vagina
       Internal urethral sphincter        Sphincter




Urethral Lumen                               Collagenous tissue
                                             cylinder extending
    Smooth Muscle fibres overlying           from urothelium to
    and intermengling with the               the outside
    collagenous tissue cylinder
     Post mortem specimen of the int. u. sphincter and the vagina
      (H & E) (X40)




           Internal urethral sphincter               Vagina




Urethral Lumen                               Collagenous tissue
                                             cylinder extending
  Smooth Muscle fibres overlying             from urothelium to
  and intermengling with the                 the outside
  collagenous tissue cylinder
        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




                                                     Vagina
Muscle
layer




Collag.
tissue
layer
            MRI picture of a normal continent woman
U.B.

                                                      Uterus
Post.
Wall of
Ureth.i
ntimate
lt relate
to ant.
Vag.
wall

                                                      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

                          URETHRAL
  RUPTURE
                          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.             SUI + DI
2- Affect the upper part only:
      loss of urethro-vesical angle ( Funnelling).
      urethral hypermobility.       SUI &/or DI
3- Affect the lower part only:
      Flask-shape on 3-D ultrasound      Genuine SUI
 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
                                             Loose and torn
     Smooth Muscle fibres                    collagenous
     overlying and                           tissue layer
     intermengling with the
     collagenous tissue cylinder
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               Compact
collagenous tissue of an     collagenous tissue of
Int. U. Sphincter in a       a normal sphincter
patient with SUI
       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

				
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