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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
