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Urinary Incontinence

Urinary Incontinence. Dr . Nedaa Bahkali 2012. Definitions:. Urinary incontinence is defined as involuntary leakage of urine. Definitions:. Stress urinary incontinence (SUI): involuntary urine leakage on exertion or with sneezing or coughing. Urge urinary incontinence:

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Urinary Incontinence

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  1. Urinary Incontinence Dr. NedaaBahkali 2012

  2. Definitions: Urinary incontinence is defined as involuntary leakage of urine.

  3. Definitions: • Stress urinary incontinence (SUI): • involuntary urine leakage on exertion or with sneezing or coughing. • Urge urinary incontinence: • women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay. • If urge urinary incontinence is objectively demonstrated by cystometric evaluation, the condition is known as detrusoroveractivity (DO).

  4. Definitions: • Mixed urinary incontinence : • When both stress and urge components are present, it is called.

  5. Epidemiology: • Prevalence of 25 - 55 %. • Among women with urinary incontinence, • the most common condition is stress incontinence, which represents 29 to 75 %of cases. • Detrusoroveractivityaccounts for up to 33 % of incontinence cases. • whereas the remainder is attributable to mixed forms.

  6. Anatomy and Physiology of Micturition

  7. Anatomy and Physiology of Micturition Detrusor muscle External and Internal sphincter Normal capacity 500-600cc First urge to void 150cc

  8. Anatomy and Physiology of Micturition

  9. Anatomy and Physiology of Micturition

  10. Anatomy and Physiology of Micturition Storage Reflex

  11. Anatomy and Physiology of Micturition Micturition Reflex

  12. Risks for Urinary Incontinence: • Age • Pregnancy • Childbirth • Menopause • Hysterectomy • Obesity • Chronically increased abdominal pressure •   Chronic cough •   Constipation •   Occupational risk • Smoking

  13. Continence Theories Pressure Transmission Urethral Support

  14. Pressure Transmission In an ideally supported urogenital tract, increases in intra-abdominal pressure are equally transmitted to the bladder, bladder base, and urethra. In women who are continent, increases in downward-directed pressure from cough, laugh, sneeze, and Valsalva maneuver are countered by supportive tissue tone provided by the levatorani muscle and vaginal connective tissue .

  15. Pressure Transmission In those with a weakened supportive "backboard", however, downward forces are not countered. This leads to funneling of the urethrovesical junction, a patent urethra, and in turn, urine leakage.

  16. Pressure Transmission

  17. Urethral Support • Urethral support is integral to continenc • (1) ligaments along the lateral aspects of the urethra, termed the pubourethral ligaments; • (2) the vagina and its lateral fascial condensation; • (3) the arcustendinous fascia pelvic; • (4) levatorani muscles . • With loss of urethral support, the urethra's ability to close against a firm supportive backboard is diminished.

  18. Urethral Support

  19. Urethral Support

  20. Urethral Support

  21. Diagnosis • History : • Duration, severity, symptoms, previous treatment,(Urinary Frequency, Urinary Retention, volume of urine lost , Postvoid dribbling is classically associated with urethral diverticulum) • medications, Past medical hx, GU surgery, Ob hx • Voiding Diary

  22. Symptom Comparison of Women with Stress or Urge Incontinence

  23. Medications That May Cause Incontinence Diuretics Anticholinergics - antihistamines, antipsychotics, antidepressants Seditives/hypnotics Alcohol Narcotics α-adrenergic agonists/antagnists Calcium channel blockers

  24. Physical Examination • General Inspection and Neurologic Evaluation • evidence of atrophy. • neurologic evaluation of the perineum: • bulbocavernosus reflex • normal circumferential anal sphincter contraction, colloquially called an "anal wink",

  25. Pelvic Support Assessment Pelvic Organ Prolapse Evaluation

  26. Pelvic Support Assessment Q-Tip Test

  27. Diagnostic Testing Urinalysis and Culture Postvoid Residual Cystometrics Uroflowmetry

  28. Treatment,,

  29. Treatment Options • Conservative/Nonsurgical: • Pelvic Floor Strengthening Exercises • Pelvic Floor Muscle Training (PFMT)

  30. Electrical Stimulation Biofeedback Therapy Dietary Scheduled Voiding Estrogen Replacement

  31. Treatment of Stress Urinary Incontinence

  32. Treatment of Stress Urinary Incontinence • Medications: • Pharmaceutical treatment plays a minor role in the treatment of women with SUI. • imipramine is reasonable to aid urethral contraction and closure. • Recently, duloxetine a selective serotonin and norepinephrine reuptake inhibitor, has been evaluated for the treatment of SUI

  33. Pessaries

  34. Surgical Treatment of Intrinsic Sphincteric Deficiency Periurethral Bulking Agents

  35. Surgical Treatment of Anatomic Stress Incontinence RetropubicUrethropexy Pubovaginal Slings Midurethral Slings

  36. Treatment of Urge Urinary Incontinence

  37. Treatment of Urge Incontinence • Antimuscarinics: tertiary amines that act to block the muscarinic receptors in response to acetocholine • First line • Oxybutinin (Ditropan) • Tolteridine (Detrol)

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