URO -

1. URO - GYNAECOLOGY

2. TYPICAL CASE SCENARIO • 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence. involuntary U.I. Whenever she coughs or sneeze… wetting herself 2-3 times a week… socially embarrassing and unable to continue with her sport activity She has asthma on medication and is trying to reduce her weight. How would you approach this case?

3. TYPICAL CASE SCENARIO • 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence. She goes to toilet every 30 minute to pass urine and if not near a toilet she might wet herself She drinks 10 cups of tea and coffee per day Medically she is diabetic and hypertensive on diuretic How would you approach this case?

4. Facts: • “ it is the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem”. • It is very common among women of all ages • 15-44 5% • 45-64 10% • >65 20% • > 40% in institutionalized women • Up to 30% post vaginal delivery,,,,,, temporarily.

5. Anatomy&Physiology of Lower U.T. • Female urethra 3-4 cm in length • Anatomy: • Innervation: • Parasympathetic. S2-4. stimulation of pelvic parasymp. Or adm of cholinergic drugs…. Bladder contract… anticholinergic drugs reduce the bladder pressure and increase the capacity • Sympathetic. T10-L2. β-fibers in detrusor muscle.. Relax urethra and detrusor muscle. Α-fiber in urethra.. Stimulation contracts the bladder neck and urethra and relaxes the detrusor

6. Classification of Incontinence • Urethral causes: • Urethral sphincter incompetence{ genuine stress inc.} • Detrusor instability • Neuropathic • Non-neuropathic • Retention with overflow • Congenital • Misc • Extra urethral: • Congenital • Fistula

7. Genuine stress incontinence • “ Involuntary loss of urine when the bladder pressure exceeds the maximum urethral pressure in the absence of any detrusor contraction”. • Causes: • Abnormal descent of bladder neck and proximal urethra • Intraurethral pressure at rest lower than the intravesical, scarring • Laxity of sub-urethral support • Aetiology: • Damage to the nerve supplying pelvic floor and urethral sphincter • Menopause • Congenital • Chronic causes, obesity, COPD,…..

8. Genuine stress incontinence • Symptoms: Leaking urine… feeling wet whenever performing activities Which raise the intra-abdominal pressure Urgency, frequency and urge incontinence Possible prolapse symptoms • Examination: • General, chest, abdomen, pelvic…… mass • Pelvic: • Demonstrate incontinence • Cysto-urethrocele

9. Detrusor Instability • “ Involuntary loss of urine due to bladder contraction, either spontaneously or on provocation, despite the patient attempting to inhibit micturition”. • Symptoms: • Urgency, urge incontinence, frequency{ 15-120 min}, nocturia, S.I., enuresis,,,, voiding difficulties • Examination: • Non specific, but exclude masses…. prolapse

10. Detrusor Instability • Pathophysiology is poorly understood • Poor toilet habit training and psychological factors have a role • Idiopathic D.I. Is the commonest • Possible causes: • Continence surgery, • outflow obstruction • Smoking and excessive tea and coffee intake

11. Investigations • History and examination may not be conclusive • The aim of urodynamic inv. Is to provide accurate DX of disorders of micturition and investigating the L.U.T. and pelvic floor function • MSU • Urinary diary • Pad test

12. Investigations 4. Dual channel subtracted cystometry • Uroflowmetry • Cystometry

13. Investigations 5. Video-cysto-urethrography • Tertiary units 6. Ambulatory monitoring 7. Cysto-urethroscope 8. Imaging. MRI

14. Treatment of GSI • Prevention • Vaginal vs abdominal delivery • If vaginal, short second stage and less trauma • Weight reduction • Chronic cough • Pelvic floor exercises • ???? Hormone replacement therapy

15. Treatment of GSI 2. Conservative: • Physiotherapy. Mild to moderate cases. Improvement in up to 40- 60%. Needs motivation • Prolapse correction. Ring pessary • ?HRT • Biofeedback techniques. Weighted cones • Maximal electrical stimulation • Continence devices 3. Medical : not effective. Duloxetine SSRI

16. Treatment of GSI 4. Surgery.. Treatment of choice….. Aims to 1) restores the urethra and bladder neck to zone of intra-abdominal pressure 2) increase urethral resistance • Procedures: • Vaginal. Anterior colporrhaphy. Poor 5 years success • Abdominal. Colposuspention. 80% 5 years f.u. • Sling operation • TVT

18. Treatment of GSI • Surgery… cont. When the defect is in the sphincteric mechanism producing a low resistance and poor functioning urethra….. Then: • Artificial sphincter • Periurethral bulking: • Collagen • macroplastiqua

19. Treatment of D.I. • Conservative: • Bladder training. Effective 60-70% needs motivation • Biofeedback, hypnosis, TENS …etc • Medical: • Anticolenergics. Oxybutanin or tolterodine {side effects} • Imipramine { TCA} …. Enuresis • desmopressin {antidiuretic hormone a’gue}… Nocturea

20. Treatment of D.I. • Surgery. • Last resort. • Urinary diversion • Bladder augmentation

21. Key Points • Urinary incontinence is 20-30% prevalent among females • GSI & DI are the commonest • Physiotherapy is effective in mild to moderate GSI • Bladder training and Anticolenergics are most appropriate treatment for DI • UTI must always be excluded before any fancy investigation or treatment started, • No incontinence surgery without urodynamic studies • Surgery for incontinence should be the patient’s decision depending on how severe and findings