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Female Urinary incontinence (Types (Stress Urinary Incontinence – 49-63%…
Female Urinary incontinence
an involuntary loss of urine-
Etiology
no single etiologic factor can be implicated in each case of urinary incontinence.
Structural and functional disorders involving the bladder, urethra, ureters, and surrounding connective tissue – pelvic floor can contribute.
Risk factors
Female sex, Age,
Childbirth-related neuromuscular and connective tissue damage to the pelvic floor
Third- and fourth-degree perineal lacerations, prolonged labour, giving birth to a large infant, instrumented delivery
The pregnant state itself (ie, apart from delivery)
Menopause, urogenital hypoestrogenism
Obesity, Chronic cough, Chronic constipation, Smoking, Prior hysterectomy
Types
Overflow UI
underactive detrusor and/or overactive urethra
neurogenic bladder, outlet obstruction, and pharmacologic incontinence
Stress Urinary Incontinence – 49-63%
normal detrusor, incompetent urethra.
loss of of urine while coughing, laughing, sneezing, exercising or other movements that increase intraabdominal pressure and thus increase pressure on the bladder.
stress urinary incontinence (SUI)
hypermobility of vesico-urethral junction
intrinsic sphincter deficiency (ISD)
Pathophysiology
damage to the neuromuscular functioning of the pelvic floor / damage to the connective tissue supporting urethra and bladder neck.
Intrapartum injury during childbirth probably is the most important mechanism. During the intrapartum period, 3 types of lesions can occur—levator ani muscle tears, connective tissue breaks, and pudendal/pelvic nerve denervation.
loss of intrinsic urethral tone (mainly neuromuscular damage to the voluntary striated urethral sphincter, but mucosal atrophy or hypovascularity are also possible) – ISD
hypermobility of urethro-vesical junction
loss of urethral and bladder neck support impairs urethral closure mechanisms during times of increased intra-abdominal pressure.
Under normal circumstances any increase in intra-abdominal pressure is transmitted equally to the bladder and proximal urethra. This is likely due to the retropubic location of the proximal and mid urethra within the sphere of intra-abdominal pressure. At rest, the urethra has a higher intrinsic pressure than the bladder. This pressure gradient relationship is preserved if pressure transmission during acute increases in intra-abdominal pressure is equal to both organs.
When the urethra is hypermobile, as it descends and rotates under the pubic bone, pressure transmission to the walls of the urethra may be diminished. Intraurethral pressure falls below bladder pressure, resulting in urine loss.
Urgency UI – 25%
loss of urine caused by an involuntary contraction of the muscles of the bladder. This involuntary contraction creates the urgent need to urinate (UI proceeds or occurs during the urge to urinate).
idiopathic & neurogenic
Mixed UI – 12%
combination of stress and urgency incontinence
40-60% of women with UI
Continuous
with totally incompetent urethra (ie, severe ISD)
urinary tract fistulas (bladder/urethra fistulas)
ectopic ureter
Functional
Infection, inflammation, foreign bodies, stones, neoplasms
normal detrusor, normal urethra.
DIAP(P)ERS
D – Delirium
I – Infection
A – Atrophic vaginitis,
P – Pharmaceuticals
(P) – Psychological
E – Excessive urine output
R – Restricted mobility
S – Stool impaction
Overactive bladder syndrome (OAB)
characterized by a group of four symptoms: urgency, urinary frequency, nocturia, and urge incontinence
diagnosis of OAB is made primarily by ruling out other causes of overactivity of the bladder such as an infection or bladder tumor, stones, post-void residual of urine
can be diagnosed after an interwiew
OAB dry – urgency without urinary incontinence
OAB wet – urgency with urinary incontinence
Patients with urgency incontinence can suffer incontinence . It may be triggered by:
hand washing, changes in posture or position, Orgasm, an anticipation of voiding (ie, key in lock incontinence)
Idiopathic – in most cases (90%)
Neurogenic OAB is a condition of uninhibited detrusor contractions in the presence of a neurologic lesion believed to be causative: spinal cord injuries, MS, cerebrovascular disease, stroke, Parkinson disease, dementia, and CNS/spinal neoplasia.
management
I line therapy: Behavioral therapy
II line therapy: Anty-muscarynic agents, β3 agonists
Mirabegron 25 and 50 mg: Strong and selective agonist B3 adrenergic receptors
III line therapy:
Intravesical administration of botulinum toxin type A
Posterior tibial nerve stimulation PTNS
Neuromodulation, sacral nerve stimulation, SNS
Rarely: augmentation of the bladder, an artificial bladder
Diagnosis
Medical history
Frequency volume chart / Bladder diary
Urine analysis, urine culture
Residual urine volume determination. Volumes greater than 50-100 mL are abnormal.
Urogynecological examination (to assess the stuctures and function of the pelvic floor)
Stress testing generally is performed with a full bladder and the patient in the standing position. A positive test result consists of urinary leakage directly observed from the urethral meatus (cough test, Valsalva)
Urodynamic studies
the study of hydrodynamics and muscle activity for the purpose of defining the functional status of the lower urinary tract. Urodynamic studies should assess both the filling-storage phase and the voiding phase of bladder and urethral function.
consists of: Uroflowmetry, Cystometry, Pressure-flow study, Urethral Profilometry
Assesment of bladder capacity, patient bladder sensation, residuaL volume.
The rate of bladder emptying depends on for example: the strenght of bladder contraction, urethral resistance
Urethral preassure profile – identifies the urethral closure pressure
Indications
Recurrent SUI
Prior SUI of POP surgery
Post-Void Residual volume > 10%
Pelvic Organ Prolapse III/IV stage
Suspicion of fistula
Previous Rth
Recurrent UTIs
Stress incontinence treatment
conservative
Pelvic floor muscle treatment
Kegel exercises have been shown to improve the strength and tone of the muscles of the pelvic floor.
Pelvic floor exercises work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence.
Pelvic floor rehabilitation
Patients with severe neuromuscular damage to the pelvic floor may not be able to perform Kegel exercises even with proper instruction.
Vaginal cones are weighted devices designed to increase the strength of the pelvic floor muscles. Typically, the cones are retained for 15 minutes twice a day, and the weight of the cones is gradually increased. Although probably no more efficacious than properly performed Kegel exercises, this method may be preferred by some individuals. The best results are achieved when standard pelvic muscle exercises (Kegel exercises) are performed with intravaginal weights.
Vaginal cones
to help with Kegel exercises
Electrical stimulation
of the pelvic floor can be achieved with a vaginal or rectal probe. Low-frequency electrical pulses of 50-100 Hz are used. This method can be useful in treating individuals who desire therapy via pelvic floor rehabilitation but have difficulty performing pelvic muscle contractions on their own. Improvement rates of close to 90% have been reported.
Biofeedback
in the form of visual or auditory signals may be an effective method of exercising the pelvic floor. The responses provide confirmation of proper performance of the muscle contractions.
Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence.
During a biofeedback therapy, a special tampon-shaped sensor is inserted in the patient's vagina or rectum and a second sensor is placed on her abdomen. These sensors detect electrical signals from the pelvic floor muscles.
Body mass reduction
pharmacological
Alfa-adrenergic agents
Tricyclic antidepressants
Estrogens
Duloxetine (Yentreve) serotonin/norepinephrine reuptake inhibitor is the first drug developed and marketed specifically for stress incontinence.
surgical treatment
Burch retropubic urethropexy
The basic goal of the Burch urethropexy is to pull up the urethrovesical juntion towards the pubic symphisis and restoring the anatomical relations
In the space of Retzius
The sutures are placed into the vagina at the both sides of the UVJ and to the iliopectineal (ie, Cooper) ligament
Sling procedures TVT - Tension-free vaginal tape
provide the support for the urethra
Biological material:
autograft – pyramid muscle or a part of abdominal rectus muscle fascia, allograft, xenograft
Synthetic material:
Prolen, polipropylen mesh
TOT – Trans-Obturator Sling Procedure
Urge incontinence
pharmacological treatment – II line therapy
Antimuscarinic agents
Musculotropic relaxants depress smooth muscle activity directly. Relaxants also may work, in part due to anticholinergic and local anesthetic properties at the level of the bladder.
Oxybutynin 5 mg, 10-15mg/day
Potential adverse effects include dry skin, blurred vision, confusion, drowsiness, nausea, constipation, and dry mouth; caution in urinary tract obstruction, reflux esophagitis
Anticholinergic agents*
The clinical and urodynamic effects of blocking cholinergic receptors in the bladder are to increase bladder capacity, increase the volume threshold for initiation of an involuntary contraction, and decrease the strength of involuntary contractions.
Darifenacin 7,5 and 15 mg/d
severe side effects from the digestive tract - constipations
superselective M3 receptors antagonist
Fesoterodine 4 and 8mg /d
pro-drug, its active metabolite is similar to the tolterodine
Tolterodine (Detusitol, Uroflow 1-2 mg twice daily)
Tolterodine has performed well in clinical trials, showing comparable efficacy to oxybutynin with lower discontinuance rates.
Competitive muscarinic receptor antagonist selective for bladder
Side effects: Hyposalivation (dry mouth), decreased gastric motility, headache, constipation, dry eyes, sleepiness.
Solifenacin (Vesicare, 5 -10 mg /day)
a competitive muscarinic receptor antagonist that causes anticholinergic effects and inhibits bladder smooth muscle contraction. More selective towards M3 than M2 receptors.
It does not affect the function of the CNS, does not cause cardiac arrhythmias
surgical treatment
Stress incontinence
There are no significant diffrences in the short term and long term results between the Burch urethropexy and sling procedures
Retropubic suspension procedures have a long-term (>4 y) success rate of approximately 84% in curing stress incontinence caused by urethral hypermobility.
Burch urethropexy has higher postoperative complications rate (standard types of abdominal surgery complications)
The sling procedures have higher intraoperative complications rate – blader injury, hemorrhage, nerve injury, hematomas) or postoperative failures as: vaginal mucosa erosion, problems with voiding)
Mixed incontinence
No contraindications for the surgical treatment
Regular physical exercises and farmacological treatment before surgery – to assess the actual stress incontinence contribution
Urge incontinence
surgery indicated only in the very rare severe cases with no response for farmacological treatment
Bladder augmentatiopn techniques, bladder denervation, urinary diversion