URINARY

INCONTINENCE

Prof Dr Zalina Nusee

Consultant Urogynecologist
International Islamic University Malaysia
 OUTLINE

• Introduction
• Review of anatomy and physiology
• Types of Urinary Incontinence &
prolapse
• Evaluation of patient with urinary
incontinence & prolapse.
• Management
Anatomy
• Urethra: 3-4 cm
• Internal urethral sphincter
-thicken smooth muscle
- sympathetic T11-L2
- adrenergic receptor
-Involuntary control
• External urethral sphincter
- skeletal muscle
- parasympathetic S2-S4
- Cholinergic receptor
- voluntary control
 Review

• The parasympathetic
)S2-S4) nerve roots
and travels via the
pelvic nerve.
- cholinergic receptor
- responsible for bladder
contraction - bladder
emptying.
• The sympathetic
innervation to the
bladder (thoracolumbar
spinal cord T10-L2)
- adrenergic receptor
• causes contraction in the
bladder neck, which
closes the bladder neck
and relaxes the bladder
body, resulting in urinary
storage
 Anatomy

Pubourethral ligaments :
*provide a strong
suspensory mechanism
*hold it forward &
in close proximity to the pubis under
conditions of stress.
 WHAT IS URINARY
INCONTINENCE?

• Involuntary loss of urine

• objectively demonstrable
• Social hygienic
• Consequences

• Incontinence doesn’t kill a woman

It just steals her life !!
Incidence

• 1 in 3 women age >55 yrs

• 1 in 10 men age > 55yrs
• Japan = 53.7 % -F 10.5% - M
• USA =43% F 11% - M
• Taiwan = 27.7% F 15% -M
Terminology
• Genuine stress incontinence (GSI)
• Stress urinary incontinence (SUI)
• Urodynamic stress incontinence (USI)
• Overt SUI
• Occult SUI
• Over active bladder syndrome (OAB)
• Wet OAB/dry OAB
• Frequency
• Urgency incontinence (UUI)
• Detrusor overactivity (DO)
Continence control
Intraurethral pressure > intravesical
pressure

Support from pubourethral ligaments &

surrounding endopelvic fascia

Reflex contraction of levator ani muscle

TYPES OF INCONTINENCE

Overflow Stress Urge

Stress Urinary Incontinence (SUI)
observation of involuntary leakage of urine from the
urethra synchronous with effort or physical exertion,
or on sneezing or coughing .
IUGA/ICS joint report on terminology 2010
 Urodynamic stress incontinence (USI)
New ICS Definitions

•Combination of
urodynamic evidence with
symptoms or signs of SUI

•Filling CMG shows

involuntary leakage of urine
with increased IAP, in the
absence of a detrusor
contraction
 WHAT CAUSES STRESS
INCONTINECE?

• Weak pelvic floor

• ( urethra hypermobility)
1.
Urethral Hypermobility
Damage urethral sphincter

– intrinsic sphinter deficiency

(ISD)
Epidemiology
• Incidence 20-30% [Kenton K et al BJU Int.
2006]
• Increased with age and parity
- prevalence peak at 45-55 yrs
- age 17-25 yrs (16%)
• Nulliparous – inherited connective tissue
deficiency
• Antenatally – 60% of pregnant women
• Post –natal – 6-34%
IUGA eXchange Kuala Lumpur, Malaysia
2nd – 3rd Nov 2012
Risk factors
• Pregnancy
• Vaginal delivery
• Trauma/ pelvic surgery
• Obesity
• Menopause
• Smoking
• Dietary habit – high fat, cholesterol
• Constipation & straining
• High impact exercises
Dallosso H et al Eur J clin Nutr 2004
Nygaard IE Obstet Gynaecol 1997
Spence –Jones et al Br J Obstet Gynaecol 1994
 A strong & sudden desire
to urinate
URGENCY
INCONTINECE (UUI)
Leakage of large amounts of urine
at unexpected times ( including
during sleep, after drinking,
listening to Running water)
Possible causes
• Idiopathic
• Urine infection
• Injury/ post operation
• Stroke
• Diseases of the nervous system ( multiple
sclerosis, Alzheimer's or Parkinson's)
• Tumors or cancer in the uterus, bladder or
prostate
• Interstitial cystitis (inflamed bladder wall)
 Bladder doesn't empty
completely, leading to
frequent urination or
dribbling.

OVERFLOW INCONTINCE
• nerve damage from diabetes or other diseases.
• when the urethra is blocked due to kidney or
urinary stones, tumors, an enlarged prostate in
men, female bladder surgery that is too tight, or
a birth defect.
Mixed
incontinence

Stress incontinence (SUI)

urgency incontinence (UUI).
Other types of incontinence

• Postural incontinence
• Continuous incontinence
• Insensible incontinence
• Coital incontinence incontinence
Lower Urinary Tract
Chief complaint
• Frequency
- “just in case going to toilet”
- frequency volume chart
• Urgency
• Nocturia: age 60yrs (1x/night),
70 yrs. (2x night)
 Urinary leakage
• Amount of leakage
• Time of leakage :
coughing/sneezing/lifting heavy object
rising from sitting position,
• Sex : Leakage during penetration = SUI
Leakage during orgasm = DO
• “Leakage without warning”= DO
• Leakage when arising from bed at night (OAB)
• Patient’s ability to reach toilet (functional)
Severity of problem
• type of pad used
• standard questions (UDI6/IIQ7)
1. how often do you leak
2. how much do you leak
3. how much it affect quality
of life
Mixed incontinence: what bother
them most
 Helpful question in the
evaluation of female UI

1. Do you leak urine when you cough , sneeze or laugh?

2. Do have such uncomfortable strong need to to urinate
that you don’t reach the toilet you will leak?
3. If yes, do you ever leak before you reach the toilet?
4. How many times do you urinate during the day?
5. How many times do you void during the night after
going to bed?
Helpful question in the
evaluation of female UI
6. Have wet the bed in the past year?
7. Do you develop an urgent need to urinate when when
you are nervous, under stress, or in a hurry?
8. Do you ever leak during or after the sexual
intercourse?
9. How often do you leak?
10. Do you find it necessary to wear a pad because of
your leaking?
Helpful question in
the evaluation of female UI

11. have you had bladder, urine or kidney infection?

12. are you trouble by pain or discomfort when you
urinate?
13. Have you had blood in your urine?
14. do you find it hard to begin urinating?
15. do you have a slow urinary stream or have to stain to
pass your urine?
16. after you urinate, do you have dribbling or feeling
that your bladder is still full?
Basic test
• Urine – FEME, C&S
• Post void residual urine
• Cough stress test
• voiding diary
• Urodynamic test (UDS)
- uroflometry
- cystometry
– filling & voiding
• Pad test
Other tests

• Renal function test

• Pelvic floor ultrasonography
• Cystoscopy
• Video cystometry
• Intravenous urography

IUGA eXchange Kuala Lumpur, Malaysia

2nd – 3rd Nov 2012
Urodynamics

• Diagnosis unclear
• Neurological disease
• Resistant to therapy
• Prior to surgery

NICE guideline
Urodynamic result
 Medical Estrogen

Pelvic floor
Non surgical
physical exercises –
Kegel-
Treatment
Intravaginal
surgical
devices

Stress incontinence
Urgency
incontinence Reduce fluid
intake

Behavioral Avoid liquid

modification during night

Increase
intervals b/w
voiding

Antimuscarinic
Oxybutyin
Treatment Pharmacological
chloride
anticholinergic

Tolterodine

Physical Kegel exercise

Functional
Electrical
Stimulation
Conservative treatment
1. Life style Intervention
2. Physical therapy
3. Bladder retraining
4. Anti-incontinence devices
5. Pharmacotherapy
INDICATIONS
1. Not medically fit/unwilling for surgery
2. Plan for future pregnancy
3. Awaiting /wish to delay surgery
4. Symptoms not serious enough for surgical
intervention
TREATMENT
• Conservative

• stop smoking
• weight reduction
• treat chronic cough
• avoid lifting heavy objects

• Diet
• fluid restriction
• Control sugar level
• Change physical activities
• Void before activity
 Bladder retraining
PELVIC FLOOR MUSCLE
THERAPY (PFMT)
Kegel exercise

Electrical stimulators Biofeedback (urostym)

 Medical Treatment
• Urgency incontinence (wet OAB)
• OAB dry
• Mixed incontinence
• ??? SUI/ UI

Oxybutinin, detrusitol, solifenacin,

mictonorm, TCA (imipramin, doxipin)
Mirabegron : beta-3 adrenergic agonist
BULKING AGENT
Incontinence pessary (SUI)
Over active bladder (OAB)
Urgency incontinence

Intravesical
botox injection
SURGICAL THERAPY
• To correct pelvic relaxation defect
• To stabilize & restore normal
support of the urethra
abdominal approach:abdominal
retropubic urethropexy
vaginal approach: suburethral sling
procedures
Laparoscopic Burch Procedure
Cooper’s ligament

Bladder
Burch Colposuspension
SUI Mid - Urethral slings

Retropubic Transobturator
Mid Urethral Sling
(TVT, TVTO, TOT)
God gave us EARS,
EYES & HANDS . Use
them on the
patient, in that
order
Thank you