Obstetrics & Gynecology

 Anatomy

o Normal Urethral Closure  must be higher than vesical pressure.

Intrinsic Factors Extrinsic Factors
Striated muscle Levator ani muscles.
(external sphincter). Endopelvic fascia.
Vascular congestion Attachments to the
of submucosal pelvic sidewalls &
venous plexus. urethra.
Smooth muscle
(circular & longitud).
Epithelial coaptation
of the folds of the
urethral lining.

o Bladder:

-pressure system that expands to

Definition accommodate  volumes of urine
without appreciable  in pressure.
❖ Bladder filling   muscle
fiber recruitment of pelvic
floor & urethra   outlet
resistance.
❖ Bladder muscle (detrusor)
should remain inactive
during filling.
Micturition
❖ Certain volume is filled 
tension-stretch receptors 
signal brain  micturition
reflex  cortical control
mechanisms depend on
social circumstances & the
state of the patient's NS.
Voluntary relaxation of pelvic floor &

Urinary Incontinence Voiding

urethra + Contraction of detrusor.

o Innervation:
Sympathetic NS Parasympathetic NS Somatic NS
T11 – (L2-L3). S2 – S4. S2 – S4.
Acts on: Function: controls Function: innervate
❖ -receptors  in urethra & bladder motor function pelvic floor, urethra,
bladder neck   urethral  contraction & external anal
tone  promotes closure. emptying. sphincter.
❖ -receptors  in bladder
body   detrusor tone.

Rawan Khandaqji Rawan Khandaqji

 Obstetrics & Gynecology

 Introduction Urge Incontinence

o Definition: involuntary leakage of urine. o Presentation: involuntary leakage of urine accompanied by urgency.
o Epidemiology: o Triggers:
 Undetected & undertreated despite its impact on individuals.  Running water.
 Prevalence in women is high.  Hand washing.
 In older women prevalence is 17-55%.  Cold weather exposure.
 In younger & middle-aged women prevalence is 12-42%. o Etiology:
 Idiopathic.
 Bladder infection.
 Classification  Bladder inflammation.
 Bladder stones.
 Bladder cancer.
Stress Incontinence  NS diseases (MM).
 DM.
o Most common type.
o Pathophysiology: detrusor over activity.
o Definition: involuntary leakage of urine when intra-abdominal pressure
exceeds urethral sphincter closure Symptoms Stress Incontinence Urge Incontinence
mechanisms. Urgency No Yes
o Etiology: Frequency No Yes
 Pregnancy, vaginal delivery Leakage with  intra-
Yes No
abdominal pressure
 most common cause.
Ability to reach toilet on time Yes No
  age   collagen. Nocturia Seldom Usually
  estrogen.
 Severe sphincter dysfunction.
 Familial. Overflow Incontinence
o Triggers: o Definition: involuntary, continuous, urinary leakage or dribbling and
 Sneezing. incomplete bladder emptying.
 Coughing. o Etiology:
 Laughing.  DM.
o Pathophysiology:  In female  rare  mostly due to damage to neurons.
 Vesical pressure = detrusor pressure + abdominal pressure. o Pathophysiology:
 Normally in coughing for example  intra-abdominal pressure is  Impaired detrusor contractility or bladder outlet obstruction.
transmitted equally to bladder & urethral sphincter & urethra  Bladder is over-distended:
remain fixed in place.  Could lead to stress incontinence
 Problem in levator ani muscle  pressure transmitted mainly to  May provoke an uninhibited contraction of detrusor
bladder  mobilization of urethra. muscle  incontinence.
o Associated Conditions: genital prolapse. o Diagnosis: PVR.
o Treatment: surgery.

Rawan Khandaqji Rawan Khandaqji

 Obstetrics & Gynecology

Fistula
Alarm Symptoms
o Presentation: continuous leakage of urine from vagina  clothes always
❖ Sudden onset of incontinence.
wet. ❖ Presence of abdominal or pelvic pain.
o Diagnosis: ❖ Hematuria.
 Taking sample of the fluid. ❖ Changes in gait or new lower extremity weakness.
 CT with contrast. ❖ Cardiopulmonary or neurologic symptoms.
❖ Mental status changes.

o Physical Exam:
 Pelvic exam:
 Inspection: vaginal mucosa for signs of atrophy
(thinning, pallor, loss of rugae), and inflammation
 Palpation: bimanually  masses or tenderness.
 Assess for prolapse.
 Bladder stress test: ask the patient, with a full bladder,
to stand, relax, and give a single vigorous cough

 Investigations:
 Urine analysis.
 Postvoid residual volume (PVR):
❖ PVR of < 50 mL  adequate emptying.
❖ PVR > 200 mL  inadequate  detrusor
weakness or bladder outlet obstruction.
 Approach  Urodynamic testing:
❖ Group of tests used to assess function of
o History:
urinary tract.
 Urinary symptoms.
❖ Cystometry: measure pressure and volume of
 How affecting quality of life.
fluid in bladder during filling, storage, &
 Associated symptoms  depression, anxiety, work impairment,
voiding.
social isolation, sexual dysfunction.
❖ Uroflowmetry: measures the rate of urine flow.
 Caffeine intake.
❖ Technique:
 Medications.
 Chronic disorders. Catheter inserted into bladder  vesical pressure
 Voiding dairies: Intravesical & rectal catheters  measure detrusor & abdominal pressure
Fill bladder with water or normal saline
Provocative maneuvers (Valsalva, running water)  determining if they cause leakage
Bladder is completely full  begin voiding  measurements are made of pressure,
volume, and flow rate.

Rawan Khandaqji Rawan Khandaqji

 Obstetrics & Gynecology

❖ Normal values: o Treatment:

Residal urine < 50 ml Stress Incontinence
1st disere to void 150-250 ml ❖ Reduce factors that worsen the problem  obesity,
Strong desire to void > 250 ml smoking, medication, excessive fluid intake…etc
Bladder compliance 400-600 ml Non-Surgical ❖ Pelvic floor exercise & biofeedback.
Flow rate during voiding > 15 ml/sec ❖ Estrogen therapy  in postmenopausal.
Detrusor pressure during voiding < 50 cm ❖ Electrical stimulation of pelvic floor muscle.
Overactive bladder ❖ Anterior vaginal colporrhaphy.
Urgency or leakage + Detrusor contraction that patient can’t suppress. ❖ Retropubic bladder neck suspension operations.
Surgical
Stress urinary incontinence ❖ Tension-free vaginal tape.
Leakage with  in abdominal pressure (coughing, Valsalva) + No  in true detrusor ❖ Periurethral injections.
pressure. Urge Incontinence
❖ Cut down volume of fluid consumed (1-1.5 L/day).
Conservative
❖ Avoid caffeine based drinks.
Vesical ❖ Void on a timed schedule, starting with a relatively
Bladder training
Filling pressure. Detrusor pressure frequent interval.
Phase By bladder remain at 0 or  slightly. ❖ Antimuscarinic drugs.
Medications
catheter. ❖ Estrogen.
Abdominal Intra-vesical therapy ❖ Botulinum toxin.
Sharp rises & falls. ❖ In refractory cases.
pressure. Surgery
Cough No  in detrusor ❖ Cystoplasty, urinary diversion.
By rectal
pressure. Overflow Incontinence
catheter.
Leak at this stage  pure stress incontinence. Medical ❖ Bethanechol.
 detrusor pressure Treat underlying ❖ Myomectomy or hysterectomy in the case of fibroid,
Voiding Vesical – cause removal of the urethral stricture
(bladder contract to
Phase abdominal. Intermittent self-
empty)
catheterization

o Prevention:
 Lifestyle changes:
 Weight loss.
 Smoking cessation.
 Increasing physical activity.
 Improving diet.
 Pelvic floor muscle exercises.
 Management of conditions associated with incontinence.
 Specific medications and surgical procedures may adversely
affect continence.

Rawan Khandaqji Rawan Khandaqji