Urinary Incontinence

Genet Gebremedhin (MD)

April 4 2017
 Urinary incontinence
“the complaint of any involuntary leakage of
urine”
 Physiology of Micturition
The bladder is a complex organ that has a
relatively simple function: to store urine
effortlessly, painlessly, and without leakage and to
discharge urine voluntarily, effortlessly,
completely, and painlessly.
 Contd.
• To meet these demands, the bladder must
have normal anatomic support and normal
neurophysiologic function
 Normal Urethral Closure
• Normal urethral closure is maintained by a
combination of intrinsic and extrinsic factors.
• The extrinsic factors include;
The levator ani muscles,
The endopelvic fascia, and their attachments to
the pelvic sidewalls and the urethra.
• This structure forms a hammock beneath the
urethra that responds to increases in intra-
abdominal pressure by tensing, allowing the
urethra to be closed against the posterior
supporting shelf
 Contd.
The intrinsic factors contributing to urethral closure
include;
Striated muscle of the urethral wall
Vascular congestion of the submucosal venous plexus
The smooth muscle of the urethral wall and associated
blood vessels
The epithelial coaptation of the folds of the urethral
lining
Urethral elasticity, and
The tone of the urethra as mediated by α-adrenergic
receptors of the sympathetic nervous system
 The Bladder
The bladder is a bag of smooth muscle that
stores urine and contracts to expel urine
under voluntary control.
It is a low-pressure system that expands to
accommodate increasing volumes of urine
without an appreciable rise in pressure.
This function appears to be mediated
primarily by the sympathetic nervous system
 Contd.
During bladder filling, there is an
accompanying increase in outlet resistance.
The bladder muscle (the detrusor) should
remain inactive during bladder filling, without
involuntary contractions.
When the bladder has filled to a certain
volume, fullness is registered by tension-
stretch receptors, which signal the brain to
initiate a micturition reflex.
 Contd.
This reflex is controlled by cortical control
mechanisms, depending on the social
circumstances and the state of the patient’s
nervous system.
Normal voiding is accomplished by voluntary
relaxation of the pelvic floor and urethra,
accompanied by sustained contraction of the
detrusor muscle, leading to complete bladder
emptying.
 Innervation
The lower urinary tract receives its innervation
from three sources:
1.The Sympathetic
2. Parasympathetic divisions of the autonomic
nervous system, and
3.The neurons of the somatic nervous system
(external urethral sphincter)
 Contd.
The autonomic nervous system consists of all
efferent pathways with ganglionic synapses that
lie outside the central nervous system.
Sympathetic system primarily controls bladder
storage, and the
Parasympathetic nervous system controls
bladder emptying.
The somatic nervous system plays only a
peripheral role in neurologic control of the lower
urinary tract through its innervation of the pelvic
floor and external urethral sphincter.
 Sympathetic nervous system
The sympathetic nervous system originates in the
thoracolumbar spinal cord, principally T11
through L2 or L3
The ganglia of the sympathetic nervous system
are located close to the spinal cord & use
acetylcholine as preganglionic neurotransmitter.
The postganglionic neurotransmitter in the
sympathetic nervous system is norepinephrine
 Contd.
The postganglionic neurotransmitter
norepinephrine, acts on two types of receptors:
α-receptors, located principally in the urethra
and bladder neck, and β-receptors, located
principally in the bladder body.
Stimulation of α-receptors increases urethral
tone and thus promotes closure, whereas α-
adrenergic receptor blockers have the opposite
effect.
Stimulation of β-receptors decreases tone in the
bladder body.
Parasympathetic nervous system
controls bladder motor function—bladder
contraction and bladder emptying.
It originates in the sacral spinal cord, primarily
in S2 to S4, as does the somatic innervation of
the pelvic floor, urethra, and external anal
sphincter.
Sensation in the perineum is also controlled
by sensory fibers that connect with the spinal
cord at this level.
 Contd.
For this reason, examination of perineal
sensation, pelvic muscle reflexes, and pelvic
muscle or anal sphincter tone is relevant to
clinical evaluation of the lower urinary tract.
The parasympathetic neurons have long
preganglionic neurons and short postganglionic
neurons, which are located in the end organ.
Both the preganglionic and postganglionic
synapses use acetylcholine as their
neurotransmitter, acting on muscarinic receptors
 Contd.
Bladder storage and bladder emptying involve the
interplay of the sympathetic and parasympathetic
nervous systems.
The modulation of these activities appears to be
influenced by a variety of nonadrenergic,
noncholinergic neurotransmitters and neuropeptides,
which fine tune the system at various facilitative and
inhibitory levels in the spinal cord and higher areas of
the central nervous system.
Neuropathology at almost any level of the
neurourologic axis can have an adverse effect on lower
urinary tract function
 Micturition
Micturition is triggered by the peripheral nervous system
under the control of the central nervous system
It is useful to consider this event as occurring at a
micturition threshold, a bladder volume at which reflex
detrusor contractions occur.
The threshold volume is not fixed; rather, it is variable and
can be altered depending on the contributions made by
sensory afferents from the perineum, bladder, colon,
rectum, and input from the higher centers of the nervous
system.
The micturition threshold is, therefore, a floating threshold
that can be altered or reset by various influences.
The spinal cord & higher centers of the
nervous system
Have complex patterns of inhibition and
facilitation.
The most important facilitative center above
the spinal cord is the pontine-mesencephalic
gray matter of the brainstem, often called the
pontine micturition center, which serves as
the final common pathway for all bladder
motor neurons
 Contd.
The cerebellum serves as a major center for
coordinating pelvic floor relaxation and the
rate, force, and range of detrusor
contractions, and there are multiple
interconnections between the cerebellum and
the brainstem reflex centers.
Above this level, the cerebral cortex and
related structures exert inhibitory influences
on the micturition reflex.
 Contd.
The upper cortex exerts facilitative influences
that release inhibition, permitting the
anterior pontine micturition center to send
efferent impulses down the complex
pathways of the spinal cord, where a reflex
contraction in the sacral micturition center
generates a detrusor contraction that causes
bladder emptying.
 What is normal?
A normal lower urinary tract is one in which
the bladder and urethra store urine without
pain until a socially acceptable time and place
arises, at which point voiding occurs in a
coordinated and complete fashion.
 Lower urinary tract disorders
Lower urinary tract disorders include
1. Abnormal Storage ( incontinence)
Stress incontinence
Urge incontinence
Mixed incontinence
Continuous urinary incontinence
Increased daytime urinary frequency ( >7x a day)
Nocturia (interruption of sleep > 1 to micturate)
Nocturnal enuresis (involuntary loss of urine that
occurs during sleep
 Contd.
Urgency
Postural urinary incontinence
Insensible urinary incontinence
Coital incontinence
Overactive bladder syndrome (OAB)
- Urinary urgency, usually accompanied by
frequency and nocturia, with or without urgency
urinary incontinence, in the absence of urinary
tract infection or other obvious pathology
2. Abnormal Sensory Symptoms
Increased bladder sensation Complaint that the desire to
void during bladder filling occurs earlier or is more
persistent from that previous experienced (differs from
urgency by the fact that micturition can be postpone
despite the desire to void)
Reduced bladder sensation Complaint that the definite
desire to void occurs later than that previously
experienced, despite an awareness that the bladder is
filling
Absent bladder sensation Complaint of both the absence
of the sensation of bladder filling and a definite desire to
void
 Contd.
3. Abnormal Emptying
Hesitancy Compliant of a delay in initiating micturition
Straining to void
Slow stream
Intermittency
Feeling of incomplete bladder emptying
Postmicturition leakage
Spraying of urinary stream
Position-dependent micturition
Urinary retention
 Contd.
4. Functional and Transient Incontinence
Reversible Causes of Incontinence
common in elderly, causes are
D Delirium
I Infection
A Atrophic urethritis and vaginitis
P Pharmacologic causes
P Psychological causes
E Excessive urine production
R Restricted mobility
S Stool impaction
 Stress Urinary Incontinence
Stress urinary incontinence occurs during
periods of increased intra-abdominal pressure
(e.g., sneezing, coughing, or exercise) when
the intravesical pressure rises higher than the
pressure that the urethral closure mechanism
can withstand.
Some advocate the term “activity-related
incontinence”
 Contd.
• Diagnosis
-Clinical
- urodynamic studies
• Management
- life style modification
- Surgery
 Continues urinary incontinence
Can be
Congenital
- Bladder exstrophy
- Ectopic ureter
Acquired
- Fistula
 Fistula
• Worldwide, the most common cause of
vesicovaginal fistulas is obstructed labor
• A fistula patient suffers from much more than
a hole in the bladder. Her whole person is
damaged. It is important to understand the
full impact of the damage to the physical and
mental well-being of the patient.