URINARY INCONTINENCE

By : Rama Nafiz Basheer

Nissreen Eyad Thafer
 Anatomy :
• Urinary bladder:
• This triangle-shaped, in the lower
abdomen.
• collects the urine. The normal capacity of
the bladder is 400-600 mL
• lined with transitional epithelium &
• Muscular layer : Three layers of
smooth muscle (Detrusor muscle)
• Nerve Supply

• Sympathetic – hypogastric nerve (T12 – L2).

relaxation of the detrusor muscle urine retention.
• Parasympathetic – pelvic nerve (S2-S4).
contraction of the detrusor muscle micturition.
• Somatic – pudendal nerve (S2-4).

voluntary control over micturition.

external urethral sphincter
 Anatomy :
• Urethra
• tube runs from bladder to open in front of
vagina
• lined with transitional epithelium and 2
layer of smooth muscle
• 1.5 inch in female , has  two sphincters to
control the flow of urine through the
urethra
• internal urethral sphincter (involuntary)
•  (external urethral sphincter ). (voluntary)
Micturition
 Pharmacology of incontinence
• α-adrenergic receptors in the urethra.
α-adrenergic agonists cause contraction of urethral smooth muscle,
preventing micturition.
Drugs: ephedrine, imipramine, and estrogens.
• α-adrenergic blockers or antagonists relax the urethra, enhancing
micturition.
Drugs: phenoxybenzamine
Con…
• β-adrenergic receptors in the detrusor muscle, cause relaxation of
the bladder wall, preventing micturition.
Drugs: flavoxate and progestins.
• Cholinergic receptors in the detrusor muscle, cause contraction of
the bladder wall, enhancing micturition.
Drugs: bethanechol and neostigmine.
• Anticholinergic medications block the receptors, inhibiting
micturition.
Drugs: oxybutynin and propantheline.
Evaluation of Incontinence
• History, the patient should complete a 3-day (full, 24-hour days) voiding diary,
a record of the bladder’s behavior that helps to identify the diagnosis.
• Amount of fluid taken and urine produced.
• Record each drink volume and voiding volume (by a measuring cup), and
incident of urine loss.
• Record how much urge is felt and IF there is pain at, before, or after voiding.
– Urine loss with physical activity suggests stress.
– Urge to empty but not getting to the toilet fast enough suggests urge.
– Incontinence with both physical activity and sense of urgency suggests mixed.
– Continuous loss of urine day and night suggests fistula.
Physical Exam,,
• Abdominal exam.
• should rule out masses, ascites, and
organomegaly, which can influence intra-
abdominal pressure.
• Assess pudendal nerve innervation of the perineum with the
bulbocavernosus and clitoral sacral reflex (lightly brushing the labia
majora or tapping the clitoris should produce a reflex of the external
anal sphincter muscle).
• Do pelvic exam to evaluate for inflammation, infection, and atrophy,
which can increase bladder sensitivity and lead to urgency,
frequency, and dysuria.
• Urinalysis & Culture. A urinalysis should be performed in all
patients, looking for leukocytes (WBC), bacteria, and RBC.

• Many WBC and bacteria would suggest a UTI; do urine culture

for identification of bacteria and antibiotic sensitivities.

• Microscopic hematuria would suggest a bladder stone or

foreign body and tumor. Do further work-up with cystoscopy.
• Cystometric Studies.
Basic office cystometry begins with :
1. The patient emptying the bladder as much as possible.
2. A urinary catheter is first used to empty the bladder.
3. Then left in place to infuse saline by gravity retrograde.
Assessing the following:
• Residual volume: (normal <100 mL)
• Sensation-of-fullness volume: (normal 200–225 mL)
……… self regenerative (stretch, contract, repeat).
• Urge-to-void volume: (normal 400–500 mL)
• Involuntary bladder contractions: (absence of contractions is
normal)
Classification of Incontinence:

1. Genuine stress incontinence.

2. Motor urge (hypertonic) incontinence.
3. Mixed incontinence.
4. Functional incontinence.
5. Overflow (hypotonic) incontinence.
6. Fistula.
Genuine stress incontinence
• in young women
• Increase in bladder pressure due to intra-abdominal pressure increases
(e.g., coughing and sneezing).
• Associated with :
• intrinsic sphincter deficiency( history of vaginal childbirth )
• urethral hypermobility ( stretching/damage of pudendal n\ avulsion, of
the pelvic floor muscles from their insertions)
• History.
•  Loss of urine occurs in small spurts with coughing or sneezing.
•  No urine lost at night.
Examination.
 Pelvic examination may
reveal a cystocele.
 Neurologic examination
is normal.
 The Q-tip test is positive.
• Investigative studies.
1. Urinalysis and culture are normal.
2. Cystometric studies are normal \ no
involuntary detrusor contractions
seen.
• Management.
• Medical therapy:
1. Kegel exercises.
2. Estrogen replacement in
postmenopausal women.
• Surgical therapy :aims to
elevate the urethral sphincter
again an intraabdominal
location . This done by:
1. Burch procedure
2. Marshall-Marchetti-Krantz
(MMK) procedure.
• The success rate of both of these
procedures is 85–90%.
 • invasive surgical procedure:
• tension-free vaginal tape procedure :a mesh tape is
placed transcutaneously around and under the mid
urethra. It does not elevate the urethra but forms a
resistant platform against intra-abdominal
pressure.

***Midurethral tapes and colposuspension are

equally effective, but tape surgery is more cost-
effective due to the short hospital stay and
rapid return to normal activities.
Motor urge (hypertonic) incontinence
• m\c in old women
• idiopathic detrusor contractions that cannot
be voluntarily suppressed. So involuntary
rises in bladder pressure occur.
• History.
• urine in large amounts lost without warning.
• Urine loss day and night
• The main symptom is urgency urination.
• Examination.
• Pelvic & Neurologic examination : normal.
• Investigative studies.
• Urinalysis and culture are normal.
• Cystometric studies :
• normal residual volume
• involuntary detrusor contractions are present even with small volumes of urine in the
bladder.
• Management.
• Changing in life style :
1. Advice about fluid balance.
2. • Reduction of caffeine intake.
3. • Bladder retraining.
4. • Pelvic floor muscle exercise.
• Medication:
1. Anticholinergic medications (e.g., oxybutynin).
2. NSAIDs to inhibit detrusor contractions.
3. tricyclic antidepressants.

4. calcium-channel blockers.

• Intradetrusor injection of Botulinum toxin and sacral neuromodulation are highly effective second-line
treatments for detrusor overactivity.
Mixed incontinence.

• m\c in old women

• is a combination of both stress and urge incontinence.
• History.
• Loss of urine may occur with both physical activity,
coughing and sneezing and urgency to urinate.
• Examination.
• Pelvic exam : -\+vaginal prolapse (cystocele, rectocele,
enterocele).
• Q-tip test is variable.
• Pudendal nerve innervation will be normal
• Investigative studies.
• Urinalysis will be unremarkable.
• Cystometry will show:
1. A normal residual volume,
2. Sensation-of-fullness & urge-to-void volume may be decreased.
3. Involuntary detrusor contractions may be seen.

• Management.
• No single therapy works for everyone;
• Treatment depends on predominant symptoms.
Functional incontinence
• mostly older women
• urinary storage and emptying functions are intact but the patient is unable to get to the toilet on time,
whether physically OR psychologically.
• History.
• Inability to toilet oneself in a timely fashion.
• Loss of urine can vary, from small leakages to full emptying of the bladder.
• Examination.
• Varies with individual but the bladder support and innervation are intact.
• Investigative studies.
•  Urinalysis and cystometry will be unremarkable & no Involuntary detrusor contractions.
• Management.
• bladder training and pelvic floor exercises (Kegel exercises).
overflow (hypotonic) incontinence
• A rise in bladder pressure occurs gradually from an
overdistended, hypotonic bladder.
• When the bladder pressure exceeds the urethral pressure,
involuntary urine loss occurs.
• Caused by:
•  Denervated bladder ( Diabetic neuropathy, multiple
sclerosis).
•  Systemic medications (Ganglionic blockers, anticholinergics).
• History.
•  Loss of urine occurs intermittently in small amounts.
•  occur in both day and night.
•  The patient may complain of pelvic fullness.
• Examination.
• Pelvic examination may show normal anatomy.
• Neurologic examination: decreased pudendal nerve sensation .
• Investigative studies.
• Urinalysis and culture are usually normal, but may show an infection.
• Cystometric studies show:
1. Markedly increased residual volume.
2. Detrusor muscle not contracted Involuntary
• Management.

• Possible intermittent self-catheterization.

• Discontinuation of the offending systemic medications, cholinergic medications
to stimulate bladder contractions, and α-adrenergic blocker to relax the bladder
neck.
 Fistula
• The urethral-bladder mechanism is intact but is bypassed by urine
leaking out through a fistula from the urinary tract.
• In many low and middle income countries, the most common cause of
VVF is prolonged or obstructed labor.
• History.
•  Radical pelvic surgery.
•  Pelvic radiation therapy.
•  Loss of urine occurs continually in small amounts CONTINUASLY.
•  occur in both day and night.
• Examination.
• Pelvic examination may show normal anatomy and normal neurologic
findings.
• Investigative studies.
•  Urinalysis and culture are normal.
•  An intravenous pyelogram (IVP) will demonstrate
dye leakage from a urinary tract fistula.
• With a urinary tract-vaginal fistula, intravenous indigo
carmine dye will leak onto a vaginal tampon.
• Management.
• Catheter: fistula is small and diagnosed early then
urine can be kept away from the fistula by a catheter
and the fistula may heal by itself. up to 12 weeks.
• Surgical repair.
Thank you