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Fifth stage
Gynecology
Lec-8
د.سراب
23/3/2016
Urinary incontinence
Definition:
involuntary loss of urine that is objectively demonstrable and cause hygienic
and social problems.
It is so common, affect 20-30% of women.
Classification:
Stress incontinence (most common): involuntary loss of urine with physical effort
(cough, jump).
Urge incontinence: involuntary loss of urine associated with urgency.
Overflow incontinence: precede by contraction then full of bladder then
incontinence.
Continuous incontinence: always loss of urine without provoking factors.
Symptoms:
Symptoms before voiding (storage phase):
Stress incontinence.
Urge incontinence.
Urgency: intense desire to void.
Frequency: urination more than usual voiding rate.
Decrease or increase bladder sensation of fullness.
Symptoms during voiding (void phase):
Poor stream (voiding difficulty).
Intermittent stream.
Hesitancy.
Symptoms after voiding (post voiding phase):
Post voiding drippling of urine (most common cause is urethral diverticulum).
Feeling of incomplete emptying.
Dysuria, hematuria, pyuria.
Stress incontinence (urodynamic incontinence):
It means involuntary loss of urine due to increased intra-abdominal pressure
demonstrating by urodynamic study.
Causes sphincter problems (innervation loss, loss of muscle, loss of support of
sphincter).
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Urge incontinence:
Cause: Detrusor muscle instability or over activity.
Associated with urgency.
Affect social activity of women.
Should be always near toilet.
Continuous incontinence:
Congenital causes:
Epispadias.
Ectopic ureter.
Fistula (following surgery of obstructed labor).
Assessment:
History:
Ask about the symptoms above.
History of chronic cough.
History of neurological diseases (Multiple sclerosis, spinal cord injury).
History of D.M.
History of other urological problems.
History of operation.
Obstetric history (prolonged labor).
Drug histoy.
Examination:
General examination:
o Obesity (increased intra-abdominal pressure).
o Gait (neurological condition).
o Chest examination (chronic infection).
o Abdominal examination (mass, operation).
o Bladder palpation.
Pelvic examination:
o Inspection: ask patient to cough.
o Cystocele or urethrocele (do reduction then ask her to cough).
o Vaginal capacity and strength of vaginal wall.
o Bimanual examination of mass.
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Investigations:
1- Local:
Mid-stream urine examination (infection treat it).
Urinary diary test (chart for input and output, episodes of incontinence, provoked
factors).
Pad test (weight the pad then do physical activities that lead to incontinence for 4
hours then weight the pad, if increased by 1 g it considered as significant
incontinence).
Three swab test:
o Put three swabs in the vagina, inject the methylene blue in bladder, then wait for
time.
o Upper swab stain vesico-vaginal fistula.
o Middle swab stain urethra-vaginal fistula.
o Lower swab stain incontinence or contamination.
o Wet but not stain urethra-vaginal fistula.
2- Urodynamic study:
Flowmetery:
o Voiding (ml) per time (min).
o Normal half of bladder = 50 ml/sec.
o Detrusor pressure = pressure inside bladder – intra-abdominal pressure.
o Storage phase first desire to void = half of bladder capacity = 150-200 ml
normally.
o Bladder capacity = 400-600 ml normally.
o Detrusor pressure = less than 15 ml of water.
o No involuntary loss of urine.
o Ask the patient to void normally 50 ml/sec and detrusor pressure during voiding
= 70.
o Residual volume = less than 50 ml normally.
o Benefits know the bladder capacity, stress incontinence, detrusor pressure,
obstruction, residual volume.
o Indications of flowmetery:
Before operation.
Neurogenic bladder.
Multiple symptoms (urge and stress).
Multiple sclerosis.
Voiding problems.
Fail of operation.
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Vedio-cystourethrography:
o Radioactive material and take colored films.
o Useful to see diverticula, fistula, reflux, same indications of flowmetery.
3- Radiological tests:
US Residual volume, bladder (stones, mass), diverticulum, mass in abdomen,
kidney.
IVU.
MRI problems in pelvic floor or sphinceter.
4- Tests for sphincter:
Nerve conduction study.
Urethral pressure profiometery.
Management:
1- Overflow insentience:
Treated by urologist and neurologist.
End by continuous catheter.
2- Stress incontinence:
Pelvic floor exercise.
Pelvic floor muscle stimulation.
Vaginal cone.
Drugs: SSRI (lead to nausea and vomiting).
Surgery:
o Colpo suspension:
Elevate the vagina and bladder.
Do it by scope or open.
Treat the cystocele and incontinence.
Problems: It lead to detrusor over-activity, fistula, obstruction.
o TPT:
Tension free vaginal tap.
Put mesh in the suburethral area.
Minimally invasive.
Problems: It lead to detrusor over-activity, fistula, obstruction, pain, injury to
near structures by the applicator, injury to bladder or obturator vessels.
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o Artificial sphincter.
o Local injection of strengthening materials like collagen.
3- Detrusor overactivity:
Bladder training:
o Restricted things that to increased urination.
o Stop smoking.
o Avoid provoking factors.
o Restrict fluid intake to 1-1.5 L by 24 hours.
o Not go to toilet for 0.5 hour then 1 hour then 2 hour gradually increased
intervals between voiding.
Drugs:
o Selective anticholinergic.
o TCA.
o Anti-diuretics (decrease urine output).
o Gabapentin (for neurogenic bladder).
Surgery:
o Sacral nerve stimulation.
o Tibial nerve stimulation.
Use pat or catheterization (suprapubic or self).
Note:
Causes of fistula:
Operation (hysterectomy, CS).
Prolonged or obstructed labor).