Urinary
Incontinence
Presented by:
Aisha Saeed Alqahtani
Mayar Amer Alshehri
Rawan Ali Asiri
Layla Essa Asiri
Supervisor Dr. Einas Mustafa
Urinary
symptom
Objectives
terminology
Treatment
for
incontinence
Relevant
functional Clinical
anatomy assessment
of investigations
incontinence
Understand the
mechanism of
icontinence in
women
Anatomy
The LUT serves to support urine storage and facilitate voiding, including
the bladder, urethra, and associated structures.
- Urinary Bladder:
- Function:Acts as a muscular organ for urine storage and expulsion.
- Composition: The bladder wall consists of several layers, including:
1. Detrusor: The main muscle layer that expands and contracts during
bladder filling and voiding.
2. Trigone:A triangular area at the base of the bladder, positioned
between the ureters and the urethra.
3. Urethral Opening:The opening through which urine exits the bladder.
continue
The Urethra and Sphincters:
- The female urethra is a tube approximately 3.5 cm long.
- It consists of two types of sphincters:
1. The Smooth Muscle Sphincter:
- Functions involuntarily.
- Controls bladder storage and release.
2. The Striated Sphincter:
- Voluntary control.
- Helps maintain urinary continence.
Pelvic Floor Support:
- The pelvic floor is supported by the levator ani muscles.
- It maintains the correct position of the pelvic organs.
- Weakness or paralysis in these muscles can lead to issues like prolapse.
Urogenital Hiatus:
- The urogenital hiatus is where the urethra passes through the pelvic floor.
- Its integrity is essential for proper bladder function and support.
URINARY INCONTINENCE
Urinary incontinence refers to the involuntary leakage of urine, often
accompanied by a strong urge to urinate.
It is increased with age,as 6% of women in their 20s experience
symptoms, with this increasing to 40% of women in their 60s.
It is higher in women than men
What is the approximate length of the female urethra?
- A) 2.5 cm
- B) 3.5 cm
- C) 4.5 cm
- D) 5.5 cm
Classification
of Urinary
incontinence
Classification
•There are many cause of urinary incontinence divided into:
Urethral causes
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence
Extra-urethral causes
Congenital
Fistula
Stress incontinence
The most common type
• Patient have involuntary leakage of urine that occurs with sneezing, coughing, laughing or anytime
an increase in intra-abdominal pressure exceeds urethral sphincter closure mechanisms
Causes
Intrinsic sphincter deficiency (weak muscle, poor blood or nerve supply).
Urethral hypermobility (decreased muscle strength)
Damage of the nerve supply of the pelvic floor, urethral sphincter and damage to pelvic floor
muscle during vaginal delivery.
Atrophy due to Menopause.
Chronic raise in intra-abdominal pressure as cough,obesity, constipation.
Congenital-collagen diseases
Prolapse (cystocele)
Stress incontinence
Often postmenopausal,multiparous, past gyn surgeries
Hx Incontinent of urine during valsalva (e.g., coughing, sneezing, laughing)
The amount lost with each stress is small
No nocturia, No urgency or increase frequency
Pelvic examination may reveal a cystocele.
px Bladder ““cough test”
The Q-tip test is positive when a lubricated cotton-tip applicator is placed in the urethra and the
patient increases intraabdominal pressure, the Q-tip will rotate >30 degre
Urge incontinence
Patient typically have symptoms of involuntary leakage of urine accompanied by urgency, frequency and
nocturia.
Causes are poorly understood. Urge incontinence is believed to be caused by detrusor over-activity.
Urgency ,increase frequency ,nocturia
Hx Large amount of urine
Px is mostly unremarkable
Mixed incontinence
• Symptoms of both urge and stress incontinence.
Overflow incontinence
Involuntary, continuous, urinary leakage or dribbling with incomplete bladder emptying.
Causes
Impaired detrusor contractility (detrusor inactivity) as Vitamin-B12 deficiency, Alcohol, Disc
prolapse, Multiple sclerosis, DM, muscle fibrosis due to recurrent infection.
Bladder outlet obstruction (outflow obstruction)
Involuntary urination/loss of urine with full bladder .
Hx Difficulty urinating
Poor emptying of bladder
px may show normal anatomy
the neurologic examination will show decreased pudendal nerve sensation.
Functional incontinence
Causes (Potentially reversible causes)- “DIAPPERS”
•Delirium, Infection, Atrophy secondary to infections
•Pharmacological as α-blockers, ACE-inhibitors, Anti- depressant, Anti-psychotic, CCBs, Progesterone,
•Psychological
•Excessive urine output as DM, Alcohol and caffeine intake
•Restricted mobilization (post-surgery)
•Stool impaction
Extra-urethral causes
The observation of urine leakage through channels other than the urethra.
• Congenital:
– Bladder exstrophy
– Ectopic ureter
• Fistula:
– Vesicovaginal fistula, esp. after hysterectomy
– Abnormal opening between the urinary tract and the outside.
– It has Obstetric and Gynaecological causes as Obstructed Labor, Malignancy and
Radiotherapy
Question
A 38-year-old multigravida woman complains of painless loss of urine, beginning
immediately with coughing, laughing, lifting, or straining. Immediate cessation of the
activity stops the urine loss after only a few drops. Which of the following is this
history most suggestive of?
A-Urge incontinence
B- Stress incontinence
C- Overflow incontinence
D-UTI
Work- up
History
Patient’s urinary symptoms (volume, onset of•
incontinence, timing, severity, hesitancy, precipitating
triggers, nocturia, intermittent or slow stream, incomplete
.(emptying, continuous urine leakage and straining to void
Investigation
Voiding (bladder) diaries (i.e, Frequency- volume
bladder charts are useful for assessing incontinence
frequency, severity and volume of urine loss during
incontinent episodes).
Investigations :
•Urine analysis and cultureid
Post-void residual volume (PVR):
PVR < 50 mL: is considered adequate emptying
PVR > 200 mL: is considered inadequate and suggestive of either detrusor weakness or
bladder outlet obstruction
RFT
Pad test:
Used to quantify urine leakage over a 1–24-hour period.
Patients are asked to wear a preweighed sanitary pad, perform
certain activities, and drink a certain volume of liquid. Tests
have become less commonly done in the last 5–10y.
Investigations :
•Urodynamic testing; group of tests used to assess function of the
urinary tract. Some specific types of urodynamic testing are
Cystometry (Cystometrogram) and Uroflowmetry
Uroflowmetry; measures the rate of urine flow.
• Cystometry (Cystometrogram); evaluates bladder
function by measuring pressure and volume of fluid in the
bladder during filling, storage and voiding.
Investigation
Overactive bladder (Detrusor overactivity) can be
diagnosed if there is urgency or leakage with a detrusor
contraction that the patient can NOT suppress.
Genuine-stress incontinence (Urodynamic stress
incontinence-USI) is characterized by leakage that occurs
with an increase in abdominal pressure, such as coughing
or valsalva, without a rise in true detrusor pressure.
Investigation
Imaging:
-Renal ultrasound.
-Micturating cystourethrography (MCU): to detect morphological
abnormalities.
-Cystourethroscopy and or dye tests: to rule out tumors and
vesicorectal or vesicovaginal fistula
A 40-year-old Para 2 presents for evaluation of new onset
urinary leakage for the past 4 weeks.
Which of the following is the most appropriate first step in this
patient's evaluation?
A. Urinalysis and culture test.
B. Post void residual volume.
C. Micturating cystourethrography.
D. Cystourethroscopy.02:08 AM
Treatment
Behavioral and life- Pelvic floor muscle
style changes: exercises; Are
Weight loss for effective in Management of Specific Medications
obesity preventing and associated and Surgical
, smoking cessation, reversing some conditions with Procedures:
physical urinary incontinence incontinence (DM, According to type
activity/exercise, in the first year after constipation)
improving diet vaginal delivery or
(excessive fluid following pelvic
intake or cut down). surgery
Management of Stress incontinence
Behavioral and life-style changes
Kegel exercises strengthen pelvic floor muscles.
Estrogen therapy (in post-menopausal women with
urogenital atrophy).
Vaginal Pessaries
Medication:
Duloxetine: to enhance sphincter contraction but have side
effects e.g: Nausea, insomnia, dizziness.
Impiramine.
Surgical Management:
-Periurethral plication ( Kelqly’s suture )
-TOT > TVT vaginal sling operation
-(Burch colposuspention ) (Gold standard ) success > 90%
-Periurethral injection of Collagen in hypermobile urethra
Management of Urge incontinence
Medications
Conservative Management: First line,Anti-cholinargic drugs
-Cut down volume of fluid consumed (Oxybutynin):
"Patients should be advised about the side
(should consume between 1-1.5 liters effects before starting TTT: dry mouth
daily). constipation, and arrhythmias."
-Avoid caffeine based drinks.
Mirabegron (B3-adrenergic agonist).
-Bladder training: the patient is
instructed to void on a timed schedule, Estrogen.
starting with a relatively frequent interval
Second line treatment
Endoscopic injection of botulinum toxin at
different points in the bladder wall
Sacral nerve root neuromodulation.
Surgery (urinary diversion) in refractory
cases
Management of Overflow incontinence
Medical therapy to enhance bladder emptying provided there is NO
obstruction; Neostigmine or Phenoxybenzamine.
Intermittent self catheterization
Treatment of the underlying cause of obstruction e.g. myomectomy
or hysterectomy in the case of fibroid, removal of the urethral
stricture ...etc.
Management of fistula:
Surgical repair of the fistula
A 50-year-old woman complains of sudden and strong urges to urinate,
often leading to leakage before reaching the toilet. Which of the following is
the most appropriate first-line management for urge urinary
incontinence?
a. Bladder training
b. Anticholinergic medication
c. Pelvic floor muscle training
d. Surgical intervention
OUR REFERENCES
Thank You
