Dr. Nedaa Bahkali
2012
 Urinary
incontinence is defined as
involuntary leakage of urine.
 Stress
•
urinary incontinence (SUI):
involuntary urine leakage on exertion or with
sneezing or coughing.
 Urge
urinary incontinence:
• women have difficulty postponing urination urges
and generally must promptly empty their bladder on
cue and without delay.
• If urge urinary incontinence is objectively
demonstrated by cystometric evaluation, the
condition is known as detrusor overactivity (DO).
 Mixed
urinary incontinence :
• When both stress and urge components are
present, it is called.
 Prevalence
 Among
of 25 - 55 %.
women with urinary incontinence,
• the most common condition is stress
incontinence, which represents 29 to 75 %of
cases.
• Detrusor overactivity accounts for up to 33 % of
incontinence cases.
• whereas the remainder is attributable to mixed
forms.
 Detrusor
muscle
 External and Internal sphincter
 Normal capacity 500-600cc
 First urge to void 150cc
Storage
Reflex
Micturition
Reflex
o
o
o
o
o
o
o
Age
Pregnancy
Childbirth
Menopause
Hysterectomy
Obesity
Chronically increased abdominal pressure
•
•
•
o
Chronic cough
Constipation
Occupational risk
Smoking
 Pressure Transmission
 Urethral
Support
 In
an ideally supported urogenital tract,
increases in intra-abdominal pressure are
equally transmitted to the bladder, bladder
base, and urethra.

In women who are continent, increases in
downward-directed pressure from cough,
laugh, sneeze, and Valsalva maneuver are
countered by supportive tissue tone
provided by the levator ani muscle and
vaginal connective tissue .
 In
those with a weakened supportive
"backboard", however, downward forces
are not countered.
 This leads to funneling of the
urethrovesical junction, a patent urethra,
and in turn, urine leakage.
 Urethral
support is integral to continenc
• (1) ligaments along the lateral aspects of the urethra,
termed the pubourethral ligaments;
• (2) the vagina and its lateral fascial condensation;
• (3) the arcus tendinous fascia pelvic;
• (4) levator ani muscles .
 With
loss of urethral support, the urethra's
ability to close against a firm supportive
backboard is diminished.
 History
:
• Duration, severity, symptoms, previous
treatment,(Urinary Frequency, Urinary Retention,
volume of urine lost , Postvoid dribbling is
classically associated with urethral diverticulum)
• medications, Past medical hx, GU surgery, Ob
hx
 Voiding
Diary
Symptom
Stress
Incontinence
Urgency
Yes
Frequency with urgency
Yes
Urine leakage with increased intra-abdominal
pressures
No
Amount of urinary leakage with each
incontinence episode
Ability to reach the toilet in time following an
urge to void
Waking to void at night
Large
Often No
Usually
Urge
Incontinence
No
No
Yes
small
Yes
Seldom
 Diuretics
 Anticholinergics
- antihistamines,
antipsychotics, antidepressants
 Seditives/hypnotics
 Alcohol
 Narcotics
 α-adrenergic agonists/antagnists
 Calcium channel blockers
 General
Inspection and Neurologic
Evaluation
• evidence of atrophy.
• neurologic evaluation of the perineum:
 bulbocavernosus reflex
 normal circumferential anal sphincter contraction,
colloquially called an "anal wink",
 Pelvic
Organ Prolapse Evaluation
 Q-Tip Test
 Urinalysis
and Culture
 Postvoid Residual
 Cystometrics
 Uroflowmetry
 Conservative/Nonsurgical:
• Pelvic Floor Strengthening Exercises
• Pelvic Floor Muscle Training (PFMT)
 Electrical
Stimulation
 Biofeedback Therapy
 Dietary
 Scheduled Voiding
 Estrogen Replacement
 Medications:
• Pharmaceutical treatment plays a minor role in
the treatment of women with SUI.
• imipramine is reasonable to aid urethral
contraction and closure.
• Recently, duloxetine a selective serotonin and
norepinephrine reuptake inhibitor, has been
evaluated for the treatment of SUI
 Periurethral
Bulking Agents
 Retropubic
Urethropexy
 Pubovaginal Slings
 Midurethral Slings
 Antimuscarinics:
tertiary amines that
act to block the muscarinic receptors in
response to acetocholine
• First line
 Oxybutinin (Ditropan)
 Tolteridine (Detrol)