Urinary Incontinence
Anatomy and Terminology Overview
Moeen Abu-Sitta, MD, FACOG, FACS
Purpose
• Locate and describe the anatomy of the Female
Urinary System
• Define terminology related to Incontinence
• Describe condition and disease states of
Incontinence
Urinary Incontinence
• Urinary Incontinence (UI)
is the involuntary loss of
urine.
• Afflicts an estimated 13
million adults in U.S. (85%
of them being women.*)
*American Urological Association, Female Stress Urinary Incontinence Guidelines Panel.
Surgical Management of Female Stress Urinary Incontinence. 1997:1
The
Anatomy of the Urinary Tract
Bladder and Uretra
Anatomy
Median Section
Ureter
Bladder
Bowel
Pubic Symphisis
Uterus
Urethra
Rectum
Deep Dorsal
Vein of Clitoris
Levator Ani
Crus
Labia Minora
Labia Majora
Levator Ani
• A broad muscle that helps to form the floor of the pelvis.
• Anterior fibers of the Levator ani descend upon the side of
the vagina
Urinary Incontinence
Causes, Symptoms, Types, Diagnosis,
Treatment Options
Common Causes of Female Urinary
Incontinence
• Pelvic surgery
• Injuries to the pelvic
region or to the spinal
cord
• Neurological diseases
• Multiple sclerosis
• Obesity
• Urinary tract infection
• Degenerative changes
associated with aging
• Childbirth
• Post-menopausal
Birth Trauma
Common Symptoms of Female Urinary
Incontinence
• Involuntary loss of urine due to physical activity
• Inability to resist urine leakage after feeling the urge
to urinate
• Urinating more frequently than usual
• Pain while urinating
• Bladder infections
• Feeling that the bladder is never completely empty
even after urinating
• Abnormal urination patterns
What is Normal Urinary Function?
Bladder
Uterus
Vagina
Pubic Bone
Bladder
Neck
Sphincter
Urethra
Common Types of Female Urinary
Incontinence?
Stress
Urge
Mixed
(Urge & Overflow)
Overflow
Urge Incontinence
The sudden involuntary
loss of urine that takes
place as soon as the urge
to urinate is felt.
Overflow Incontinence
The involuntary loss of urine
that occurs when the
bladder overfills to the point
of leakage. The bladder
feels as though it is never
completely empty.
Mixed Incontinence?
A Mixture of Incontinence Types
Urge
Overflow
Hypermobility
(“Hyper” means too
much and “mobility”
refers to movement.)
When the normal pelvic
floor muscles can no
longer provide support to
the bladder and thus,
involuntary leakage occurs.
Bladder Neck
Drops
How is Urinary Incontinence
Diagnosed?
Medical history
Physical examination
Diagnostic tests:
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•
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•
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Blood test
Cystoscopy
Post Void Residual (PVR)
Stress test
Urinalysis
Urodynamic testing
Urodynamic Tests
Evaluate the storage of urine in the bladder through the
urethra
Measures:
• Contraction of bladder muscle as it fills/empties
How:
• Fill bladder with water or gas
• Another catheter in rectum to measure pressure on the
bladder when straining/coughing
• Can substitute water with x-ray dye so pictures can be
taken to detect bladder abnormalities
Urodynamics
Urodynamics
What are Some Common
Non-Surgical Treatment Options?
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Bladder training
Timed voiding
Pelvic muscle exercises (Kegels)
Drug therapy (urge incontinence)
Absorbent products
Double void, after urinating wait a few seconds and void again
Avoid constipation by eating many fruits, vegetables and whole
grains each day
• Avoid over consumption of urethral irritants such as alcohol,
caffeine and nicotine
• Avoid overuse of drugs such as diuretics, antidepressants,
antihistamines, cough/cold preparations
What are Some Common Surgical
Treatment Options?
• Burch Procedures: retropubic
procedure performed
percutaneously through abdomen
• MMK Procedures
• Needle Suspensions: place
sutures through fascia into publc
bone through abdominal incision
What are Some Common Surgical
Treatment Options?
• Sling Procedures: minimally
invasive surgical procedure that is
intended to create “hammock
like” support for the bladder &
sphincter.
• Bulking Agents: Injectable agents
increase the bulk around the
urethra, helping to close the
sphincter and control urinary loss.
Pelvic Floor
Anatomy, Disease State &
Treatment Options
Purpose
• Locate and describe the anatomy of the Pelvic
Floor Structure
• Define terminology related to pelvic floor
reconstruction
• Describe conditions and disease states of the
pelvic floor
The Pelvic Floor
• Network of muscles, ligaments, and fascia that
support abdominal and pelvic organs
• Proper support of pelvic organs is important to
proper functioning of those organs
Pelvic Floor Reconstruction
• Surgical correction of pelvic floor defects
• Goal: improve support, positioning and therefore functioning
of pelvic organs
• Structures affected: vagina, bladder, urethra
Support Anterior Vagina & Urethra
Prolapse
• Slipping or falling out of place
• Type of hernia, with tissue protruding into another space
because of weakened tissue
Pelvic Prolapse
• Inadequate support from system of pelvic connective
tissues
• Three types:
– Anterior
– Posterior
– Apical
– Uterine
Pelvic Floor Defects
• 5 to 10 million women affected by pelvic floor dysfunction
• 400,000 surgical procedures performed in U.S.
• 40% of all women age 45-85 will have significant
prolapse (grade 2 or better)
What causes Pelvic prolapse?
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Intra-abdominal pressure during childbirth (99%)
Hysterectomy
Chronic respiratory disease
Obesity
Aging
Chronic cough
Work that requires heavy lifting or high impact activity
Chronic constipation
Decreased estrogen levels during menopause can
decrease the strength of pelvic tissues
Affects approximately 100,000 patient every year in U.S.
Only 42,000 seek treatment
Symptoms of Pelvic Prolapse
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•
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Lump or heavy sensation in the vagina
Lower back pain that eases when you lie down
Pelvic pain or pressure
Pain or lack of sensation during sex
Bladder prolapse may cause incontinence, frequent or
urgent need to urinate or difficulty urinating
• Prolapse of the rectum may cause constipation or difficulty
defecating
Anterior Defects: Cycstocele
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•
•
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Herniation of the bladder into the vagina
“Dropped bladder”
Midline defect: damage to pubocervical fascia
Lateral defect: detachment of fascia from arcus tendineus
Entrocele Anterior & Posterior
Bulging of the small
intestine into the vaginal
wall
Anterior Entrocele
Normal
Posterior Entrocele
Posterior Defects: Rectocele
• Bulging of the rectum into a weakened lower vaginal wall
Apical Defects
Uterine Prolapse
“Dropped womb” uterus and cervix drop down toward the
opening of the vagina after the pelvic tissues that support them
have been weakened.
Pelvic Floor Reconstruction
Treatment Options
Review
• Symptoms of pelvic prolapse
• Non-surgical and surgical treatment options
Symptoms
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Incontinence
Frequent or urgent need to urinate or difficulty urinating
Constipation or difficulty defecating
Dragging or heaviness in pelvic area
Lower back pain that eases when lying down
Pelvic pain or pressure
Pain or lack of sensation during sex
With severe prolapse: skin may become irritated, raw or
infected
Diagnosing Pelvic Prolapse
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Pelvic examination
Feel for lumps or bumps in pelvic area
Examine walls of vagina for bulges
Ask patient to cough or strain to see if pelvic organs
prolapse into vaginal walls
• Exam might be done while standing
• Determine Grade of Pelvic Prolapse
• When cycstocele is present can do a strain-hold-elevate
test to determine mid-line or lateral defect
Uterine Prolapse
Grade 1
Grade 2
Grade 3
Grade 4
Grade 1
• The most distal portion of the
vagina is more than 1 cm above
the hymen
Grade 2
• The most distal portion of the
vagina is within 1 cm above or
below the level of the hymen
Grade 3
• The most distal portion of the
vagina protrudes 1 and 2 cm
past the hymen
Grade 4
• The vagina is completely everted
and protruding from the hymen
Apical Defects
Complete eversion
Entire vagina lying outside of the pelvic area. Due to loss of
support in the uterosacral and cardinal ligaments.
Non-Surgical Treatment Options
• Watchful waiting
• Pessaries
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Ring placed in apex of vagina to help support the vagina
Placed intra-vaginally
What it does:
Help physician verify a diagnosis of pelvic prolapse
Uncover stress urinary incontinence “pessary test”
Suppor the vagina and help relieve symptoms
Alleviate symptoms while patient waits for surgery
Surgical Treatment Options
• Colporrhaphy
• Sacrospinous ligament fixation
• Sacrocolpopexy
• Vaginal vault suspension
Vaginal Vault Prolapse Repairs Involve
Performing Several Procedures
A typical case could include:
• Hysterectomy
• Cystocele, enterocele, and rectocele repair
• Lateral defects repair
• Incontinence repair
The Surgical Goals for Vaginal
Reconstruction Surgery include:
• Relieve the symptoms
• Restore the anatomic relationships between the
pelvic organs
• Restore the function of each pelvic floor
compartment