2Definitions:Urinary incontinence is defined as involuntary leakage of urine.
3Definitions: 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).
4Definitions: Mixed urinary incontinence : When both stress and urge components are present, it is called.
5Epidemiology: Prevalence of 25 - 55 %. Among 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.
13Continence TheoriesPressure TransmissionUrethral Support
14Pressure Transmission 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 .
15Pressure Transmission 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.
17Urethral Support 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.
21Diagnosis History : Voiding Diary 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 hxVoiding Diary
22Symptom Comparison of Women with Stress or Urge Incontinence Stress IncontinenceSymptomNoYesUrgencyFrequency with urgencyUrine leakage with increased intra-abdominal pressuressmallLargeAmount of urinary leakage with each incontinence episodeOften NoAbility to reach the toilet in time following an urge to voidSeldomUsuallyWaking to void at night
23Medications That May Cause Incontinence DiureticsAnticholinergics - antihistamines, antipsychotics, antidepressantsSeditives/hypnoticsAlcoholNarcoticsα-adrenergic agonists/antagnistsCalcium channel blockers
24Physical Examination General Inspection and Neurologic Evaluation evidence of atrophy.neurologic evaluation of the perineum:bulbocavernosus reflexnormal circumferential anal sphincter contraction, colloquially called an "anal wink",
25Pelvic Support Assessment Pelvic Organ Prolapse Evaluation
32Treatment of Stress Urinary Incontinence 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