2. TYPICAL CASE SCENARIO 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence. involuntary U.I. Whenever she coughs or sneeze… wetting herself 2-3 times a week… socially embarrassing and unable to continue with her sport activity She has asthma on medication and is trying to reduce her weight. How would you approach this case?

3. TYPICAL CASE SCENARIO 45 years old woman P5 came to see you in the gyn clinic complaining of urinary incontinence. She goes to toilet every 30 minute to pass urine and if not near a toilet she might wet herself She drinks 10 cups of tea and coffee per day Medically she is diabetic and hypertensive on diuretic How would you approach this case?

4. Facts: “ it is the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem”. It is very common among women of all ages –15-44 5% –45-64 10% –>65 20% –> 40% in institutionalized women –Up to 30% post vaginal delivery,,,,,, temporarily.

5. Female urethra 3-4 cm in length Anatomy: Innervation: Parasympathetic. S2-4. stimulation of pelvic parasymp. Or adm of cholinergic drugs…. Bladder contract… anticholinergic drugs reduce the bladder pressure and increase the capacity Sympathetic. T10-L2. β-fibers in detrusor muscle.. Relax urethra and detrusor muscle. Α-fiber in urethra.. Stimulation contracts the bladder neck and urethra and relaxes the detrusor

6. Urethral causes: –Urethral sphincter incompetence{ genuine stress inc.} –Detrusor instability Neuropathic Non-neuropathic –Retention with overflow –Congenital –Misc Extra urethral: –Congenital –Fistula

7. “ Involuntary loss of urine when the bladder pressure exceeds the maximum urethral pressure in the absence of any detrusor contraction”. Causes: –Abnormal descent of bladder neck and proximal urethra –Intraurethral pressure at rest lower than the intravesical, scarring –Laxity of sub-urethral support Aetiology: –Damage to the nerve supplying pelvic floor and urethral sphincter –Menopause –Congenital –Chronic causes, obesity, COPD,…..

8. Symptoms: Leaking urine… feeling wet whenever performing activities Which raise the intra-abdominal pressure Urgency, frequency and urge incontinence Possible prolapse symptoms Examination: –General, chest, abdomen, pelvic…… mass –Pelvic: Demonstrate incontinence Cysto-urethrocele

9. “ Involuntary loss of urine due to bladder contraction, either spontaneously or on provocation, despite the patient attempting to inhibit micturition”. Symptoms: –Urgency, urge incontinence, frequency{ 15-120 min}, nocturia, S.I., enuresis,,,, voiding difficulties Examination: –Non specific, but exclude masses…. prolapse

10. Pathophysiology is poorly understood Poor toilet habit training and psychological factors have a role Idiopathic D.I. Is the commonest Possible causes: –Continence surgery, –outflow obstruction –Smoking and excessive tea and coffee intake

11. History and examination may not be conclusive The aim of urodynamic inv. Is to provide accurate DX of disorders of micturition and investigating the L.U.T. and pelvic floor function 1.MSU 2.Urinary diary 3.Pad test

12. 4. Dual channel subtracted cystometry –Uroflowmetry –Cystometry

13. 5. Video-cysto-urethrography –Tertiary units 6. Ambulatory monitoring 7. Cysto-urethroscope 8. Imaging. MRI

14. 1.Prevention I.Vaginal vs abdominal delivery II.If vaginal, short second stage and less trauma III.Weight reduction IV.Chronic cough V.Pelvic floor exercises VI.???? Hormone replacement therapy

15. 2. Conservative: I.Physiotherapy. Mild to moderate cases. Improvement in up to 40- 60%. Needs motivation II.Prolapse correction. Ring pessary III.?HRT IV.Biofeedback techniques. Weighted cones V.Maximal electrical stimulation VI.Continence devices 3. Medical : not effective. Duloxetine SSRI

16. 4. Surgery.. Treatment of choice….. Aims to 1) restores the urethra and bladder neck to zone of intra-abdominal pressure 2) increase urethral resistance  Procedures: –Vaginal. Anterior colporrhaphy. Poor 5 years success –Abdominal. Colposuspention. 80% 5 years f.u. –Sling operation –TVT

18. Surgery… cont. When the defect is in the sphincteric mechanism producing a low resistance and poor functioning urethra….. Then: –Artificial sphincter –Periurethral bulking: Collagen macroplastiqua

19. 1.Conservative: I.Bladder training. Effective 60-70% needs motivation II.Biofeedback, hypnosis, TENS …etc 2. Medical: I.Anticolenergics. Oxybutanin or tolterodine {side effects} II.Imipramine { TCA} …. Enuresis III.desmopressin {antidiuretic hormone a’gue}… Nocturea

20. 3.Surgery.  Last resort.  Urinary diversion  Bladder augmentation

21. Urinary incontinence is 20-30% prevalent among females GSI & DI are the commonest Physiotherapy is effective in mild to moderate GSI Bladder training and Anticolenergics are most appropriate treatment for DI UTI must always be excluded before any fancy investigation or treatment started, No incontinence surgery without urodynamic studies Surgery for incontinence should be the patient’s decision depending on how severe and findings