2. ** SUI : The involuntary leakage of urine on effort or exertion or on sneezing or coughing.
* Affects 4%-35% of women.

3. ** Continence:
* is achieved when the urethra maintains a pressure greater than bladder pressure. (during a detrusor muscle contraction or an increase in intraabdominal pressure)

5. Etiology 1 -- Pregnancy, child birth 2 – Aging
3 -- Repetitive stress on the pelvic floor
4 --Genetic factor (deficient collagen structure)

6. Clinical Evaluation

7. شرح حال نشت ادرار با عطسه و سرفه بی اختیاری استرسی
نشت ارادی با فوریت ادراری و به دنبال عوامل تحریک کننده
بی اختیاری فوریتی
ترکیبی از هر دو شکایت
بی اختیاری مخلوط
نشت ادرار به صورت مداوم یا قطره قطره یا دفع ناکامل
علایم همراه: جریان ضعیف و منقطع ادراری
تاخیر در ادرار کردن- فرکونسی- ناکچوری
بی اختیاری سرریزی

8. *** Bladder Diary:
* Particularly in patients in whom the etiology of urinary incontinence is UNCERTAIN.

9. معاینه فیزیکی
معاینه جنرال
معاینه لگن

11. Detailed neurologic examination ???

13. تست های کلینیکی SUI تست سرفه
- با مثانه پر انجام شود.( حداکثر ظرفیت سی سی )
- حالت خوابیده و ایستاده و در پوزیشن بیان شده توسط بیمار می توان مثانه را با مایع استریل پر کرد.
تست منفی سرفه
علیرغم شرح حال مثبت بیمار و عدم حضور نشت ادراری
ارزیابی ارودینامیکی
تست مثبت سرفه
نشت فوری و دیدن توسط معاینه کننده
بی اختیاری استرسی
نشت تاخیری ادراری
مقدار زیادی مایع
عدم امکان کنترل
بیش فعالی
دتر سور
حجم باقیمانده ادراری
ارزیابی هیپرموبیلیته اورترا
تست Q tip
ارزیابی پرولاپس نقطه Aa

15. Post void Residual Volume ???

16. PVR
حجم باقیمانده ادراری
بیش از 200 سی سی
انسداد خروجی مثانه
فعالیت ضعیف دترسور
کمتر از 50 سی سی
نرمال

17. Laboratory tests
FBS
U/A , U/C

19. ارزیابی اورودینامیک Uncomplicated SUI نشت ادراری مثبت
مواردی که نیاز به ارزیابی اورودینامیک ندارند
نشت ادراری مثبت
آزمایش ادرار نرمال
حجم باقیمانده ادرار کمتر از 150سی سی
هیپرموبیلیته مجرا داشته باشد
پرولاپس stage 2کمتر باشد
Uncomplicated SUI

20. Level A
Preoperative UDS is not necessary before planning primary anti – incontinence surgery in women with uncomplicated SUI :
1 - defined as PVR less than 150 ml
2 – negative UA
3 – a positive cough stress test
4 – no pelvic organ prolapse beyond the hymen
ACOG 2015

21. ارزیابی اورودینامیک اندیکاسیون انجام بی اختیاری فوریتی مقاوم به درمان
عدم تطابق شرح حال و معاینه فیزیکی
تست سرفه منفی علیرغم شرح حال+ بی اختیاری استرس حتی در حالت ایستاده
Complicated SUI
سابقه جراحی لگن
سابقه رادیاسیون لگن
اختلال نورولوژیکی
اتیولوژی غیر استرسی جهت بی اختیاری
تصمیم به جراحی بیمار
بی اختیاری فوریتی مقاوم به درمان

22. * UDS does not improve treatment outcomes in women with uncomplicated SUI prior to midurethral sling surgery.
** women with uncomplicated SUI in whom conservative treatment has failed and who desire midurethral sling surgery, UDS does not affect treatment outcomes .

23. ** Mixed urinary incontinence does not impact the choice of surgical procedure. these women should undergo a trial of pharmacologic therapy prior to surgery. ** Occult SUI, can usually be diagnosed by repeating the urinary stress test while the prolapse is reduced by the examiner. there is no evidence that UDS is required to detect occult SUI.

24. Treatment

25. درمان دارویی مورد توافق همگانی نیست.*
درمان بی اختیاری SUI
درمان کنسرواتیو
تغییر سبک زندگی
رفتار درمانی
فیزیو تراپی
پساری
دارویی *
درمان جراحی
درمان دارویی مورد توافق همگانی نیست.*

26. Level B
Incontinence pessaries may improve the symptoms of stress and mixed urinary incontinence but objective evidence regarding their effectiveness has not been reported.
When SUI is demonstrated during cough test :an increased rate of SUI after pelvic organ prolapse surgery is expected.
ACOG 2015

27. Pelvic muscle exercises (PME) :
Kegle exercises strengthen the muscular urethral closure mechanism.( grade 2A )

28. درمان دارویی SUI دالوکستین اندیکاسیون :
- عدم تمایل به جراحی و افسردگی همزمان
سایر داروها
ایمی پرامین
فنیل پروپانول آمین

30. Local topical Estrogen:
There is inconsistent evidence whether local topical estrogen ( cream , ring , dissolving tablets) improves incontinence symptoms.( grade 2C)
* Randomized trials have demonstrated that Oral Estrogen worsen urinary incontinence.
Up to date 2017

31. Surgical trearment

32. 1 -- Women who decline or have persistent symptoms following conservative therapy
Surgical treatment have consistently been shown to have a higher efficacy rate than conservative therapy.
*Surgery is associated with increased morbidity , postoperative voiding difficultly & development or worsening of urgency incontinence.

33. 2 -- Women with occult SUI :
*Concomitant anti-incontinence surgery is warranted in some women who are undergoing repair of advanced pelvic organ prolapse

34. 3 -- Women finished with childbearing :
* Since pelvic support may be disrupted during pregnancy and particularly a vaginal birth ,most physicians recommend delaying surgical management of SUI until childbearing has been completed.

35. Pre operative counseling
Patient & surgeon satisfaction with treatment can be optimized by having a discussion during the planning phase for the surgery about the individual patient goals & expectations for her treatment & awareness of potential adverse events.

36. Suburethral sling :A suburethral sling is a sling that is inserted through a small vaginal incision and placed either at the bladder neck, midurethra or proximal urethra.
1 - Bladder neck sling : A suburethral sling that is placed at the level of the proximal urethra and bladder neck
2 - Midurethral sling :A suburethral sling that is placed at the level of the midurethra in a tension free manner (eg, tension-free vaginal tape procedures).
3 - Retropubic colposuspension :Procedures performed through laparotomy or laparoscopy in which the vaginal wall adjacent to the midurethra and bladder neck is suspended, using sutures, in a retropubic position

37. انواع جراحی SUI TOT TVT Burch Fascial Sling (Transe obturator Tape )
(Tenstion – Free Vaginal Tape)
Burch
TOT
(Transe obturator Tape )

38. Level A
Initial midurethral sling surgery results in higher 1 – year subjective and objective cure rates than pelvic floor physical therapy in women with SUI.
MUS demonstrate efficacy that is similar to traditional suburethral fascial slings – open colposuspension and laparoscopic colposuspension.
Compared with suburethral fascial slings: fewer adverse events have been reported with MUS.
ACOG 2015

39. Level A
Voiding dysfunction is more common with open colposuspension than with MUS.
There are substantial safety and efficacy data that support the role of MUS as a primary surgical treatment option for SUI in women.
ACOG 2015

41. Recurrent incontinence
کاندیدای جراحی TOT
اندیکاسیون
بی اختیاری استرسی علامتدار
کاندید ترمیم پرولاپس آپیکال و مورد شناخته شده یا محتمل بی اختیاری استرس مخفی
کنتراندیکاسیون
عفونت مجاری ادراری
حاملگی*
اختلال انعقادی
آبسه کشاله ران
عفونت مزمن
درد مزمن
ترجیحاَ انجام نشود
ISD
Recurrent incontinence

42. Surgical Technique 1. antibiotic administration. 2. Sterile urine
3. Patient positioning and preparation.

43. 4. Anesthesia.
5. The exit site of the needle is marked. It should be 2 cm above the level of the urethra and 2 cm lateral to the labial fold.

49. 6. Vaginal incision.
7. Vaginal dissection

50. CHOOSING A TYPE OF TRANSOBTURATOR SLING
●Inside-out – The trocars are passed from a midurethral vaginal incision to exit through bilateral groin incisions (TVT Transobturator, often abbreviated as TVT-O).
●Outside-in – The trocars are passed from bilateral groin incisions to exit through a midurethral vaginal incision (Monarc, often abbreviated as TOT).

51. 8. Trocar passage The trocar tip is inserted into the previously dissected vaginal incision lateral to the urethra and advanced gently while rotating the trocar handle.

54. The two types of transobturator procedures appear to be equally effective and have similar complication rates
One disadvantage of the outside-in approach is that it results in a larger vaginal incision and has a higher rate of vaginal perforation .
some data suggest that the inside-out approach is more likely to cause groin pain, but this finding has varied across studies .

55. COMPLICATIONS
Transobturator insertion of midurethral slings was developed to avoid some of the complications of retropubic slings (eg, bladder perforation, vascular injury, bowel injury).
This appears to have been largely successful and few serious or long-term complications have been reported following transobturator midurethral sling procedures .

56. FOLLOW-UP
Women may experience vaginal, periurethral, or lower abdominal discomfort and pain at incision sites for up to two weeks following the procedure.
These symptoms are typically well controlled with oral narcotics and non-steroidal anti inflammatory drugs.
Many women also have vaginal spotting for up to two weeks.

57. Patients are advised to avoid heavy lifting, actions that increase intraabdominal pressure, or exercise for at least two to four weeks.
Ambulation, however, is encouraged.
Sexual activity should be avoided until the vaginal epithelium is healed, which takes approximately four to six weeks.
The patient may return to work when she feels sufficiently comfortable.

58. We see patients for a routine follow-up visit at four to six weeks.
We perform abdominal and vaginal examinations to ensure that the incisions have adequately healed and to check for vaginal mesh erosion.
We check a post void residual volume to assess whether the patient has been adequately emptying her bladder.
This can be measured with a bladder ultrasound or catheterization.

60. اسلینگ میداورترای رتروپوبیک TVT
کنتر اندیکاسیون نسبی
کنتر اندیکاسیون مطلق
شرایطی که احتمال چسبندگی داخل لگن را افزایش میدهند : آندومتریوزمرحله 4.سابقه جراحی آپاندیسیت پرفوره
عفونت ادراری
حاملگی
بیماری انعقادی
مصرف آنتی کواگولانت خوراکی
وجود ساختارهای مهم در مسیر تروکار مثل کلیه لگنی.گرافت عروقی.هرنی شکمی پایین
تمایل به حاملگی درآینده

61. CHOOSING A TYPE OF RETROPUBIC SLING
●Bottom-to-top – Two needle trocars are inserted through a vaginal incision and passed through the retropubic space, exiting at the abdominal wall
●Top-to-bottom – Two needle trocars are inserted through abdominal incisions and passed through the retropubic space, exiting through a vaginal incision

62. ** Lower rates of urinary tract injury, voiding dysfunction, blood loss with TOT.
** Post operative de novo urgency or UI occurred at similar rates for TOT & TVT.
** Post operative groin pain was significantly more likely to occur with TOT.
** Higher rate of de novo dyspareunia in women who underwent TOT.

71. COMPLICATIONS
 Retropubic midurethral sling placement is a minimally invasive procedure and complications are uncommon.
The most frequent complications of this procedure are bladder perforation, voiding dysfunction, and development of urinary urgency symptoms.

72. Antibiotic prophylaxis is not required for short- or long-term bladder catheter use. Antimicrobial therapy should be reserved for patients with a urinary tract infection
Sling release — Most cases of postoperative urinary retention resolve with conservative management. Urinary retention that persists after four to six weeks may require surgical intervention in the form of a sling release

73. Risk factors for failure
previous anti-incontinence surgery (2-fold increased risk)
urgency symptoms (as measured by a questionnaire score; 2-fold)
maximum Q-tip excursion <30° on preoperative urethral hypermobility testing (1.9-fold)
Objective, but not subjective, failure was associated with age (1.5-fold per 10 years)
Having concomitant surgery was associated with a lower risk of subjective, but not objective, failure (0.44-fold)  

74. بی اختیاری استرسی علامتدار و تمایل به جراحی شکمی
Burchاندیکاسیون
بی اختیاری استرسی علامتدار و تمایل به جراحی شکمی
(لاپاراسکوپی یا لاپاراتومی)
پروفیلاکتیک
پرولاپس پیشرفته که به نظر می رسد دچار پیشرفت بی اختیاری استرسی اداری پس از ساکروکولپوپکسی شکمی می شوند.
بعضی از جراحان ترجیح می دهند که حتی در صورت انجام ساکرو کولپوپکسی شکمی ، از روش اسلینگ میداورترا استفاده کنند .
در زنان بدون هیپرموبیلته اورترا مناسب نیست.

76. اولین خط درمان بی اختیاری ادراری استرسی محسوب نمی گردد.
اسلینگ فاشیایی
اولین خط درمان بی اختیاری ادراری استرسی محسوب نمی گردد.
کنتراندیکه بودن اسلینگ مید اورترا
1- آسیب مجرا به دنبال جراحی بی اختیاری استرسی
2- سابقه جراحی قبلی دیورتیکول مجرا
نا موفق بودن اسلینگ میداورترا قبلی
عدم تمایل بیمار به استفاده از مش سنتتیک

78. Level C
Autologous fascial bladder neck slings should be considered in women with:
1 - severe SUI and a non mobile fixed urethra
2 – urethral diverticula or fistula
3 – with complications from mesh previously placed in the anterior vagina
ACOG 2015

79. Injection of urethral bulking agents
*The use of urethral injectable agents is often reserved for women who are unable to tolerate , or wish to defer , surgery.
*these agents are used in some patients with recurrent or refractory incontinence after a prior incontinence procedure.( grade 2C )
Up to date 2017

81. Level B
Urethral bulking injections are a relatively noninvasive treatment for SUI that may be appropriate if :
1 – surgery has failed to achieve adequate symptom reduction
2 – symptoms recur after surgery
3 – in women with symptoms who do not have urethral mobility
4 – in older women with comorbidities who can not tolerate anesthesia or more invasive surgery
ACOG 2015

82. Persistent or recurrent SUI
????

83. For patients who present at the postoperative visit after a retropubic midurethral sling procedure and report persistent stress urinary incontinence, the position of the sling should be evaluated.
Clinicians may assess positioning of the sling with palpation along the urethra. They may also check for the presence or absence of urethral hypermobility.

84. Failed slings were often positioned too proximally.
When a midurethral sling is too proximal, continence can be achieved by placing a repeat midurethral sling properly under the midurethra without removing the non-functioning sling.

85. Subsequent pregnancy 
??????

86.  Since pelvic support may be disrupted during pregnancy, and particularly following a vaginal birth, most physicians recommend delaying midurethral sling placement until childbearing has been completed.
In women who become pregnant following anti-incontinence surgery, the best choice for mode of delivery is uncertain.