1. URINARY INCONTINENCE & PROLAPSE MR O.O. SORINOLA Consultant Obstetrician & Gynaecologist Hon. Associate Professor Warwick University

2. Objectives n Revise relevant anatomy n Understand the mechanism of continence n Describe the causes, investigation, and management of prolapse / incontinence n Counsel a patient regarding treatment of prolapse and incontinence

3. Anatomy & Physiology-Muscles Bladder n Detrusor muscle (interlocking fibres) Urethral n External urethral sphincter – striated muscle n Internal urethral sphincter – smooth muscle Pelvic floor n Levator ani – supports bladder neck & compresses urethra

4. Anatomy & Physiology-Nerves Autonomic nerves n Parasympathetic S 2,3,4 contraction of detrusor muscle during voiding n Sympathetic T12 - L2 contraction of sphincter during storage Somatic nerves S 2,3,4 n Contraction of pelvic floor during storage, relaxation during voiding Connections to cortex n Cortical awareness

5. MECHANISM OF MICTURITION 2. SENSORY RECEPTORS 5. HIGHER CENTRES 4. MICTURITION INITIALED 4. MICTURITION INITIALED RELAXATION OF THE PELVIC FLOOR RELAXATION OF THE PELVIC FLOOR URETHRAL RELAXATION DETRUSOR CONTRACTION 1. BLADDER FILLS 3. SPINAL CORD

6. Urinary Incontinence n Involuntary loss of urine which is a social or hygienic problem. Prevalence n 10 – 35% of adults suffer from urinary incontinence n > 50% of institutionalized patient have urinary incontinence n Only 10 -20% seek medical care

9. Impact on Quality of Life (QoL)   Impact on lifestyle and avoidance of activities   Fear of losing bladder control   Embarrassment   Impact on relationships   Increased dependence on caregivers   Discomfort and skin irritation   Depression

10. Types of Incontinence n Urinary Stress incontinence n Urinary Urge Incontinence (Overactive Bladder OAB) n Mixed incontinence n Overflow incontinence n True incontinence n Functional incontinence

12. Urinary Stress Incontinence (USI) n Loss of urine with increases in abdominal pressure in the absence of detrusor activity. n Caused by pelvic floor damage / weakness or due to a weak sphincter n Symptoms include loss of urine with coughing, laughing, sneezing, running, lifting, walking

13. Causes of urinary stress incontinence (1) – Urethral hypermobility

14. Causes of urinary stress incontinence (2) – Intrinsic Sphincter Deficiency Normal Closure Abnormal Closure

16. Urge Urinary Incontinence Overactive Bladder (OAB) n Urge Incontinence – Involuntary leakage of urine accompanied by or immediately preceded by urgency n OAB – a bladder storage problem characterised by increased frequency, urgency, with or without urge incontinence n Urgency is a sudden strong desire to void n Detrusor Overactivity - Loss of urine due to an involuntary bladder spasm (contraction)

22. Patient Evaluation n History n Physical examination n Voiding diary – 3 days n Basic investigation – Urinalysis / MSU n Specialist investigation – UDS, VCU, USS

23. Frequency / Volume Chart n It is very useful to have this information prior to the urodynamic investigations, as it provides the info: n Voiding patterns n Fluid intake & output n Incontinent episodes

24. MSU  Urinary tract infections are not a common cause of incontinence, but they will certainly aggravate any symptoms which are present.  They may also invalidate the results of any investigations performed.

25. Specialist Investigations n Cystometry n Imaging Techniques: Video cysto-urethrography Ultrasonography n Cysto-urethroscopy

27. Treatment of Stress Incontinence Behavioural PharmacologicMechanicalSurgery -PFM Exercises -Biofeedback -Electrical stimulation -Duloxetine -Oestrogen -Pessaries -Intraurethral devices - Mid-urethral sling (vaginal procedures) -Retropubic urethropexy (Colposuspension) -Periurethral injections

28. Pelvic Educator

29. Vaginal Cones / Biofeedback

30. TransObturator Tape (TOT)

33. Treatment of OAB / Urge Incontinence Behavioural Pharmacologic Surgical -Fluid advice –1.5L /d -Bladder retraining -PFM Exercises -Biofeedback -Anticholinergics -Antidepressants -B 3 agonist -Oestrogen - Botox injection -Sacral nerve stimulation -Augmentation cystoplasty

34. Genital Prolapse n Anterior compartment 1. Urethrocele 2. Cystocele n Middle compartment 1. Uterus cervical prolapse 1 st, 2 nd, or 3 rd degree 2. Vault prolapse n Posterior compartment 1. Rectocele 2. Enterocele

38. Predisposing factors n Age n Menopause n Parity n Connective tissue disease n Obesity n Smoking

39. Symptoms n Something coming down n Backache or lower abdominal pain n Urinary incontinence n Faecal incontinence n Difficulty with micturition or defecation n Bleeding / discharge n Apareunia

40. Management Options n Do nothing! n Conservative treatment 1. Measures to reduce intra-abdominal pressure – lose wt, stop smoking, stop straining 2. PFE and physiotherapy 3. Pessaries – ring, shelf 4. Topical oestrogen's n Surgical treatment

42. Principles of surgery n Remove lump n Restore organs to correct places n Correct incontinence ( if present) n Preserve sexual function

43. To Summarise Learning Outcomes: n Revise relevant anatomy n Understand the mechanism of continence n Describe the causes, investigation & management of prolapse and incontinence n Counsel a patient regarding treatment of prolapse and incontinence