urinary incontinence dr engy final 2014
TRANSCRIPT
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URINARY INCONTINENCE
BY
Professor Dr. Engy Taher
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The pelvis is a basin with 4 walls & floor.
Front wall:back of symphysis pubis.
Back wall: sacrum & pyriformis muscle.
2 side walls: obturator internus muscle.
Floor.
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Bony Pelvis:
bony pelvis consists of 2hip bones, fused tosacrum posteriorly and
to each other anteriorlyat symphysis pubis.
Each one composed of:
ilium,
ischium,
pubis.
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Numerous
projections andcontours provide
attachment sites
for ligaments,
muscles, and
fascial layers.
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Basic anatomy of lower urinary tract
Bladder
Urethra
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Anatomy of female pelvic floor
support
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Basic anatomy of pelvic floor
Pelvic floor Consists of 3 functional layers:
I. Muscle: (levator ani + coccygeus = pelvic
diaphragm)
II. Fascia: as endopelvic fascia
III. Perineal membrane(urogenital diaphragm)
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Muscular support of pelvic floor
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II- Urogenital diaphragm
Perineal body:
Pyramidal fibromuscular structure between
anus & vagina
3.5 cm
Responsible for closure of vaginal introitus.
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Urogenital Diaphragm
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Perineal body
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III- Fascial components of pelvic floor
Includes parietal& visceralfascia
visceral fascia termed endopelvic fascia
Uterosacral & cardinal ligaments arecondensations of endopelvic fascia
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Endopelvic fascia & connective tissue
supports:
3 compartments
Anterior
Middle
Posterior
Urethral supportBladder support
Vaginal supportUterine support
Rectal support
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Anterior supports:
Urethropelvicligament: The mostimportant support ofproximal urethra andbladder neck.
distal half of urethra issupported bypubourethral ligamentand levator
musculature. pubocervical fascia:
the main support ofbladder base.
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Posterior supports:
lateral rectal ligaments
is the fascial supports
for rectum.
Additional prerectaland pararectal fascial
elements.
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Normal Continence In Women
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Functions of urinary bladder:
1. Reservoirfor urine(resting phase).
2. contractile organ to actively expel the
contents (urine) to urethra (active phase)
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Micturition cycle :
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Principle of sphincter function is water tight
opposition of the urethral lumen,
compression of the wall around the lumen,
structural support to keep the proximalurethra from moving during increased
abdominal pressure and neural control.
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Functions of lower urinary tract:
Storage of urine (accomodation property). Expulsionmicturition.
Functions of pelvic floor:
Maintain continence. Prevent P.O.P.
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Neural control
I. Parasympathetic nerves (S2,3,4)
II. Sympathetic nerves (T10-L1)
III. Somatic motor.IV. Central control
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Continence
Urethral closure pressure must be greater
than bladder pressure both at rest and during
increase in intra abdominal pressure.
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During rest:
Tone of urethral muscles maintains a favorable
pressure relative to bladder pressure.
During activity:
dynamic process increases urethral closure
pressure to maintain continence
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Classification of incontinence
A. Genitourinary causes1. Urodynamic stress incontinence
2. Urge incontinence
3. Mixed incontinence
4. Overflow incontinence
5. Incontinence caused by fistula
6. Congenital causes
B. Non- Genitourinary Causes:-1. Neurological disorders
2. Medications.
3. Metabolic disorders
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Stress Incontinence
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Definition:
involuntaryescape of urine onlywith increase
in intra abdominalpressure withoutdetrusor
muscle contraction.
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Incidence & risk factors
Stress urinary
incontinence is the
most common type
of urinaryincontinence in
women.
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Risk factors for stress incontinence:
1. Being female.
2. Childbirth.
3. Coughingover a long period of time (aschronic bronchitis & asthma)
4. Getting older.
5. Obesity.
6. Smoking.
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Pathophysiology
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a)Urethral hypermobility (80-90%):
Due to loss of normal pelvic support of
bladderand urethradue to:
1-Trauma& stretchingof vaginal delivery.
2-Hysterectomy.
3-Hormonalchanges(menopause).
4-Pelvic denervation.5-Congenitalweakness
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Due to sphincter damage due to:
1-Multiple prior operations.
2-Trauma.3-Radiation.
4-Neurogenicdisorders including Diabetes
Mellitus.5-Atrophicchanges: lack of estrogen
B) Intrinsic Sphincter Dysfunction
(10 - 20% of patients):
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Degrees
I. Grade Iincontinence with severe stress
(sneezing, coughing, jogging).
II. Grade II incontinence with moderate
stress (rapid movement, waking up &
down stairs).
III. Grade IIIincontinence with mild stress
(standing up).
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Diagnosis & Treatment
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Diagnosis:
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History
Examination
investigations
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History
1. Durationof incontinence.
2. Frequencyand intensityof the incontinence.
3. Use of protectivepads.
4. Impactof symptoms on lifestyle.
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Physical examination
Abdominal examination.
Pelvic examination.
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Special tests:
1) Stress test
2) Bonneystest
3) Q-tip test
4) Pad test
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Treatment:
Conservative Surgical
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Conservative treatment:
1. Pelvic floor muscle exercises.
2. Biofeedback.
3. Lifestylechanges.
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Peri-urethral bulking injections
1. Collagen.
2. Teflon paste.
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4) Vaginal cones
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Surgical treatment:
Anterior vaginal repair (Kelly's plication)
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Abdominal retropubic cystourethropexy
(Marshall-Marchetti-
Krantzprocedure)
(Burchcolpo-suspension)
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Laparoscopic colpo-suspension:
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Suburethral sling procedure:
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URGE INCONTINENCE
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Definition:
Sudden involuntary
contractionsof muscular wall
of bladder, result in urgency
and immediate urge tourinate. And involuntary loss
of urine.
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Incidence
Urge incontinence is the 2nd mostcommon cause of incontinence. About 3 in 10 cases of incontinence are due to
urge incontinence.
It can occur at any age, but commonlyfirst startsin early adult life.
Women are more commonly affectedthan men.
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Causes:
In urinary incontinence, patient leaks urine as
bladder muscles contract at wrong times.
these contractionsoccurno matterhow much
urineis inthe bladder.
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Although there is no definite cause, Urgeincontinence may be resulted from:
1. - Nervous system disease (as multiple sclerosisor Parkinsonism).
2. - Nervous system injuries (as spinal cord injury
or stroke).3. - Infection(UTI).
4. - Bladder inflammation(Interstitial cystitis)
5. - Bladder outlet obstruction.
6. - Bladder stones.
7. - Bladder Cancer.
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Risk factors:
1. Elderly.2. Pregnant Women or whojust delivered.
3. C-sectionor other pelvic surgery.
4. Obese.5. Men had prostate surgery or prostateconditions, as enlarged prostateor prostatitis.
6. Nerve damage from conditions as diabetes,
stroke, or injury.7. Certain cancers, including bladderand prostate.
8. Urinary tract infections.
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Clinical Picture:
The main symptom is uncontrolled loss of urineassociated with sudden, strong desire to urinatethat cannot be postponed.
Women may describe sudden loss of urine in a
rush to reachthe toilet. Often, this occurs with certain triggering events,
as: fumbling with keys to open the door,
sound or sensation of running water, drinking much water, coffee or Alcohol
exposure to sudden cold.
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Treatment of Urge Incontinence
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THANKS