Transcript Over flow incontinence

Urinary incontinence :
defined as involuntary loss of urine.
Incidence:
 5% between 15 and 44.
 10% between 45 and 64 years.
 20% greater than 65 years.
Common symptoms
associated with incontinence:
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Stress incontinence : loss of urine on physical efforts.
(a symptom and a sign)
Urgency sudden desire to void.
Urge incontinence is involuntary loss of urine
associated with a strong desire to void.
Over flow incontinence occurs without any detrusor
activity when the bladder is over distended.
Frequency is passage of urine seven or more times a
day ,or being awoken from sleep more than once a
night to void.
Classification of incontinence
Urethral causes:
urethral sphincter incompetence.
(genuine stress incontinence)
Detrusor instability or the unstable bladder
either neuropathic or non neuropathic.
Retention with over flow
Congenital
Miscellaneous.
 Extra urethral causes:
Congenital.
Fistula.
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Continence occurs when the urine
remains in the bladder.
Urine remains in the bladder as
long as the pressure is less
than in the bladder neck or
urethra.
Continence is under sympathetic
nervous system control
maintained by:
 Detrusor relaxation
(b adrenergic stimulation)
 Bladder neck contraction
(a adrenergic stimulation)
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a adr. Symp. Cont urethra. contin
b adr. symp. Relax
continence
c chol. Parasym. Cont voiding
Incontinence occurs when:
pressure within the bladder rises above that of
the bladder neck or urethra.
 Incontinence result from parasympathetic
stimulation which control:
-detrusor contraction.
-bladder neck relaxation.
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Genuine stress incontinence:
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Is the most common cause of incontinence in
women.
Occurs when the bladder pressure exceeds the
maximum urethral pressure in the absence of any
detrusor contraction as in case of coughing
,sneezing ,the abdominal pressure is transmitted to
the bladder more than the urethra ,this occur at
day time not during sleep ,and there is no
contraction in the detrusor muscle..
Symptoms of stress incontinence ,urgency,
frequency and urge incontinence and may be
awareness of prolapse (cystourethrocele)
Likely causes of GSI
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Abnormal descent of bladder neck and proximal
urethra with failure of equal transmission of
intra abdominal pressure to the bladder and
urethra leading to reversal of normal pressure
gradient between the bladder and the urethra.
Increased intravesical pressure more than intra
abdominal pressure because of abnormal
urethral scarring as a result of surgery or
radiation.
Laxity of suburethral support.
Aetiology of GSI :
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Damage to the nerve supply of the pelvic floor
and proximal urethra by child birth : especially
after prolonged second stage ,large babies and
instrumental deliveries.
Menopause and atrophy of pelvic floor.
Congenital cause.
Chronic cause ; obesity , chronic obstructive,
pulmonary disease, raise intra abdominal pressure
and constipation.
Drugs such as diuretics and a adrenergic blockers.
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Pelvic examination:
inspection of the anterior vaginal wall
with single blade speculum, may
reveals cystourethrocele ,scarring and
fibrosis of the anterior vaginal wall
from previous surgery or trauma ,
urogenital atrophy as a result of
oestrogen deficiency.
Diagnostic test:
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Urinanalysis : invoulantary detrusor contractions
can be caused by cystitis ,tumor foreign body or
stone.
Stress test : patient in lithotomy position with full
bladder, asked to cough, presence of short spurts
of urine suggest SUI ,if not demonstrated
the test is repeated in standing position.
Cotton swab (Q-test)
lubricated cotton swab is inserted in the urethra to
the level of the urethrovesical junction ,the patient
asked to strain ,then descend of the urethrovesical
junction this will move the cotton swab by up to 30
degrees in normal patient while patients with SUI
will range from 30 to 60 degrees.
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Urethroscopy : this useful to detect bladder
stones , tumors , diverticula or sutures from
prior surgery.
Cystometrogram :
cystometry consist of distending the bladder
with known volume of water and observing
pressure changes in the bladder function
during filling ,the most important observation
is the presence of detrusor reflex and the
patient ability to control or inhibit this reflex.
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150-200 ml is the first sensation of bladder filling.
400-500 ml volume at which the individual desire
to urinate .
when she start voiding there will be a detrusor
reflex when sudden rise in intravesical pressure
,this can be inhibited in normal persons ,
uninhibted detrusor contraction occurs in urologic
or neurologic abnormal persons in over active
bladder, in hypotonic bladder the bladder will
accommodate large volume with out contraction
even when the patient is asked to void the
terminal detrusor contraction is absent .
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Urethral pressure measurements:
low urethral pressure may be found in
patients with SUI,
An abnormally high urethral closure
pressure may be associated with
voiding difficulties ,hesitancy and
urinary retention.
Uroflowmetry : records rates of urine
flow through the urethra when the
patient is voiding spontaneously
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Voiding cystourethrogram:
Fluoroscopy is used to observe bladder filling,
the mobility of the urethra and bladder base
during voiding.
It gives idea on bladder size , competence
of bladder neck during coughing ,bladder
trabeculation ,vesicourethral reflux, urethral
diverticula and outflow obstruction.
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Ultrasonography : information about
inclination of the urethra ,flatness of
bladder base mobility ,funneling of the
urethrovesical junction ,urethral and
bladder diverticula.
Treatment of GSI:
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Physical therapy :
pelvic floor muscle exercises ( kegel exercise ) are first
line therapy to improve or cure mild to moderate form
of incontinence especially in patients before and after
delivery.
Medical therapy:
oestrogen therapy in postmenopausal women improve
urethral closing pressure, vascularity and thickness of
vaginal epithelium.
a adrenergic stimulant as phenylpropanolamine and
pseudoephedrine may enhance urethral closure and
enhance continence
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Vaginal pessaries :
Larger size of pessaries are used to elevate and the
support the bladder neck and urethra ,they have been
effective for SUI.
 Surgery:
Is the most commonly employed treatment for USI.
The aim is to correct pelvic relaxation and restore normal
supports of the urethra ,the approach may be vaginal
abdominal and combined abdominovaginal approach.
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Abdominal approach:
Abdominal and laparoscopic retropubic
urethropexy by placing sutures in the fascia
lateral to the and on both sides of the bladder
neck and proximal urethra elevating the vesicourethral junction by attaching the sutures to
the symphysis pubis (marshall marchetti –
krantz procedure),
or to the cooper’s ligaments (burch procedure)
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Vaginal approach : suburethral sling
procedure the new one is tension free
synthetic mesh placed at the mid
urethra placed retropubically.
Others: in patients with poor urethral
sphincter we can use periurethral
bulking injections to improve urethral
function.
Detrusor instability:
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Other name :over active bladder ,urge
incontinence ,detruser hyperreflexia (if
associated with neuropathy.
All These describe problem with
bladder control that is associated with
a strong desire to pass urine with a
decreased ability to control it.
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Classically women with OAB describe a
sudden strong desire to urinate with an
inability to suppress the feeling ,rushing to
the bathroom and leaking before making it
to the toilet, awaking several times a night
to urinate is also a prominent feature .
Symptoms of urgency ,urge incontinence ,
frequency ,nocturia ,stress incontinence
,enuresis and sometimes voiding difficulty
Risk factors associated with over active
bladder:
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Older age 30 % in geriatric population.
Chronic disorders (multiple sclerosis, alzheimer’ s disease ,
spinal cord injury, stroke ,diabetes mellitus) .
Pregnancy (contribute to neural injury or development of
pelvic organ prolapse).
Menopause (oestrogen deficiency leads to urogenital atrophy
and organ prolapse)
Pelvic surgery (scarring or operative trauma injure nerve and
supporting structures.
Obesity (increase bladder pressure).
Immobility (impair mobility).
Medications (diuretics, Ca-channel blockers and psychotic
agents).
Smoking (chronic cough).
Pathophysiology:
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Normal anatomical relation between the
bladder and urethra are maintained.
Involuntarily detrusor contraction occurs
spontaneously and may be stimulated by
coughing ,sneezing or hearing running water.
With detrusor contraction bladder pressure
rises above the urethral pressure with passage
of large volume of urine.
Clinical features:
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We should exclude any mass compressing the bladder ,
prolapse ,or any vaginal atrophy.
Pelvic examination is normal.
Urine loss occurs day and night.
Neurological examination is normal but spontaneous detrusor
contraction occurs without voluntary inhibition.
Cystometry is abnormal :
bladder residual volume is abnormal<75ml,
sensation of fullness volume <150 ml,
urge to void volume<250 ml.
Treatment of OAB:
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identification of any triggering factors as caffeine
,carbonated beverages.
use of self reported diary.
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Behavioral modification:
reduce fluid intake and avoiding liquid during the
evening hours.
gradually increase the intervals between voiding .
pelvic floor muscle strengthening exercises as kegel’s
exercises.
Medical treatment:
Anticholinergic drugs:
oxybutynin chloride and tolterodine (specific
to the bladder)
 Imipramine hydrochloride : tricyclic antidepressant with anticholinergic properties
increase bladder storage by increasing it’s
compliance.
it’s effective in both type of incontinence
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Physical intervention:
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Functional electrical stimulation:
offer alternative treatment in patients
with SUI and urge incontinence by
stimulating pelvic floor muscle and
periurethral muscle contraction by
electrical stimulation through vaginal
or rectal probe improving their tone
and function.
Over flow incontinence:
Urinary retention due to hypotonic detrusor
muscle with overflow increased bladder
volume due to ongoing urine production
with gradual increase in intravesical
pressure more than urethral pressure with
spontaneous urine loss occurs day and night
till the bladder pressure is decreased below
the urethra but the bladder never empties.
Retention with over flow incontinence may
result from :
-detrusor a reflexia or hypotronic bladder in lower
motor neuron disease .
-spinal injury.
-diabetic neuropathy.
-outflow obstruction.
(straining to void, poor stream ,retention of urine,
and incomplete emptying).
-postoperative over distention of bladder occurs
temporarily because of postoperative pain .(may be
managed by continuous bladder drainage for 24-48
hours).
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Neurological examination may shows
bladder denervation and detrusor
contraction will not occur.
Cystometry is abnormal
Bladder residual volume >500ml.
Decreased bladder sensation .
increased bladder capacity >1000ml
Management:
 Medical :
Cholinergic medication (contract the
detrusor (bethanechol).
a adrenergic drugs phenoxybenzamine
can decrease bladder neck tone.
 Intermittent bladder catheterization
can ensure bladder emptying.
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Urinary fistula:
Is uncommon in developed countries it may be caused
by:
 prolonged neglected deliveries with pressure necrosis.
 Operative forceps delivery.
 Pelvic surgery especially after radical hysterectomy
due to devascularization of the ureter rather than due
to direct injury (ureterovaginal fistula).
urethrovaginal fistula as complication of urethral
diverticulum and anterior vaginal wall prolapse or SUI.
 Pelvic irradiation.
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Suggestive history is history of painless and
continuous vaginal leakage of urine soon after
pelvic surgery.
Instillation of blue dye into the bladder will discolor
a vaginal pack if vesicovaginal fistula is present.
Cystourethroscopy , determine the number and site
of fistula.
Intravenous pyelography can localize the fistula.
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Treatment of fistula:
Surgical repair of fistula ,after:
Waiting some weeks for resolution of
inflammation.
treatment of UTI.
oestrogen therapy in postmenopausal
women.