female incontinence
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Female Incontinence
Dr Alin CiopecTrust SGO O&G
EDGH
21/10/10
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Clasification of urinary incontinence
Stress Urinary Incontinence involuntary leakage of urine on effort orexertion, or on sneezing, or coughing. It commonly arises as a result ofurethral sphincter weakness
Urge Urinary Incontinence involuntary leakage of urine accompanied by,or immediately preceded by, a strong desire to pass urine (void). Can be asymptom of overactive bladder syndrome
Mixed Urinary Incontinence involuntary leakage of urine associated bothwith urgency and with exertion, effort, sneezing, or coughing. Usually, oneof this is predominant
Overflow Incontinence occurs when the bladder becomes large andflaccid and has little or no detrusor tone or function usually due to injury orinsult after surgery or postpartum. Condition is diagnosed when the urinaryresidual is more than 50% of bladder capacity. The bladder simply leaks
when it becomes full Continuous Urinary Incontinence classically associated with fistula orcongenital abnormality, e.g. ectopic ureter
Other Types of Incontinence arising from UTI, medications, immobilityor cognitive impairment. Situational incontinence e.g giggle incontinence
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Urinary Symptoms
Urinary incontinence stress or urge incontinence
Daytime frequency normal 4-7 voids/day
Nocturia up to the age of 70 years more than a single void is considered abnormal
Nocturnal Enuresis
Urgency sudden compelling desire to pass urine , which is difficult to defer -secondary to detrusor overactivity, or interstitial cystitis
Voiding difficulties hesitancy(difficulty in initiating micturition), straining to void,slow or intermittent urinary stream. All suggestive of urethral obstruction, anunderactive detrusor muscle, or loss of coordination between detrusor contractionand urethral relaxation. Intermittency is seen in neurological disease
Postmicturition feeling of incomplete bladder emptying, terminal dribble (aprolonged final part of micturition), postmicturitional dribble (involuntary lost of urineimmediately after passing urine)
Absent or reduce bladder sensation overflow - caused by spinal cord injuries or
pelvic surgery Bladder pain intravesical pathology
Urethral pain
Dysuria UTI
Haematuria warrants further investigations
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Assessment of the lower urinary
tract History
Quality of Life assessment (QoL)
questionnaires Frequency/volume chart (in/out/wet)
Physical examination general,
abdominal,pelvic
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Assessment of the lower urinary
tract InvestigationsBasic Investigations Urinalysis
Urine specimen MSU
Residual check (by U/S or catheterization)
Pad test
Cystourethroscopy +/- biopsy
indications:
Recurrent UTI
Haematuria
Bladder pain Suspected urinary tract injury or fistula
To exclude bladder tumour or stones
If interstitial cystitis is suspected
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Assessment of the lower urinary
tract - Imaging Ultrasonography Plain abdominal radiograph
Intravenous urography foreign bpdies or calculi
Micturating cystourethrography neuropathic bladder, fistulae
Contrast CT MRI
Conditions requiring imaging of urinary tract:
Recurrent UTI
Haematuria
Urethral diverticula, which need to be differentiate from paravaginal
cysts Suspected ureteric injuries
Suspected urethral or vesical fistulae
Suspected malignancy or renal stones
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Assessment of the lower urinary
tract urodynamic investigationsCombination of test that look at the ability of thebladder to store and void urine
Uroflowmetry can be used to screen forvoiding difficulties
Cystometry involves measuring thepressure/volume relationship of the bladderduring filling and voiding
Video-urodynamics enables detection of
detrusor sphincter dyssynergia, vesico-uretericreflux, presence of abnormalities
Ambulatory urodynamic monitoring
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Stress Urinary Incontinence
SUI (Stress Urinary Incontinence) isthe complaint of involuntary leakage ofurine on effort/exertion/sneezing/coughing
USI(Urodynamic Stress UrinaryIncontinence) is the involuntary leakageof urine during increased intra-abdominal
pressure in the absence of detrusorcontraction can be only diagnosed byurodynamic testing
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Stress Urinary Incontinence
Incidence 1 in 10 women; 50% complain of pure stressincontinence; 30-40% have mixed symptoms of urge and stressincontinence
Pathophysiology and aetiology
1. SUI occurs when the intravesical pressure exceeds the closing
pressure on the urethra2. Childbirth is the most common causative factor, leading to
denervation of the pelvic floor, using durin delivery
3. Oestrogen deficiency at the time of menopause, leads toweakening of the pelvic support and thinning of the urothelium
4. Occasionally, weakness of the bladder neck occur congenitally or
through trauma from radical pelvis surgery or irradiation
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Stress Urinary Incontinence
Clinical features:
Symptoms:
Leakage of urine when she coughs,sneezes, runs, jumps, carries heavyloads the leakage is usually samll ,discrete amount , coinciding with
physical activities Signs: prolapse of the urethra and
anterior vaginal wall
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Stress Urinary Incontinence
Investigations Midstream Urinary Sample to exclude
infection or glycosuria
Frequency/volume chart Urodynamic studies check for voiding
dysfunction and coexisting detrusor
overactivity
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Stress Urinary Incontinence
conservative management Lifestyle interventions weight reduction if BMI>30/smoking cessation/treatment of chronic cough andconstipation
Pelvic floor muscle training for at least 3 months
Biofeedback - refers to the use of a device to convertthe effect of pelvic floor contraction into a visual orauditory signal to allow women objective assessment ofimprovement
Electrical stimulation Vaginal cones for applying graded resistance against
which the pelvic floor muscles contract
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Stress Urinary Incontinence
conservative management Pharmacological management of SUI Duloxetine for moderate to severe SUI
Indications for conservative treatment od SUI:
1. Mild or easily manageable symptoms
2. Family incomplete
3. Symptoms manifest during pregnancy
4. Surgery contraindicated by coexisting medicalconditions
5. Surgery declined by patient
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Stress Urinary Incontinence
surgical managementPeriurethral injections Bulking agents have a lower immediate success
rate(40-60%) and a long-term continued decline incontinence
Most commonly used: Glutaraldehyde crosslinkedbovine collagen and Macroparticulate siliconparticles(Macroplastique)
May be appropriate for:
1. Frail, elderly, or unfit women2. Women who have had other multiple failed procedures
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Stress Urinary Incontinence
surgical managementBurch colposuspension Largely replaced by TVT
Now rarely performed
The retropubic space is entered through a lowtransverse suprapubic incision and two or threesutures places between the paravaginal fasciaand ipsilateral ileopectinal ligament (Coopers
ligament) at the level of the bladder Efficacy as primary procedure 90%, as repeat
procedure 83%
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Stress Urinary Incontinence
surgical managementLaparoscopic colposuspection
Efficacy and complications similar to those
of the open procedure The surgery is technically more
demanding and requires considerable
laparoscopic expertise
But quick recovery and low cost due to
spitalisations
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Stress Urinary Incontinence
surgical managementTVT (Tension free Vaginal Tape) The most commonly performed surgical procedure for USI in the
UK
A polypropylene tape is placed under mid-urethra via a smallvaginal incision, using a local or general anaesthesia
Cystourethroscopy is carried out to ensure no damage to thebladder or urethra
Is minimally invasive and return to normal activity within 2 weeks
Complications:
1. Moderately high risk of bladder injuries 5-10%, but these do notseems to have long-term sequelae, if treated appropriately
2. Bleeding in retropubic space, infections and voiding difficulties3. Tape erosion into the vagina and urethra has also been reported
The objective cure rate is 82-98%
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Stress Urinary Incontinence
surgical managementTOT (Transobturator Tape)
The polypropylene tape is passed via a
transobturator foramen through thetransobturator and puborectalis muscles
The main difference from TVT is the
retropubic space is not entered and the
risk of bladder perforation is low
Similar success rate with TVT
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Overactive Bladder Syndrome
(OAB) Is a chronic condition defined as urgency, with or withouturge incontinence, usually with frequency or nocturia
Is affecting 1 in 6 women
The incidence is increasing with age
Is the second most common cause of urinaryincontinence
Aetiology
Idiopathic in most cases
Neurogenic detrusor overactivity multiple sclerosis,
spina bifida, upper motor neuron lesions Secondary to pelvic floor surgery
OAB due to outflow obstruction is uncommon in women
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Overactive Bladder Syndrome
(OAB)Clinical features of OAB
Urinary frequency
Urgency
Urge incontinence Nocturia
Nocturnal enuresis
Provocative factors: cold weather, opening the
front door, hearing running water, by raisedintra-abdominal pressure-coughing, sneezing,
QoL can be significantly impaired by theunpredictability and large volume of leakage
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Overactive Bladder Syndrome
(OAB) - Investigations Urine culture
Frequency/volume chart
Urodynamics is essential for diagnosis of
OAB with multiple and complex symptoms
Other factors need to be excluded when diagnosisof OAB is made:
1. Metabolic abnormalities diabetes orhypercalcemia
2. Physical causes prolapse or faecal impaction
3. Urinary pathology UTI or interstitial cystitis
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Overactive Bladder Syndrome
(OAB) - managementConservative management
Behavioral therapy 1-1,5l of liquids/day;avoid caffeine based drinks and alcohol; somediuretics or antipsyhotics drugs need to bereviewed
Bladder retraining ability to suppress urinaryurge and to extend the intervals betweenvoidings
Hypnotherapy and acupuncture Antidepessants
oestrogens
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Overactive Bladder Syndrome
(OAB) - managementPharmacological interventions
Anticholinergic(antimuscarinic)drugs
- they block the parasympathetic nerves thereby relaxing the detrusormuscle
- the dosage need to be titrated against efficiency and adverse effects
(dry mouth, blurred vision, dizziness, insomnia, palpitations andarrhythmia)
Contraindications:
Acute (narrow angle) glaucoma
Myasthenia gravis
Urinary retention or outflow obstruction
Severe ulcerative colitis
Gastrointestinal obstruction
E.g.: Oxybutynin, Propiverine, Solifenacin, Tolterodine, Trospium,Darifenacin
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Overactive Bladder Syndrome
(OAB) - management
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Genital prolapseGenital prolapse
ISMAEL YOUSIFISMAEL YOUSIF
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DefinitionDefinition
Genital Prolapse:Genital Prolapse:
Is herniation of the genital organsIs herniation of the genital organs
through the genital tract.through the genital tract.
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Support of the pelvic organs:Support of the pelvic organs:
The main support is by the :The main support is by the :
11--pelvic floor muscles:pelvic floor muscles:
--Levator aniLevator ani--CoccygeusCoccygeus
--Internal ObturatorInternal Obturator
--PiriformisPiriformis--Transverse perineal musclesTransverse perineal muscles
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Support of the pelvic organsSupport of the pelvic organs
22-- Pelvic ligaments:Pelvic ligaments:
-- Transverse cervical ligaments (Cardinal)Transverse cervical ligaments (Cardinal)
-- Uterosacral ligamentsUterosacral ligaments-- Pubocervical ligamentsPubocervical ligaments
-- Pubourethral ligamentsPubourethral ligaments
33-- Pelvic FasciaPelvic Fascia
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Minor support:Minor support:
Round ligamentRound ligament
Broad ligamentBroad ligament
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ClassificationClassification
Vaginal wall prolapse:Vaginal wall prolapse:
#Anterior:#Anterior:
11-- Urethrocele:Urethrocele:
Descend of the lower part of the anteriorDescend of the lower part of the anteriorvaginal wall containing the urethra.vaginal wall containing the urethra.
22-- Cyctocele:Cyctocele:
Descend of the upper part of the anteriorDescend of the upper part of the anteriorvaginal wall containing the bladder.vaginal wall containing the bladder.
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Vaginal wall prolapse:Vaginal wall prolapse:
#Posterior:#Posterior:
11-- Enterocele:Enterocele:
Descend of the upper posterior vaginal wallDescend of the upper posterior vaginal wallcontaining small bowl from the pouch ofcontaining small bowl from the pouch ofDouglasDouglas
22-- Rectocele:Rectocele:
Descend of the lower posterior vaginal wallDescend of the lower posterior vaginal wallcontaining the rectum.containing the rectum.
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Vaginal wall prolapse:Vaginal wall prolapse:
#Middle:#Middle:
Vault prolapse:Vault prolapse:
Descend of the vaginal vault afterDescend of the vaginal vault afterhysterectomy , usually contains : smallhysterectomy , usually contains : small
bowl and omentum.bowl and omentum.
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Uterine Prolapse:Uterine Prolapse:
11-- First degree:First degree:
The uterus is with in the vagina.The uterus is with in the vagina.
22-- Second degree:Second degree:The cervix protrudes outside through theThe cervix protrudes outside through the
introitus .introitus .
33-- Third degree (Procidentia):Third degree (Procidentia):The entire uterus has come out the vagina.The entire uterus has come out the vagina.
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Uterine ProlapseUterine Prolapse
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Uterine ProlapseUterine Prolapse
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Vaginal Vault ProlapseVaginal Vault ProlapseVaginal Vault Prolapse
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Vaginal Vault ProlapseVaginal Vault Prolapse
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AetiologyAetiology
Major causes:Major causes:
11-- CCongenital weakness of the pelvic floorongenital weakness of the pelvic floorligaments and fascia.ligaments and fascia.
22-- CChild birth:hild birth:Pregnancy, prolonged or difficult labour,Pregnancy, prolonged or difficult labour,
bearing down before full cervical dilatation,bearing down before full cervical dilatation,multiparity and instrumental delivery.multiparity and instrumental delivery.
33-- CClimacteric: weakness and denervation of thelimacteric: weakness and denervation of thepelvic floor muscles due to oestrogen deficiency.pelvic floor muscles due to oestrogen deficiency.
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AetiologyAetiology
Minor causes:Minor causes:
--CChronichronic CCoughough
--ChronicChronic CConstipationonstipation
--Increased Intra abdominal pressure:Increased Intra abdominal pressure:
.Masses.Masses
.Ascitis.Ascitis
.Pulmonary disease.Pulmonary disease
.heavy lifting.heavy lifting
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Presentation:Presentation:
Minor Prolapse can be asymptomaticMinor Prolapse can be asymptomatic
Uterovaginal prolapse patients can complain ofUterovaginal prolapse patients can complain of
feeling of some thing coming down .feeling of some thing coming down .
.. Pelvic insecurityPelvic insecurity
.. Low backache ,relieved by lying flat.Low backache ,relieved by lying flat.
Procidentia may present with bloody stainedProcidentia may present with bloody stained
vaginal discharge some times purulent due to :vaginal discharge some times purulent due to :Decubitus ulcer of the vaginal skin of the cervix.Decubitus ulcer of the vaginal skin of the cervix.
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Management:Management:
Prevention:Prevention:
..Reducing weightReducing weight
..Avoid smokingAvoid smoking
..Avoid difficult labourAvoid difficult labour
..ContraceptionContraception
..Pelvic floor exercise after delivery.Pelvic floor exercise after delivery.
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Medical management:Medical management:
HRT:HRT:
.Hormone replacement therapy:.Hormone replacement therapy:
Increases vaginal blood supply andIncreases vaginal blood supply andcollagen turnovercollagen turnover
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Ring Pessaries:Ring Pessaries:
Indications:Indications:
Patient requestPatient request
Patient is medically unfit for surgeryPatient is medically unfit for surgery
Therapeutic test before surgeryTherapeutic test before surgery
To relieve symptoms while the patient isTo relieve symptoms while the patient is
awaiting surgeryawaiting surgery During and after pregnancies if the patientDuring and after pregnancies if the patient
want to preserve her fertilitywant to preserve her fertility
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Surgical management:Surgical management:
Cyctourethrocele:Cyctourethrocele:
Anterior ColporrhaphyAnterior Colporrhaphy
Rectocele:Rectocele:
Posterior ColpoperineorrhaphyPosterior Colpoperineorrhaphy Uterine Prolapse:Uterine Prolapse:
11stst 22ndnd Degree:Degree:
Manchester RepairManchester Repair
33ed Degree (procedentia):ed Degree (procedentia):Vaginal hysterectomyVaginal hysterectomy