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INTRODUCTION
Over 200million people world wide experience problems
associated with U.I.
Impact on health resources and quality of life.
50-100million suffer from O.A.B. syndrome.
U.I. affects 50% of woman occasionally and 10% regularly.
DEFINITION (I.C.S.)
Unstable bladder is one that is shown objectively to contract
sponteneously or on provocation during the filling phase of
cystometry while the patient is attempting to inhibit micturition
TERMINOLOGY
Uninhibited detrustor
Detrusor reflex instabilty
Over active bladder
Detrusor Instability
Detrusor hyper reflexia-Neuropathy
INCIDENCE
Common condition, which are with age
10% of post menopausal women with climacteric symptoms
nd
2 commonest cause of urinary incontinence (30-50% of
cases)
AETIOLOGY
No specific underlying cause, but some probabilities exist
- Idiopathic - 29%
- Psychosomatic - Neutrotic personality
- - Respond to psychotherapy
- Neuropathic (Upper motor neuron lesion)
- Multiple sclerosis
- Spinal injuries
- Incontinence surgery - Due to extensive dissection at
bladder neck
- Out flow tract obstruction-rare
PATHOPLY SIOLOGY
SYMPATHETIC
- T11-L3
- Via hypogastric Nerves
- Acts predominantly on and receptors - relaxation of
detrusor muscle
- Stimulates and receptors to cause contraction of
bladder neck and urethra.
Parasympathetic Stimulation - Incontinence
- Sympathetic stimulation - continence
- Bladder fills with little increase in intra vesical
pressure
(3-5cm water)
- Desire to void - 150 - 200ml
- Strong desire to void - 400 - 600ml
CLINICAL PRESENTATION
The term OAB syndrome refer to a spectrum of lower urinary
tract symptoms, namely:
Frequency > 8 voids/day
Urgency - sudden desire (difficult to control)
Nocturia - waking more than once to void
Incontinence - urge, stress, coital
Noctunal enuresis.
CLINICAL EVALUATION
HISTORY
Presenting symptoms
Presence of other urinary tract symptoms to rule out other
causes.
• Voiding difficulty
• Haemauria
• Dysuria etc.
History of neurological conditions.
• spinal injury, multiple sclerosis
Psychollogical problems - Neurosis
Pelvic survey
Drugs - diurectics, anticholinergics
Other gynaecological problems - VUF, prolapse pelvic
masses, etc.
Excessive fluid intake - coffee.
PHYSICAL EXAMINATION
PELVIC MASSES
DISTENDED BLADDER - URINARY RETENTION
VE - prolapse
- Fistula
- Oestrogen deficiency,
- Stress incontinence
- Neurological assessment at the vulva
- Sensation
- Lower limb reliexe.
INVESTIGATIONS
(IN UROYNAECOLOGY)
1. Urinalysi / mlcls
2. E&U
3. Bladder diary (By patient)
- time of micturition
- voiding volume
- incontinence episodes
- pad usage
- fluid intake
- degree of urgency / incontinence
- method of choice for evaluation
4. PAD TEST
• Confirm and quantify leakage
a. simple test - 10 - 15 minutes
b. extended:
- wear preweighed pad
- drink 500ml of water
- simple exercise for 30 minutes
- more provocative exercise and weigh pads
- > 1g = positive
URODYNAMIC STUDIES
1. UROMETRY: Measure flow rate and volume
flow rate ie. < 15ml / s = abnormal
voiding volume - < 150ml = abnormal
T voiding time
ABNORMAL CYSTOMETRY
LEAKAGE ON COUGHING IN THE ABSENCE OF A
RISE IN DETRUSOR PRESSURE (gsi)
SPONTANEOUS OR PROVOKED DETRUSOR
CONTRACTION WHICH THE PATIENT CANNOT
SUPPRESS DURING THE FILLING PHASE
(DETRUSOR INSTABILITY)
3. VIDEO CYSTOMETRY
Uses contract media (urograffin)
View lower urinary tract during micturition.
Tumours, calculi, bladder neck opening incontinence
etc.
IMMAGING
1. Cystoscopy
2. IVU - co-existing loin pain, prolapse, recurrent
UTI,fistula.
3. USS (TV & Trans urethra)
TREATMENT
Medical
Surgical
Others
MEDICAL
1. DRUGS REDUCE DETRUSOS CONTRACTILITY
ANTIMASCURINIC Drugs (Ach antagonist)
They I, bladder contractility
T bladder capacity, darifencis, otibutinin
5. ANTI DEPRESSANTS
Local anaesthetic and sedative-sedative properties
Used for Nocturnal enuresis
SURGICAL TREATMENT
1. 'CLAM' Cystoplasty
most popular
bisect bladder almost completely
patch of gut (25cm ileum) put in place to reduce
contration
PROBLEMS
Inneficient voiding - use catheter
Mucus retention in urine
Malignant changes - chronic exposure to urine
Electrolyte problems
2. Auto augmentation
3. Urinary diversion - ileal conduit
OTHERS
BLADDER TRAINING
Programme of sheduled voiding
increase Intervals between void
BIOFEED BACK
During cystometry
Increasing patients awareness to stabilize detrusor presure
Patent is thought to inhibit detrusor constractions
Phycholoneapy
Neurotic (phychological aetiology)