INCONTINENC

E OF URINE

Physiology of
Micturition

Bladder innervation:
somatic, parasympathetic (PSN)
and sympathetic (SNS)
as urine fills the bladder, the
detrusor stretches and allows the
bladder to expand
~300 ml in bladder before the brain
recognizes bladder fullness

Physiology of Micturition

Physiology of Micturition
Low bladder volumes: SNS is stimulated
and PNS is inhibited
Bladder full: PNS stimulated (bladder
contracts) SNS inhibited (internal
sphincter relaxes)
Intravesical pressure > resistance within
the urethra: urine flows
Pudenal nerve innervates external
sphincter

DEFINITION OF
INCONTINENCE OF URINE

It is involuntary

escape of urine

:TYPES
1. True incontinence.
2. False incontinence
3. Stress or sphincter incontinence.
4. Urgency incontinence
5. Nocturnal enuresis.

Incidence of Subtypes of
Urinary Incontinence in
Women
Stress

Incontinence 50%
Urge Incontinence 20%
Mixed 30%

True (continuous). 1
incontinence
In this case, urine escapes

continuously by day and by night.

It is caused by:
(a) Urinary fistulae as vesicovaginal
fistula;
(b) Ectopia vesica.

False incontinence
.2
(Overflow incontinence)
It is involuntary loss of urine following

overdistension of the bladder.

Overflow incontinence, usually short-term,
can occur after vaginal deliveryespecially
if epidural anesthesia was used.
Other causes include diabetes, neurological
diseases, severe genital prolapse, and post
surgical obstruction.

STRESS INCONTINENCE. 3

Definition :
It is involuntary escape of few
drops of urine with increased
intra-abdominal pressure as
during straining, sneezing,
coughing, laughing ... etc.

DEGREES OF STRESS
INCONTINENCE
Grade I
Incontinence occurs only with severe stress,
such as coughing, sneezing, etc
Grade II
Incontinence with moderate stress, such as
rapid movement or walking up and down
stairs
Grade III
Incontinence with mild stress, such as standing.
The patient is continent in the supine position

TYPES OF STRESS
INCONTINENCE

Type 1 : There is complete loss of the

posterior urethrovesical angle.
Type 2 : There is complete loss of the
posterior urethrovesical angle together
with increase in the angle between the
urethra and vertical line to be more than
30 degrees.
This type leads to severe stress incontinence

AETIOLOGY

It is due to either :
Weakness of the internal
urethral sphincter or
Descent of bladder neck
below the level of the pelvic
floor.

AETIOLOGY
1. Congenital weakness of the
internal urethral sphincter, seen in
the young nullipara.
2. Congenital defects as:
1.
2.
3.
4.

Epispadias,
Short urethra (less than 1 cm),
Wide bladder neck, and
Separation of symphysis pubis.

AETIOLOGY
3. Trauma to the region of the bladder
neck due to vaginal delivery or
operation.
The incidence of stress incontinence
increases with parity due to repeated
birth trauma.
In fact vaginal delivery is the
commonest cause of stress
incontinence.

Pathophysiology of Stress
Incontinence
The basic pathology is urethral

incompetence.
This can be either due to:
A) Urethral hypermobility
(80
- 90% of patients)
B) Intrinsic Sphincter Dysfunction
(10 - 20% of patients)

A) Urethral hypermobility
(80 - 90% of patients)
This results from loss of the normal
pelvic support mechanism of the bladder
and urethra due to:
Trauma and stretching of vaginal
delivery
Hysterectomy
Hormonal changes ( Menopause)
Pelvic denervation
Congenital weakness

1.
2.
3.
4.
5.

A) Urethral hypermobility
(80 - 90% of patients)
As the bladder neck support is

weakened, the increase in intraabdominal pressure is no longer

transmitted equally to the
bladder outlet, and therefore
instantaneous leakage occurs.

B) Intrinsic Sphincter Dysfunction

(10 - 20% of patients)
This results from damage to the sphincter
due to:
Multiple prior operations
Trauma
Radiation
Neurogenic disorders including Diabetes
Mellitus
Atrophic changes: lack of estrogen.

1.
2.
3.
4.
5.

Urgencyincontinence. 4
.(precipitancy-detrusor instability or detrusor dyssynergia)

The woman feels the desire to micturate but

before she reaches the bathroom, urine passes
involuntarily.
It is due to irritability of the bladder muscle and so
the patient cannot inhibit it.
It is due to :

1.
2.
3.

emotional disturbance,
neurologic diseases, and
bladder diseases as cystitis, stone or tumour.

Detrusor instability (DI)

Detrusor instability (overactive bladder) is a

condition in which the bladder contracts

involuntarily in response to filling.
It was called detrusor dys-synergia in the past.
No cause is identified in more than 90% of
these patients.
Advancing age is an important risk factor.

Detrusor instability (DI)

Detrusor instability caused by neurologic

diseases such as cerebrovascular disease,

multiple sclerosis, or spinal cord injury is
called detrusor hyperreflexia.
Irritation of the bladder by inflammation
(such as urinary tract infection) or prior
pelvic surgery can also cause detrusor
instability.

Urge incontinence

NOCTURNAL ENURESIS. 5
Bedwetting
Definition : involuntary urination while asleep
after the age at which bladder control
. usually occurs
Nocturnal enuresis is considered primary
(PNE) when a child has not yet had a
.prolonged period of being dry
Secondary nocturnal enuresis (SNE) is when a
child or adult begins wetting again after
. having stayed dry

A. History
A detailed history differentiates between the
different types of incontinence.
2. Stress incontinence and detrusor instability
frequently occur together.
3. Gradual onset after menopause suggests
oestrogen deficiency.
4. History of vaginal repair or operation in the
region of the bladder neck and history of any
neurologic disease.
1.

1.
2.
3.
4.
5.
6.

Stress Test
Booney Test
Yousef Test
Urinalisis
Cystourethroscopy
Cystourethrography

I. Prophylactic Treatment
1. During labour, the bladder should be kept
empty.
2. Episiotomy is performed if necessary.
3. Physiotherapy.
Pelvicfloorexercises are started after delivery.

These include repeated stoppage of the urinary

stream during micturition and repeated contractions
of the pelvic floor muscles.

II. Conservative (non-surgical)

Treatment
Indications:
1.Mild stress incontinence.

2.Patient is unfit for surgery or refuses

surgery.
4.When stress incontinence is combined
with detrusor instability.

Conservative treatment cures or

:improves 50% of cases and include
1. Physiotherapy: Kegl perineometer may be
used.
2. Faradic current stimulation of the levator ani
muscles to improve their tone.
3. Vaginal cones:
A set consists of 5 or 9 cones.
Weight ranges from 20 to 100 grams.
Patient inserts the cone in the vagina and keeps it
for 15 minutes twice daily.
If this succeeds she inserts the next cone.
This improves the tone of the pelvic floor muscles.

Conservative treatment cures or

:improves 50% of cases and include
4.Oestrogen therapy for menopausal
patients:
It causes thickening of the urethral mucosa
and engorgement of the underlying blood
vessels thus increasing the urethral
pressure and resistance.
Oestrogen is given orally or as vaginal cream.
5. Alpha-adrenergic stimulants:
which stimulate contraction of the internal
urethral sphincter, e.g. ephedrine.
6.Large vaginal diaphragms, Hodge
pessary to elevate ' and support the
bladder neck.

AETIOLOGY
4. Menopause: Lack of oestrogen leads to
atrophy of bladder neck supports.
5.Pregnancy and continuous
administration of oestrogen-progestogen
preparation to induce psuedopregnancy
state to treat endometriosis.
The hormonal imbalance with increased
progesterone weakens the internal
urethral sphincter.

AETIOLOGY
6. Genital prolapse:
If the bladder neck descends below the
level of the pelvic floor, the increased
intra-abdominal pressure will be
transmitted to the bladder and not to the
upper urethra leading to escape of urine.
7. Organic nervous diseases
as disseminated sclerosis.