Dr. Abdullah Ahmad Ghazi (R5)KSMC

22/01/1433H

Incontinence define: any involuntary loss of urine Stress UI: Urge UI: Mixed UI: Unconscious UI: Continuous UI: Nocturnal enuresis: Postmicturation dribbling: Overflow UI: Extraurethral UI:

W:M 2:1

Prevelance 5-72%.◦ Adult life 20-30%◦ Middle age 30-40%◦ Elderly 30-50% mixed◦ Severe incontinence 6-11%◦ Prevelance with pregnancy 31-60%

stress

Urethral hypermobility. Intrinsic sphinctric deficiency. Transient causes. Neurological causes Medication.

Age Parity Rout of delivery Obesity Others; menopause, smoking, chronic

cough & prior pelvic surgery.

Delirium Infection Atrophic vaginitis Psychological Pharmacologic Excess urine production Restricted mobility Stool impaction

Characteristics Severity Impact on quality of

life Evaluate of risk

factor Transient causes Acute/chronic Neurological

condition

• Hx of surgery• Radiation• Medication• Hx bowel, sexual

function, obstetric, menstrual & hormonal replacement therapy.

Neurological: gait, speech, facial asymmetry.

Abdomin: hernia, palpable bladder.

Rectal: prostate.

Sacral: sphincter tone & control, genital sensation, bulbocavernosus reflex.

Pelvic Ex Anterior/posterior vaginal wall Pelvic floor strength.

U/A PVR Voiding diary Pad test Dye test UFM UDS

Bladder filling require:◦ Accommodation of increase volume of urine at a

low intravesical pressure ( N compliance) and appropriate sensation.

◦ A bladder outlet that closed at rest and remain closed in increase intraabdominal pressure.

◦ Absence of involuntry bladder contraction.

Bladder empty require:◦ A coordination of the bladder smooth musculature

of adequate magnitude and duration.◦ Lowering of resistance at the level of sphincter.◦ Absence of anatomical obstruction

Rehabilitative techniques:◦Behavior modification◦Pelvic floor muscle training◦Biofeedback◦Electrical stimulation

Oral pharmacologic treatment◦ Antimuscarinic agent◦ Impiramine

Intravesical/intradetrusor therapy:◦ Oxybutynin◦ Botulinum toxin

Surgery:◦ Sacral nerve neuromodulation

Effective non-neurogenic population, effective frequency/urgency & idiopathic AUR.

◦ Denervation procedures Bladder transection & reattachment Complete S2-S4 rhizotomy Partial rhizotomy

◦ Subtrigonal phenal/alcohol injection.◦ Augmentation cystoplasty.◦ Autoaugmentation of the bladder.◦ Diversion

Rehabilitative technique. Pharmacologic treatment

◦ A-adrenergic agent (ephedrine, …)◦ Impramine◦ Duloxetine◦ Estrogens.

Urethral bulking agents “collagen, silicon macropaticles”.

Surgery:◦ Sling procedure “TVT, TOT” 80-94%◦ Suspension procedures 83-84%◦ Sphincter prosthesis

Associated with prolapse

120 pt. F/U 12-30M Age 31-86y (mean 58y) 70% pure SUI

Results:◦ Operative time: 12min◦ Catheterization time 0.9day◦ 13 minor lateral vaginal tear.◦ 3 urethral, 1 bladder perforation (learning phase)◦ 2 have AUR need SPC and tab release

80% completely dry 12% greatly improved Global satisfaction 78%