Urinary Stress incontinence
- Genuine stress incontinence,Sphincteric stress incontinence.
- Detrusor overactivity
Stress incontinence physiological background
A. Continence at rest is maintained by:
1) Intra-urethral pressure 50 cm H2O is more than intra-vesical pressure:
♦ This is the most important factor which depends on 3 factors:
a) Urethral mucosal resistance.
b) Peri-urethral vascular plexus pressure.
c) Resting intra-abdominal pressure against the functional length of the urethra.
(N.B. Part of urethra above urogenital diaphragm).
2) External anal sphincter & other muscles.
3) Posterior urethra-vesical angle: it is a functional angle: *at rest= 100-120.
*At voiding =180.
4) Urethral length: important factor only if the urethra is very short.
B. Continence at stress is maintained by:
1) Bladder neck: pulled upwards & forwards behind the symphysis pubis.
2) Bladder base: pulled downwards & backwards.
♦ This leads to kinking of urethra & maintenance during stress.
Genuine sphincteric stress incontinence
(Pressure equalization stress incontinence)
Genuine sphincteric stress incontinence definition:
Involuntary escape of urine through the urethra when the intra-abdominal pressure is suddenly increased in the absence of Detrusor overactivity.
Genuine sphincteric stress incontinence aetiology:
(these factors are worsened by anti-hypertensive drugs which block the
receptors in the urethra).
1) Congenital: weakness of ligaments & muscles.
♦ Obstetric causes: weakness of ligaments muscles supporting the bladder neck.
♦ Genital prolapse: bladder neck displaced below the levator.
3)Degenerative: post menopausal atrophy of ligaments & muscles supporting the bladder neck.
Genuine sphincteric stress incontinencediagnosis:
1) Incontinence of urine appears at stress.
2) Degrees of stress incontinence:
Grade I: with severe stress as coughing, sneezing incontinence occurs.
Grade II: with moderate stress such as walking up stairs incontinence occurs.
Grade III: with mild stress such as standing incontinence occurs
(The patient is continent in the supine position).
B. Signs (special tests):
Tests for diagnosis of the disease: stress test & Youssef test.
Tests for diagnosis of the cause: Bonney’s test & cotton tip applicator.
1. Stress test
♦♦♦ The bladder shouldn’t be empty.
♦♦♦ Ask the patient to strain while she is crying in lithotomy position & detect any escape of urine.
2. Youssef test
♦♦♦ Indication: negative stress test.
♦♦♦ Method: the prolapse is reduced & asks the patient to strain.
♦♦♦ Explanation: stress incontinence may be due to large cystocele causing
kinking of the urethra.
3. Bonney’s test
♦♦♦ Indication: – Positive stress test.
– Determine whether the cause of incontinence is descent of the
bladder neck or weakness of sphincter.
♦♦♦ Method: index & middle finger are put inside the vagina on both sides of the urethra
to elevate the bladder neck upwards & ask the patient to strain.
• If no urine escapes: the cause of descent of bladder neck.
• If urine still escapes: the cause is weakness of the sphincter.
4. Cotton tip application test (Q tip test)
1) While patient lies in lithotomy position.
2) Special applicator is introduced through urethra till the bladder neck.
3) Measured the angle between applicator & horizontal line.
4) By Valsalva maneuver descent of the bladder neck
upward movement of applicator.
5) The new angle between applicator & horizontal line is measured.
1) Normally: the ↑ in the angle < 30.
2) Abnormally: the ↑in angle > 30: indicates poor support & bladder neck descent.
1) Type I: * loss of the posterior urethro-vesical angle (detected by cystourethrography).
* Treated by vaginal route.
2) Type II: * type 1 + ↑ pubourethral angle due to rotational descent of urethra.
* Treated by abdominal route.
1) Lab.: exclude infection by urine analysis.
2) Imaging: cystourethrography:
AP view: funneling.
Lateral view: loss of posterior urethro-vesical angle.
3) Instrumental: cystourethrometry(the most important):
It differentiate between:
− Detrusor instability: abnormal contraction during filling.
− Stress incontinence: ↓ urethral closing pressure.
D. D.D.: from Detrusor overactivity (def. & symptoms).
Genuine sphincteric stress incontinencetreatment:
♦♦♦ Intranatal: Proper management of 1st stage (evacuate bladder).
♦♦♦ Post-natal: pelvic floor exercise.
B. Active treatment:
1. conservative treatment.
2. Surgical treatment.
1) Conservative treatment:
1) Mild stress incontinence.
2) Contraindication to surgery:
• Temporary contraindications: associated Detrusor activity
(should be treated before surgery).
• Permanent contraindications: patients unfit for surgery.
1) Estrogen replacement therapy for post-menopausal atrophy.
2) Kegel’s exercise for 3 – 6 months.
3) Electrical stimulation of pubococcygeus part of levator ani.
2) Surgical treatment:
A. Vaginal operations
• Principle: vaginal urethroplasty (cases associated with prolapse).
1) Kelly’s suture: plication of fascia around the bladder neck only.
2) Kennedy operation: placation of para-urethral fascia along the
whole length of urethra.
B. Abdominal operations
• Principle: abdominal urethropexy= colosuspension.
1) Marshall- Marchetti operation:
Suturing of fascia around the bladder neck to the
periosteum of pubic bones.
2) Burch operation:
Suturing of fascia around the bladder neck to the
pectineal part of inguinal ligament.
C. Sling operations in recurrent cases.
1) Rectus sheath sling:
i. Aldridge operation:
♦ Fascia lata sling is passed below the bladder neck &
sutured to the rectus sheath.
ii. Peryera operation:
♦ Nylon sling is passed below the bladder neck & sutured to
the rectus sheath.
2)Tension free vaginal tape (TVT):
Done using prolene tape, under local anesthesia, it is inserted
around the midurethra & passed through rectus muscles.
3)Trans obturator tape(TOT):
Using special device, polypropelene tape is introduced through
obturator foramen to be passed under the urethra.
D. Peri-urethral injection of polytef paste
Involuntary escape of large amounts of urine after involuntary Detrusor contraction.
* local causes may irritate bladder e.g. cystitis.
* Neurological causes affecting urinary bladder e.g. stroke.
A. Symptoms: *History of weak bladder control even before pregnancy.
*History of enuresis, nocturia or frequency.
B. Signs (special tests): to diagnose possible associated stress incontinence.
1) Stress test.
2) Youssef test.
3) Bonney’s test.
1) Motor urge: Detrusor instability.
2) Sensory urge: Detrusor hyperreflexia or hypersensitivity.
A. Medical treatment:
1) Antispasmodic (alleviating bladder tension).
2) Tricyclic antidepressant (Improve neurotransmission).
B. Electrical stimulation:gives promising results in muscle control.
C. Psychological support, and psychotherapy.
Urinary stress incontinence videos:
Urinary Stress Incontinence in Women, Animation
Urine is produced in the kidneys and stored in urinary bladder. Urination is the process of emptying the bladder through the urethra that connects the urinary bladder to the external urethral orifice. There are two sphincters, or valves, that keep the urethra closed to prevent leak: internal urethral sphincter located at the neck of the bladder, and external urethral sphincter located right above the external urethral orifice and is supported by the pelvic floor muscles. When the bladder is full, stretch receptors in the wall of the bladder send a signal to the spinal cord and the brain. At times when it’s not appropriate to urinate, the brain sends back an inhibitory signal to keep the sphincters closed and prevent voiding. When you wish to urinate, this inhibition is removed, the spinal cord instructs the muscle of the bladder — the detrusor muscle – to contract and the sphincters to open to let the urine out.
In stress incontinence, small amount of urine leaks when the person is sneezing, coughing, laughing or having any activity that creates abdominal pressure on the bladder. This usually occurs because the pelvic floor muscles are weakened and can no longer support the sphincters. In women, this typically happens as a result of pregnancy, childbirth during which these muscles are overstretched. In most cases, this condition can be treated with exercises that strengthen pelvic floor muscles.
Urinary Stress Incontinence
Three surgical treatments for stress urinary incontinence, or SUI, include open abdominal bladder suspension (Burch), laparoscopic bladder suspension and a sling procedure.