Urinary Stress Incontinence

SUI:-Let us first refresh out knowledge of anatomy & neuronal control of bladder (emptying ) evacuation?:-To put in other way round how the continence is maintained?

Causes of GSI:- A diseases of theories:-First Theory::: .(theory of Enhorning). Theory of hyper mobility of bladder neck and descent of bladder neck from abdomen to pelvis:-Childbirth damage / Senile changes in nulliparous women cause  pubourethral ligament & Levator Any muscles weakness .This is the  first step: This theory presupposes that bladder neck is  intra-abdominal in  position ;     Theory of hyper mobility of bladder neck and descent of bladder neck and proximal urethra with rise of inure-abd. pressure.(theory of Enhorning).

 So what? During sneezing/coughing the intraluminal pressure in proximal urethra is raised above the pelvic floor pressure. Therefore continence is achieved. No leakage of urine. To be continent & effective the level of proximal urethra should be at the level of pelvic floor. If prox. Urethra comes below/down the level of P. floor then SUI will occur.

To be effective the proximal urethra must be within the intra-abdominal pressure zone and should not prolapse further down. If there is damage to pelvic floor muscles or end pelvic fascia then proximal urethra will be hyrermotile and will sag down and therefore out of intraabdominal    pressure zone.

 SECOND THEORY of SUI:---Hammock Theory: vaginal fascia act like a hammock on bladder neck which is pulled during coughing.  -- Loss of angle between Bladder & Internal urethral opening :--Relevance of vaginal fasciae , pubourethral ligament , Pubococcygeus   ms. These ligaments along with vaginal fascia act like a hammock on bladder neck which is pulled during coughing.  This concept is based on the fact that bladder neck though becomes mobile in diff. dis. Conditions the proximal urethra is basically remaining as an immobilized part of soft tissue. Normally with cough/sneezing- vaginal fasciae along with the bladder neck is pulled backwards and downwards while proximal urethra remains in fixed .Therefore normal angulations between neck and urethra is maintained and continence is  achieved.

Third Theory:::  Stress incontinence is a mid urethral disease  Supports of midurethra is poor with increasing age- Support of mid urethra:- pubourethral ligament  is normal and uninjured. Loss of  supports mid urethra is te cause of Stress.. Then SUI.

CLINICAL TESTS FOR SUI:

Bonney’s Test, 2) Miyazaki  Bonney’s Test – by using sponge forceps, 3) Q-Tip cotton swab test- lubricated cotton swab n the urethra-evaluates urethral hyper motility. 4) Foley’s catheter Test_ Paid. Foley six 8- 5ml. Saline-withdraw easily comes- Denotes sphincter deficiency.

 If catheter comes easily then consider the test as +.

If + Q Tip Test and negative Foley test then COLPOSUSPENSION Will help her

LIST of Investigation to be done in a case suspected to be suffering from SUI. Unfortunately there is no clinical test which is highly sensitive and specific. Most are lab oriented.,

 Urine RE.C/S 2) Whole Abd. USG & Post void urine must be below 100ml. If excessive then revise the diag in favour of overflow incontinence.

Voiding/Bladder diary:- a) Normal bl. Capacity is 300-500 ml. That she can measure. B) Volumetric summary of diurnal urinary frequency. C) Volumetric summary of nocturnal urinary frequency. C) Any provocative/Associated events /activities.

Pad test. = International Continence Society Pad Test: - . Allow her to drink Na free water 500ml. in 15 mats. Then ask her to perform strenuous exercises. If after one hour  The wt. of pad ≥ 2Gms. Then diag of SUI is confirmed.-

  Urolowmetry  :Normal Figures are Residual ≤ 50ml., First desire after filling of 150-200ml. Total capacity 400ml,

Leak Point Pressure:     This test is aimed to test the resistance of urethral sphincter and also diagnoses intrinsic sphincter deficiency. Placement of intavesical  & intravaginal catheters and assess by Valsalva method.

INFERENCE OF UROFLOWMETRY REPORTS & EVALUATION THEREOF;

SUI=  Leakage only during raised intraabdominal. Pressure in absence of Detrusor contr.

Bladder Neck Hypermobility:  High Valsalva Leak point pressure. or High maximum urethral closure pressure.

Intrinsic Sphincter deficiency:- Low Valsalva Leak point pressure or Low  maximum urethral closure pressure.

Urge Urinary Incontinence:- Incontinence due to involuntary .  detrusor . Contractions . If there is associated urge then termed as Det. Over activity.

Mixed Incontinwence . SUI & Urge Incontinence

Cysto-Urethroscopy -Bladder pathology ? Sensory urgency

Micturating  cryptography. –Any fistulae/ diverticulum.

TREATMENT OF URGE INCONTINNENCE

Usually surgical but it will be prudent to try with medicines as because the Tr. Outcome with surgery is unpredictable and it is  not a life threatening condition.

  Anti incontinent Surgeries. Plicatin  /urethropexy /needle suspension/ pubovaginal  slings/bulking agents

Inj. Of bulking agents (FDA approved)  /

 Later came Urethral placation  Surgeries(Plicatin of Suburethral  tissues)-Kelly 1914; Kennedy 1937;

 Retro Pubic Urethropexy:-  a) MMK-   1949     Marshall-Marchetti-Kranitz procedure-fixes fix such tissue with back of S.Pubis periosteum b. ) BURCH-modification of MMK on in 1961 Periurethral and per vesicular fibro muscular tissues are fixed to ileo-pectineal line. Instead of periosteum/cartilage of S. Pubis as was done in MMK procedure

  Trans vaginalis needle suspension  procedures    RETRO PUBIC SUSPENSION   Urethropexy/ Colposuspension operations   e.g.PEREyRA / Stamey procedure  .

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PUBOVAGINAL  SINGS:-   Approach is through retropubic space , Either R. Sheath/ Fascia Lata is used to make a sling under the urethra. PARAVAGINAL Defect Repairs        Abdominal  Approach to correct lateral  vaginal support  –mostly abd. Route: now mostly used for Prolapse repair

MIDURETHRAL SLINGS.    TVT/TOT    (Mid-Urethral SLINGS).  Midurethal placement of MESH

This is very popular method because it takes care of all the three important structure that support bladder neck and proximal urethra. Such 3 structures are a) pubourethral ligaments b) suburethral  vaginal hammock, abd c) Pubococcygeus muscles. I) TVT (Tension- free vaginal tape)- Retropubic approach   via trocar and ii) TOT(Transobturator tape)—Vaginal/Obturator approach.

Vaginal approach TVT May be OPD procedure.    Possibly TOT is superior,

Transobturator Approach:- insert the mesh from  out-to-in method or better  in-to-out method . Polypropelene  mesh-----But limitation of this method is that this type of surgery cannot possibly correct  where SI is due to intrinsic sphincter defects.

Minimally invasive Slings:-also called micro sling/minis ling:-Vaginal approach- no trocar- 8 cm long strip of Polypropelene mesh is placed beneath the midurethra. TVT- Secur.

What is ISD or intrinsic sphincter deficiency?  To diagnose one should assess following 3 tests e.g.( Preoperatively always assess a)  MUCP(Maximal Urethral Closure Pressure Profile  If there is poor intrinsic sphincter deficiency then Obturator technique may fail. Also assess    b) VLPP (Valsalva - Low Leak point Pressure –will suggest ISD     c) additionally if there is Low-Q-tip angle then also think of ISD and there is little urethral hypermotility.

Sacral Neuromodulation- only when all other modes of Ry for Urge .Incon fails, Electrical nerve stimulation   pump device also available-FDA approved.