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Prof. A.K.Sil
Definitions
What is continence? Ability to control urine in between two voluntary acts of micturition. What is incontinence? Involuntary leakage of urine which is objectively demonstrable and a social and hygienic problem.
Types of Incontinence
Congenital Epispadias
Transurethral
USI Neuropathic OAB Acquired Retention with overflow Misc.& functional Fistulae Ureteric, Vesical Urethral
Nonneuropathic
Congenital Extraurethral
Acquired
Anatomy- Bladder
Multilayered- Mucosa, Submucosa, Muscle, Adventitia. Mucosa3 layers of transitional epithelium Superficial impermeable umbrella cell layer primary urine plasma barrier Secrete glycosaminoglycans protective barrier preventing bacterial adherence.
Bladder musculature
Outer longitudinal
Detrusor 3 layers smooth m act as syncytium
Middle circular
Inner longitudinal
Sparse parasymp.n supply, continuous with that of prox urethra & ureter
Inner layer
Anatomy - Urethra
Length 3-5 cm Smooth muscleContinuous with Detrusor but minimal parasympathetic innervation. Striated muscle- Act as a single unit, circumferentially constricting upper 2/3rd and laterally compressing lower 1/3rd.
Slow twitch Wraps circumferentially External urethral sphincter/ Sphinter urethrae/ Rhabdosphincter at mid urethra
Striated m
Act as single unit circumfere ntially constrictin g upper 2/3rd & laterally compressin g lower 1/3rd
Fast twitch
Arch ventrally over urethra and insert into fibromuscular tissue of anterior vagina Maintains continence during stress
Endopelvic fascia
Levator ani muscles, ligaments, endopelvic fascia work in synergy. Defect of any of them cause support defect and incontinence.
Innervation - Bladder
S2,3,4 Muscarinic receptors in bladder wall M2, M3 predominant T10-L2, carried via hypogastric n.plexus Main Parasympathetic
Efferent
Little Sympathetic
receptors
Afferent
receptors
Innervation - Urethra
Smooth muscle are supplied by
Parasympathetic which causes contraction, shortening & widening of urethra, no sphincteric function. Sympathetic predominantly adrenoceptors.
Striated muscle
Rhabdosphincter by pelvic splanchnic travelling with parasympathetic fibres. External periurethral m. by perineal br.of Pudendal nerve.
CNS Control
Discrete areas in cerebral cortex are responsible for
Perception of sensation of bladder fullness Inhibition of micturition Initiation of voiding.
Superior frontal gyrus & Anterior cingulate gyri Voluntary postponement of voiding Lesion causes abolition of conscious & unconscious inhibition of micturition.
Paracentral lobule Controls relaxation of sphincter Lesion causes spasticity of sphincter & retention.
Subcortical areas
Thalamus principal relay centre to cerebral cortex Reciprocal connection with lower spinal centres Basal ganglia Limbic system Hypothalamus Mesencephalic pontine medullary reticular formation 2 areas having inhibitory and excitatory effects on micturition centre.
Mechanism of Continence
Complex dynamic process involving fascia, ligaments, muscles, with accompanying nerve & vascular supply and control of higher centres.
Maximum urethral pr. > Intravesical pressure
Counteracted by simultaneous rise in intra-urethral pressure by Pressure transmission to proximal urethra and vesical neck Contraction of external sphincter Contraction of peri-urethral fibres of levator ani (fasttwitch fibres) Also shortening of levator ani lifting anterior vaginal wall pushing vesical neck against precervical arc Compression of urethra against anterior vaginal wall.
Urethra is supported by a hammock anterior vaginal wall (VW) with its attachment to ATFP. Shortening of Levator ani (LAM) lifts vagina & pushes vesical neck (VN) against pre-cervical arc (PCA)
Normal Micturition
Filling and storage:
Bladder is filled at a rate of 0.5ml/min. Gradually distends but wall pressure is not increased due to relaxation Proprioceptive afferent from stretch receptor Pelvic nerves Sacral Dorsal roots of S 2,3,4 Ascend via Lateral Spinothalamic tract To reticular formation Detrusor contraction is inhibited by descending inhibitory impulses.
Urine flow diminishes. Pelvic floor and intrinsic striated muscles contracted
Urine flow is stopped at mid-urethra Urine in upper urethra is milked back into bladder Urethra closed cephalad
Mechanisms of Incontinence
During stress, increases in intra-abdominal pr leads to greater increase in intravesical pr than intraurethral pr due to lack of urethral support or abnormally positioned bladder neck & proximal urethra Leads to - GSI. Loss of intraurethral pr due to loss of urethral integrity i.e. lead pipeurethra Leads to GSI due to ISD Causes Menopause, Post RT, Post surgery.
Evaluation of Incontinence
1. Urinary symptoms Number of voids Pads used/day Type of pad Frequency of pad changing Degree of pad saturation Circumstances & manouevres inciting leakage
6.
Cystometry contd.
All measurements in cm of water, upper edge of symphysis pubis as zero reference 12 F catheter Filling rate 10100ml/min Slow fill <10ml/min indicated in neuropathic bladder Assessment of Pves Pabd Pdet = Pves - Pabd
Cystometry contd.
Normal values
Residual volume < 50ml First desire to void at 150-200ml Capacity (strong desire to void) >400ml No Detrusor pressure during filling Absence of systolic Detrusor contraction No leakage on coughing Detrusor pr rises on voiding maximum voiding pr < 50cm of water with peak flow rate >15ml/sec for a voided volume > 150ml.
Cystometry contd.
Abnormality
Leakage on coughing in absence of rise in Pdet GSI Spontaneous or provoked Detrusor contraction during filling phase DO Phasic Detrusor contraction Systolic overactive bladder Pressure rise > 15cm of water on filling the bladder with 500ml of fluid which does not settle after filling is stopped Low compliance bladder
ii. IVP
Only for neuropathic bladder, suspected ureterovaginal fistula
iii. VCU
Not routinely used. Helpful in vesico-ureteric reflux, post-micturition dribble.
Radiology contd.
iv. Micturating Cystogram
Not useful in assessment of incontinence Useful in demonstrating vesico-ureteric reflux, diverticula, bladder/urethral fistula
12. VLPP
Abdominal Leak point pressure measure of urethral resistance to intraabdominal pr by valsalva. Leakage at Intravesical pr < 60cm of water sphinter incompetence or ISD
BNEC & DUEC Investigation & treatment of OAB and sensory urgency Demonstrates bladder neck opening Deflection > 8mA with quick return to baseline GSI Deflection > 8mA lasting > 3sec Overactive bladder.
USI or GSI
Urethral sphincter incompetence/ Urodynamic stress incontinence
USI or GSI
Prevalence 25-55% exact figure not known 1 in 4 seek med. adv. due to embarrassment, limited access to med care & poor screening USI comprises 29-75% of incontinent pts Stress incontinence is a
Symptom Sign Underlying disease GSI/USI
Defined as involuntary loss of urine when intravesical pr exceeds maximal urethral pressure in the absence of detrusor activity.
Aetiology of USI
Parturition Direct injury to muscles of pelvic floor & supports of lower urinary tract Indirectly by damage to supplying nerves. Aging Urethral closure pr & functional urethral length decrease Associated medical problems & medications. Menopause Oestrogen deficiency causing atrophy of vagina & supporting structures. Obesity Causes greater fluctuation of intraabdominal pr
Assessment of patient
Thorough history
Urinary/defaecatory/sexual dysfunction Complaints related to prolapse Exacerbating/relieving factors Effect of medical problems/medications Exploration of her daily activities QoL assessment by IIQ-7, UDI-6.
Investigations
Urine R/E & C/S Q Tip test Pad test Pessary test Post void residual urine USG for PVR, Assessment of bladder neck mobility, bladder wall thickness, Urethral diverticula. 3D for cross-section of urethral sphincter. Radiology Fluoroscopy voiding cystometrogram. Urodynamic studies Cystometry, Uroflowmetry Urethral pressure profilometry VLPP BNEC, DUEC
MANAGEMENT
USI to be differentiated from DO All patients should be offered conservative therapy Even partial improvement may help in improving QoL and thereby may be more acceptable
Behavioral therapies
PFE- subjective cure rate upto 36%; improvement 17-75% patient education for proper ms recognition Biofeedback- auditory, visual, tactile weighted vaginal cones Electrical stimulation of pudendal nv vaginal or rectal probe IFT Extracorporeal Magnetic Innervation
Devices
Vaginal pessaries Urethral occlusion devices- intraurethral or at ext. urethral meatus
Pharmacotherapy
Principal- to increase urethral resistance by adrenoceptors, bladder relaxation by adrenoceptors/ anticholinergic ephredrine, pseudoephedrine, norephedrine,phenylpropanolamine Imipramine- agonist + anticholinergic 1025mg po qd Oestrogen 2-4 gm vaginally 3-7 times/wk
1) High rate of relief of incontinence, subjective & objective , and improved QOL 2) Low rate of complication 3) Primary surgical procedure should have maxm cure rate
Cases with ISD Sling operation: Autologous fascia Cadaveric donor fascia Synthetic mesh
Recurrent incontinence
Sling procedure: After failed urethropexy Periurethral injection of Bulking Agent : specifically for fixed scarred low pressure urethra Artificial urinary sphincter At the same time ,one should look for undected UTI, Fistula, associated Detrusor Instability or de novo DI
Other surgeries
Anterior Colporraphy with Kellys buttressing suture Needle suspension procedure- Pereyra ,Raz , Stamey
Burch colposuspension
Initial procedure same as MMK Two sutures 1st 2 cm. lat. to UV junc. 2nd 2cm. Lat to proximal urethra Fixed with ipsilateral ileopectineal lig Suture no. 0 PDS or Ethibond There should not be any suture bridge After tying , 2 finger should pass between urethra and pubis Cure rate: subj 90% ,obj 84% ( Jervis et al) overall 90% at 1yr. 70% at 10yr.(Alcay et al )
Paravaginal repair
Indicated in Displacement cystocele Endopelvic fascia reattached to ATFP eventually elevating bladder neck Results are not lasting So along with paravaginal repair Burch colposuspension should be done
Conclusion
USI not life threatening , but affects QOL considerably Conservative measures should be tried first Proper councelling before operation Results assessed not only by obj. cure rate but also by improved QOL
Detrusor Instability
Detrusor Instability is one that is shown objectively to contract spontaneously or on provocation , during the filling phase whilst the patient is attempting to inhibit micturtion Quite common 10% of population who not learnt bladder control at proper age 10% of postmenopausal woman 30-50% of adult woman investigating for ur. incontinence. commonest cause( upto 80%) in elderly undergoing urodynamic assessment Worldwide 50-100 million people suffering from OAB syndrome
Aetiology
Not known ; probabilities are Idiopathic: common in subjects who had h/o poor potty or bladder training in childhood Psychosomatic: OAB pt. has higher psychoneurotic score poor responder to oxybutinin has higher psychoneurotic score Neuropathic: Multiple sclerosis, spinal injuries, CNS lesi ons of frontal lobe, paracentral lobule, ponti ne reticular formation etc. Following incontinence surgery & outflow obstruction
Pathophysiology .
Remains a mystery Partial denervation of detrusor, postjuctional supersensitivity, hypertrophy of cells production of elastin & collagen within ms. fascicles, excitability and spreading between cells resulting in coordinated myogenic contraction of whole detrusor In Detrusor hyperreflexia ,altered spontaneous motor activity consistent with electrical coupling of cells, patchy denervation, supersensitivity to potassium P2X receptors (purinergic)in DO No. of VIP immunoreactive Nvs Reduced blood flow (ischaemia) to detrusor
Clinical presentation
Multiplicity of Symptoms Frequency Urgency 80% of pt.s Nocturia Urge incontinence > preceded by urgency > unaware of any sensation Nocturnal enuresis Coital incontinence > during penetration USI > orgasm - DI Increased risk of OAB with 1)Obesity, 2) Smoking, 3)Carbonated drinks Decreased ,, ,, ,, 1)Vegetables, 2)Bread, 3)Chicken
Signs
No specific cl. Sign Look for Vulval excoriation Urogenital atrophy Residual urine Stress incontinence Neurologic lesions - cranial, spinal Integrity of sacral reflex arc
Investigations
Urine c/s Frequency/vol. Chart : for 5 days - to some acting as bladder drill Uroflowmetry : to exclude voiding difficulty Cystometry : subtracted provocative cystometry >Uninhibited systolic contraction during filling same sympyom >Steep rise in PDET during filling low compliance diff to differen >Abnormal rise PDET on change of posture >Detrusor contraction provoked by coughing Symptoms with cystometric finding Common features are early first sensation, small bladder capacity, inability/difficulty in interrupting urine flow, slow or absent milk-back (in VCU)
Investigation (contd.)
Ambulatory cystometry : more physiological, more accurate DI detected 50% more often than routine cystometry Cystourethroscopy: to exclude Bladder tumour, calculus Coarse trabeculation, interstitial cystitis Bladder/ urethral diverticulae, fistulae Suture material in bladder from previous surgery Urethral pressure profilometry BNEC DUEC : TYPE III - >8mA , lasting 3sec USG : bladder wall thickness increased
Management
Behavioral modification: less drinking- 1-1.5l/day avoiding tea, coffee, alcohol tampon in vag. dur. sport. act. Alteration in medication-diuretics Drug therapy Behavioral therapy Maximal electrictal stimulation, Neuromodulation Transvesical phenol Surgery
Drug therapy
A. Inhibit bladder contractility
Antimuscarinic &musculotropic
Oxybutinin: 5mg tds ; 70% cure rate Tolteradine : selective M2, M3 blocker; 2mg bd / 2-4 mg SR od; less side effect Derifenacin : 5 times more selective; 7.5/15 mg p.o. daily Solifenacin : 5-10 mg p.o. daily Trospium chloride: 20 mg bid
Other drugs
Imipramine: 50 mg bd Flavoxate : 200 mg tds Calcium channel blocker: nifedipine Potassium channel opener: cromokaline , pinacidil PG synthetase inhibitor: flubiprophen Desmopressin (DDAFP): 2mg po at night Oestrogen
Intravesical application
Capsaicin: Neurotoxin of C fibres thereby removing affarent limb of reflex arc Indication: Detrusor Hyperreflexia, Detrusor Sphincter Dyssynergia Resiniferatoxin: 1000 times more potent, fewer side effects
Behavioral therapy
Bladder drill: Biofeedback: Hypnotherapy: Acupuncture: Endorphins & Encephalins which inhibit detrusor contraction
Transvesical applications
Phenol Injecting 10 ml. Of 6% phenol submucosally midway between blad. neck & ureteric orifice Effective in Neurogenicbladder Idiopathic overactive bladder BOTOX injection
Surgery
For severe/ intractable cases 10% Clam enterocystoplasty:Bladder bisected in coronal plane patch of gut (ileum) 25cm. Sewn around circumference may need self-catheterisation , risk of adenocarcinoma Detrusor myomectomy Urinary diversion Ileal bladder
Others
Cystodistension
Conclusion
OAB is more common than USI , may co-exist Idiopathic DO more common in mid-reproductive age Cystometry is the key urodynamic test Behavioral therapy should be tried first, then medical therapy. Surgery is the last resort. It is a disease of spontaneous exacerbations & remissions, so short courses of med. Therapy when symptom worse When co-existent with USI , DO should be treated first
Genito-urinary Fistulae
Definition
Abnormal communication between urinary system ( ureter , bladder , urethra ) and genital system (uterus , cervix , vagina ) .
True incidence not known ; av. 0.3 5% Most common is Vesico-vaginal fistula
Pathophysiology
Disruption of normal wound healing following tissue injury/trauma (which involves inflammation , angiogenesis , collagen deposition , scar remodelling) , leads to fistula formation Healing adversely affected by hypoxia, ischaemia, malnutrition, radio/chemotherapy Most present 1-3 wks after tissue injury Edges epithelialise & chronic fistula tract formed
Etiology
Congenital : e.g. ectopic ureter Acquired : obstetric pelvic surgical malignancy radiation miscellaneous : infection- LGV,TB,Actinomycosis others : forgotten pessary, other foreign body, penetrating trauma, vesical calculi etc.
Obstetric trauma
Most common cause in developing country: >90% Obstructed labour Caesarean section Difficult forceps Destructive operation
Pelvic surgery
In developed countries 90% cause is pelvic surgery ; incidence of fistula following surg is 0.1 2% Laparoscopic hysterectomy , abdominal hyst, vaginal hyst. Radical hyst, endometriosis With routine intra op. Cystoscopy case detection rate is 6.2/1000 for ureteral inj and 10.4/1000 for bladder injury
Classification
Simple Complicated: tissue loss, scarring, impaired access, ureteric orifice involvement, coexistent RVF according to siteUrethral , bladder neck, subsymphysial, midvaginal, juxtacervical, vault fistula, massive fistulae, vesicouterine, vesicocervical fistulae
Classification
from Goh
Type 1: distal edge >3.5cm from ext ur meatus Type 2: " " >2.5 3.5 cm Type 3: " " 1.5 >2.5cm " Type 4: " " < 1.5cm " Size in the largest diameter : a)<1.5cm , b) 1.5-3cm ,c) >3cm i)no/mild fibrosis and/or vag >6cm, normal capacity ii)mod./severe fibrosis &/or reduced vaginal length/capacity iii)special: postradiation,ureteric involvement, circumferencial , previous repair
Clinical presentation
Continuous dribbling of urine per vagina In large fistula , no sensation of bladder filling Sometimes levator hypertrophy , in small fistula, helps in controlling incontinence In ureterovaginal fistula, cont dribbling plus normal voiding Cyclical menouria in vesicouterine fistula Amenorrhoea , vulval excoriation Socially ostracised due to uriniferous smell
Diagnosis
History Typical uriniferous smell Identifying fistulous tract in ant vag wall/vault Finding no. of fistulous tract and coexistent other fistula Differentiating fistula from stress incontinence Measurement of Cr. content of vag fl. value >17mg/dl consistent with urine
Diagnosis
contd.
Dye test 3 swab test Cystourethroscopy : no. of fistula, prximity to ureteral opening IVP: to see renal function , ureteral involvement ; use of oral phenazopyridine with dye test/3 swab test help to identify ureteral involvement Voiding cystourethrography
Diagnosis
Retrograde pyelography Fistulography Colpography and HSG EUA
contd.
Treatment
Conservative Continuous bladder drainage by folleys catheter for 19 54 days. Small 2-3mm fistula closes in 10%cases. At least size will become smaller Fibrin sealant
Surgical
High cure rate with first attempt Appropriate pre & intra operative preparation Timely repair Multilayer , tensionfree , watertight closure Proper haemostasis Assessment of surrounding tissue viability Adequate postoperative bladder drainage
Timing of surgery
Immediately when detected at the time of surgery /within 24 hrs After 3 months : detected late .can be done early if surrounding tissue infection/ inflammation is controlled After 8 wks of failed surgery
Route of surgery
Vaginal : proper exposure is necessary scuchardts incision may be helpful position lithotomy ;reverselithotomy with head up tilt in subsymphysial fistula Abdominal :in high fistula,fixed to vault, stenosed vagina, co existent ureteral or gut fistulae Transperitoneal Transvesical Both
Interposition grafting
Martius graft: labial fat & bulbocavernosus graft. Useful in urethral or bladder neck repair Gracilis graft Omental pedicle graft Peritoneal flap graft
Ureteric fistula
Reimplantation direct reimplantation with psoas hitch Boari-Ockerblad technique Ureterouretorostomy end to side anastomosis or interposing a loop of small bowel
Results
Cure rate of obst fistula is higher: 81.7% with 1st attempt, 65% with 2nd/3rd procedure Post operative stress incontinence occurs in 10%cases specially in obst fistula involving sphincter mechanism and involving urethra or bladder neck
Subsequent pregnancy