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Female UrinaryIncontinence -An update in
surgical management
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Overview

• The Problem
• Anatomy of the female urethra
• Incontinence stress and urge
• Diagnosis
• Non-surgical and surgical treatment

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Definition
Incontinence Stress incontinence leakage
associated with exertion, coughing sneezing or
laughing Urge incontinence leakage with
antecedent urgency Mixed incontinence leakage
associated with both symptoms
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Epidemiology
Incontinence in women 19 billion dollars / yr
Silent Epidemic
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Prevalence in women
Stress 49 Urge 22 Mixed 29
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Risk and Contributing Factors

• Age
• Parity
• Obesity
• Vaginal delivery
• Episiotomy
• Diabetes
• Stroke
• menopause
• Genitourinary surgery and radiation

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ANATOMY

• Bladder functions as low pressure reservoir
  allowing intermittent voiding within socially
  acceptable limits.
• Continence is maintained as UCP is higher than
  expulsion pressure.
• Urethra supported by - Externally pubourethral
  ligament, striated muscle of pelvic floor.
  Internally smooth muscle of urethra, ext
  urethral sphincter, periurethral collagen
  connective tissue, submucosal venous plexus,
  mucosal coaptation of the urothelium.
• Proximal urethra is well supported so a rise in
  intraabdominal pressure is equally transmitted to
  bladder urethra.

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NERVE SUPPLY

• Bladder,bowel sexual functions- parasympathetic
  somatic via S2,3,4.
• Sympathetic supply - T10-L2 segments - detrusor
  muscle.
• Parasympathetic promotes micturition -
  contracting detrusor, relaxing urethra.
• Sympathetic - B receptors in bladder -
  relaxation, A receptors in bladder neck
  increasing urethral resistance.
• Central control - pontine center, receiving
  afferent and efferent from cerebral cortex,
  cerebellum and spinal center.
• Normally detrusor is reflexly inhibited by
  sympathetic neurones (storage and filling),
  control acquired in infancy. Detrusor contraction
  mediated by parasympathetic supply. M3 receptors .

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Anatomy
Urethral sphincter 2 components striated and
smooth muscle
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Anatomy
Striated sphincter is a horseshoe configuration
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Stress Incontinence

• Hammock theory
• Intrinsic sphincter deficiency

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Hammock Theory

• Urethral hypermobility structural loss of
  support for urethra leads to movement of the
  urethra during stress maneuvers and leak
• Problem little correlation many women had
  urethral hypermobility with no incontinence

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Hammock Theory
ATFP
The arcus tendinous fascia pelvis acts as beams
in the pelvis with the endopelvic fascia serving
as a hammock underneath the urethra
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Hammock Theory
Pressure
Hammock of endopelvic fascia acts as a backboard
for the urethra to be compressed against when
there are increases in abdominal pressure
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Urethral hypermobility
Valsalva
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Intrinsic Sphincter Deficiency (ISD)

• ISD certain number of women did not have
  hypermobility, but had a fixed incompetent
  sphincter
• Integrated theory Stress incontinence is a
  spectrum, all women have some degree of ISD the
  urethra should remain closed during any amount of
  descent and rotation during stress

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ISD
Open and pipe like urethra
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Stress Urinary Incontinence Assessment Medical
History

• Urinary function
• Sexual difficulties
• Bowel function
• Quality of Life (QoL) patient perspective
• Relevant general medical history

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Urinary Incontinence Investigation
Simple Complex (Office
tests) (Urodynamics) Urinalysis
Uroflowmetry Urine culture Cystometry Urinary
diary Urethral function tests Pad test
Ultrasound Videocystometry Ambulat
ory urodynamics
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History
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Diagnosis

• Simple question in history
• Vaginal Exam and pelvic organ prolaps
• Stress Test
• Questionnaire
• A systematic assessment combining
• the history, physical examination, and results of
  bedside tests
• Voiding Diary
• Urodynamics

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Diagnosis

• Physical exam rule out pelvic organ prolapse or
  vaginal atrophy
• Voiding Diary
• UA rule out infection or hematuria
• Direct observation demonstration of stress
  incontinence with valsalva or cough
• Pad test

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Urogynecology Blending Of Specialties


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Treatment Stress Incontinence

• Nonsurgical
• Pelvic floor muscle training (Kegels)
• Biofeedback
• Electrical stimulation
• Pessaries
• Surgical recreating urethral support
• Abdominal
• Vaginal

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Outcomes Nonsurgical

• Modest improvements
• Pts with a small amount of leakage
• Pts who want a conservative trial
• Pts with significant comorbidities

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Each capsule contains your medication plus a
treatment for each o f its side effects.

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Surgical

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Surgical

• Surgical recreating urethral support allowing
  for coaptation of the urethra during increased
  abdominal pressures
• Abdominal approaches
• Open retropubic colposuspension
• Burch
• Marshall-Marchetti-Krantz (MMK)
• Contemporary
• Pubo-vaginal sling
• Tension free vaginal tape (TVT)
• Tranc obtrator tape( TOT)
• Mini-slings
• injectables

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Surgery
A Burch Colposuspension
C Tension-free Vaginal Tape
B Fascial Sling
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A Burch Colposuspension
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Facial sling
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Tension-free Vaginal Tape
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Stress Urinary Incontinence Less Invasive
Surgery Mid-urethral Tapes
meatus
mid-urethra
bladder neck
Cadaveric dissection showing position of
mid-urethral hammock
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Stress Urinary Incontinence Less Invasive
Surgery Trans-obturator Tapes
Anatomical landmarks Tape passes through medial
edge of obturator foramen just below the
insertion of the adductor longus tendon
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Obturator Approach
Transobturator tape (TOT)
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Midurethral Slings
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Suprapubic Approach
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Midurethral Sling

• Day surgery
• 10-20 minute procedure
• IV Sedation local anesthesia
• Requires 1-2 weeks off work
• Complications Rare
• Bleeding, infection, voiding dysfunction, mesh
  erosion
• TVT bladder/bowel/ vessel injury
• TOT vaginal perforation, leg/groin pain
• Efficacy
• Almost comparable

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Mid Urethral Tapes - MUTS


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Mini Sling TVT SECUR System
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Priurethral Injection

The principle of peri-urethral bulking
injections is to create sub mucosal cushions
ensuring apposition of the urethral wall, which
aids continence. The advantages of this
technique include the low associated morbidity.
. It can be carried out under local
anesthesia does not necessitate an inpatient
stay. The injection of collagen as a bulking
agent was compared with three types of open
surgery for SUI (Burch colposuspension, Sling
procedure and Bladder neck suspension procedure)
in a study by Corcos in 2001.44 The subjective
outcomes at 12 months were not significantly diffe
rent (53 cured in injection group compared with
72 in the open surgery group), but objective pad
weight testing revealed more people were cured
after open surgery. However complication rates
were significantly higher for those undergoing
open surgery and the nature of those
complications more severe.
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Priurethral Injection for SUI
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Patient reported outcomes
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Stress Urinary Incontinence Surgical Treatment
Cure Rates
Objective cure rates for first procedure and
recurrent incontinence6
Randomised control trial evidence suggests that
Tension-free Vaginal Tape (TVT) has a similar
cure rate to colposuspension. Many of the other
less invasive, mid-urethral slings have not yet
been adequately tested
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Summary

• SUI is a common problem in women
• Conservative Tx
• Kegels, weight reduction, pessary, (meds)
• Surgical Tx
• Minimally invasive mid urethral slings
• Day surgery
• Quick recovery
• Little risk
• Good outcome

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Prevention
Given the observational data indicating
increased rates of stress incontinence among
women who have undergone vaginal delivery as
compared with cesarean delivery cesarean
delivery has been proposed as a strategy to
prevent stress incontinence.

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