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PROLAPSE amp UROGYNECOLOGY
DrSarsquoadeh S Jaber
MBBS MRCOGMRCPI
Consultant Gynecology ampObstetric
Makased Islamic Charitable hospital
PELVIC ANATOMY
RISK FACTORS
1048697 Vaginal delivery 1048697 Age ----- menopause 1048697 Previous prolapsed surgery 1048697 Other 1048697 Physical stress 1048697 Increase intra-abdominal pressure
DIAGNOSIS
1048697 History taking 1048697 Physical examination 1048697 Pelvic examination
stage Description
0 No descensus of pelvic structure during straining
Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring
Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring
Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
PELVIC ANATOMY
RISK FACTORS
1048697 Vaginal delivery 1048697 Age ----- menopause 1048697 Previous prolapsed surgery 1048697 Other 1048697 Physical stress 1048697 Increase intra-abdominal pressure
DIAGNOSIS
1048697 History taking 1048697 Physical examination 1048697 Pelvic examination
stage Description
0 No descensus of pelvic structure during straining
Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring
Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring
Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
RISK FACTORS
1048697 Vaginal delivery 1048697 Age ----- menopause 1048697 Previous prolapsed surgery 1048697 Other 1048697 Physical stress 1048697 Increase intra-abdominal pressure
DIAGNOSIS
1048697 History taking 1048697 Physical examination 1048697 Pelvic examination
stage Description
0 No descensus of pelvic structure during straining
Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring
Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring
Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
DIAGNOSIS
1048697 History taking 1048697 Physical examination 1048697 Pelvic examination
stage Description
0 No descensus of pelvic structure during straining
Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring
Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring
Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
stage Description
0 No descensus of pelvic structure during straining
Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring
Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring
Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
TREATMENT
1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
URINARY INCONTINENCE Definition - (ICS)
involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem
Incidence -
10-25 among population 15-64 years of age
Up to 45 around age of 70- 80
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
ETIOLOGY Multifactorial Reversible causes
delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool
impaction Anatomic defect
genuine stress incontinence
urethral sphincter incontinence
ectopic ureter
fistula Neurological defect
Detrusor instability Bladder hyperreflexia
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
CLASSIFICATION
Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence
mechanism
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
CLINICAL EVALUATION
History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia
enuresis - Triggering circumstances
key in the door intercourse helliphellip- Medical history
DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
CLINICAL EVALUATION (CONT)
Physical examination A- Routine Exam
nutritional status mental statusmobility presence of hernia neurologic exam
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
B- Specific Exam
anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia
LMNL ----- absence abdominal pelvic mass
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
C ndash Pelvic Exam
Inspection -atrophy fistulainfection irritation
palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary
incontinence
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
INVESTIGATION
1 ndash UA Culture may indicate infection or stone
2 ndash Pad test weighing pad after exercise
3 ndash Provocative testuarr intra abdominal pressure on full bladder
4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as
well as detrusor instability
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
5 - Uroflowmetry
does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
NORMAL VOIDING
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
OBSTRUCTIVE VOIDING
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
6 ndash Cystometry = Gold Standard =Demonstrate -
capacity filling phase storage detrusor function
Demonstrate -volume pressure contraction
relationship
Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700
ml
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
7 ndash Video urodynamics cysto flowmetry + radiological
contrast imaging
8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
STRESS INCONTINENCE Definition -
objectively demonstrable UI associated with increased intra abdominal pressure
Incidence -
Diagnosis -History exam urodynamic
assessment Note - bladder is unreliable wittness
D Dx -DI Overflow Extra urethral
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
MANAGEMENT
1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine
Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
3) SURGICAL -
Overview about principle
a- anterior vaginal wall repair ldquokelly plication
particularly relevant if cystocele present
gt5 year success rate 37complication rate 1voiding problem DI 4
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
b- Marshall-Marchetti-Krantz urethropexy-
suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
c- Burch colposuspension -
suturing the periurethral tissue to cooperrsquos ligament
initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10
modification
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
d- Bladder neck suspension -(Pereyra stamey Raz )
transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
e- TVT
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic
can be done at bladder neck level ldquopreferablerdquo or at periurethral
meatus
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
Injection of collagen in the periurethral tissue for the treatment of stress incontinence
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
g- artificial sphincter
h- urinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
COMPLICATION -
- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
DETRUSOR INSTABILITYInvoluntary detrusor contraction
Unknown etiology -associated with SI bladder outlet
obstruction aging CNS problemIncidence -
5-50 depending on age up to 80 of institutionalized women
Diagnosis- history exam urodynamic study---contraction during
the filling phase
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
MANAGEMENT
a- behavioral modification
education timed voiding + reinfocement
b- bladder retraining (drill)
resisting urge sensation rarr increase bladder volume by postponing voiding
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
c- Medical
1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect
2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile
3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis
coital UI4) HRT plusmn
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion
d- Surgical -
Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion