Mechanisms of Incontinence

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Genuine stress incontinence: Following trauma and/or other causes of weakness of the pelvic diaphragm (such as childbearing), the proximal urethra may fall below the pelvic diaphragm. When the patient coughs, intra-abdominal pressure is exerted to the bladder but not to the proximal urethra. When the bladder pressure equals or exceeds the maximal urethral pressure, then urinary flow occurs. Because this is a mechanical problem, the patient feels no urge to void, and the loss of urine occurs simultaneously with coughing. There is no delay from cough to incontinence. Urethropexy replaces the proximal urethra back to its intra-abdominal position (Figure 1-1). More recently, narrow strips of polypropylene mesh have been used to suspend the midurethra because of the theory that urinary incontinence occurs due to pubourethral ligament insufficiency. These include various tension-free vaginal tape procedures, but long-term outcomes are not yet available.

Tension Free Vaginal Tape

nence, and after urethropexy. Normally, a Valsalva maneuver causes the increased intra-abdominal pressure (P) to be transmitted equally to the bladder and urethra (A). With genuine stress urinary incontinence, the proximal urethra has fallen outside the abdominal cavity (B) so that the intraabdominal pressure no longer is transferred to the proximal urethra, leading to incontinence. After urethropexy (C). pressure is again transmitted to the urethra.

Table 1-1

DIFFERENTIAL DIAGNOSIS OF URINARY INCONTINENCE

Table 1-1

DIFFERENTIAL DIAGNOSIS OF URINARY INCONTINENCE

DIAGNOSTIC

MECHANISM

HISTORY

TEST

TREATMENT

Genuine

Bladder neck

Painless loss

Physical

Urethropexy

stress urinary

has fallen out

of urine

examination:

(Burch

incontinence

of its normal

concurrent

loss of bladder

procedure) to

intra

with Valsalva;

angle;

return

abdominal

no urge

cystometric

proximal

position

to void

examination

urethra back to

intra-abdominal

position

Urge

Detrusor

Urge

Cystometric

Anticholinergic

incontinence

muscle is

component,

examination

medication to

overactive and

"I have to

shows

relax detrusor

contracts

go to the

uninhibited

muscle

unpredictably

bathroom and

contractions

(surgery

can't make

may worsen)

it there in lime"

Overflow

Overdistended

Loss of urine

Postvoid

Intermittent

incontinence

bladder due to

with Valsalva;

residual

self-

hypotonic

dribbling;

(catheterization)

catheterization

bladder

diabetes or

shows large

spinal cord

amount of

injury

urine

Fistula

Communication

Constant

Dye into

Surgical repair

between

leakage after

bladder

of fistulous

bladder or

surgery or

shows

tract

ureter and

prolonged

vaginal

vagina

labor

discoloration

Urge incontinence: With uninhibited spasms of the detrusor muscle, the bladder pressure overcomes the urethral pressure. Dysuria and/or the urge to void are prominent symptoms, reflecting the bladder spasms. Sometimes, coughing or sneezing can provoke a bladder spasm so that a several-second delay is noted before urine loss.

Overflow incontinence: With an overdistended bladder, coughing increases the bladder pressure and eventually lead to dribbling or small loss of urine.

Clinical approach: The history, physical examination, urinalysis, and postvoid residual are part of the initial evaluation of urinary incontinence (Table 1-1). Behavior therapy, including timed voiding and pelvic musculature strengthening, seem to have a role and generally should be the first line of treatment.

Comprehension Questions

Match the following single best therapy (A-G) that most likely will help in the clinical situation described (1.1-1.4):

A. Burch urethropexy

B. Oxybutynin (Ditropan. an anticholinergic medication)

C. Placement of ureteral stents

D. Surgical repair of the fistulous tract

E. Propranolol (Inderal)

F. Placement of an artificial urethral sphincter

G. Intermittent self-catheterization

11.1] A 42-year-old woman has long-standing diabetes mellitus and complains of small amounts of constant dribbling of urine loss with coughing or lifting.

[ 1.2] A 39-year-old woman wets her underpants two to three times each day. She feels as though she needs to void, but she cannot make it to the restroom in time.

[ 1.3] A 35-year-old woman has undergone four vaginal deliveries. She notes urinary loss six to seven times per day concurrently with coughing or sneezing. She denies dysuria or an urge to void.

[ 1.4) A 55-year-old woman notes constant wetness from her vagina following a total vaginal hysterectomy.

Answers

[ 1.11 (i. This patient has long-standing diabetes mellitus, which is a risk factor for a neurogenic bladder leading to overflow incontinence. Other causes include spinal cord injury or multiple sclerosis. These patients generally do not feel the urge to void and accumulate large amounts of urine in their bladders. The best therapy for overflow incontinence (neurogenic bladder) is intermittent self-catheterization.

11.2] B. This woman's prominent urge component makes urge incontinence the most likely diagnosis, best treated with anticholinergic medications.

[ 1.3] A. This clinical presentation is consistent with GSUI and is best treated by urethropexy. There is some evidence that vaginal deliveries may increase the incidence of GSUI due to trauma to the pelvic diaphragm.

11.4| D. Constant wetness after a pelvic operation suggests a fistula, such as vesicovaginal fistula, which is best treated with surgical repair.

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