Urinary Incontinence. Anatomy and Terminology Overview. Moeen Abu-Sitta, MD, FACOG, FACS

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1 Urinary Incontinence Anatomy and Terminology Overview Moeen Abu-Sitta, MD, FACOG, FACS

2 Purpose Locate and describe the anatomy of the Female Urinary System Define terminology related to Incontinence Describe condition and disease states of Incontinence

3 Urinary Incontinence Urinary Incontinence (UI) is the involuntary loss of urine. Afflicts an estimated 13 million adults in U.S. (85% of them being women.*) *American Urological Association, Female Stress Urinary Incontinence Guidelines Panel. The Surgical Management of Female Stress Urinary Incontinence. 1997:1

4 Anatomy of the Urinary Tract

5 Bladder and Uretra

6 Anatomy Median Section Ureter Bladder Pubic Symphisis Urethra Deep Dorsal Vein of Clitoris Crus Labia Minora Labia Majora Bowel Uterus Rectum Levator Ani

7 Levator Ani A broad muscle that helps to form the floor of the pelvis. Anterior fibers of the Levator ani descend upon the side of the vagina

8 Urinary Incontinence Causes, Symptoms, Types, Diagnosis, Treatment Options

9 Common Causes of Female Urinary Incontinence Pelvic surgery Injuries to the pelvic region or to the spinal cord Neurological diseases Multiple sclerosis Obesity Urinary tract infection Degenerative changes associated with aging Childbirth Post-menopausal

10 Birth Trauma

11 Common Symptoms of Female Urinary Incontinence Involuntary loss of urine due to physical activity Inability to resist urine leakage after feeling the urge to urinate Urinating more frequently than usual Pain while urinating Bladder infections Feeling that the bladder is never completely empty even after urinating Abnormal urination patterns

12 What is Normal Urinary Function? Bladder Uterus Vagina Pubic Bone Bladder Neck Urethra Sphincter

13 Common Types of Female Urinary Incontinence? Stress Urge Overflow Mixed (Urge & Overflow)

14 Urge Incontinence The sudden involuntary loss of urine that takes place as soon as the urge to urinate is felt.

15 Overflow Incontinence The involuntary loss of urine that occurs when the bladder overfills to the point of leakage. The bladder feels as though it is never completely empty.

16 Mixed Incontinence? A Mixture of Incontinence Types Urge Overflow

17 Hypermobility ( Hyper means too much and mobility refers to movement.) When the normal pelvic floor muscles can no longer provide support to the bladder and thus, involuntary leakage occurs. Bladder Neck Drops

18 How is Urinary Incontinence Diagnosed? Medical history Physical examination Diagnostic tests: Blood test Cystoscopy Post Void Residual (PVR) Stress test Urinalysis Urodynamic testing

19 Urodynamic Tests Evaluate the storage of urine in the bladder through the urethra Measures: Contraction of bladder muscle as it fills/empties How: Fill bladder with water or gas Another catheter in rectum to measure pressure on the bladder when straining/coughing Can substitute water with x-ray dye so pictures can be taken to detect bladder abnormalities

20 Urodynamics

21 Urodynamics

22 What are Some Common Non-Surgical Treatment Options? Bladder training Timed voiding Pelvic muscle exercises (Kegels) Drug therapy (urge incontinence) Absorbent products Double void, after urinating wait a few seconds and void again Avoid constipation by eating many fruits, vegetables and whole grains each day Avoid over consumption of urethral irritants such as alcohol, caffeine and nicotine Avoid overuse of drugs such as diuretics, antidepressants, antihistamines, cough/cold preparations

23 What are Some Common Surgical Treatment Options? Burch Procedures: retropubic procedure performed percutaneously through abdomen MMK Procedures Needle Suspensions: place sutures through fascia into publc bone through abdominal incision

24 What are Some Common Surgical Treatment Options? Sling Procedures: minimally invasive surgical procedure that is intended to create hammock like support for the bladder & sphincter. Bulking Agents: Injectable agents increase the bulk around the urethra, helping to close the sphincter and control urinary loss.

25 Pelvic Floor Anatomy, Disease State & Treatment Options

26 Purpose Locate and describe the anatomy of the Pelvic Floor Structure Define terminology related to pelvic floor reconstruction Describe conditions and disease states of the pelvic floor

27 The Pelvic Floor Network of muscles, ligaments, and fascia that support abdominal and pelvic organs Proper support of pelvic organs is important to proper functioning of those organs

28 Pelvic Floor Reconstruction Surgical correction of pelvic floor defects Goal: improve support, positioning and therefore functioning of pelvic organs Structures affected: vagina, bladder, urethra

29 Support Anterior Vagina & Urethra

30 Prolapse Slipping or falling out of place Type of hernia, with tissue protruding into another space because of weakened tissue

31 Pelvic Prolapse Inadequate support from system of pelvic connective tissues Three types: Anterior Posterior Apical Uterine

32 Pelvic Floor Defects 5 to 10 million women affected by pelvic floor dysfunction 400,000 surgical procedures performed in U.S. 40% of all women age will have significant prolapse (grade 2 or better)

33 What causes Pelvic prolapse? Intra-abdominal pressure during childbirth (99%) Hysterectomy Chronic respiratory disease Obesity Aging Chronic cough Work that requires heavy lifting or high impact activity Chronic constipation Decreased estrogen levels during menopause can decrease the strength of pelvic tissues Affects approximately 100,000 patient every year in U.S. Only 42,000 seek treatment

34 Symptoms of Pelvic Prolapse Lump or heavy sensation in the vagina Lower back pain that eases when you lie down Pelvic pain or pressure Pain or lack of sensation during sex Bladder prolapse may cause incontinence, frequent or urgent need to urinate or difficulty urinating Prolapse of the rectum may cause constipation or difficulty defecating

35 Anterior Defects: Cycstocele Herniation of the bladder into the vagina Dropped bladder Midline defect: damage to pubocervical fascia Lateral defect: detachment of fascia from arcus tendineus

36 Entrocele Anterior & Posterior Bulging of the small intestine into the vaginal wall Normal Anterior Entrocele Posterior Entrocele

37 Posterior Defects: Rectocele Bulging of the rectum into a weakened lower vaginal wall

38 Apical Defects Uterine Prolapse Dropped womb uterus and cervix drop down toward the opening of the vagina after the pelvic tissues that support them have been weakened.

39 Pelvic Floor Reconstruction Treatment Options

40 Review Symptoms of pelvic prolapse Non-surgical and surgical treatment options

41 Symptoms Incontinence Frequent or urgent need to urinate or difficulty urinating Constipation or difficulty defecating Dragging or heaviness in pelvic area Lower back pain that eases when lying down Pelvic pain or pressure Pain or lack of sensation during sex With severe prolapse: skin may become irritated, raw or infected

42 Diagnosing Pelvic Prolapse Pelvic examination Feel for lumps or bumps in pelvic area Examine walls of vagina for bulges Ask patient to cough or strain to see if pelvic organs prolapse into vaginal walls Exam might be done while standing Determine Grade of Pelvic Prolapse When cycstocele is present can do a strain-hold-elevate test to determine mid-line or lateral defect

43 Uterine Prolapse Grade 1 Grade 2 Grade 3 Grade 4 Grade 1 The most distal portion of the vagina is more than 1 cm above the hymen Grade 2 The most distal portion of the vagina is within 1 cm above or below the level of the hymen Grade 3 The most distal portion of the vagina protrudes 1 and 2 cm past the hymen Grade 4 The vagina is completely everted and protruding from the hymen

44 Apical Defects Complete eversion Entire vagina lying outside of the pelvic area. Due to loss of support in the uterosacral and cardinal ligaments.

45 Non-Surgical Treatment Options Watchful waiting Pessaries Ring placed in apex of vagina to help support the vagina Placed intra-vaginally What it does: Help physician verify a diagnosis of pelvic prolapse Uncover stress urinary incontinence pessary test Suppor the vagina and help relieve symptoms Alleviate symptoms while patient waits for surgery

46 Surgical Treatment Options Colporrhaphy Sacrospinous ligament fixation Sacrocolpopexy Vaginal vault suspension

47 Vaginal Vault Prolapse Repairs Involve Performing Several Procedures A typical case could include: Hysterectomy Cystocele, enterocele, and rectocele repair Lateral defects repair Incontinence repair

48 The Surgical Goals for Vaginal Reconstruction Surgery include: Relieve the symptoms Restore the anatomic relationships between the pelvic organs Restore the function of each pelvic floor compartment

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