Genuine stress incontinence

INTRODUCTION:

• Genuine stress incontinence (GSI) occurs when the bladder pressure exceeds urethral pressure during physical stress in the absence of detrusor contraction.
• It is defined as a small involuntary leakage of urine with increased abdominal pressure in the absence of detrusor contract

ETIOLOGY:

• Anatomical changes in the urinary tract such as hypermobility of urethra (80%), loss of posterior angle or sphincteric dysfunction.
• Age: Older menopausal women with loss of pelvic muscle tone are liable to develop GSI (oestrogen deficiency).
•  Multiparous women after repeated childbirth are prone to loss of tone of the pelvic floor muscles.
• Obesity, smoking, prolapse and constipation.
• Pregnancy and puerperium—during pregnancy, stress incontinence is due to the progesterone hormonal effect and the pressure of the gravid uterus on the bladder neck.
• Urinary incontinence in uterovaginal prolapse is mostly is due to Stress incontience
• During puerperium, the stress incontinence is caused by the descent of the bladder neck, the loss of urethrovesical angle due to pudendal nerve denervation, and diminished tone and stretching of levator ani muscles during vaginal delivery.
• Hereditary—loss of collagen tissue.
• Repair of VVF and urethral fibrosis may also cause GSI.

INVESTIGATIONS:

• Creatinine and Electrolytes, fasting Glucose and Calcium (for patients with Polyuria).
• Renal Ultrasound in patients with incomplete emptying.
• Urine Culture.
• Bead cystogram is used for the diag­nosis of Stress incontinence    
• Bonney’s test
• Urodynamic Evaluation(To differentiate between stress incontinence and detrusor instability)
• Residual Urine
• Uroflow
• Pressure flow study
• Cystometrogram
• Abdominal Leak-Point Pressure (ALPP)
• Cystoscopy

TREATMENT: 

Non-Surgical Treatment

1. General – Fluid intake, weight loss, smoking, cough. Distance to toilet – bedside urinal, underwear with Velcro, pads.
2. Estrogen 
3. Stop Alpha Blockers (Cardoxan) 
4. Alpha-adrenergic agonists
5. Bladder relaxants – e.g. Detrusitol (Tolterodine), Ditropan (Oxybutynin),  Imipramin (Imipramine)
6. Physiotherapy :Pelvic floor muscle exercises, Tension Free Vaginal Taping (TVT)

• Stress incontinence is repaired by  Marshall Marchatti Krantz repair 
• Bladder neck & vault of vagina are sutured to the  eriosteum of Pubic sym­physis

• Kelly’s plication : It is done for management of stress incontinence.
• The technique includes anterior colporrhaphy with plication of bladder neck.

Burch Colposuspension­:

• Here bladder neck and va­gina vault are suspended using the ileopectineal ligaments.
• Pacey’s repair- In this technique medial fibres of Puborectalis muscle are apposed in midline under the bladder neck to elevate it
• Pereyra’s operation: Combined Abdominal & Vaginal operation
• Stanley’s combined vaginal and supra pubic operation

Exam Question

 

• Bonney’s test is used to demonstrate Stress incontinence
• Stress incontinence is repaired by  Marshall Marchatti Krantz repair 
• Stress incontinence is a common symptom in Prolapse uterus
• Kelly’s suture is done in Stress incontinence
• Urinary incontinence in uterovaginal prolapse is mostly is due to Stress incontience
• Treatment of genuine stress incontinence are Anterior colporrhaphy, Pelvic floor exercise & Colposuspension
• Bead cystogram is used for the diag­nosis of Stress incontinence    
• The recommended non surgical treatment of stress incontinence is Pelvic floor muscle exercises
• Tension Free Vaginal Taping (TVT)  is the treatment of choice for genuine stress incontinence
• To differentiate between stress incontinence and detrusor instability investigation done is  Urodynamic study