排尿障礙治療中心版權所有 stress urinary incontinence hann-chorng kuo department of...

排尿障礙治療中心版權所有

Stress Urinary Incontinence

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


Incontinence

• Definition

Failure of voluntary control of urination causing loss of urine per urethra


Types of Incontinence by symptomatology

• Continuous or total incontinence

• Urge incontinence

• Stress incontinence

• Overflow incontinence

• Transient incontinence

• Giggle incontinence


Types of Incontinence by Pathophysiology

• Bladder related incontinence

Detrusor overactivity

Detrusor underactivity & low compliance

• Urethral related incontinence

Intrinsic sphincteric deficiency

Hypermobility of bladder neck & urethra

• Mixed type of incontinence


Continence mechanism

• Stable bladder

• High position of bladder neck

• Good urethral coaptation

• Competent bladder neck

• Positive pressure transmission ratio

• Reflex contraction of periurethral muscles


Extrinsic Continence Mechanism

• Pubourethral & pubovesical ligaments

• Pubocervical fascia

• Attachments to archus tendineus fascia pelvic

• Vaginal endopelvic fascia

• Attachments to levator ani

• Uterosacral ligaments


Pubovesical pubourethral and pubocervical ligaments


Extrinsic continence mechanismThe Levator ani muscles


Extrinsic continence mechanismThe puborectalis muscles


Extrinsic continence mechanismThe Uterosacral ligaments


Extrinsic continence mechanism


Attachments of endopelvic fascia


Defects in Exterinsic continence mechanism• Hypermobility of Bladder neck and urethra

• Loss of hammock effect during increased abdominal pressure

• Low pressure transmission ration to urethra

• Causing cystocele or stress incontinence

• Coexisting prolapse


Causes of defects in Extrinsic continence mechanisms• Multiple childbirth

• Hysterectomy

• Menopause

• Surgical trauma

• Peripheral neuropathy (Pudendal nerve)

• Ageing process

• Chronic debilitative diseases


Hypermobility of Bladder neck & urethra


Low pressure transmission ratio


Cystocele formation in defects of extrinsic continence mechanism


Intrinsic Continence Mechanism

• Urethral mucosa

• Submucosal vasculature

• Connective tissue

• Urethral smooth muscles

• Urethral striated muscles


Urethral muscles

• Urethral smooth muscle

Thick inner longitudinal & outer circular m.

Pudendal anesthesia cannot block • Urethral striated muscle

Surround smooth muscle coat

about 20-64% of urethral length

mainly of slow twitch fibers

muscle blocker blocks 40% of muscle tone


Anatomy of female urethra


Changes of maximal urethral closure pressure with age

Age Number MUCP

(cmH2O)

FPL

(cm)

≦ 29 12 90.28±39.43 (7) 2.86±0.44 (7)

30-39 39 81.52±22.78 (21) 2.89±0.47 (21)

40-49 61 72.40±26.95 (29) 2.85±0.59 (29)

50-59 62 66.74±32.16 (28) 2.98±0.83 (28)

60-69 40 63.19±26.09 (21) 2.88±0.66 (21)

≧ 70 23 53.36±26.13 (8) 2.71±0.59 (8)

Regression analysis P=0.0010 P=0.8279

Total 237 70.75±29.80 (114) 2.89±0.65 (114)


Anatomical classification of SUI

• Type I: hypermobility of bladder neck without loss of urethrovesical angle

• Type II: hypermobility of bladder neck with inferior and external rotation of VUJ

• Type III: intrinsic sphincteric deficiency with none or minimal hypermobility

• Mixed type II & III SUI


Classification of SUI by Leak-point pressures

• Type 1 SUI : Abdominal leak-point pressure >120cm water with hypermobility

• Type 2 SUI : ALPP >90 cm water with urethral hypermobility

• Mixed type 2 & 3 SUI : 60 <ALPP< 90 with hypermobility

• Type 3 SUI : ALPP < 60 cm water without hypermobility


Cough vs Valsalva LPP

• Cough induced reflexic contraction of levator ani and enhance urethral closure by vaginal endopelvic fascia, against urethral resistance and extrinsic continence mechanism

• Valsalva maneuver causing bearing down of pelvic floor muscles, against intra-urethral resistance

• CLPP > VLPP in most cases with SUI


Continence mechanism and LPP


Grades of Stress incontinence

• Rare: occur less than 1/month, small amount, no pad protection

• Minimal: occur only with severe straining, small amount, no pad protection

• Moderate: occur with mild straining, pad protection is needed

• Severe: occur with changing position or total incontinence


Diagnosis of stress incontinence

• Symptomatology: grades of SUI, types of urinary incontinence

• Physical signs: demonstration of incontinence or fistula, associated with cystocele or uterine prolapse

• Endosonography of bladder & urethral• Urodynamic study• Leak point pressure measurement


Physical examination of SUI

• Cystocele Uterine prolapse


Ectopic ureteral orifice & urinary incontinence


Urodynamic study for SUI

• Routine cystometry cannot confirm SUI, but can diagnose detrusor overactivity and low compliant bladder

• Leak point pressure is a better diagnostic tool to stage stress incontinence

• Maximal urethral closure pressure has a low but significant correlation with ISD


Poor compliant bladder and SUI


Detrusor instability and mild Intrinsic sphincter deficiency


Videourodynamics in SUI

• Videourodynamic study can determine leak point pressures and the bladder neck hypermobility during stress

• Leakage of urine is clearly demonstrated and the accurate leak point pressure can be measured

• Concomitant pressure flow study to avoid misdiagnosis of bladder outlet obstruction


Detrusor overactivity without Anatomical stress incontinence


Uterine prolapse and cystocele causing bladder outlet obstruction


Reduction of prolapse relieves BOO in patient with SUI


Measuring LPP and Pressure flow study in SUI


Leak point pressure in SUI

• Cough LPP and Valsalva LPP should be measured concomitantly

• VLPP measures intrinsic urethral resistance

• CLPP measures resistance from intrinsic and extrinsic continence mechanisms

• Measure the pressure at exactly the point that urine loss


Cough v Valsalva Leak-point pressure


Pelvic Floor RelaxationLow LPP without Hypermobility


Pelvic Floor Relaxation High LPP with hypermobility


Pelvic Floor RelaxationCLPP>VLPP, mild hypermobility


Pelvic Floor RelaxationCLPP=VLPP with hypermobility


Mechanisms causing leak-point pressures and Hypermobility


Urethral pressure profilometry in Diagnosis of SUI

• Perfusion UPP or microtip catheter UPP• A lower MUCP was measured by microtip

catheter• A lower MUCP is associated with a lower

Valsalva LPP (p=0.011) and cough LPP (p= 0.005)

• Dynamic UPP to measure pelvic floor muscle contractility and effect on urethra


Good PTR and Pelvic floor contraction pressure


Low PTR and good pelvic floor contraction pressure


Equal pressure transmission in urethra during stress UPP


Higher pelvic floor muscle contraction pressure at distal urethra


Correlation of MUCP with VLPP and CLPP


Endosonoraphy of Bladder and urethra in SUI


Measurement of Urethral striated muscle component


Poor urethral striated muscle component in type III SUI


Reduced striated muscle component in SUI

Patients NCross-Sectional Area

(mm2)

Smooth Muscle Component

(mm2)

Striated Muscle Component

(mm2)

A.Non-SUI 51 104.4 ±35.6 46.1±22.5 58.3±27.3

B.SUI 60 86.7 ±29.9 43.9±19.0 42.8±20.7

Cystocele* (9) 75.7 ±23.1 37.9±12.2 37.8±22.8

Statistics A vs B:P=0.005 NS A vs B: P=0.001


Measurement of hypermobility of bladder neck


Measurement of hypermobility and pubourethral ligaments


Increased rotational angle but not pubourethral length by endosonographic classification of SUI

Types of SUI 1 (n=25) 2 (n=31) 3 (n=31) 4 (n=12) 5 (n=3) Statistics1

PV angle

Resting(degrees)

25±14.2 33.7±17.1 39±17.4 75.8±13.1 46.7±47.3 P<0.01

Straining 42.4±18.9 64.4±20 82.6±21.9 109±12.4 50±53 P<0.01

Increase 17.4±15.3 30.8±15.6 43.5±19.5 33.3±8.9 3.3±5.8 P<0.01

Statistics2 P<0.005 P<0.005 P<0.005 P<0.005 P>0.1

PV length

Resting (mm)22.6±4.8 22.6±5.7 19.2±4.6 21.5±4.2 19.7±2.9 P>0.05

Straining 22.5±4.5 22.8±5.7 21.1±5.1 26.3±6.8 22±7.2 P>0.05

Increase 0.1±1.59 0.2±3.04 1.9±3.72 4.8±4.94 2.3±4.51

Statistics2 P>0.4 P>0.3 P>0.005 P>0.005 P>0.2


Diagnosis of Stress Incontinence

• Determine the underlying pathophysiology causing incontinence

• Therapeutic modality depends on grades of SUI

• Correct the exact defects in continence mechanisms

• Search for coexisting mixed incontinence and vaginal prolapse

排尿障礙治療中心 版權所有 stress urinary incontinence hann-chorng kuo department of...

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排尿障礙治療中心版權所有 stress urinary incontinence hann-chorng kuo department of...