Incontinence Flashcards
Intrinsic sphincter deficiency
Proposed by McGuire in 1970s
Sphincter denervated or undergoes direct mechanical or ischaemic injury
ie childbirth
ISD often co exists with urethral hypermobility
Difficult to separate out as distinct entities
Female urethra continence mechanism
Bladder neck IUS absent in 40% of women, weak
Distal sphincter longitudinal smooth intrinsic muscle
And larger extrinsic muscle striated
Of which 87% slow twitch tonic contraction
Relaxation by inhibition of guarding reflex which is inhibiting PSNS
Ex muscle in proximal and mid urethra
Horseshoe shaped ventral and lateral
Submucosa vascular in middle and distal third contributes to urethral closure pressure
In females, the bladder neck sphincter is far weaker than in the male and
is absent in 40% of women.
Therefore, urinary continence relies upon the integrity of the distal
sphincter, which is composed of longitudinal intrinsic urethral smooth
muscle and a larger extrinsic striated muscle component located in
proximal and or mid urethra.
The horseshoe-shaped circular striated sphincter is most developed in the
middle-third of the urethra, with the muscle fibres present ventrally and
laterally.
It is composed of 87% type I slow-twitch fibres (13% fast twitch)
surrounded by collagen. Given the lack of a proximal sphincter, during a
cough, urine will enter the proximal urethra. In addition, in the middle and
distal thirds of the urethra, a richly vascular submucosa supports the
urethral epithelium and contributes significantly to urethral closure
pressure
Up to 30% of forces responsible for maintaining continence in women
derived from intrinsic properties urethral mucosa and urethral wall
Urethral submucosa enhances apoosition of urethral mucosa helping to
create an effective watertight seal
Incontinence and pressures
UI results when intravesical pressure exceeds intra urethral pressure
External sphincter
muscle vs levator ani
Striated muscle of ex sphincter comprised
Causes of UI due to bladder dysfunction
ncreased detrusor pressure may result in UI
Either due to low compliance or DO
Low compliance – damage to innervation, radical pelvic surgery or
suprasacral spinal cord lesion or
Processes that alter extracellular matrix content of bladder wall by
producing fibrosis following irradiation or BOO may also reduce
compliance
DO idiopathic or neurogeni
Bulbocavernosus reflex
Present in all normal males and 70% of females
Represents S2-4
Elicited by squeezing glans penis or clitoris
During UDS, positive BCR shows increased
Complicated incontinence-9
Pain Haematuria Recurrent UTI Pelvic surgery or radiotherapy Constant leakage suggesting fistula Grade 3 or symptomatic prolapse Previous pelvic surgery Previous surgery for UI Pelvic mass
Neurological screening questions (4)
Tremor Coordination Reduced mental faculties Erectile dysfunction Back pain
Because neurological disease can underlie incontinence or sudden onset
urgency, some simple screening questions should be considered to
exclude undiagnosed (occult) neurological disease.
These include new-onset tremor, coordination problems, reduced mental
faculties, and erectile dysfunction in men
Blaivas classficiation appearance at rest and with cough
Type 0 rotational descent urethra nad bladder base no leak
Type 1 - descent and bladder neck and urethra open with leakage
Type II - marked descent and rotation of bladder and uretra below pubis, bladder neck and urethra opens with leakage
Type III - bladder base remains above pubis, but bladder neck and urethra open further and leaks, also open bladder neck and proximal urethra at rest
