1. Urinary incontinence in the female
1. Definition
2. Stress incontinence
3. Prevalence
4. Pathophysiology
5. Causes
6. Clinical presentation
7. Physical examination
8. Investigations
9. Management-
 Genuine stress
incontinence
 Detrusor instability

2. Definitions
 Involuntary loss of urine which is
objectively demonstrable & is a social or
hygienic problem.
 Stress incontinence: Involuntary expulsion of
urine under conditions of stress like rise of
intra-abdominal pressure due to coughing,
sneezing , laughing or lifting weights.

3. Prevalence
Upto 57% in women 45-64 yrs.
14% in general population.
Common condition, but rarely life
threatening
Adverse effect on quality of life
Embarrassment and anxiety.

4. Pathophysiology of stress
incontinence
1. Intravesical
pressure exceeds
urethral pressure
because of
weakness of
urethral sphincter
mechanism i.e.
Genuine Stress
Incontinence
2. Detrusor pressure
excessively high i.
e. Detrusor
Instability or
Hyper-reflexia of
Bladder.

5. Causes of urinary incontinence
1. Genuine stress
incontinence- congenital
weakness of bladder
neck, denervation of
sphincter mechanism
of pelvic floor (during
delivery), estrogen
deficiency in
menopause etc.
2. Detrusor instability
3. Retention with overflow
incontinence
4. Urogenital fistula
5. Temporary – UTI,
drugs-α-blockers.
6. Urethral diverticulum

6. Causes (contd…)
7. Congenital abnormalities- ectopic ureter,
bladder exstrophy etc.
8. Functional /neurologic disorders- dementia,
spinal lesions, space occupying lesions in
brain etc.

7. Clinical presentation
 Stress incontinence-
most common.
 Associated features-
urgency, frequency,
dysuria, urge
incontinence, voiding
difficulties- poor stream,
straining, incomplete
emptying.
 Detail history- prolapse,
obstetric history,
recurrent UTI, episodes
of retention etc.
 H/O diabetes, drugs –
diuretics, α-blockers etc.
 Neurological symptom

8. Physical examination
 With full bladder in stress incontinence.
 Local- excoriation of vulval skin.
 Atrophic changes, cystocele, prolapse.
 Bladder neck elevation test(Marchetti test)- To
see whether surgery will benefit or not.
 Mental state, developmental anomalies,
neurological examination.

9. Investigations
 General
i. Urine-
(MSU)Routine/microsc
opy, c/s
ii. Frequency/volume
chart or urinary diary.
iii. Pad test.
 Basic Urodynamics
i. Uroflowmetry- 15-
25ml/sec
ii. Cystometry-
differentiate betn GSI
&DI- Intravesical
pressure during filling ,
if > 15cm water after
250 ml DI

10. Investigations (contd…)
 Residual urine- <5oml.
 First sensation of urge
~250ml. If earlierurge
incontinence.
 Bladder capacity- 500-
600ml. If
increasedneurologic
disease.
 Videocystourethrography
 Combines cystometry,
uroflowmetry &
radiological screening of
bladder & urethra.
 Most informative, but
expensive/time
consuming.

11. Special investigations
 Metallic bead chain
urethrocystogram
 Urethral pressure
profilometry.
 Cystourethroscopy.
 Micturition cystography
 USG- position &
excursion of bladder
neck.
 Electromyography of
pudendal nerve.
 Urethral electric
conductance.

12. Management of GSI
 Conservative
a. Kegel’s exercises of pelvic floor muscles.
b. Wt. Reduction in obese patients.
c. Treat chronic cough, UTI.
d. Faradism- interrupted current to stimulate
muscles & nerves.
e. Drugs- Estrogen, α adrenergic agonists-
phenylpropanolamine.

13. Management (contd..)
 Surgical
 90% cure rate.
 Elevate bladder neck & proximal urethra into
intra-abdominal position, support the bladder
neck.
a. Anterior colporrhaphy with Kelly suture.
b. Marshall-Marchetti-Krantz operation-
suprapubic approach.

14. Surgical management (contd…)
c. Burch colposuspension.
d. Pereyra procedure.
e. Sling procedures- secondary- Stamey, Raz
f. Artificial sphincter implant.
g. GAX-collagen- periurethral injection.
h. Urinary diversion- Last.

15. Detrusor Instability
 Spontaneous or provoked detrusor
contractions during the filling phase when the
pt. Is attempting to inhibit micturition.
 Urgency, urge incontinence, enuresis,
frequency.
 No specific clinical signs.

16. Management of DI
1. Behavioral interventions.
2. Drugs- most widely used- anticholinergic agents-
oxybutynin, propantheline., calcium channel blocker-
terodiline, Tricyclic antidepressant-imipramine,
αadrenergic stimulants., estrogen, synthetic
vasopressin.
3. Denervation- phenol injection, bladder transection,
vaginal denervation, sacral neurectomy.
4. Cystoplasty- clam ileocystoplasty.