1. Definition:

Is an objectively demonstrable involuntary loss of urine that is a social or hygienic problem.

2. Magnitude of the problem:

• It affects individual's physical, social & hygienic life.
• It reduces quality of life.
• The prevalence of regular female urinary incontinence increases with increasing age.

3. Commonly used uro-gynecological terms:

1. Stress incontinence: is involuntary loss of urine associated with raised intra-abdominal pressure.
2. Urgency of micturition: is a strong & sudden desire to void.
3. Urge incontinence: is urinary leakage associated with strong & sudden desire to void.
4. Overflow incontinence: is involuntary loss of urine occur without any detrusor action when the urinary bladder is distended.
5. Frequency of micturition: is passage of urine more than 7-8 times per day.
6. Nocturia: is voiding more than twice per night.

4. Causes:

4.1. Urethral causes: Genuine Stress Incontinence (GSI):

• Caused by incompetent urethral sphincter.
• Urethral closure pressure is produced by the passive effect of elastic & collagen fibers & active striated & smooth muscles, causing urethral closure.
• In the resting state the urethral closure pressure is higher than the relatively low bladder pressure resulting in urinary incontinence due to positive pressure gradient from the urethra to the bladder.
• Urinary incontinence occurs when the bladder pressure exceeds the maximal urethral pressure with no detrusor contraction.
• GSI associated with:
  • Increasing age due to decreased maximal urethral closure pressure.
  • Increasing parity.
  • Genital prolapse.
  • Post menopausal status.
  • Previous pelvic floor surgery.

4.2. Detrusor instability:

• In women with instability detrusor, the urethral functions is normal, but if the uninhibited detrusor activity increases bladder pressure above maximal urethral closure pressure, urinary leakage occurs.
• Causes:
  • Idiopathic.
  • Surgery to the bladder neck or proximal urethra.
  • Multiple sclerosis.
  • Autonomic neuropathy.
  • Spinal lesion.

4.3. Urinary retention with overflow incontinence:

• Due to detrusor ischemia & denervation associated with chronic over distention of the bladder. This occur in:
  • Central lesion (CVA).
  • Spinal lesion (cord injury-multiple sclerosis).
  • Peripheral neurological lesion (disc prolapse-autonomic neuropathy).

4.4. Sensory urgency:

• Irritation of the bladder mucosa due to:
  • Infection (cystitis).
  • Bladder stones or tumors.

4.5. Diverticular diseases:

4.6. Extra-urethral causes:

• Congenital causes such as ectopic ureters or ectopia vesicae.

4.7. Vesico-vaginal fistula:

• Obstetric causes: most common cause is obstructed labour due to compression of the bladder by the fetal head against the bony pelvis which leads to necrosis & sloughing of the muscle tissues.

• Gynecological causes:
  • Malignancy (cervical ca.).
  • Pelvic surgery.
  • Pelvic irradiation.

5. Investigations:

1. Mid stream urine: it is essential to exclude UTI that is a common cause of sensory urgency.
2. Uro-flow-metry: measurement of urine flow rate.
3. Cysto-metry: measurement of bladder pressure & volume.
4. Video-cystourethrograpgy: is a combined radiological with pressure & flow studies that gives the most information about bladder function. It is a very useful test to perform prior to incontinence surgery, because it can identify GSI as well as detrusor instability & other disorder.
5. Ultrasound scan (to identify pelvic masses).
6. MRI.
7. Cysto-urethroscopy: can be helpful by inspecting the anatomy of the bladder & urethra & hence excluding mechanical causes of incontinence but does not allow assessment of their function.
8. Infusion colored dyes into the bladder & observing vaginal leakage may confirm the presence of vesico-vaginal fistula.

6. Management:

Treatment is determined according the underling condition & the severity of symptoms.

• GSI:
  • Conservative treatment: physiotherapy, teaching women to use pelvic floor muscles to achieve better urinary control.
  • Medical treatment: estrogen replacement therapy improve the symptoms of GSI in postmenopausal women.
  • Surgical treatment:
    • abdominal procedure are more effective than vaginal one. Colpo-suspension in the procedure of choice performed through a suprapubic incision, this involve placing suture from the vagina adjacent to the bladder neck to the ligaments at the back of symphysis pubis.
    • Vaginal procedure: such ad anterior colporrhaphy.

• Detrusor instability:
  • Behavioral therapy: bladder retraining aims to increase voiding intervals.
  • Drug therapy: antimuscarinic (anticholinergic) drugs increase bladder capacity.

• Fistula:
  • Stenting of the uterus or catheterization of the bladder to provide continuous free drainage of urine in small fistula.
  • Surgical repair