Urinary stress incontinence 199

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D: Involuntary urine loss following a rise in intra-abdominal pressure. ^^

A: Developmental or damage to the bladder neck support. ^^

A/R: Associated with vaginal prolapse in 50% of cases. Multiparity " the risk of developing urinary stress incontinence.

_E Very common (25% of older women suffer from mild symptoms, 5-10% with severe symptoms). Uncommon in men.

H: Involuntary loss of urine associated with a sudden rise in intra-abdominal pressure (e.g. coughing, sneezing, lifting). A patient can be asked to keep a fluid diary: asking patient to record intake, times and volumes of urine passed and episodes of incontinence.

E: Urinary leakage on coughing, there may be an associated cystocoele on speculum examination.

P: Raised intra-abdominal pressure is not adequately transmitted to the proximal ^^ urethra, resulting in a disproportionate rise of bladder pressure over urethral pressure. Also, the descent of the urethra-vesical junction (from weakness in the pelvic floor muscles) results in a loss of normal sphincter closure. This is exacerbated during pregnancy, as progesterone promotes relaxation of the bladder and proximal urethral muscles.

_I: Urinalysis: To exclude infection and glycosuria.

Imaging: MRI pelvis.

Urodynamic studies: To differentiate from other forms of urinary incontinence if the diagnosis is unclear.

M: Conservative: For mild symptoms, pelvic floor exercises are recommended to strengthen levator ani muscles. Intra-abdominal pressure is # by weight reduction, avoiding excessive physical exertion and treating excessive coughing or sneezing.

Medical: Hormone Replacement Therapy: May be effective in postmenopausal women with urogenital atrophy.

Anticholinergic (e.g. imipramine): " Urethral and bladder neck tone and relaxes detrusor muscles, thereby improving symptoms.

Surgical: Retropubic bladder neck suspension: Achieved by suturing the perivesical fascia to the pectineal ligament (Burch colposuspension) or suturing the periurethral fascia to the posterior surface of the symphysis pubis (Marshall-Marchetti-Krantz operation).

Sling operations: Insertion of synthetic material or natural tissue around the bladder and urethra, which are attached to the anterior rectus fascia supporting and partially compressing the urethra. It is indicated for patients with intrinsic sphincter damage or weakness.

Anterior colporrhaphy: Effective in patients with other prolapses as it also corrects these conditions.

C: From surgery: Obstructed voiding on micturition.

P: In mild cases, pelvic floor exercises will cure 40% and provide significant improvement in 80% long term. Retropubic bladder neck suspensions have an 80-90% long-term success rate whereas anterior colporrhaphy has only a 40% long-term success rate.

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