Magnus Murphy, MD

Urogenital Damage/dysfunction: 
 • Vaginal delivery
 • Aging 
 • Estrogen deficiency 
 • Neurological disease 
 • Psychological disease

Compounding Problems: 
 • Embarrassment leads to silence 
 • Time constraints lead to inadequate attention
 • Knowledge limits lead to patients accepting 
 • Technology limits lead to inadequate investigation
 • Resource limits lead to inadequate access

Myths: Urinary incontinence/prolapse is a natural part of aging 
 • Nothing can be done about it
 • Surgery is the only solution

Urogenital Aging:  
 • Urogenital aging is a symptom complex with associated physical findings
 • Involves the lower urinary and genital tracts and the pelvic floor

Symptoms: 
 • Frequency
 • Nocturia 
 • Dysuria 
 • Incomplete emptying 
 • Incontinence 
 • Urgency 
 • Recurrent infections 
 • Dyspareunia 
 • Prolapse

Statistics: 
 • 10-60% of women report urinary incontinence
 • 50% of women that have had children develop prolapse
 • Only 10-20% seek medical care 
 • Billions of dollars spent annually on incontinence products (in North America)

Statistics: 

 • 10-25% of women age 15-64 report urinary incontinence
 • 15-40% of women over 60 in the community report incontinence
 • More than 50% of women in nursing homes are incontinent 
 • W.H.O. recognizes incontinence as an international health concern

Cost of Urinary Incontinence
 1994 - Direct Costs


  – $11.2 billion/year in the community 
  – $5.2 billion/year in nursing homes
 • 60% greater than the 1990 estimate


 • Does not count urgency/frequency along
1995 - Total Societal Costs 


– individuals +65 - $26.3 billion/year
– per person cost - $3,565/year
(↑ 174% from 1884)
 1. Hu. National Multi-Specialty Nursing Conference on Urinary Incontinence, 1994. 
 2. Hu. 

Quality of Life Impact:
• Impact on lifestyle and avoidance of activities
• Fear of losing bladder control
• Embarrassment
•Impact of relationships
• Increased dependence on caregivers
• Discomfort and skin irritation

Types of Urinary Incontinence: 
• Genuine stress incontinence 
• Urge incontinence
• Mixed 
• Chronic urinary retention and overflow incontinence 
• Functional incontinence 
• Miscellaneous (UTI, dementia)

Genuine Stress Incontinence: 
• Loss of urine with increases in abdominal pressure
• Caused by pelvic floor damage/weakness or weak sphincter(s) 
• Symptoms include loss of urine with cough, laugh, sneeze, running, lifting, walking

Urge Incontinence:
• Loss of urine due to involuntary bladder spasm (contraction) 
• Complaints of urgency, frequency, inablity to reach the toliet in time, up a lot at night to use the toilet
• Muliple triggers

Mixed Incontience: 
• Combination of stress and urge incontinence
• Common presentation of mixed symptoms 
• Urodynamics necessary to confirm

Chronic Urinary Retention
• Outlet obstruction or bladder underactivity 
• May be related to previous surgery, aging, development of bad bladder habits, or neurologic disorders
• Medication, such as antidepressants
• May present with syptoms of stress or urge incontinence, contiuous leakage, or urinary tract infection

Functional and Transient Incontinence: 
• Mostly in the elderly 
• Urinary tract infection
• Restricted mobility 
• Severe constipation
• Medication - duretics, antipsychotics
• Psychological/congnitive deficiency

Unusual Causes of Urinary Incontinence: 
• Urethral diverticulum
• Genitourinary fistula
• Congenital abnormalities (bladder extrophy, ectopic ureter) 
• Detrusor hyperreflexia with impaired contractility

Causes of Incontinence: 
 Inherited or genetic factors
• Race
• Anatomic differences 
• Connective tissue
• Neurologic abnormalities

Causes of Incontinence: 
 External factors
• Pregnancy and childbirth
• Aging 
• Hormone effects 
• Nonobstetric pelvic trauma and radical surgery
• Increase intra-abdominal pressure
• Drug effects

Pregnacy and Childbirth: 
• Hormonal effects in pregnancy
• Pressure of the uterus and contents
• Denervation (stretch or crush injury to pudendal nerve)
• Connective tissue changes or injury (fascia)
• Mechanical distruption of muscles and sphincters

Aging: 
• Gravity
• Neurologic changes with aging 
• Loss of estrogen
• Changes in connective tissue crosslinking and reduced elasticity

Hormone Effects: 
• Common embryonic origin of bladder urethra and vagina from urogenital sinus
• High concentration of estrogen receptors in tissues of pelvic support 
• General collagen deficiency state in postmenopausal women due to the lack of  estrogen (falconer 

., 1994)
• Urethral coaptation affected by loss of estrogen

Increased Intra-abdominal Pressure: 
• Pulmonary disease
• Constipation/straining 
• Lifting
• Exercise 
• Ascities/hepatomegaly
• Obesity

Drug Effects: 
Alpha-blocking agents 
• Terazosin
• Prazosin
• Phenoxybenzamine 
• Phenothiazines 
• Methyldopa
• Benzodiazepines

Fecal Incontinence: 
• Approximately 10% of women with urinary incontinence have incontinence of flatus or stool

Patient Evaluation: 
• History
• Physical examination
• Urinalysis
• PVR - if indicated 
• Symptoms of incomplete emptying 
• Longstanding diabetes mellitus
• History of urinary retention
• Failure of pharmacologic therapy
• Pelvic floor prolapse 
• Previous incontinence surgery

Patient History : 
• Focus on medical, neurologic, genitourinary history
• Review voiding patterns/fluid intake
• Voiding diary
• Review medications (rx and non-rx) 
• Explore symptoms (duration, most bothersome, frequency, precipitants) 
• Assess mental status and mobility

Physical Examination: 
• General examination
• Edema, neurologic abnormalities, mobility, cognition, dexterity
• Abdominal examination
• Pelvic and rectal exam - women 
• Examination of back and lower limbs
• Observe urine loss with cough

Articles

Compounding Problems:  
• Embarrassment leads to silence  
• Time constraints lead to inadequate attention 
• Knowledge limits lead to patients accepting  
• Technology limits lead to inadequate investigation 
• Resource limits lead to inadequate access

Urinary Incontinence

Childbirth and the Pelvic Floor

Please click thumbnails       for full size images - all images are copyright Magnus Murphy, MD

Reproduced with permission from Dr. Murphy's web site 

Tension Free Vaginal Tape for Stress Urinary Incontinence

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OBGYN.net Conference CoverageFrom the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003

Magnus Murphy, MD & Barbara Nesbitt discuss Pelvic Health & Childbirth Video

   “Hi, I’m Barbara Nesbitt, I’m at AUGS and I have the pleasure of  sitting here today with Dr. Magnus Murphy from the University of  Calgary.  I think you are all familiar with him, he has written a book  that we’ve had on OBGYN.net for quite a while, “Choosing Caesarean  Birth” and it’s been a little controversial with people that don’t want  to choose that way.
 
 But we’re at an Urogynecology conference and obviously we’re talking  about incontinence and prolapse and all the things that come from, a lot  of times, vaginal birth.  We have Dr. Murphy’s new book, “Pelvic Health  and Childbirth” and we’re going to discuss it and the reason he wrote  this as a follow-up to his first book.  It will also be available to us  to buy and to read sections of.  Dr. Murphy is also a member of the  Editorial Advisory Board of OBGYN.net, Urogynecology.  Nice talking to you doctor.”
 
 

 “Well, thank you  Barbara.  It’s my pleasure, and the privilege is entirely mine.   Especially sitting here and looking at this beautiful view out here, all  the birds out in the woods.  Thank you for having me.”
 
 

  “You wrote the  first book, and then you were telling me that there was a whole area  left that you wanted to explore in this second book.”
 
 

 “Yes, the first  book, I started working on that in 1998, and as you mentioned, called  “Choosing Caesarean Birth”.  It basically focuses on caesarean as a  possible preventative measure for preventing urinary incontinence and  other pelvic floor disorders.  What really led to this book is the  perceived need, specifically in my own practice, and I’m sure in many of  my colleagues’ practices, of education.  Educating women on, firstly,  what the pelvic floor actually is.  I usually get a blank stare when I  start talking about the pelvic floor because it’s this esoteric part of  our bodies that many people don’t have any idea that even exists.   Secondly, to explain what is actually going wrong.
 
 For instance, to give an example, one of the comments I often hear from  patients is that they have a bulge in the vagina and so I’m trying to  explain what this bulge is, where it came from, why it happened, what  can be done about it through various ways; non-surgical, including  surgical, and then also what could possibly have been done to prevent  it.
 
 So the book will be hopefully, of enough use to women who already have  problems, but also for those who still have to decide, specifically  then, in terms of how they are going to have their babies.”
 
 

  “So this is  something that I think is important because we’re seeing more older  women having a first child.  We’re not talking about 20 or 30 years ago  when it was 18 or 19 year-old girls who didn’t even think to ask the  question.  Now we’re into 35-year-old and older women having infertility  treatments and there’s a plan there. Now they don’t want or need to  ruin a bladder system that’s been working fine for years.”
 
 

 “The other thing  is also, not only are women postponing pregnancies, but they are also  having fewer babies.  Obviously I can’t generalize, it’s a certain  section of the population, but in general in western countries anyway,  the fecundity, that means the number of babies women are having, has  dropped remarkably.  Now there has been a slight rise again in certain  countries but still it’s incredibly low.  The point is that women are  having fewer babies, maybe one, or two, at the most three, later in  life.
 
 They are also living a lot longer and living more active, productive  lives.  They want to be able to enjoy life after childbirth, whereas you  know in the older days women were either having babies every two years,  or life expectancy basically ended at the time when fertility wasn’t an  issue anymore.  That’s certainly not the case now fortunately, and  therefore the long-term effects of childbirth and pregnancy are today a  major issue and it’s of prime importance in my view.  Whereas in  previous centuries and previous years, obstetrics focused specifically  firstly on, whether the mother was going to survive childbirth because  that was the main issue, and the fetus really was of secondary  importance.
 
 In the previous century it all evolved regarding saving the fetus and  making obstetrics and delivery and having babies safe for the baby  because, to a large degree, we’ve overcome the immediate  life-threatening risks to the mother.  We’ve gotten to a point where  having babies is relatively safe, not only for the mother but also for  the baby.  My point is that it’s now time to think about the mother’s  morbidity, meaning the health of the mother and the effects of having  children on their future quality of life.  So, it’s not only survival  that’s of importance anymore, but now quality of life, and that is to a  large degree what this book is about.”
 
 

  “I think we can  say that, as you said, in the different generations, this is a  generation of a more educated woman who knows to ask questions; maybe  more than 20 years ago, ten years ago but they don’t always know what  options are available for them.  So is this something that they should  go to their obstetrician and say, ‘I want to look at having a  c-section?’”
 
 

 “That’s a very  good question.  I think the important thing is that I fully believe in  the principle of not only informed consent but complete understanding of  the implications of decisions.  The days of paternalistic medicine are  long past.  I believe women should educate themselves about decisions  made, and not have the physicians make decisions completely on their  own.  Therefore, yes, I think the book discusses childbirth, the pros  and cons of vaginal birth and caesarean.  The caesarean choice doesn’t  necessarily come without risks attached, and it’s important to note that  I am not suggesting that women should have a caesarean.  What I’m  suggesting is that women educate themselves about the choices, about the  risks of the different choices, including those risks of caesarean;  there are many.  And then go to their physicians and discuss this with  the physicians.
 
 I’ll give you an example.  My sister lives in Pennsylvania and she is a  highly educated professional woman.  She’s 37-years-old, she’s having  her first baby.  She asked her obstetrician for a caesarean.  This was a  few weeks ago.  According to her, this person almost fell off his  chair.  I want to educate women that it’s their right to discuss this,  and also physicians that it is their duty to discuss with patients the  implications on childbirth of vaginal delivery and also discuss the  risks of caesarean.
 
 I think one of the problems with pre-natal care is that we don’t have  time.  We don’t have the time to discuss many of these things and  because of that it becomes neglected.  There was this well known study  that’s being talked about a lot at these conferences, where in Britain,  female obstetricians and female obstetrical senior residents were asked  what they would like for themselves for a first baby.  More than 30%  actually indicated they would like to have a primary, preventative,  elective caesarean section.  Eighty-five percent of those indicated that  they would want this specifically for protection of the pelvic floor.  A  minority indicated they would want it because caesarean is arguably,  although I think there is enough proof of it, safer for the baby.
 
 The point is I am quite sure that very few of those female obstetricians  will then go to their offices and discuss this with their own patients.   It is something that’s neglected and I think that women have the right  to know and have the obligation to educate themselves.  Then discuss it  and then make their own decision jointly with their physician.”
 
 

  “You and I have  been emailing back and forth and you certainly have submitted access to  your first book.  Anyone who wants to can go online and read chapters  from it.  You have answered questions.  You freely let women write to  you and you answer them.  Some are very upset with you, some are very  glad to hear what you have to say.  Controversy is always good.  It  opens minds, doesn’t it?  Makes people think.”
 
 

 “Yes, I think so.   I don’t know if you’ve actually noticed, in this book I have abstracts  from certain comments that were posted on my own personal website,  which is 

.   There was one particular posting that was very poignant, and this lady  just tore into me about how dare I make comments like this.  And it  illustrated to me what a passionate topic this is, and of course, it’s  bringing a new life into the world, it is very passionate.  This is why I  want to again stress that I and Carol Wasson, my co-author, whom I’d  really like to acknowledge here, has made a large contribution to the  project, we are not suggesting what women should decide.  We’re not  telling them what they need to do; we are trying to educate them about  the fact that they should make a choice.”
 
 

  “You are giving them the option to learn both ways and then make the choice, which they feel is the right one.”
 
 

 “Exactly, but of  course, as you mentioned, it is a continual source of controversy, and I  think as women become more knowledgeable, it will be even more so.
 
 I have been told, and this is second-hand information, but I have been  told that Germaine Greer, who is a well-known person in feminist  circles, has made a comment in Australia where she has said that “the  battle for vaginal delivery has already been lost.”  Now I apologize if I  have this wrong but this is something that I heard second hand.  There  was also a very, very good lecture by Mrs. Margaret Summerville, who is a well-known ethicist in North America, in Toronto  last November 2002.  She gave one of the seminal lectures on ethics  regarding elective caesarean, and basically indicated that the whole  evolution of law and medical ethics, is developing in a direction where  physicians may actually be found negligent not having informed people of  these issues.  That is quite a frightening thought as you can imagine.   It is not being done today, and it is very problematic because it is  almost like opening a can of worms.
 
 But I do believe that the tide is turning and it’s unstoppable and I wanted to do my part in educating.”
 
 

  “So, come on the website, read the excerpts from this book.* There will be a few chapters on it to begin with before we get the whole thing.  Read the whole first book, “

.”  And write to Dr. Murphy if you have anything that  you want to ask him because he has his email address on there, readily  available.
 
 I thank you.  I was from a day when you just had a baby and you didn’t ask any questions. I like this new way very much.”
 
 

Editor's note: The publisher has not yet released the chapters for on-line publication. As soon as we get them they will be available on 

. For purchasing information, please see the listing on 