Magnus Murphy, MD

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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

Author | Magnus Murphy, MD

Articles

Urinary Incontinence

Childbirth and the Pelvic Floor

Tension Free Vaginal Tape for Stress Urinary Incontinence

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