Urinary Incontinence in Gynecology: A Review Article

Abstract (click here for full text article)

Urinary Incontinence (UI) means involuntary escape of urine. There are 11 types of UI:

¨  True UI - continuous escape of urine, due to genito-urinary fistula
¨  Overflow incontinence - neurologically impaired patients
¨  Urge incontinence - due to an organic cause in the lower UT e.g., infection, stone, tumor, etc.
¨  Stress UI or SUI - genuine
¨  Detrusor Over activity, (DO) Detrusor Instability, (DI) Urge, Overactive bladder, Irritable bladder - abrupt and strong desire to void. Due to non-organic cause
¨  Mixed UI
¨  Nocturia
¨  Nocturnal enuresis
¨  Functional UI - the patient feels the desire to void, but she is unable, or unwilling to reach the toilet to void, e.g., visual and\or physical or psychological impairment
¨  Transient UI - infection, drugs, (alpha blockers), alcohol, delirium, severe fear, etc
¨  Post voiding dribbling - urethral diverticulum

Urinary continence depends on two main factors, one inherent and, one acquired:

I.  The acquired factor (Second stage of micturition): is an acquired behavior gained by learning and training in early childhood how to maintain a high alpha sympathetic tone (T.10-L.2) at the internal urethral sphincter keeping it closed all the time until voiding is needed or desired.

II. The inherent factor: is the presence of an intact and strong internal urethral sphincter. The internal sphincter is a collageno--muscular tissue cylinder that extends from the bladder neck down to the perineal membrane. *Functional disturbance, and/or structural damage of the internal urethral sphincter will lead to urinary incontinence

A.  Functional disturbance⁽³⁾:

1.  Failure to gain the acquired behavior of having high alpha sympathetic tone, completely, or partially will lead to Nocturnal Enuresis
2.  Sympathetic over activity, e.g., pain, spinal cord lesion will lead to retention of urine, and overflow incontinence
3.  Sympathetic failure e.g., severe fear, deep anesthesia will lead to transient UI
B.  Structural damage of the internal urethral sphincter⁽³⁾: 1.  Whole thickness damage, will lead to Genito-urinary fistula leading to true urinary incontinence
2.  Partial thickness damage⁽²⁾a.  damage from outside, more common; is mostly caused by child birth trauma, it will lead to weakness of the internal u. sphincter, that will induce SUI, DO and/or Mixed UI
b.  damage from inside, will lead to urethral diverticulum inducing, Post-voiding dribbling.
III.  A new operation is innovated to treat SUI, DO and mixed-type of urinary incontinence. It is a simple vaginal operation, which depends on identifying the rupture in the wall of the internal urethral sphincter and mending the torn wall with simple interrupted sutures, Urethro-raphy.

IV.  A new operation “urethro-plasty” is innovated to treat SUI, DO, DI and mixed types of urinary incontinence.

It is a vaginal operation, which depends on identifying the rupture in the wall of the internal urethral sphincter and mending the torn wall with simple interrupted sutures, Urethro-raphy. Furthermore, in order to fortify the internal urethral sphincter, a rectangular piece of the anterior wall of the vagina about 2x5 cm. is cut and put on the repaired wall, and fixed longitudinally, to cover the finely mended sphincter wall.