اضطرابات قاع الحوض وسلس البول | د. سامر مرسيPelvic Floor Disorders & Urinary Incontinence | Dr. Samer Morsy

Urinary Incontinence — Types & Diagnosis

Urinary incontinence is a symptom, not a single diagnosis. The mechanism must be identified before treatment:

• Stress UI: Leakage on coughing, sneezing, or exercise — due to urethral sphincter insufficiency or hypermobility
• Urge UI: Sudden compelling urgency with involuntary leakage — due to detrusor overactivity
• Mixed UI: Combination of both, most common presentation in women over 50

Urodynamic Assessment

Urodynamics quantifies bladder and urethral pressure during filling and voiding. It identifies:

• Detrusor overactivity (urgency aetiology)
• Low urethral closure pressure (stress UI severity)
• Bladder outlet obstruction in men or post-surgical patients
• Impaired detrusor contractility

Results directly determine whether conservative, pharmacological, or surgical treatment is appropriate — and which surgical technique is most likely to succeed.

Stress UI — Surgical Options

• Mid-urethral slings (TVT/TOT): First-line surgery — 85% success at 5 years, day-case, 30-min procedure
• Burch colposuspension: Laparoscopic — durable for patients with concurrent prolapse repair
• Urethral bulking agents: For frail patients or mild cases — office-based, no incision

Overactive Bladder (OAB)

OAB is characterised by urgency, frequency ± urgency incontinence without infection. Management is stepwise:

• Bladder training, fluid and caffeine modification
• Antimuscarinics (solifenacin, tolterodine) or β3-agonists (mirabegron)
• Intravesical Botox injection (100–200 U) — effective for refractory OAB
• Sacral neuromodulation (SNM) for cases unsuitable for Botox

Frequently Asked Questions — Pelvic Floor

Is urodynamic testing always necessary before surgery for incontinence?

In most cases, yes. Urodynamics objectively characterises the type of incontinence (stress, urgency, or mixed), identifies detrusor overactivity, and measures urethral closure pressure — information that directly determines the most appropriate intervention. Studies show urodynamic findings change the planned management in up to 40% of patients. It is particularly important before TVT insertion or when mixed symptoms make the dominant aetiology unclear.

How does the TVT sling work?

TVT (Tension-free Vaginal Tape) places a polypropylene mesh tape loosely under the mid-urethra through two small abdominal or vaginal punctures. The tape provides a backboard of support during moments of raised intra-abdominal pressure (coughing, sneezing) without creating resting obstruction. The procedure takes approximately 30 minutes under local or general anaesthesia with a day-case discharge, and achieves 85% cure rates at 5-year follow-up.

How long does intravesical Botox last?

Botulinum toxin A injected into the detrusor (100 U for idiopathic OAB; 200 U for neurogenic bladder) typically provides symptom relief for 6–9 months. Some patients experience benefit for up to 12 months; others require 6-monthly injections. The procedure is performed cystoscopically under local anaesthesia or mild sedation as a day case. Response is assessed at 4 weeks post-injection.

What is the difference between stress and urge incontinence?

Stress incontinence is leakage triggered by physical exertion — lifting, coughing, sneezing — due to insufficient urethral support or sphincter weakness. Urge incontinence involves a sudden, overwhelming desire to void that cannot be deferred, leading to leakage before reaching the bathroom — caused by involuntary detrusor contractions. The distinction is clinically critical: surgery (TVT) is the mainstay for stress UI, while pharmacotherapy and Botox are first-line for urge UI. Mixed presentations require urodynamic characterisation to prioritise treatment.

Can pelvic floor exercises alone cure urinary incontinence?

Pelvic floor muscle training (Kegel exercises) is evidence-based for mild-to-moderate stress incontinence and can significantly reduce leakage episodes with consistent practice over 3 months. However, they are insufficient as sole treatment for severe stress UI, post-partum sphincter damage, or significant urethral hypermobility. Supervised physiotherapy-led pelvic floor rehabilitation is more effective than unsupervised exercise alone, and should always be the first step before considering surgical intervention.