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WHAT IS CONTINENCE?. Continence is the ability to pass urine or faeces voluntarily in a socially acceptable place.. The continent person can:recognize the needidentify the correct placehold on until he reaches the correct placereach the correct placepass urine or faeces when he gets thereIncontinence - involuntary loss of urine which is objectively demonstrable

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1. URINARY INCONTINENCE Dr Fatima Z Ashrafi DGO (Dub), FRCS (Edin), MRCOG (Lon), FRANZCOG Gisborne Hospital, New Zealand

4. INCIDENCE 1 in 3 female age 55 or more complain of incontinence. 1 in 10 women will have surgery for prolapse or SI in life time. One third will need further surgery. Urinary incontinence - not a recent medical or social phenomena. Disorders of urinary tract written in ancient times. Women more willing to talk about it. Improved understanding of the diverse pathophysiology of incontinence. Advent of new treatment. Development of urology & urogynaecology as a specialty.

6. Bladder,bowel &sexual functions- parasympathetic & somatic via S2,3,4. Sympathetic supply - T10-L2 segments - detrusor muscle. Parasympathetic promotes micturition - contracting detrusor, relaxing urethra. Sympathetic - B receptors in bladder - relaxation, A receptors in bladder neck increasing urethral resistance. Central control - pontine center, receiving afferent and efferent from cerebral cortex, cerebellum and spinal center. Normally detrusor is reflexly inhibited by sympathetic neurones (storage and filling), control acquired in infancy. Detrusor contraction mediated by parasympathetic supply. M3 receptors .

7. ANATOMY Bladder functions as low pressure reservoir allowing intermittent voiding within socially acceptable limits. Continence is maintained as UCP is higher than expulsion pressure. Urethra supported by - Externally: pubourethral ligament, striated muscle of pelvic floor. Internally : smooth muscle of urethra, ext urethral sphincter, periurethral collagen & connective tissue, submucosal venous plexus, mucosal coaptation of the urothelium. Proximal urethra is well supported so a rise in intraabdominal pressure is equally transmitted to bladder & urethra.

25. DETRUSOR INSTABILITY 2nd common cause of incontinence in UD studies.Incidence increases with age. Normal control of detrusor is lost. 15% incidence of DI following bladder neck surgery. Cost: Australia - 1997, NIH - $17.5 billion on urinary incontinence, $12.7 billion on overactive bladder, $13.8 on osteoarthritis, $11 billion on gynae & breast cancer Important to identify DI prior to continence surgery as urgency may be worsened. Frequency, urgency, urge incontinence, key in door leaking are typical of DI.

26. DETRUSOR INSTABILITY Rarely completely cured by any form of treatment. Symptoms and QOL can be improved. Continence adviser essential member of continence service. Behavioural & conservative therapies are helpful Anticholinergic drug eg Oxybutinin is used in DI. S/E: dry mouth, blurred vision, constipation, drowsines, urinary retention. A new antimuscarinic, Tolteradine is in market now. Darifenacin - highly selective M3 blocker - phase 3 trials. TCA, DDAVP, Ca channel blockers. Oestrogen therapy : systemic no effect, topical decreases UTI. Good for atrophic vaginitis. Surgical: cystodistension, clam cystoplasty, diversion procedures

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