Pathophysiology of

Stress Urinary Incontinence

Benny Hasan
Urogynecology Division
Obstetric Gynecology Department
Faculty of Medicine Padjadjaran University/Hasan Sadikin Hospital
Bandung
Normal Pressure
Abdominal Cavity
No leaked

Raised
Pressure
Abdominal
Cavity
 P2: pabd (measured rectally or vaginally)

P1: pves
p det = P1-P2
P3: pura

From: http://www.urologyweb.com
puc(Urethral Closure) = P3-P1
 VESICAL PRESSURE (pves)
The pressure information obtained is a combination of the pressure being
exerted on the bladder by the abdominal contents, the weight or pressure
of any urine in the bladder and the force that the detrusor muscle is
exerting on that fluid

RESTING PRESSURE (The pressure in an empty bladder)

The normal bladder resting pressures may vary between 8-40 cmH2O,
depending upon the particular patient and position during study.Resting
pressure changes with position

DETRUSOR PRESSURE
Subtracted pressure that is calculated by subtracting the abdominal
pressure from the vesical pressure
URETHRAL CLOSURE PRESSURE PROFILE

The average URETHRAL CLOSURE PRESSURE

female is 60 cmH20 and male it is 80 cmH20
Abdominal and Detrusor Pressure as Forces
Opposed by the Urethra

The average URETHRAL CLOSURE PRESSURE

female is 60 cmH20
male it is 80 cmH20
Topography and Mobility of the Normal Proximal Urethra and
Vesical Neck Based upon Resting and Voiding in Nulliparae

Resting

Voiding

Cardozo. Textbook female urology and Urogynaecology. 2006

 Stress Urinary Incontinence
What is it?
Cough

Increased
Abdominal
Pressure

Increases
Bladder
Pressure

Urine
Leakage

The complaint of involuntary leakage of urine on

effort or exertion, or on sneezing or coughing.
Abrams, et al. Neurourol. & Urodyn. 21:167-178, 2002.
 Normally muscles of the pelvic floor contract to maintain continence
However a defect with this structure can lead to
urethral hypermobility and stress incontinence

A) Normally, contraction of pelvic floor muscles maintains continence.

B) Loss of pelvic support due to weakened muscles results in loss of
continence.
Al-Hayek S, Abrams P. (2005). Stress incontinence: why it occurs. Women's health medicine. 2 (6), 26-28.
 The Condition Stress Incontinence
Exists when involuntary leakage is produced by
an increase in Total Vesical Pressure

Pves = (Pabd + Pdet ) > (P ura)

 “Genuine” Stress Incontinence
Must involve little or no Pdet component
In the expulsive force

(Pves = Pabd + Pdet ) > P ura

 The Major cause of Stress Incontinence is
Urethral Hypermobility
due to Impaired Support from Pelvic Floor

A less common cause is an Intrinsic Sphincter Deficiency

usually secondary to pelvic surgeries

Urethral Sphincter Function is impaired

Resulting in Urine Loss at Lower

than usual abdominal pressures
Sudden increases in Intra-abdominal Pressure
and Hypermobility may coexist with
Intrinsic Sphincter Deficiency
 In A Patient Who Has
Stress Incontinence

The Proximal Urethra Is

No Longer In The
Abdominal Cavity

Moved Down And Out

The pressure upon the

bladder is not transmitted
to the urethra

Continence
Lack Of Pressure Transmission
The Resisting Forces In The Urethra
Are Easily Overcome
Urine is Lost
Clinically
A stress leakage test is sufficiently accurate in that it demonstrates
That coughing or straining induces visible urine leakage
often associated with rotational descent of the urethra into the vagina

However
The test does not rule out a Detrusor Component
to the expulsive force and
Does Not Provide Information On The Severity
of the Stress Incontinence Condition

The test is usually performed in the Supine Position

A Negative result does not rule out Stress Incontinence
 Stress Incontinence is present when Pves is greater than
Urethral Pressure (Pura) when it is simultaneously
determined that the Detrusor Pressure is nearly zero
This definition is misleading for a number of reasons ?

Cystocele

Gross leakage with stress No leakage.

P ves = 21 cm H2O P ves = 73 cm H2O
P ura = 24 cm H2O P ura = 67 cm H2O

Pura: Measured during straining or coughing is not truly a pressure

In Fact: No urethral measurement is an actual pressure
Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17
 Urethral Support System Deficits
Labour Or Vaginal Delivery May Cause Direct Damage
Damage The PFM, Such As Avulsions Of
The Nerve Supply The Pubococcygeus–puborectalis
Of The PFM Complex
(Dietz and Lanzarone, 2005)

Stretching Or Tearing Of The Fascial Supports For The Urethra And

The Bladder Can Result In Hypermobility Of The Urethra And Bladder

http://ars.sciencedirect.com/content/image/1-s2.0-S0022534701644951-gr1.jpg
DeLancey (1996 ) Proposed A Consolidated Theory Of SUI

The Pubocervical Fascia And Anterior Vaginal Wall Provides

Hammock-like Support And Creates A Backboard For Compression
Of The Proximal Urethra During Increased Intra-abdominal Pressure

Proposes That SUI Arises From A Laxity Of This Support

Appropriately Corrected By Surgical Repositioning Of

The Proximal Urethra And Bladder Neck
(eg. Burch Colposuspensions & Pubovaginal Slings)

“Hammock Hypothesis”

Bullock, T.LBJU Int 2006, 98 (Suppl 1): 32-40.

DeLancey, J.O. Am J Obstet Gynecol 1994, 170: 1713-23.
Petros and Ulmsten (1990) Identified The Midurethral Support
Provided Mainly By The Pubourethral Ligaments To Be
Central To The Maintenance Of Continence

This Evolution Of Ideas Has

Shifted The Focus For Treatment
Of SUI To The Midurethra

Away From Anatomical Models Of

Pathophysiology

The Development Of Midurethral

Slings (The Tension-free Vaginal
Tape And Other Variations)
Petros P., Ulmsten, U. Acta Obstet Gynecol Scand Suppl 1990
Recurrent stress incontinence after TVT procedure
The impression of the tape on the urethra; it appears to be closer
to the bladder neck than we would expect

The Position Where The Sling Appears

To Compress The Posterior Aspect Of
The Urethra

The Pabd LP = 46 cmH2O

No Urethral Mobility

The proximal urethra is open and

leaks easily with straining

Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17

 All cases of Stress Urinary Incontinence
are not the same

Urethral Pressures
Prolapse Conditions
Congenital Acquired Sphincteric Dysfunction

All Contribute To SUI Pathophysiology

Proper patient evaluation:

including video urodynamics and measurement of Valsalva leak point pressure
is key to making the best treatment decisions and obtaining optimal patient outcomes

Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17

 Poor Compliance Detrusor Contraction Or The Expulsive Force
Is Not Mainly P.abd

But Includes A Significant Pdet Component

Sphincteric Dysfunction And Abdominal Pressure Interact To

Induce Leakage

Any Case When Pabd Causes Leakage And Pdet

At The Time Is Minimal
True Stress Incontinence Is Present
 Stress Incontinence Does Not Develop In
Patients With Poor Pelvic Support Unless
Intrinsic Sphincter Deficiency Is Also Present

Before Exercise After Exercise

Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17

 Urethral closure system deficits
Intrinsic sphincteric deficiency is caused by
a reduced ability of the intrinsic urethral
sphincteric mechanism to maintain mucosal
coaptation either at rest or in the presence
of minimal physical stress
 Abdominal Leak-Point Pressure
The ALPP Will Be More Than 60 Cm Water, But With
Intrinsic Sphincter Dysfunction The ALPP Is Less
Than 60 cmH2O And Often Less Than 20 cmH2O

Ostergard, DR. Bent AE, ed. Urogynecology and Urodynamics: Theory and Practice.3rd ed. Baltimore, Md: Lippincott, Williams & Wilkins;
1991:74.
 Causes Of ISD
Previous Pelvic Surgery
• Anti-incontinence surgery
• Urethral diverticulectomy
• Radical Hysterectomy
• Urethrotomy
• Resection or incision of vesical neck

Aging & Hypo-oestrogenic States

Pelvic Irradiation

Neurologic Conditions
• Myelodysplasia
• Anterior spinal artery syndtome
• Lumbosacral neurologic conditions
• Shy-Drager syndrome
 Association of Simple Hysterectomy with Intrinsic Sphincter
Deficiency

A Case Control Study (N=67)

All patients were evaluated by a fluoroscopic urodynamic technique and
abdominal leak point pressure was determined

Result
Intrinsic sphincter deficiency was present in 48% of the 67 patients and 24% of
the 67 controls in the lower risk subgroup, we noted this condition in 29
patients (52%) and 53 controls (21%)

Conclusions
In this population of incontinent women intrinsic sphincter deficiency, as
diagnosed by low abdominal leak point pressure, appears to be a complication
of simple hysterectomy

J.L. MORGAN, H.E. O’CONNELL, E.J. McGUIRE. The Journal of Urology Volume 164, Issue 3, Part 1, September 2000, Pages 767–769
 Specifically
Patient Who Loses Urine In The Supine Position With
A Relatively Empty Bladder

This Particular Patient Has A

Very High Probability Of
Having Intrinsic Urethral
Sphincteric Deficiency

Urine Is Lost With Stress

The Intra-abdominal Pressure On

The Bladder Very Easily Overrides
Urethral Resistance
 “The Standard Way To “Rule Out” A Detrusor
Pressure Component Within An Expulsive Force
Is With A Twin-channel Subtracted
Cystometrogram (CMG) In Which Rectal
Pressure Is Subtracted From Pves Continuously
And True Pdet Is Recorded”

“The Test Has Little Meaning If Performed Alone; Only If Done In

Conjunction With A Stress Maneuver Can The Test Provide Evidence Of
A Phasic Detrusor Contraction-generated Pressure Component”

Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17

Detrusor Pressure as a Complicating Factor
Actual Phasic Contraction Of The Bladder And Poor Compliance In Which Bladder Volume
Increments Are Associated With Progressive Increases In Pdet, Is By Far The Most Important

Poor Compliance Is Associated

With Symptoms That Are Similar
To Stress Incontinence
P det = P ura
The Condition Occurs As The Rising Pdet
Begins To Approach The Closing
Pressure In The Proximal Sphincter

Identical To Intrinsic Sphincteric Deficiency (ISD)

Although The Expulsive Force Is Actually Pdet And Not Pabd

Edward J. McGuire .Rev Urol. 2004;6(suppl 5):S11-S17
Video Study Of A Patient With A Poorly Compliant Bladder

Volume Increments Result In An

Abrupt Increase In Pdet
Which Ultimately Overcomes
The Closing Forces In The
Proximal Sphincter

Both Areas Are Isobaric

Minimal Effort Will Cause
Leakage

The Major Expulsive Force Here Is Pdet

Urethral Procedure Will Not Resolve
The Leakage
Edward J. McGuire, REVIEWS IN UROLOGY. 6 SUPPL. 5 2004
 Abdominal and Detrusor Pressure as Forces Opposed
by the Urethra

SUI Occurs When Proximal Urethral Sphincter Function Is Lost Or Very Weak
Regardless Of The Function Of The Midurethral Highpressure Zone
Midurethral Closing Function Has An Uncertain Relationship With The Ability Of
The Urethra To Resist Pabd As An Expulsive Force
McGuire EJ, Fitzpatrick CC, Wan J, et al. Clinical assessment of urethral sphincter function. J Urol. 1993
 Intrinsic Sphincter Dysfunction and Urethral Hypermobility

“Women with primary SUI had urethral mobility that could be measured
by upright cystourethrography “

The existence of urethral mobility suggests

that achieving better urethral support with
an operation might cure the leakage
If The Urethra Is Not Mobile
But Nonetheless Leak

Intrinsic Closure Of The Urethra Problem

Unsuccessful Support Operation

.Jeffcoate TN, Roberts H. Observations on stress incontinence of urine. Am J Obstet Gynecol. 1952

Green TH. Development of a plan for the diagnosis and treatment of stress urinary incontinence.Am J Obstet Gynecol. 1962
Less controversy regarding the evaluation of complicated SUI, such as that after
failed incontinence surgery, or associated with neurological conditions, fistulae, or
pelvic organ prolapse. In this situation we primarily seek to determine:
• If the primary etiology for SUI had been wrongly diagnosed prior to the initial surge
• If new or mixed conditions exist
• If bladder outlet obstruction co-exists

Flow phase study and fluoroscopic appearance of obstructed voiding following placement of
a post-midurethral sling
 Videourodynamic Grading Systems
Used To Emphasise A Distinction Between Stress Incontinence From Anatomical Factors

Mcguire. Obstet Gynecol 1976 : Blaivas, J.G. J Urol 1988:Dupont, M.C. Urol Clin North Am 1996
 Videourodynamic Grading Systems

The Key Selection For Surgical Treatment :

Type III SUI Or Intrinsic Sphincter Deficiency (ISD)

Associated With A Failure Rate Of Up To 35%

With Standard Urethral Repositioning Surgery

Women With Symptoms :

Severe Large Volume SUI More Likely To Have ISD

Low Valsalva Leak Point Pressure (VLPP) As A Major Component Of Their SUI
Maximum Urethral Closure Pressure (MUCP)

Cummings, J.M., J Urol 1997, 157: 818-20.

Persistent stress incontinence after a retropubic suspension:

no urethral mobility at all

The impression of the Burch sutures on the

bladder lateral to the urethra is obvious
leaks with straining
 The Patient Supine Is Less Accurate Than One Performed With
The Patient Upright
Although This Type Of Evaluation Is Clinically Acceptable
(Relatively Insensitive And Not Specific)

Should a patient who was evaluated in

this manner have failure of surgery

The Data Are Insufficient To Determine Whether The Failure Was

Due To The Procedure Itself
Or Whether The Treatment Chosen Was Simply Unsuitable For
The Patient’s Condition
 ISD and Gynecology
Severe Type III :
SUI Can Develop Immediately Postpartum
Which Is Not Associated With Any Levator Muscle Injury Or With Prolapse

Weakness of the levator ani

complex and poor function urethral
sphincter found to be related to
childbirth and the secondary
development of SUI and genital
prolapse

DeLancey. Am j Obste-Gynecol .2009. Volume 202, Issue 6

The Surgical Correction Of Complex Incontinence Associated With:
• Pelvic Organ Prolapse
• Mixed Or Atypical Symptoms
• Following Radical Pelvic Surgery Or Radiotherapy

Depends On An Accurate Urodynamic Videourodynamics Remains A

And Pivotal Investigation In Such
Anatomical Diagnosis Situations
To Achieve Reasonable Outcomes
eg.

Cystocele associated with incontinence

Reduction of pelvic organ prolapse prior to urodynamics may unmask urinary incontinence
 Type 1 stress incontinence
The Well-supported Bladder Neck At
Rest On The Left, And Urinary Leak On
Coughing

The Diagnosis Of ISD Remains Dependent On A Combination Of Patient

History, Examination Findings, Videourodynamic Observations And The VLPP

Not Recommend VUDS For Every Patient With SUI

Being Contemplated For Surgery, It May Be A Valuable
Option If ISD Is Suspected On Clinical Grounds
 The pathophysiology of SUI is
complex and multifactorial

While the exact mechanisms of SUI have not yet been fully
elucidated, it appears that SUI can develop as a result of one
or multiple deficits within the structural systems, the
modifiable factors or both

Although intact components of the continence mechanism can

compensate for deficient ones, it appears that in each individual there is
a threshold at which multiple factors combine to eventually strain the
continence system to the point where symptoms of SUI emerge