MENOPAUSE and VOIDING TROUBLES

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MENOPAUSE and VOIDING TROUBLES

• Prof . Abdel karim M. El Hemaly
• MRCOG- FRCS

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The most common voiding troubles in menopausal
women are

• Increased frequency of micturition.
• Polyuria undiagnosed, uncontrolled diabetes M.
• Dysuria.
• Urgency and urgency incontinence .
• Stress urinary incontinence.
• Mixed type of incontinence.

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• Less common voiding troubles
• True incontinence from genitourinary fistula,
  resulting from malignancy and/or operative
  trauma.
• Urine retension and retention with overflow
  resulting from neurologic disease, drugs, pelvic
  surgery and incarcerated ovarian cyst.
• Haematuria infection, stone, neoplasm.

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Menopause
Marked drop of ovarian steroid hormones.
Cumulative effects of trauma from previous
childbirth.
General conditions e.g.
Increased total body weight
Diabetes Mellitus and other metabolic disorders
Hypertension
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Menopause

• Marked drop of ovarian steroid hormones will lead
  to
• loss of urogenital trophic support.
• atrophy of urogenital tract.
• atrophy of collagenous tissue of the internal
  urethral sphincter leading to its weakness
• atrophy of urothelium, this will increase the
  chance of infection leading to more persistent,
  recurrent or chronic infection

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Menopause

• Estrogen deficiency will lead to drop in the
  levels of
• Serotonin.
• Neuro-peptides.
• Nor-epinephrine.
  

changes in the mood, and Behavior
Decrease of the tone of the int, ureth, sphincter.
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Menopause
Cumulative effects from previous childbirth trauma
Marked drop of ovarian Steroid hormones
Weakness of the internal Urethral sphincter
Voiding troubles
infection
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Recently, In 1996 we put forward a new concept,
based on evidence explaining the act of
micturition and urinary continence.
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Micturition can be divided into 2
stages Stage-I in Infancy before training of
micturition. Stage-II in childhood after
training of the act of micturition (how to
control).
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Micturition

• Stage-II the mother starts to train her infant
  at the age of 18-24 months how to control
  micturition. This is gained by acquiring high
  alpha sympathetic tone at the internal sphincter
  closing it all the time except on need and /or
  desire.

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Urinary continence depends on

• 1- An acquired behavior gained by learning in
  early childhood to keep a high alpha sympathetic
  tone in the internal urethral sphincter keeping
  it closed all the time except on need and/or
  desire.
• 2- An intact and strong internal urethral
  sphincter.

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The structure of the internal urethral sphincter

• It is mainly a cylinder composed of compact
  collagenous tissue. It extends from the bladder
  neck down to the perineal membrane.

It is lined by urothelium. The muscle fibers
intermingle with the collagenous fibers in the
middle part The muscle layer is controlled by
alpha-sympathetic nerves T10-L2.
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NORMAL INTERNAL URETHRAL SPHINCTER
U.B.
U.B.
Closed urethra due to a strong, intact int. u.
sphincter
3-D. ULTRASONOGRAPHY
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3D U.S. Cross section
Closed lumen
Intact wall, compact sheet of collagenous tissue
with muscle fibers lie on and intermingle with
the collagen fibers In the middle part of the
cylinder
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MRI picture of a normal continent woman
Urethra
Urethral lumen
Vagina
Muscle layer
Collag. tissue cylinder
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MRI picture of a normal continent woman
U.B.
Uterus
Post. Wall of internal urethral sphincter.
Vagina
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• Collagen is the most abundant protein in
  humans.
• Collagen fibers are usually found in bundles
  of fibers and provide strength to the
  tissues.
• Each fiber is made up of fibrils,
  chemically it has a high content of
  hydroxy-proline and hydroxy-lysine,

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• Many different types of collagen are
  identified on the basis of their molecular
  structure.
• Type I is the most abundant being found in
  the dermis, bone, dentin, tendons, fascia,
  sclera, and organ capsules.

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• In old age, the amount of intervening
  mucopolysacharide decrease.
• Also aging, with/ or without infection, cause
  fibrinoid necrosis of the collagen leading to
  its weakness
• In addition, marked drop of ovarian hormones
  leads to loss of urogenital trophic support.

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• Important sites of collagen atrophy after
  menopause
• - bone osteoporosis
• - urethra weakness voiding
  troubles
• - skin wrinkling
• - fascia organs loss of strength,
  form and shape.

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• Collagen atrophy mucosal thinning will lead to
  
• Frequency
• Dysuria
• Urgency
• Cystitis
• SUI
• DI
• Mixed type of incontinence.

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• Weakness of the int. urethral sphincter will lead
  to
• DI, overactive bladder , Urge and Urgency
  incontinence.
• SUI
• Mixed type of incontinence.

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SUI, DI, and mixed incontinence are sequel of a
torn weak internal urethral sphincter.

• So, we innovated a new operation , trying to
  correct such types of urinary incontinence.
  Mending the torn edges of the internal urethral
  sphincter together by simple interrupted sutures,
  will restore the integrity of the internal
  urethral sphincter, and hence its strength. We
  called this operation urethro-raphy.
  
  

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References

• El Hemaly AKMA, Mousa LA. Micturition and Urinary
  Continence. Int J Gynecol Obstet 199642, 291-2.
• El Hemaly AKMA, Mousa LAE. Stress Urinary
  Incontinence, a New Concept. Eur J Obstet Gynecol
  Reprod Biol 199668, 129-35.
• El Hemaly AKMA. Nocturnal Enuresis Pathogenesis
  and Treatment. Int Urogynecol J Pelvic Floor
  Dysfunct 19989, 129-31.
• Abdel Karim M. El Hemaly, Ibrahim M Kandil,
  Mohamed M. Radwan. Urethro-raphy a new technique
  for surgical management of Stress Urinary
  Incontinence.www.obgyn.net/urogynecology/urethrora
  phy
• El hemaly AKMA, Kandil I. M. Stress Urinary
  Incontinence SUI facts and fiction, Is SUI a
  puzzle?! www.obgyn.net/ PowerPoint
  presentations.
• Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila
  A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El
  Hemaly and Bahaa E. Elmohamady. Evidence based
  Facts on the pathogenesis and management of SUI.
  www.obgyn.net/ PowerPoint presentations.

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• Authors
• Abdel Karim M. El Hemaly, Ibrahim M.Kandil, and
  Bahaa E. El Mohamady M.
• Prof. Ob. Gyn. Faculty of medicine Al Azhar
  University, Cairo, Egypt.
• corresponding author e mail m_hemaly_at_hotmail.co
  m

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ThankYou