What is urinary incontinence?
A condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable.
International continence society (ICS) definition: The complaint of involuntary leakage of urine on effort or exertion or on sneezing or coughing.
Causes:
Stress Urinary incontinence (50%). Overactive bladder syndrome (25%) mixed incontinence (25%), Overflow incontinence, fistula, etc.
Stress Urinary incontinence (SUI) is most common type of urinary incontinence in women, with 78% of women presenting with symptoms of SUI.

MANAGEMENT:
* Behavioural therapy
• Pelvic floor muscle exercises: Pelvic floor muscle training (PFMT like Kegel exercise can be effective treatment for SUI. Kegel exercises involve strengthening and retraining the detrusor bladder muscle to regain some control of urinary function.

• Life style interventions: Weight reduction, Fluid and dietary management like adding more fibre to diet and avoiding food that has potential to irritate the bladder, timed voiding, prompted voiding, or bladder training.

*Medical Therapy:
Although, there are no approved medications to specifically treat stress incontinence. Some treatments listed below provides significant outcome.
• Hormonal Therapy: Estrogen receptors are consistently expressed in the urethra and detrusor muscle, as well as the pubococcygeal muscle in the pelvic floor.

*Pharmacological treatment:
• α-adrenergic agonists: The bladder neck and urethra contain an impressive concentration of α1-adrenergic receptors that, when stimulated, induce muscle contraction and, thus, can increase outlet resistance. Numerous α-adrenergic agents, including phenylpropanolamine, have been used in patients with SUI.
• Dual SNRI (serotonin–norepinephrine reuptake inhibitor): It suppresses bladder activity through central serotonin receptor mechanisms and enhances urethral sphincter activity through serotonergic and α1-adrenergic mechanisms.

• β-adrenergic antagonists: β-adrenergic receptor blockade enhances the effect of norepinephrine on α-adrenergic receptors in the urethra. It has been shown to have a beneficial effect in patients with SUI.

• Imipramine: The tricyclic antidepressant imipramine has been used to treat patients with SUI. The alpha-adrenergic and

anticholinergic properties of this agent may provide the dual benefit needed in these patients.

*Devices
• Vaginal pessaries (Ring pessary): First line option for treatment for SUI. These pessaries compress the urethra against pubic symphysis and elevate the bladder neck at the urogenital angle.

• Urethral inserts: Intraurethral devices are single-use, disposable, and thin and flexible enough to insert directly into the urethra to obstruct the flow of urine into the proximal urethra.

*Minimally invasive surgical management:

• Injectable bulking agents: Bulking agents like Silicone, carbon beads, porcine dermal implants, calcium hydroxyapatite or synthetic polysaccharides and gels are placed at the bladder neck to improve continence.

• Sling procedure: This is the most common procedure performed in women with stress urinary incontinence. In this procedure, the person’s own tissue, synthetic material (mesh), or animal or donor tissue to create a sling or hammock that supports the urethra.

• Bruch colposuspension and fascial sling: This procedure involves suspending of anterior vaginal wall to ileopectineal ligament.

• Mid urethral synthetic slings: A sling i.e., a piece of human or animal tissue or a synthetic tape is attached to ligaments along the pubic bone to lift and support tissues near the bladder neck and upper portion of the urethra. Can be performed retropubically or trans obturator.