**1. Introduction**

144 Urinary Incontinence

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effects of differences in definition, population characteristics, and study type.

We put forward a novel concept on the Pathophysiology of micturition, urinary continence and urinary incontinence 1-7. Urinary continence depends on two main factors, one inherent and one acquired.

The inherent factor is the presence of an intact and strong internal urethral sphincter (IUS). The IUS is a collagen-muscular tissue cylinder that extends from the bladder neck down to the perineal membrane. It gets its nerve supply from the alpha sympathetic nerves from the hypogastric plexus T10-L2. The collagen sheet, being the strongest tissue in the body, is to give the IUS its high wall tension necessary to create in the urethra the high urethral pressure. The muscle fibers lie on, intermingle with the collagen fibers in the middle of the cylinder thickness, and are responsible for closure and opening of the urethra in response to alpha sympathetic tone.

The functions of the IUS are 1- to keep the urethra closed and empty all the time due to the high alpha sympathetic tone gained by learning and training early in childhood. 2- On relaxation to open the urethra to allow voiding. In women, the IUS is intimately lying on the anterior vaginal wall.

The acquired factor is an acquired behavior gained by learning and training in early childhood how to maintain a high alpha sympathetic tone at the IUS to keep it closed and empty all the time until there is a desire or a need to void.

#### **2. Micturition**

Micturition develops in two stages. First stage is uncontrolled reflex, which then gets central control in the second stage.

First stage of micturition: 2,

As the urinary bladder fills afferent sensations travel along the pelvic parasympathetic nerves (S. 2, 3 & 4) to the spinal cord. When it is full efferent pelvic parasympathetic nerve

<sup>\*</sup> Corresponding Author

The Concept and Pathophysiology of Urinary Incontinence 147

Sensations of bladder distension travel along the pelvic parasympathetic (S. 2, 3 & 4) to the central nervous system (CNS). Controlled by the high CNS, sensations of desire to void and bladder fullness, allows the person to choose either to retain the urine to a later time or to void according to the social circumstances available. If he chooses to retain the urine then three neuro-muscular actions take place: 1- He increases the alpha sympathetic tone to the IUS confirming its closure. 2- He inhibits the parasympathetic impulses to the detrusor muscle inhibiting its contractions. 3- He increases the tone of the EUS which is a skeletal muscle innervated by voluntary nervous system. When, appropriate time and place are available, then, controlled by the CNS, synergistic actions between the somatic and the autonomic nervous systems four neuro-muscular actions take place. (1) He will lower the high alpha sympathetic tone at the IUS relaxing the sphincter and opening the urethra, (2) he relaxes the EUS which is a striated muscle innervated by somatic nerve supply, (3) he activates the pelvic parasympathetic nerves to induce contraction of the detrusor muscle

(4) The external urethral sphincter (Compressor Urethrae) acts to propagate and propel the stream of urine and at the end to squeeze the urethra to expel the last drops of urine in the

When social circumstances allow, he will inhibit the high alpha sympathetic tone at the IUS, thus opening the urethra. He will activate the pelvic parasympathetic inducing detrusor contractions. He will relax the EUS thus allowing voiding. The EUS tone increase to allow propulsion and ejection of the stream of urine and at the end of micturition to squeeze the urethra from the last few amount of urine. The grey drawing is from the scientific net pages

In addition, we described the structure of the vagina in a novel way 1 & 7. The vagina is composed of collagen-muscular-elastic layer. The collagen layer is the tough layer that give the vaginal walls their strength and to keep the vagina in its upward position. Childbirth, especially prolonged, difficult, repeated & frequent and instrumental vaginal deliveries cause overstretching of the vagina with subsequent rupture of it collagen sheet. The rupture of the vagina affects mainly its transverse axis leading to flabby redundant vaginal walls with subsequent vaginal prolapse. The same trauma will affects the intimately overlying IUS leading to rupture of its collagen layer. The torn weak IUS will not stand sudden increase of abdominal pressure as coughing, jumping, sneezing, laughing and even coitus, and urine will leak involuntary, stress urinary incontinence (SUI). As soon as the woman feels wetting herself due to escape of urine, being embarrassed, reactive sympathetic activity reflex, will increase the sympathetic tone at the IUS to confirm its closure and preventing further leak of urine. This may explain the strong indications that there is a causal relationship between OAB and POP (8-18). Thus by understanding this new concept, we can

Functional disturbances, and/or structural damage of the IUS will lead to urinary

1. Failure to acquire the second stage of micturition leads to Nocturnal Enuresis. These failures can be complete failure, (here there is a stop at the first stage of micturition), as the urinary bladder fills it empties irrespective to neither time nor place, leading to day

and empty the urinary bladder.

on micturition, www.obgyn.net

explain most of the voiding troubles.

incontinence, and voiding troubles 1-7.

urethra to keep the urethra closed and empty as it should be.

impulses induce detrusor muscle contraction; as urine enters the urethra it leads to relaxation of the external urethral sphincter (EUS) which is a skeletal muscle innervated by the somatic nerve supply, and thus micturition occurs irrespective of time and place.
