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Female Urinary Incontinence

  1. Clitoris
  2. Labium minora
  3. Labium major
  4. Vagina
  5. Cervix
  6. Uterus body
  7. Fundus of the uterus
  8. Urethra
  9. Anus
  10. Rectum
  11. Colon
  12. Urinary bladder

Urinary incontinence can be defined as involuntary urine pass.

This hygienic problem which has an incidence of 50% in elder ladies appears as an important public health problem.

 

Before deepening the subject, let us look at how female continence occurs.

 

First of all, intervesical pressure should not be more than intraurethral pressure in no case to provide continence both on rest and during any physical process. In another words, the pressure in the urinary bladder should exceed the urethral closing pressure for urine pass.

Structures that provide continence ( to keep the urine inside):

 

  1. Intrinsic sphincter mechanism
  2. Extrinsic sphincter mechanism
  3. Supporting tissues which provide to keep the urethrovesical junction on appropriate position
  4. Appropriate innervation of all these structures (nerve network)

 

Intrinsic sphincter mechanism:

Roughly, it consists of urethral mucosa and elastic nature of the urethral wall. These structures are estrogen dependent. (namely, when woman goes through menopause, estrogen will reduce and this structure can not function normally)

 

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Extrensic sphincter mechanism:

It consists of a sphincter formed by periurethral (around the urethra) muscle fibers and muscles of urogenital diaphragm.

 

STRUCTURES THAT KEEPS VESICOSPHINCTERIC UNIT ON NORMAL POSITION

These structures consists of structures belonging to bottom muscles of the female pelvis (condensations of levator muscle fascia).

 

These fascial structures and levator muscle fibers contract and pull the urethra onto the symphisis, the osseous structure in the front in any intraabdominal pressure increase (coughing– straining – ascending or descending a ladder etc.).

 

TRUE STRESS INCONTINENCE (TSI)

Urge incontinence

Neuropathic incontinence

Congenital incontinence

Paradoxical or overflow incontinence

Post traumatic or iatrogenic incontinence

Fistulous incontinence

 

THE MOST COMMON FORMS OF INCONTINENCES ARE TSI, URGE INCONTINENCE AND MIXED TYPE WHICH INCLUDES THE TWO CONDITIONS.

 

TRUE STRESS INCONTINENCE

It may be defined as involuntary urine pass from the urethra which is the normal path of urination without any urination desire and any contraction on the urinary bladder in the cases where intraabdominal pressure increases.

Many theories have been suggested for physiopathology of TSI.

 

The most accepted hypothesis is as follows: None devolvement of the pressure that should devolve into the urethra during stress (straining etc.) because of position fault of the urethra.

 

It is generally seen in women who had many and difficult deliveries and/or are elder or has lost and gained excess weight. As a result of damage of hip muscles or nerves during the delivery, the neck of the urinary bladder replaces or can not close during coughing, sneezing, laughing, climbing a ladder, carrying a load, sexual intercourse and the patient passes urine.

 

DIAGNOSIS FOR TSI

What should we do for a patient referred by stress incontinence complaint?

Like every condition, anamnesis (history) should be taken well.

Especially, daily urination characteristics are investigated. These details are important for the diagnosis as well as to assess the patient monitoring after the treatment.

Answers are sought for the questions such as frequency of urination, frequency and conditions of incontinence, whether incontinence occurs during lying, presence of nocturia (urination at night), whether dysuria (burning sense while urinating) and/or urgency symptoms accompany to the stress and how many pads should the patient change.

Furthermore, gynecological and obstetric history of the patient are investigated.

Menstruation; if the patient is in menopause, the period; number of deliveries; number of miscarriages; whether the patient had cesarean or any other gynecological operation; whether the patient had any intervention related with incontinence previously are determined. The important aspect here is having difficult and traumatic deliveries, presence of gynecological malignancies, radiotherapy, accompaniment of cystocele – rectocele- uterine prolapse will provide a preliminary information to us about insufficiency of pelvic floor muscles and/or urethral sphincter.

Also, questions are asked about neurological and endocrinological history of the patient. Here, accompaniment of Parkinson’s Disease, Multiple Sclerosis and Diabates.  İnkontinans

After the anamnesis, simple physical examinations are performed.

Gynecological examination and local neurological examination become prominent.

In gynecological examination: Female genital system is examined; and if cystocele or any other organ prolapse is present, it is important and absolutely recorded. Then, Marshal Boney test is applied. The patients is asked to urinate and then she was placed on a gynecological table and a very thin catheter is placed into her urinary bladder and it is recorded whether urine is left in the urinary bladder (residual urine) is recorded. Then, the urinary bladder is started to be filled with serum and rough information is obtained about bladder sensation and capacity; a vibrating movement of the catheter without desire of urination in early stages of the filling may indicate detrusor muscle instability and it should be recorded; when urination desire appears, catheter is removed and the patient is asked to strain; this procedure is repeated when lying and standing. If urine pass is present, the tissue around urethra is pressed along symphisis with two fingers and after providing the straining, it is observed and recorded whether the urine pass continues. By this test, the response of the patient for a possible operation is controlled.

Routine biochemical tests are applied to the patient and complete urine test and urine culture are applied. Urodynamic testing which is a more detailed examination is applied for the patients who continue on passing urine although urinary continence operation was performed and whom the operation type can not be determined. During this procedure, salty water is given into the bladder of the patient via a catheter and filling, passing and urinating pressures are recorded by a computer and printed in numerically and graphically. Because urodynamic testing is very complex and expensive, it is not correct to apply to every incontinence patient.

Actually, conditions that may be confused with TSI or seen with TSI are determined with a detailed anamnesis and physical examination.

Urgency incontinence: It may be defined as having a sudden urination sense and inability to suppress this sense and passing a little urine until urinating.

Sense of urgency is occurrence of a urination sense with low volumes of urine in the bladder. Over stimulation of bladder nerves is in question. The most frequent urodynamical finding of the urgency incontinence is instability f the detrusor muscle.

Detrusor Instability (DI): It is presence of involuntary contractions in filling phase of the bladder.

DI may be solely or together with TSI. When it is seen solely, it is like urgency and urgency incontinence rather that discomfort and the patient defines that she does not pass urine suddenly; physical examination supports this. Generally, it is together with urinary tract infection. The picture shall recover after an antibiotic treatment in this case. If only DI is present and no inflammation findings are present, anticholinergic agents are used for the treatment. When TSI and DI is together as it has a ratio up to 60%, the patient defines both stress pattern and urgency incontinence.

Detrusor hyperreflexia is same clinical picture with DI and the underlying cause should be a neurological disorder.

Overflow incontinence defines presence of a continuous residual urine basically. It is not a true incontinence. Obstruction and neurogenic problems are seen as well. An overflow type incontinence occurs.

In congenital incontinence cases; the event already starts on delivery and urine pass which is seen with some abnormalities of the urinary tract (ectopies, duplications, extrophy and epispadias) occurs. Diagnosis is not difficult.

Traumatic incontinences: Incontinence occurs if structures preventing the incontinence are damaged mistakenly after various surgical interventions.

Fistulous incontinences: Here, urine pass from the body does not occur via normal urethra, but urine pass on canals called fistula which have appeared by different causes is in question. For example, in vesico-vaginal fistula, a channel appears between the bladder and the vagina and the urine passes through the vagina.

 

After TSI is diagnosed; another important aspect for treatment success is to determine the type of TSI.

There are two types of TSI according to Stame.

  1. Anatomical SI
  2. Intrinsic sphincteric failure

The most important issue in TSI treatment is accurate determination of TSI type.

 

 

TREATMENT FOR TSI

  1. Medical and non-surgical therapies
  2. Surgical therapies

 

The accepted opinion for today is that:

Non surgical treatments may be used for patients who can not handle an operation and have mild complaints.

 

NON-SURGICAL TREATMENTS

İnkontinans If the patient is fat, weight loss

 

Using estrogen preparations orally or vaginally (especially mucosa loosing closing function due to hypoestrogenism in the menopause)

 

Alpha-adrenergic agents

 

Tricyclic antidepressants (imipramine) and antimuscarinic drugs (oxybutynin chloride)

 

Physiotherapy (Keegle’s exercises)

 

Electrical stimulation, incontinence chairs, biofeedback

 

Vaginal cones and pezzer catheters

 

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Urethral catheter placement

SURGICAL TREATMENTS

There are hundreds of operation techniques in incontinence surgery from open operations to closed techniques; from abdominal operations to intravaginal ones; from operations performed without any cut to laparoscopic techniques performed from several holes on the body.

 

Each technique has advantage and disadvantage by itself. ( For example, a technique may be applied very easily, however it may be very expensive. On the contrary a technique is very successful, however recovery period is long etc.)

 

While selecting a treatment method, it should be discriminated that if stress incontinence (SI) type is “anatomical or intrinsic failure?” and further factors that should be considered are as follows: If another disorder that accompanies to SI and should be repaired is present, experience of the surgeon, patient preferences, long term achievements of the methods and costs.

 

The main purpose of anatomical SI treatment is; TO CORRECT THE URETHRA ANGLE DEFORMED AND TO CORRECT TRANSMISSION OF INTRAABDOMINAL PRESSURE ACCORDINGLY.

 

The basic purpose in the intrinsic failure is; to increase urethra resistance and to provide coaptation (capacity to be closed).

 

This group has the highest achievement rate. There is an achievement rate of 85 to 90% for 5 years and more surveys, however operation period is long and bleeding possibility is more and hospitalization period is long. It is hard to apply on fat people.

 

Transvaginal Techniques

– Kelly placation 1912

– Needle hanger methods

Pereyra 1959, modified pereyra methods: stamey 1973, raz 1981, gittes 1987, modifiye gittes yahya 1989, leach 1991)

Although all these needle sling methods are very successful within the early period, long term achievement rates decrease from 90% to 65 to 70%!

Sling methods

Pubovaginal sling (rectus fascia or fascia lata pr pyramidal muscle etc. have been used)

Anteriovaginal wall sling (Raz)

Sling with synthetic materials (polyglycolic acid – Teflon etc.)

TVT operation

When long term achievements and applicability are considered; advantage of sling methods is not needing to make TSI differentiation.

Laparoscopic methods

Burch and slings

Artificial Urehtral Sphincter (AUS (AMS 800))

FREQUENTLY ASKED QUESTIONS ABOUT TSI TREATMENT

* GROUND FOR PROPHYLACTIC HYSTERECTOMY? =NONE

* Detrusor instability appeared after the surgery? = MAY BE IN 20% OF THE CASES; ANTICHOLINERGIS drugs should be added and it should be detected that no OBSTRUCTION is present.

* IS IT NECESSARY TO APPLY URODYNAMIC PROCEDURE + UPP FOR EVERY CASE? =NONE