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Stress incontinence Causes and Risks:
NORMAL URINATION:
The ability to hold urine and maintain continence is dependent on normal function of the lower urinary tract, the kidneys, and the nervous system. Additionally, the person must possess the physical and psychological ability to recognize and appropriately respond to the urge to urinate.
The process of urination involves two phases: 1) the filling and storage phase, and 2) the emptying phase. Normally during the filling and storage phase, the bladder begins to fill with urine from the kidneys. The bladder stretches to accommodate the increasing amounts of urine. The first sensation of the need to urinate occurs when approximately 200 milliliters of urine is stored. The healthy nervous system will respond to this stretching sensation by alerting you to the need to urinate while also allowing the bladder to continue to fill. The average person can hold approximately 350 to 550 milliliters of urine. The ability to fill and store urine properly requires a functional sphincter (muscle controlling output of urine from bladder) and a stable bladder wall muscle (detrusor).
The emptying phase requires the ability of the detrusor muscle to appropriately contract to force urine out of the bladder. Additionally, the body must also be able to simultaneously relax the sphincter to allow the urine to pass out of the body.
STRESS INCONTINENCE:
Stress incontinence is a storage problem in which the strength of the urethral sphincter is diminished, and the sphincter, reacting to the increased pressure from the abdomen, is not able to prevent urine flow. Storage problems may occur as a result of weakened pelvic muscles that support the bladder, or because of malfunction of the urethral sphincter. Prior trauma to the urethral area, neurological injury, and some medications may weaken the urethral closure. Sphincter weakness may occur in men following prostate surgery or in women after pelvic surgery. Stress incontinence may be seen in women who have had multiple pregnancies, or who have pelvic prolapse (protrusion of the bladder, urethra, or rectal wall into the vaginal space), with a cystocele, cystourethrocele, or rectocele. Additionally, women with low estrogen levels may have stress incontinence due to decreased vaginal muscle tone.
Studies have documented that about 50% of all women have occasional incontinence , and as many as 10% have regular incontinence. Nearly 20% of women aged 75 or over experience daily incontinence. The risk increases with advancing age, obesity , chronic bronchitis , asthma , and childbearing.
Prevention:
Performing Kegel exercises (tightening muscles of the pelvic floor as if trying to stop urine stream) may help prevent the development of symptoms. An adequate episiotomy before giving birth and exercising before and during pregnancy can minimize the trauma to some muscles.
Symptoms:
Note: A wide variety of lower urinary tract symptoms or vaginal symptoms may be associated with stress incontinence.
Signs and Tests:
Physical examination will include an abdominal and rectal exam, a genital exam in men, and a pelvic exam in women. A pelvic examination may detect cystocele or urethrocele (protrusion of the bladder or urethra into the vaginal space).
Tests include: - Post void residual (PVR) to measure amount of urine left after urination.
- Urinalysis / urine culture to rule out urinary tract infection .
- Urinary stress test (the patient is asked to stand with a full bladder, and then cough ).
- Pad test (after placement of a pre-weighed sanitary pad, patient asked to exercise ; following exercise, the pad is re-weighed to determine the degree of urine loss).
- A pelvic or abdominal ultrasound .
- X-rays with contrast dye.
- Cystoscopy ( inspection of the inside of the bladder).
- Urodynamic studies (tests to measure pressure and urine flow).
- An EMG (myogram) (rarely performed).
Other tests may include the measurement of the change in the angle of the urethra when at rest and when straining (Q-tip test). An angle change of greater than 30 degrees often indicates significant weakness of the muscles and tendons that support the bladder.
Treatment:
The choice of a specific treatment will depend on the severity of the symptoms and the extent to which the symptoms interfere with your lifestyle. There are three major categories of treatment for stress incontinence: medication, surgery, and bladder retraining therapy.
MEDICATIONS:
Medications used to treat stress incontinence are aimed at increasing the contraction of the urethral sphincter muscle. There are three types of medications that can improve the function of the sphincter: alpha-adrenergic agonists, beta-adrenergic blockers, and estrogen.
Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine (common components of over-the-counter cold medications) may be used to treat stress incontinence. They work by increasing the closure of the urethral sphincter. Additionally, the tricyclic antidepressant, imipramine, has similar properties, and so may also be used to treat stress incontinence. A new prescription medication, tolterodine tartrate (Detrol), is also being used to treat certain types of urinary incontinence.
Estrogen therapy may be used in some postmenopausal women to treat stress incontinence. Estrogen has been shown to increase the tone and blood supply of the urethral sphincter muscles. Estrogen may be taken in an oral (by mouth) form, applied to the vagina mucosa in a cream form, or absorbed into the body through a skin patch. Women with a history of breast, cervical, or uterine cancer should not use estrogen therapy for the treatment of urinary stress incontinence.
SURGERY:
Surgical treatment is usually only recommended after thorough evaluation and determination of the exact cause of the voiding malfunction. The person considering surgery should be aware of the potential risks as well as the expected benefit of the procedure.
The goal of these surgical procedures is to cure the cause of the urinary incontinence, either by supporting the bladder and urethra in its proper position, so it can function properly, or by tightening the urethral sphincter. The procedures are similar in men and women; however, the rationale for performing the procedure and the outcomes vary by gender.
A minor surgical procedure called collagen periurethral injection may be recommended for treatment of male and female stress incontinence caused by urethral sphincter dysfunction. This procedure is performed in an outpatient setting, with a local or spinal anesthesia. The procedure may need to be repeated after a few months to achieve bladder control. The collagen injection helps control the urine leakage by bulking up the area around the urethra, thus compressing the sphincter.
Women who were treated with collagen injection therapy reported a higher success rate (75% improved or cured) than men (52% cured or improved) who were treated with the same collagen therapy. Potential complications that can occur after a collagen injection include: infection, urine retention, and, in men, a temporary erectile dysfunction.
Some people may have a potentially serious allergic reaction to collagen. Any potential candidate for collagen injection must have a skin test prior to treatment to check for an allergic reaction.
This procedure is rarely performed in men, but is more often used to treat women who have stress incontinence caused by weakened urethral sphincter muscles. A sling is formed by taking a piece of the abdominal tissue (fascia) or a piece of synthetic material and using it to compress the urethral sphincter, thus preventing leakage of urine during stress maneuvers.
Among the people who have had sling procedures to correct their stress incontinence, there is an 89% cure rate. Possible complications include infection, erosion of the sling, a nonhealing vaginal wall, fistula or abscess formation, urgency, urge incontinence , and urinary retention.
- ARTIFICIAL URINARY SPHINCTER INSERTION
Insertion of an artificial urinary sphincter is a surgical procedure which treats stress incontinence in men that is caused by urethral dysfunction, such as may occur after prostate surgery. Additionally, this procedure may be performed in men and women with intrinsic sphincter dysfunction related to spinal cord injury , multiple sclerosis , or other injury to the sphincter. Most experts advise their patients to try medication and bladder retraining therapy first, before resorting to this treatment.
Men who are treated with this device have an 82% cure rate, while women have a 92% cure rate. Possible complications of this surgery include wound infection and urethral erosion, requiring removal of the device. Additionally, because the pump mechanism is placed in the labia in women and the scrotum for men, the patient may need to modify some activities (such as bicycle riding) to accommodate this pump.
This procedure is occasionally used to treat stress incontinence by supporting the bladder and urethra in its proper position, so it can function properly. As with most other surgical procedures, it is advised that medication and bladder retraining therapy be tried first, before resorting to this treatment.
To perform the anterior vaginal repair, an incision is made through the vagina to release a portion of the anterior (front) vaginal wall that is attached to the base of the bladder. The pubovesicocervical fascia (fibrous membrane covering pelvic muscles and organs) is folded and stitched to bring the bladder and urethra into proper position. There are several variations on this procedure that may be necessary based on the severity of the dysfunction. This procedure may be performed using general or spinal anesthesia.
Women treated with this procedure have a 62% cure rate. Possible complications include infection and inability to urinate.
Retropubic suspension is used to describe a large group of surgical procedures that are performed to elevate the bladder and urethra within the pelvic region. The various procedures (Marshall-Marchetti-Krantz ( MMK ), Burch colposuspension, or paravaginal repair) differ based on the structures that are used to anchor and support the bladder.
Women treated with these procedures have a 78% cure rate. Possible complications include urinary tract infection , inability to urinate, wound infection, development of a fistula (rarely), and new onset of urge incontinence.
- NEEDLE BLADDER NECK SUSPENSION
There are several surgical procedures that are performed through a minor abdominal incision to repair the bladder and urethral dysfunction. These procedures are called needle procedures because special needle instruments are utilized during the surgery, which requires only a minor or small abdominal incision. The various procedures (Modified Pereyra and Stamey procedure) differ based on the structures that are used to anchor and support the bladder.
Women treated with these procedures have an 84% cure rate. Possible complications include urinary tract infection, inability to urinate, wound infection, development of a fistula (rarely), and new onset of urge incontinence.
OTHER THERAPY:
Pelvic muscle training exercises called Kegel exercises may prove to be beneficial in controlling the leakage of urine that occurs in people with stress incontinence. The principle behind Kegel exercises is to strengthen the muscles of the pelvic floor, thereby improving the urethral sphincter function. The success of Kegel exercises depends on proper technique and adherence to a regular exercise program.
Some women may use vaginal cones to strengthen the muscles of the pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. Twice daily the cone is inserted, the pelvic floor muscles are contracted in order to hold the device in place, and the contraction is held for up to 15 minutes. Within 4 to 6 weeks, about 70% of women have had some improvement in their symptoms.
If you are unable to correctly perform these exercises, biofeedback and electrical stimulation may be used to help identify the correct (proper) muscle group to work. Biofeedback is a method of positive reinforcement. Electrodes are placed on your abdomen and along the anal area. Some therapists place a sensor, in the vagina in women or the anus in men, to monitor contraction of the pelvic floor muscles. A monitor will show you which muscles are contracting and which are at rest. The therapist can help you identify the correct muscles for performing Kegel exercises. Of the people who used biofeedback, about 75% have reported improvement of their symptoms, and 15% were cured.
Electrical stimulation therapy uses low-voltage electric current to stimulate and contract the correct (proper) group of muscles. The current is delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in a clinic or at home. Treatment sessions usually last 20 minutes and may be performed every 1 to 4 days.
A new technique uses a specially designed chair with an electromagnetic field; the field causes the pelvic floor muscles to contract while the patient sits in the chair. New devices, which are placed into the vagina to provide correct bladder and urethral support or to help occlude the urethra, are currently being tested. Ask your health care provider about these special devices.
EXERCISE AND ACTIVITY:
Some people with severe stress incontinence may modify their activity level to avoid movements that cause greater leakage of urine. Incontinence sufferers may want to modify activities that involve jumping or running, and any activity that causes an increase in abdominal pressure.
MONITORING:
Urinary incontinence is a chronic (long-term) problem. Although some people may be cured by various treatments, you should continue to see your health care provider to evaluate the progress of your symptoms and monitor possible complications of treatment.
Prognosis:
Medical management of true stress incontinence usually improves symptoms rather than cures the disorder. Surgery may have a 75% to 95% cure rate when patients are carefully selected. There is a poorer prognosis (probable outcome) for people with previous surgical failures, other pathology in the region, or systemic conditions that may prevent adequate healing or make the technical aspects of the surgery more difficult.
Complications:
Physical complications such as vaginal discharge , vulvar irritation, and pain during intercourse are relatively rare and mild. Unpleasant odors may occur. Psychosocial implications of incontinence may be extreme because the condition may affect or disrupt careers and relationships. Urinary tract infections , constipation , and hemorrhoids may result from poor muscle tone.
Call Your Healthcare Provider:
Call for an appointment with your health care provider if symptoms of stress incontinence occur.
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