| Stress incontinence | |
|---|---|
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| Pelvic floor | |
| Specialty | Urology, gynaecology, urogynecology  |
Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter.
It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increasing the pressure on the bladder. The urethra is normally supported by fascia and muscles of the pelvic floor. If this support is insufficient due to any reason, the urethra would not close properly at times of increased abdominal pressure, allowing urine to pass involuntarily.[ citation needed ]
Most lab results such as urine analysis, cystometry and post-void residual volume are normal.
Some sources distinguish between urethral hypermobility and intrinsic sphincter deficiency. The latter is more rare, and requires different surgical approaches. [1]
Stress incontinence in men is most commonly seen after prostate surgery, [2] such as prostatectomy, transurethral resection of the prostate, laparoscopic prostatectomy, or robotic prostatectomy.[ citation needed ]
In women, pregnancy, childbirth, obesity, and menopause often contribute to stress incontinence by causing weakness to the pelvic floor or damaging the urethral sphincter, leading to its inadequate closure, and hence the leakage of urine. [3] [4] [5] Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels. In female high-level athletes, effort incontinence may occur in any sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance. [6]
Medications are not recommended for those with stress incontinence. [7]
Some behavioral changes can improve stress incontinence. It is recommended to decrease overall consumption of liquids and avoid drinking caffeinated beverages because they irritate the bladder. Spicy foods, carbonated beverages, alcohol and citrus also irritate the bladder and should be avoided. Quitting smoking can also improve stress incontinence because smoking irritates the bladder and can induce coughing (putting stress on the bladder).[ medical citation needed ] The effectiveness of these approaches to treat people for whom synthetic midurethral tape surgery did not result in a cure (failed surgery) is not clear. [8]
Results of a 2019 systematic review of urinary incontinence in women found that most individual, active treatments are better than no treatment. [9] Behavioral therapy, alone or combined with other interventions such as hormones, is generally more effective than other treatments alone. [10]
One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage. [11] Patients younger than 60 years old benefit the most. [11] The patient should do at least 24 daily contractions for at least 6 weeks. [11] It is possible to assess pelvic floor muscle strength using a Kegel perineometer.[ citation needed ]
Bladder training is a technique that encourages people to modify their voiding habits (lengthening the time between voiding). Weak evidence suggests that bladder training may be helpful for the treatment of urinary incontinence. [12] This type of intervention can take a person months to learn and would not be a therapy option for people who are not physically or mentally able to control their voiding. [12]
An incontinence pad is a multi-layered, absorbent sheet that collects urine resulting from urinary incontinence. Similar solutions include absorbent undergarments and adult diapers. Absorbent products may cause side effects of leaks, odors, skin breakdown, and UTI. Incontinence pads may also come in the form of a small sheet placed underneath a patient in the hospital, for situations when it is not practical for the patient to wear a diaper.[ medical citation needed ]
People have different preferences regarding the type of pad they use to stay dry when they have incontinence. [13] In addition, the effectiveness of incontinence pads differ between people. [13] Using different designs depending on the activity (sleeping/going out/staying in) is recommended. [13] For men, the most cost-effective design is an incontinence pad in a diaper format. [13] For women, incontinence pads that are in the form of disposable pull-ups are generally preferred, however there is a higher cost associated with this type of solution. [13] For women who are in nursing homes, diapers are preferred at night. [13] Washable diapers are cost effective, however, most people do not prefer washable diapers with the exception of some men who prefer as a means to control incontinence at night. [13] There is no evidence that one type of incontinence pad is superior with regard to skin health. [13]
A pessary is a medical device that is inserted into the vagina. The most common kind is ring shaped, and is typically recommended to correct vaginal prolapse. The pessary compresses the urethra against the symphysis pubis and elevates the bladder neck. For some women this may reduce stress leakage, however it is not clear how well these mechanical devices help women with stress urinary incontinence. [14]
Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success. Less-invasive variants of the sling operation have been shown to be equally effective in treating stress incontinence as surgical sling operations. [15] One such surgery is urethropexy.[ citation needed ] Insertion of a sling through the vagina (rather than by opening the lower abdomen) is called intravaginal slingplasty (IVS).[ medical citation needed ]
The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling implant usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine or porcine) or the patients own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a backboard of support under the urethra. Transvaginal mesh has recently come under scrutiny due to controversy relating to the Food and Drug Administration. Initially, the FDA approved implantable mesh devices due to their similarity to earlier prototypes, known as the 510(k) process. [16] [17] As patients allege long-term harm and suffering as a result of implanted mesh; the FDA released a safety communication in 2008, and led to the reclassification of surgical mesh to a class 3 or high risk device in January 2016 [18] .[ medical citation needed ] Insertion of a sling through the vagina (rather than by opening the lower abdomen) is called intravaginal slingplasty (IVS).[ medical citation needed ]
The transobturator tape (TOT or Monarc) sling procedure aims to eliminate stress urinary incontinence by providing support under the urethra. The minimally-invasive procedure eliminates retropubic needle passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area. [19]
A procedure that involves placing polypropylene tape under the outlet from the bladder to improve stress incontinence. [8]
Most stress incontinence in women results from the urethra dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the urethra up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the urethra and secures it with a string attached to muscle, ligament, or bone. For severe cases of stress incontinence, the surgeon may secure the urethra with a wide sling. This not only holds up the bladder but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.[ medical citation needed ]
A variety of materials have been historically used to add bulk to the urethra and thereby increase outlet resistance. This is most effective in patients with a relatively fixed urethra. Blood and fat have been used with limited success. The most widely used substance, gluteraldehyde crosslinked collagen (GAX collagen) proved to be of value in many patients. The main downfall was the need to repeat the procedure over time.[ medical citation needed ]
Another procedure to treat incontinence is the use of an artificial urinary sphincter, more used in men than in women. In this procedure, the surgeon enters and wraps the cuff of the artificial urinary sphincter around the urethra, in the same manner a blood pressure cuff wraps around your arm. The device includes a pump implanted under the skin that, when pressed by the patient, loosens the cuff, allowing for free urination. After that, the artificial sphincter automatically regains its pressure, closing the urethra again, and providing proper continence. [20]
No useful studies have been done to determine whether acupuncture can help people with stress urinary incontinence. [21]
Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.
Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.
Kegel exercise, also known as pelvic floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many times a day, for several minutes at a time but takes one to three months to begin to have an effect.
A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.
The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.
Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarassment and stigma.
Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for erectile dysfunction, moderate risk for bleeding, and a large risk for retrograde ejaculation.
The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.
Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.
Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.
Neurogenic bladder dysfunction, or neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladder depending on the underlying cause and the symptoms. Symptoms include overactive bladder, urinary urgency, frequency, incontinence or difficulty passing urine. A range of diseases or conditions can cause neurogenic bladder including spinal cord injury, multiple sclerosis, stroke, brain injury, spina bifida, peripheral nerve damage, Parkinson's disease, or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. Treatment depends on underlying disease as well as symptoms and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can have a significant impact on quality of life.
Retropubic space is a potential avascular space located between the pubic symphysis and the urinary bladder. The retropubic space is a preperitoneal space, located behind the transversalis fascia and in front of peritoneum.
The urethral sphincters are two muscles used to control the exit of urine in the urinary bladder through the urethra. The two muscles are either the male or female external urethral sphincter and the internal urethral sphincter. When either of these muscles contracts, the urethra is sealed shut.
Sacral nerve stimulation, also termed sacral neuromodulation, is a type of medical electrical stimulation therapy.
An artificial urinary sphincter (AUS) is an implanted device to treat moderate to severe stress urinary incontinence, most commonly in men. The AUS is designed to supplement the function of the natural urinary sphincter that restricts urine flow out of the bladder.
A urethral bulking injection is a gynecological procedure and medical treatment used to treat involuntary leakage of urine: urinary incontinence in women. Injectional materials are used to control stress incontinence. Bulking agents are injected into the mucosa surrounding the bladder neck and proximal urethra. This reduces the diameter of the urethra and creates resistance to urine leakage. After the procedure, the pressure forcing the urine from the bladder through the urethra is resisted by the addition of the bulking agent in the tissue surrounding the proximal urethra. Most of the time this procedure prevents urinary stress incontinence in women.
Urethral hypermobility is a condition of excessive movement of the female urethra due to a weakened urogenital diaphragm. It describes the instability of the urethra in relation to the pelvic floor muscles. A weakened pelvic floor muscle fails to adequately close the urethra and hence can cause stress urinary incontinence. This condition may be diagnosed by primary care providers or urologists. Treatment may include pelvic floor muscle exercises, surgery, or minimally invasive procedures.
If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.
Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.
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