Urethral bulking injections

Urethral bulking injections
Urethral bulking injections
Specialty	Gynecology
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Last updated December 01, 2024

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.

Uses

A urethral bulking injection is one type of treatment for incontinence in women. Urethral bulking injections are considered by a clinician when the woman has urinary sphincter dysfunction, urethral hypermobility, persistent stress urinary incontinence after a urethral sling or urethropexy, or stress urinary incontinence in women who cannot undergo surgery due to other illnesses or conditions. It restores the ability to retain urine during coughing, laughing and other normal occurrences that increase inter-abdominal pressure^[1] Some women choose to have urethral bulking injections because they wish to avoid surgery or the use of mesh material. Another reason other treatments may not be chosen include the desire to maintain fertility. Woman who benefit most from this treatment are those who have a stable bladder neck and an inadequate muscle strength of the sphincter muscles that close the urethra. Urethral instability is identified by the angle of the urethra. This can be evaluated when the woman lies on her back and the angle of the urethral is greater than 30° during coughing. Tests are performed to confirm the diagnosis of stress urinary incontinence such as the bladder capacity to hold urine and the strength of the bladder muscle contractions.^[2]

Diagnosis is aided before the procedure by a thorough evaluation of the woman. Information that is gathered prior to the injection includes consists of a medical history and physical exam. The residual, postvoid residual urine determination and urinalysis and urine culture help in the diagnosis. The surgeon will ask the woman to keep a diary of urine output and frequency. The physician may order a urodynamic evaluation to establish the diagnosis of intrinsic sphincter deficiency. A voiding diary and/or a measured voided volume gives an estimate of bladder capacity. A free-flow uroflowmetric examination gives additional information about flow rate, voided time and volume. A cystometrogram will evaluate detrusor over-activity, bladder compliance, bladder capacity, and abdominal (Valsalva) leak pressure. Another diagnostic tool is the urethral pressure profile. This measures the maximum urethral closure strength. The physician will use instrumentation and do a visual examination called a urethroscopic visualization.^[2]

Contraindications

A woman may not be a good candidate for the procedure. Contraindications for this treatment are having a current urinary tract infection, having difficulty emptying the bladder, having a urethral stricture, having a urethral obstruction or having fragile or sensitive tissue where the injections are to be placed. In some women, cancer treatments may have created changes in the urethra, bladder and sphincter muscles which would prevent the success of the treatment.^[2]

Available bulking agents

Durasphere
Macroplastique
Coaptite

These are the most popular urethral bulking agents in the United States^{[ as of? ]} now that Contigen is no longer available. The ideal bulking material should be non allergic, tissue friendly, not migrate and be long-lasting. However, this has not been found, and despite a prolonged search, nothing financially feasible as yet appeared to be better than the available bulking agents. Urolastic is a new injectable product that seems to be a good candidate to become the ideal product for a minimal invasive and outpatient treatment of stress urinary incontinence since it is not degraded by the body and maintains form.^{[ citation needed ]}

History

Urethral bulking agents were first used in 1938 and incorporated morrhuate sodium as the injection material. Bovine collagen use began after 1989 and was considered the best example of treatment. All subsequent studies afterwards were compared with this agent. Its use was stopped in 2011. Other bulking agents have been in use since the 1990s. The use of some was discontinued due to complications, the 'unpleasantness' of the procedure and the cost of the procedure.^[2]

Research

Improved materials continue to be investigated. A successful bulking agent should be readily available, non-inflammatory, easy to inject, easy to prepare, efficacious, durable, inexpensive, biocompatible, nonimmunological, long-lasting, non-migrating (the size of the particles should be larger than 80 μm) adult stem cell injection therapy using autologous muscle-derived stem cells for the regenerative repair of an impaired sphincter is currently at the forefront of incontinence research. The implanted cells fuse with muscle and release trophic factors promoting nerve and muscle integration. Small pilot studies have suggested restoration of the urethral sphincter over several months' time.^[2]

Related Research Articles

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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. Urinary incontinence is common in older women and 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.

Retrograde ejaculation occurs when semen which would be ejaculated via the urethra is redirected to the urinary bladder. Normally, the sphincter of the bladder contracts before ejaculation, inhibiting urination and preventing a reflux of semen into the bladder. The semen is forced to exit via the urethra, the path of least resistance. When the bladder sphincter does not function properly, retrograde ejaculation may occur. It can also be induced deliberately by a male as a primitive form of male birth control or as part of certain alternative medicine practices. The retrograde-ejaculated semen is excreted from the bladder during the next urination.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

<span class="mw-page-title-main">Cystocele</span> Protrusion of the bladder into the vagina

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.

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.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

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.

In urology, voiding cystourethrography (VCUG) is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates (voids). It is used in the diagnosis of vesicoureteral reflux, among other disorders. The technique consists of catheterizing the person in order to fill the bladder with a radiocontrast agent, typically diatrizoic acid. Under fluoroscopy the radiologist watches the contrast enter the bladder and looks at the anatomy of the patient. If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score. The exam ends when the person voids while the radiologist is watching under fluoroscopy. Consumption of fluid promotes excretion of contrast media after the procedure. It is important to watch the contrast during voiding, because this is when the bladder has the most pressure, and it is most likely this is when reflux will occur. Despite this detailed description of the procedure, at least as of 2016 the technique had not been standardized across practices.

Neurogenic bladder dysfunction, often called by the shortened term 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, multiple system atrophy or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. In addition to symptomatic treatment, treatment depends on the nature of the underlying disease and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can severely degrade a person's quality of life.

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.

A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles. In this case, the term used is cystourethrocele.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

Urodynamic testing or urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests can help explain symptoms such as:

<span class="mw-page-title-main">Overflow incontinence</span> Medical condition

Overflow incontinence is a concept of urinary incontinence, characterized by the involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate. This condition occurs in people who have a blockage of the bladder outlet, or when the muscle that expels urine from the bladder is too weak to empty the bladder normally. Overflow incontinence may also be a side effect of certain medications.

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A urethral diverticulum is a condition where the urethra or the periurethral glands push into the connective tissue layers (fascia) that surround it.

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.

<span class="mw-page-title-main">Surgery for benign prostatic hyperplasia</span> Type of surgery

If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.

These procedures aim to inject bio-compatible material into the walls of the anal canal, in order to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing fecal incontinence. This procedure has many advantages over more invasive surgery, since there are rarely any serious complications.

References

Hoffman, Barbara (2012). Williams gynecology, 2nd edition. New York: McGraw-Hill Medical. pp. 1198–1199. ISBN 0071716726. 1 2 3 4 5 Walters, Mark (2015). Urogynecology and reconstructive pelvic surgery, Chapter 22. Philadelphia, PA: Elsevier/Saunders. ISBN 9780323113779; Access provided by the University of Pittsburgh

↑ Hoffman, Barbara (2012). Williams gynecology, 2nd edition. New York: McGraw-Hill Medical. pp. 1198–1199. ISBN 978-0071716727.
1 2 3 4 5 Walters, Mark (2015). Urogynecology and reconstructive pelvic surgery, Chapter 22. Philadelphia, PA: Elsevier/Saunders. ISBN 9780323113779; Access provided by the University of Pittsburgh {{cite book}}: CS1 maint: postscript (link)

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[Hoffman2012-1] Hoffman, Barbara (2012). Williams gynecology, 2nd edition. New York: McGraw-Hill Medical. pp. 1198–1199. ISBN 978-0071716727.

[Walters2015-2] 1 2 3 4 5 Walters, Mark (2015). Urogynecology and reconstructive pelvic surgery, Chapter 22. Philadelphia, PA: Elsevier/Saunders. ISBN 9780323113779; Access provided by the University of Pittsburgh {{cite book}}: CS1 maint: postscript (link)

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