Treatment of urinary incontinence in women

What is female stress urinary incontinence?

In medicine, stress is usually called this type of urine incontinence, in which it leaks due to a sharp increase in intra-abdominal pressure, combined with weakness of the sphincters that lock the bladder. Here, the concept of “stressful” does not mean a woman’s emotional experiences, but rather the suddenness and unexpectedness of a pressure surge inside the abdominal cavity. This condition occurs during physical activity (lifting weights, running, jumping or even walking), coughing, screaming, laughing, talking loudly, sneezing, hiccupping, etc. Popularly, this problem is better known as stress urinary incontinence .

Female stress urinary incontinence is most often caused by incompetence of the pelvic floor muscles and bladder sphincter.

Another synonym for stress urinary incontinence is stress incontinence.

The disease tends to progress. The amount of urine released involuntarily during stress incontinence gradually increases. Its daily volume can vary from 3–4 drops to 1.5–2 liters. This forces sick women to constantly wear sanitary pads, diapers and dark clothes.

Urological pads are a modern invention that becomes a salvation for women with urinary incontinence.

Classification of pathology

In urological practice, it is customary to assess the severity of stress incontinence based on the following classification:

1. Easy. Urine is spontaneously released with a strong cough, sneezing, or sudden lifting of weight.
2. Average. Urine leaks during fast walking or running, or when suddenly getting out of bed.
3. Heavy. The fluid comes out when the bladder is full, even at rest, without any action by the patient.

Effective ways to treat the disease

In the early stages, getting rid of the disease occurs without problems. Timely treatment means the fastest recovery and minimal medical intervention. Exercises against stress urinary incontinence can help in the early stages. A set of Kegel exercises is designed to strengthen the pelvic floor muscles.

Any treatment occurs only after the provoking factor has been eliminated.

The Clinic for Men's and Women's Health uses conservative and surgical treatment methods:

• drug treatment of stress urinary incontinence in women - antidepressants, estrogens, hormonal drugs, systemic HRT are prescribed.
• Biofeedback therapy – control of the pelvic floor muscles according to a schedule;
• laser treatment;
• shock wave therapy;
• tvt o surgery for stress urinary incontinence (prolene loop surgery);
• artificial sphincter implantation;
• bulinotherapy (introducing a gel to increase elasticity);
• urethrocystopexy.

Experts may recommend physiotherapy:

• warming up;
• electrophoresis.

Drugs for stress urinary incontinence are selected taking into account contraindications. The clinic’s doctors will study the disease in detail to prevent allergic reactions.

Laser treatment of stress urinary incontinence is recognized as one of the most effective techniques in the world. In our clinic, the treatment procedure takes place in 4-5 sessions.

Surgical treatment of stress urinary incontinence is prescribed only in extreme cases when conservative methods do not bring the desired result.

Highly qualified doctors will perform tvt o surgery for stress urinary incontinence. The intervention occurs with minimal tissue damage. The patient can leave the clinic the next day and wait for recovery at home.

In the clinic, patients are required to receive psychotherapeutic assistance in the treatment of delicate illnesses. A positive emotional background contributes to the patient’s recovery. Therefore, the time frame for complete recovery is reduced.

Causes and factors for the development of stress incontinence

The main condition for urine retention is the correct balance of pressure in the bladder and urethra. In the latter it should be slightly higher, which is the case in healthy women. This balance is ensured by the normal functioning of the sphincter apparatus, which is a plexus of muscle fibers - both striated and smooth. Its function is supported by collagen and elastin - components necessary for soft tissues.

The locking function of the vesico-urethral sphincters is carried out by:

• anatomical structure of the locking apparatus;
• complete nervous regulation;
• the normal state of the pelvic floor, which serves as support and fixation of the bladder.

Pathological changes in these factors lead to disruption of the sphincter's ability to withstand external pressure, loss of its elasticity and deterioration of contractility. The development of stress urinary incontinence is based on an anatomical cause - insufficiency of the locking mechanism located between the bladder and urethra.

When tension occurs, intra-abdominal pressure is transmitted to the bladder. Normally, it should be balanced by pressure inside the urethra. But since the tone of the pelvic tissues is weakened, the neck of the bladder protrudes into the urethra like a hernial protrusion. Intraurethral pressure decreases, which is why urine is released out.

The pressure in the urethra does not compensate for the pressure in the bladder, hence stress urinary incontinence.

Risk factors for stress urinary incontinence

There are 3 groups of factors contributing to the development of this pathology.

Obstetrics and gynecology:

• pelvic organ prolapse;
• birth of a large fetus;
• multiple pregnancies;
• dissection of the perineum during childbirth (episiotomy);
• previous gynecological operations;
• radioactive irradiation of the pelvic organs;
• instrumental aid during childbirth (application of forceps, etc.).

Pelvic organ prolapse often results in urinary incontinence.

The percentage of morbidity also depends on such factors as the number of births in the history and methods of their resolution: urinary incontinence due to stress occurs in 10% of nulliparous women, in 20% of those who gave birth to a child through natural means and in 15% of those who became mothers by caesarean section.

Predisposing:

• complicated heredity (older women in the patient’s family already suffered from urinary incontinence);
• diseases and injuries of the nervous system;
• race.

Ethnologists and urologists have noticed that women of the Negroid and Asian races are much less likely to encounter this problem than European women.

Provoking:

• elderly age;
• being overweight;
• smoking;
• concurrent diseases.

Most often, this misfortune strikes 40–50-year-old women who work and lead an active social life. The incidence of the disease increases with age. So, at the age of 40, every sixth woman suffers from stress incontinence, at 50 - every fifth, at 60 - every fourth, at 70 - every third, and after 80 - almost half.

Complete urinary incontinence

Pathogenesis . Complete urinary incontinence usually results from urinary fistulas that form between the bladder and vagina (vesicovaginal fistula), or between the urethra and vagina (urethrovaginal fistula), or between the ureter and vagina (ureterovaginal fistula).

In developing countries, the most common cause of genitourinary fistula formation is obstetric trauma (long 2nd stage of labor, surgical delivery - use of obstetric forceps, etc.). In developed countries, genitourinary fistulas occur primarily as a result of previous pelvic surgery or pelvic radiation (radiation therapy). Urethral diverticula or ectopic ureter can also cause complete urinary incontinence.

Epidemiology . Previous pelvic surgery and pelvic radiation account for more than 95% of cases of complete urinary incontinence in women in many countries around the world. In particular, abdominal and vaginal hysterectomies account for more than 50% of vesicovaginal fistulas. Urethrovaginal fistulas can occur as a complication of reconstructive surgery for urethral diverticula, prolapse of the anterior vaginal wall, or stress urinary incontinence. Urethrovaginal fistulas, observed in 1-2% after radical hysterectomy, are more often due to devascularization than direct surgical trauma.

Risk factors for complete urinary incontinence include a history of traumatic operative vaginal delivery; operations for severe endometriosis, pelvic inflammatory diseases, gynecological oncological diseases; other pelvic surgery; preoperative irradiation of the pelvic organs.

History . Patients with complete urinary incontinence complain of painless and constant leakage of urine following traumatic childbirth, pelvic surgery, or pelvic radiation. The development of a fistula after surgery usually occurs within 5-14 days.

Diagnosis of complete urinary incontinence

Methylene blue test . In the presence of a vesicovaginal fistula, an aqueous solution of methylene blue, which is instilled into the bladder, leaks onto a pad or tampon inserted into the vagina.

In order to diagnose a ureterovaginal fistula, indigo carmine is administered and the color of the tampon inserted into the vagina is monitored. Indigo carmine is filtered through the kidneys, enters the ureters and then into the vagina. In the case of ureterovaginal fistula, the methylene blue test will be negative and the indigo carmine test will be positive.

Cystourethroscopy may be useful in identifying the number and location of fistulas. Sensitive methods for diagnosing ureterovaginal fistulas are also intravenous pyelography (excretory urography) and retrograde pyelography (urography).

Treatment . The main treatment for complete urinary incontinence is reconstructive surgery. Most obstetric fistulas can be repaired immediately after delivery. Post-surgical fistula is usually operated on 3-6 months after the previous operation. This period is necessary to reduce the inflammatory response and possibly increase vascularization of the injured tissue.

For urinary tract infections, a course of etiotropic antibiotic therapy is carried out; Estrogen replacement therapy has a positive effect in postmenopausal women with symptoms of urogenital atrophy. Corticosteroids are sometimes used to reduce the inflammatory response, although their role has not yet been determined.

Diagnostics

Diagnosis of stress urinary incontinence usually does not cause difficulties for a urologist. Already when interviewing the patient, you can find out that urine is spontaneously released during any physical stress. This is also noticeable visually: the patient, placed on a gynecological chair, is asked to strain or cough. As a result, the doctor can see with the naked eye how urine is expelled from the urethral opening when intra-abdominal pressure increases.

To confirm the preliminary diagnosis, the patient is prescribed a number of examinations:

• Ultrasound with a vaginal probe. Using this method, you can find out the thickness of the walls of the bladder, determine its location and distortion of shape, the presence and volume of residual urine. In addition, calculate the thickness of the urethral-vaginal septum and the diameter of the urethra. An ultrasound scan allows you to see stones, tumors and diverticula in the bladder, which may well provoke urinary incontinence.

  In photo (a) the arrow indicates a gaping bladder neck with sphincter insufficiency; in photo (b) - prolapse of the vaginal wall

• Profilometry of the urethra. Determines intraurethral pressure.
• Urethrocystometry. The method allows you to evaluate local changes in pressure inside the urethra when it changes inside the bladder.
• Uroflowmetry. Examines the evacuation ability of the bladder and determines anatomical obstacles to its emptying.
• Cystourethrography. This X-ray examination is used to study vesicourethral anatomy and topography, determine the location of the bottom of the bladder relative to the pubic symphysis, the shape and volume of the organ. The method clarifies the dynamics of changes occurring in the vesicourethral sphincter at rest and during physical stress.

  This cystourethrogram shows a change in the form of a bubble in the neck of the ureter, characteristic of sphincter insufficiency

• Victory cystourethrography with X-rays taken during urination. The test provides information about the presence of diverticulum, vesicourethral reflux and residual urine.
• Laboratory examination of urine and blood samples. Signs of urolithiasis or an inflammatory process in the test results will tell the doctor the origin of increasing urinary incontinence.

Differential diagnosis

Most often in the practice of a urologist, there is a need to distinguish stress incontinence from urgent (imperative) incontinence.

Urgent urinary incontinence is the loss of urine due to a strong uncontrollable urge to urinate, which does not give the patient time to get to the toilet. Often in the same patient this form is combined with a stress form, forming a mixed form of pathology.

Table: differences in complaints of patients with stress and urgency urinary incontinence

Treatment

The fight against stress urinary incontinence should be aimed at increasing the tone of the closing sphincters of the bladder. Drug therapy, electrical stimulation, physical exercises and training for the pelvic muscles, vaginal pessaries, surgical correction - all these methods are widely used if a woman has a confirmed diagnosis of stress incontinence. Treatment can be conservative, surgical and complex.

Drug therapy

Urinary incontinence in women with stress during menopause is successfully treated with hormonal drugs containing estrogens. However, the use of these systemic agents is often accompanied by undesirable side effects, so the question of their purpose is controversial. It is possible to use vaginal creams and suppositories containing estriol. When used locally, there is no systemic effect on the body.

For drug control of stress urinary incontinence, urologists readily prescribe α-adrenergic agonists (Ephedrine, Duloxetine). They stimulate well the smooth muscles of the bladder neck and the adjacent urethral segment. The muscle contraction caused by these drugs during stressful moments helps close the urethra.

When stress urinary incontinence is combined with urgency, it is advisable to prescribe antidepressants (Amitriptyline) and anticholinergic drugs:

• Oxybutynin;
• Trospium chloride;
• Rolitena et al.

Injections directly into the muscular lining of the bladder with drugs such as Botox or Botulax are performed exclusively in a urological hospital.

Photo gallery: drugs used in the treatment of female urinary incontinence

Tolterodine, which is part of Rolitene, is widely used in the treatment of urological diseases

Duloxetine is also prescribed for the treatment of depression.

Amitriptyline, which belongs to the group of antidepressants, has a sedative (calming) effect on the nervous system

Hormonal creams with estriol are successfully used in the treatment of urinary incontinence in menopausal women.

Botulax, administered intramuscularly, inhibits neuromuscular transmission in the bladder

Oxybutynin is a drug from the group of anticholinergics, successfully used for problems with urination.

Physiotherapy

Special exercises prescribed to patients to train the pelvic floor muscles are alternating long and short contractions of the levator anus muscle. They also help strengthen the sphincter apparatus of the bladder.

For the same purpose, special vaginal cones are used to enhance the effect of the exercises. These devices are inserted into the vagina, after which the patient must hold them there with the strength of the pelvic floor muscles. First, light cones are used, then, as training progresses, their weight gradually increases; You can hang a load from them. These items need to be held in the vagina for 15 minutes twice a day with the body in an upright position - while standing or walking.

To train the pelvic muscles, special vaginal cones with weights are used

Another way to train the bladder locking mechanism is to tense the muscles that compress the anus while sitting on the floor with your legs apart. During urination, it is useful to stop and resume the act several times with an effort of will. It is also advisable, when the urge comes, to try to wait for a while, and not to empty the urinary organ immediately.

Kegel exercises, which involve tensing the vaginal muscles, are considered effective in combating urinary incontinence. Indirectly, the sphincter mechanism of the bladder is also strengthened.

Regularly doing Kegel exercises will help strengthen your pelvic floor muscles.

Video: Kegel exercises for women with stress urinary incontinence

Physiotherapeutic methods

Like special gymnastics, electrical stimulation of the perineal muscles strengthens the sphincter apparatus. During the procedure, special electrodes are inserted into the vagina. Or they are applied to the skin of the perineum. High and low frequency currents conducted through the electrodes cause reflex contractions of the muscles in this area of ​​the body. The result is a strengthening of the bladder locking mechanism and the elimination of mild urinary incontinence.

A vaginal electrode is inserted into the vagina to stimulate the perineal muscles with currents.

Surgical intervention

Surgery is the most effective and common way to solve a delicate problem. It is especially indicated for severe urinary incontinence. Urologists have developed about 300 intervention techniques. They can all be divided into 5 types:

1. Application of narrowing sutures at the junction of the cervix and urethra.
2. Formation of the vesical sphincter from the vaginal muscles.
3. Torsion of the urethra around its axis.
4. Attachment of the bladder neck to the pubic symphysis.
5. Formation of an inflection of the vesicourethral segment.

The latest invention in operative urology is biologically inactive synthetic tapes. The latter are installed under the urethra, preventing its increased mobility and enhancing the locking function of the vesical sphincter. This intervention is low-traumatic, does not require general anesthesia and is easily tolerated by patients.

The most popular operation has become the installation of a free loop with a slight tension. An incision is made in the anterior wall of the vagina just below the urinary organ, through which, bypassing the vesical neck, a synthetic tape is passed into the suprapubic area. It is placed freely, without tension or fixation with seams.

As a variant of this operation, a technique is used in which the ends of the loop are passed not through the pubic area, but through the obturator foramina. This way, when passing the tape, the risk of injury to the bladder wall is reduced.

A loose synthetic band in the pelvis supports the bladder

If urinary incontinence is caused by prolapse or prolapse of the uterus, rectum or anterior vaginal wall, then during the intervention these pathologies are also surgically eliminated, otherwise their inevitable progression will negate the entire effect of the operation.

Laser therapy

Laser treatment of the vaginal and urethral walls is one of the latest advances in medicine in the treatment of urinary incontinence. For this, an erbium laser is used, which has a thermomechanical effect on soft tissue. The heat waves emitted by it shorten and tighten old, stretched collagen fibers, and also stimulate the active growth of new ones.

During a laser therapy session, a device consisting of a laser head enclosed in a metal hollow flask is inserted into the vagina. The latter is rotated in a circle to apply thermal impulses to the tissues of the vagina and urethra. The result of laser treatment is tightened and elastic tissue in the problem area, increased tone of the bladder sphincter and subsidence of symptoms of stress incontinence.

A flask with a laser device emitting heat pulses is inserted into the vagina

Vaginal devices

For the purpose of therapeutic control of stress incontinence, vaginal diaphragms and pessaries are sometimes used. These devices support the bladder and limit the mobility of its cervical region and urethra in a situation of sudden increase in intra-abdominal pressure. However, due to the difficulty of installing them and the discomfort caused to patients, they are not popular among women.

Pessaries are silicone devices inserted into the vagina to support the uterus and bladder in the desired position.

Folk remedies

Traditional healers offer a huge arsenal of drugs for the treatment of stress urinary incontinence, which can be freely taken from nature.

Here are 2 simplest remedies:

• Infusion of fireweed herb, St. John's wort, nettle or yarrow. Plants can be used individually or all together as a collection. Pour 2 tbsp. l. crushed raw materials 0.5 liters of boiling water, let it brew for 2 hours, strain and drink the product in small sips throughout the day.

  The beautiful fireweed plant is included in many medicinal preparations used for urinary problems.

• Decoction of bay leaves. Pour 2 cups of hot water over 6-7 bay leaves and boil for 15 minutes. Drink this decoction for a week, ½ cup 3 times a day before meals.

  Few people know that a modest bay leaf, which can be found in any housewife’s home, can help in the fight against urinary incontinence.

Video: modern methods of treating stress urinary incontinence in women

Which type of stress incontinence treatment is right for me?

Introduction

Stress incontinence can disrupt plans, cause inconvenience and embarrassment. If you find yourself unable to control your urine output when sneezing, coughing, or exercising, you need treatment. It is selected depending on the cause of incontinence and your personal preferences. When choosing the most optimal treatment, consider the following:

• Incontinence can have several causes, and the most significant one is treated first. First of all, the least invasive types of treatment are used.
• Stress incontinence, which causes a relatively small amount of urine to be produced, can be effectively treated with specific exercises, medications, or a combination of these treatments.
• In more than 70% of cases, women suffering from stress incontinence significantly reduce the symptoms of this problem when coughing, laughing, sneezing or playing sports by mastering a set of Kegel exercises aimed at strengthening the pelvic floor muscles.
• Antidepressants may be used, but their effectiveness depends on the individual case.
• Surgery to provide additional support to the bladder neck is used for severe cases of incontinence that do not respond to medication or exercise.
• In addition to the above treatment methods, mechanical devices are also used, such as uterine rings, intermittent self-catheterization (not used for stress incontinence), absorbent pads and special underwear.

General information about the disease

What is stress incontinence?

Stress urinary incontinence is unwanted urination that occurs when additional pressure is placed on the bladder by sneezing, coughing, or exercising. This is the most common type of incontinence in women. The cause of this type of incontinence is the lowering of the bladder neck into the pelvic area, which develops in old age or during multiple births. Most often, stress incontinence is a long-term (chronic) problem that can be treated.

What
are Kegel exercises ?
Kegel exercises, also called pelvic floor strengthening exercises, train the muscle group responsible for urination. You can do them at any time without worrying about anyone noticing what you are doing. The essence of Kegel exercises is to tense the muscles that block the flow of urine for 3 seconds and relax them for the same time. Do these exercises 10-15 times per set, doing more than 3 sets per day. Kegel exercises can significantly reduce or eliminate incontinence problems for many people who use them. They can also be combined with biofeedback, a relaxation technique that aims to teach you to control functions of your body that are normally performed unconsciously, such as skin temperature or blood pressure. This combination is even more popular than each of them individually.

What medications are used for stress incontinence?

There are two types of antidepressants used to relieve (but not cure!) symptoms of incontinence.

Duloxetine is able to control the manifestations of stress incontinence. Studies have shown that this drug significantly reduces the number of unwanted urinations. Imipramine (such as Tofranil) can also be used as an incontinence treatment, but it should be noted that it is not very effective for stress incontinence sufferers.

Can surgery eliminate the symptoms of stress incontinence?

Surgery is used to treat stress urinary incontinence only if it is the only treatment option or other treatments have failed. The decision about the need for surgery should be based on an accurate diagnosis and a realistic prediction of the results of surgery. Most unsuccessful surgeries are due to an incorrectly identified cause of stress incontinence.

The operation lifts and supports the tissues connecting the bladder and urethra. After surgery, the patient will either experience a significant reduction in the number of uncontrolled urinations during activities that put additional pressure on the bladder, such as sneezing, coughing, and laughing, or these symptoms will stop altogether.

Absorbent products, such as mechanical devices (eg, a catheter, uterine ring, or special patch) or electrical stimulation, are often used to treat incontinence before the decision to proceed with surgery is made. These treatments have no serious side effects, can be done at home, and do not limit other treatments. Most of these methods are successful in treating small amounts of uncontrolled urination. Electrical stimulation is under study.

If you would like more information on this, see the section on Urinary incontinence in women.

Additional Information

You can choose:

• Doing special exercises (Kegels) that strengthen the pelvic floor muscles in order to reduce the symptoms of the problem.
• Using absorbent pads, medical devices, or electrical stimulation to control incontinence.
• The use of medications to eliminate signs of stress incontinence.
• Performing surgical intervention after accurately identifying the cause of incontinence in the presence of serious, uncontrolled manifestations of the problem or significant complications in the patient’s daily life caused by incontinence.

When deciding whether to perform such an operation, medical facts and the patient's personal wishes are taken into account. The choice of the most productive treatment method should be based on:

• Identifying the exact cause of stress incontinence.
• Did the patient try to use the least invasive methods at the beginning of treatment?
• Degree of complexity and frequency of symptoms of stress incontinence.
• Optional use of other treatments that may also influence the decisive conclusion.

A wise decision

To make the only right decision, use this questionnaire. By filling it out, you can finally decide which type of treatment is most suitable for you. Discuss your results with your doctor.

Circle the answer that suits you best.

*NA=Not applicable

Use this blank space to make notes on other important details to consider when making your decision.

What is your overall impression?

Your answers to the questionnaire above will give you a general idea of ​​where you are in this decision process. You may have one dominant reason for which treatment method to choose.

In the table below, check the box that best matches your general attitude regarding solving the problem.

Is it possible to avoid stress incontinence?

To minimize the possibility of developing the described illness, you need to follow preventive measures:

• exercise, in particular, strengthen the pelvic floor muscles;
• promptly treat inflammatory diseases of the genitourinary organs;
• watch your figure, get rid of extra pounds;
• do not endure the urge to urinate for a long time, but go to the toilet immediately;
• limit the consumption of spicy and sour foods that irritate the mucous membrane of the urinary tract;
• get rid of bad habits (smoking, drinking alcohol).