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UROGYNAECOLOGY

Urinary Incontinence

Urinary incontinence is the involuntary leakage of urine from the bladder. About one woman in three may report urinary incontinence at some time in their life, especially as she becomes older. Fortunately, treatment can often be highly effective.

The Normal Action of the Bladder

The ability to pass urine requires a complex series of actions, involving the brain, bladder, urethra, pelvis floor muscles and the pelvis nerves.

As the bladder fills with urine, the muscle in the bladder wall (the detrusor) slowly stretches. The detrusor must remain relaxed to allow continued filling. When the bladder is filled to a certain level, the woman feels a need to pass urine, the bladder (detrusor) contracts the urethra relaxes, allowing urine to pass to the outside. The upper urethra and bladder neck are cradled by muscles and connective tissues. Normally increase in pressure from inside the abdomen compress the urethra against the front vaginal wall and prevents urine leakage.

Types of Urinary Incontinence

Stress Incontinence

Stress incontinence in the involuntary leakage of urine that occurs during an increase of abdominal pressure. This is most likely during to happen during actions such as sneezing, coughing, laughing, jogging, rapid walking, jumping or lifting heavy items. Stress incontinence is usually a result of the urethra being too mobile and not being compressed against the vaginal wall during increased abdominal pressure. This changes normal anatomy of the junction between the bladder and the urethra. It can be weak from birth or may become weak over time, often as a result of giving birth. Stress incontinence may also be caused by weakness in the urethral sphincter, rather than supporting tissues. This causes unconscious dribbling of urine and is usually more difficult to treat. Women can have a combination of both types of stress incontinence.

Urge Incontinence

Urge incontinence is the involuntary loss of urine associated with a strong sensation to pass urine. It is sometimes called and ‘’over active bladder’’ and may be due to the detrusor muscle contracting when it should be relaxed. It may also be caused by irritation of the bladder from a number of causes, such as infection. In most cases, no cause for this condition can be found. Other medical problems may provoke the condition. Some women may be born with a tendency for this condition.

Mixed Incontinence

Mixed incontinence is a combination of bother urge incontinence and stress incontinence.

Overflow Incontinence

Overflow incontinence is the involuntary loss of urine due to an overfull bladder caused by poor emptying. The bladder does not empty normally, becomes overfull than leaks. Overflow incontinence is uncommon.

Risk Factors

Pregnancy and method of delivery

Stress incontinence is more common in women who have had children. The more pregnancies and vaginal deliveries they have had the bigger the baby, the higher the risk. Forceps delivery or a difficult vaginal delivery of a baby may increase the risk.

Previous prolapse surgery

Due to urethral scarring, this surgery is associated with an increased risk of urinary incontinence, whether or not the uterus has been removed.

Menopause

Incontinence may become worse after menopause as the bladder and urethra tissue weakens.

Age

Urge incontinence increases with age. Stress incontinence is most common in women in their 40s and 50s.

Medications, smoking and caffeine

Some medications cause urethral muscle or urethral sphincter to relax, increasing the risk of incontinence. Caffeine can increase bladder irritability.

Constipation obesity, chronic cough and heavy constant lifting

These can lead to an increase of abdominal pressure and can aggravate stress incontinence.

Other conditions

Diabetes, multiple sclerosis, arthritis, back problems, pelvis masses, hypothyroidism and chronic lung diseases can increase the risk or urinary incontinence.

Genetic factors

About six women in 100 may have a genetic factor.

Before Treatment

Prior planning treatment, your gynaecologist takes a full medical history. Tell your doctor about any health problems you may have had because some problems may interfere with the surgery, anaesthesia or recovery. Tell your doctor if you have or have had an allergy or any medicines, prolonged bleeding. Excessive bruising when injured any illness, and previous surgery. Give your doctor a list of ALL medicines you are taking or have recently taken, including blood thinners, aspirin, arthritic medication or insulin. Your doctor may ask you to stop taking some medications for a week or more before your procedure, or you may be given an alternate dose.

Testing for Urinary Incontinence

First the cause of leakage must be determined. Although symptoms may suggest which type of incontinence is present, a pelvis and vaginal examination, a urinary diary (of symptoms and passing urine) and sometimes specialised urinary tests are needed for diagnosis, including a test for infection.

  • To help diagnosis, your doctor may ask you to cough while you have a comfortably full bladder.
  • A thin, hollow plastic tube may be guided up the urethra to obtain a fresh sample of urine for examination, or to allow your doctor to measure how much urine is in the bladder after you have emptied it.
  • An ultrasound scan can determine how much urine remains in the bladder after it empties and can assess bladder position and pelvic floor function.
  • Urinary tests called urodynamic studies can be performed, depending on the type of urinary incontinence and the extent of the symptoms. Urodynamic studies involve the use of a catheter to fill the bladder with fluid and a pressure device to test the bladder and its ability to empty properly. The urethra, the capacity and sensation of the bladder, and the mechanism or cause of the incontinence. A small tube is also inserted into the rectum (or the vagina, infrequently) to measure abdominal pressure.
  • In some cases, a cystoscopy is needed. A think telescope is guided up the urethra and into the bladder to inspect it. Cystoscopy can assist in the diagnosis of infection, urethra mobility, and inflammation of the lining of the bladder ( for example, interstitial cystic)

Effective Treatments for Incontinence

Effective treatment for incontinence is available. Treatment included pelvic floor muscle exercise, medicines and surgery.  While surgery has a high success rate, it is often not the first line of treatment. Less invasive treatments may improve symptoms and may avoid the need for surgery.

Pelvic floor muscle training

Pelvic floor muscle exercises involve learning to contract the pelvic floor muscles. Theses muscles are the ones your normally squeeze when you try to stop wind from escaping. Some women find it difficult to identify the correct muscle, so it is best to learn to contract it while your doctor of therapist checks with their finger in the vagina to confirm the correct muscle is being used. To improve learning these exercises, a number of devices have been developed. However, their use is not essential to the success of pelvic floor exercises. Weighted vaginal cones are the commonest. These look a little like tampons and come in a variety of weights. Like all training, the benefits of pelvic floor exercise only continue for as long as they are performed. The maximum benefit occurs after about six months of regular exercise. Exercises directed by a trained therapist have been shown to be the most effective method of doing pelvis exercise.

Bladder training

Bladder training is used to improve urge incontinence. It involves learning to increase the time interval between passing urine so the bladder does what you want it to. The training helps break the cycle of frequently going to the toilet (frequency), or the feeling the strong urge to pass urine (urgency), which can lead to urge incontinence. Urine passed at slowly increasing intervals over a period of weeks and months, this time is increased each week. Keeping a urinary diary is important. Bladder training can be highly successful. It is usually done with the help of continence therapists.

Electrical stimulation

This may be used to treat stress and urge incontinence and involves the use of gentle electrical stimulation of the pelvic floor muscles. It is usually supervised by physiotherapists. There are many types if electrical stimulators, each with their own features. Do not buy one on your own without advice of a continence health professional. This is a safe technique (unless you have a heart pacemaker) and has almost no side effects.

Medical treatment

Urge incontinence can improve with the use of medications called anticholinergic or antispasmodic drugs. In addition, a group of antidepressant drugs improves urge incontinence as a side effect of their action, so can be used un a much lower dose than is needed to treat depression. These drugs act on the nervous system of the bladder to reduce the overactivity of the detrusor muscle. A different group of antidepressant drugs has recently been shown effective for stress incontinence.

Surgical treatment

Surgery may cure stress incontinence but is usually not effective for urge incontinence. The particular operation best suited to your case depends on:

  • Whether additional problems in the pelvis region require surgical repair, such as bladder prolapse or vaginal prolapse
  • Your general health and well-being
  • Your personal preference, following discussion with your gynaecologist
  • Your gynaecologist preference

Anaesthesia

Depending on the surgery, a local, regional or general anaesthetic may be used. Your anaesthetist can provide more information about the best type of anaesthesia for you.

Surgical Options for Stress Incontinence

The aim of surgery is to correct and support any weakness or abnormality effecting the bladder or urethra. A number of procedures have been developed. Surgical options include the following.

Mid-urethral tape procedures (minimally invasive slings)

Mid-urethral tape procedures have become increasingly popular. These operations are generally performed though the vagina via a small cut made in the vaginal wall. Strips of synthetic tape are threaded around the middle section of the urethra, and the gynaecologist uses an instrument called a trochar to tunnel behind the pubic bone to just under the abdominal wall or labial skin. Sometimes the tunnel is made from the inside of the leg to the pelvis (the transobtrurator technique). A mid-urethral tape procedures are fairly new, long –term success rates are still being monitored. They appear to be as successful as the more established operations.

Pubovaginal sling

This operation may be performed by two gynaecologists working together, using both a vaginal approach and an abdominal approach. Tissue obtained from the deep abdominal wall (called the rectus sheath) or a special synthetic mesh is fashioned into a sling and place under the bladder neck (upper urethra) to elevate it. The sling is stitched to the rectus muscle of the abdomen or some other supporting structure. This method is as successful in treating stress incontinence as the open Burch coposuspension.

Periurethral injections

A bulking agent is injected into the tissues of the urethra to create a cushioning effect. This bulking agent may be collagen or silicon. The procedure does not have a good success rate as the Burch colposuspension or tape operations but avoids open surgery. It may be affective when the patient has had previous surgery, the urethra is unsuitable for other types of surgery, or the causes of stress incontinence is intrinsic sphincter deficiency.

Open colposuspension (known as Burch colposispension or bladder neck elevation).

This operation elevates the bladder neck outlet back to its normal position. During surgery a cut of about 10 to 12 centimetres is made horizontally in the abdomen below the pubic hairline. The tissues on either side of the bladder neck are lifted and permanent sutures are inserted to elevate the anterior vagina by suspending it from the side walls of the pelvis. This improves support to the bladder neck outlet. Open Burch colposuspension is considered one of the best operations for stress incontinence and has a success rate of about 75 to 85 patients in every 100.

Laparoscopic Burch colposuspension

Gynaecologists train in laparoscopic (keyhole) surgery may perform the Burch colposuspension using laparoscope. A laparoscope is a narrow telescope with miniature camera equipment that allows the gynaecologist to see into the pelvis. The procedure is similar to an open Burch composuspension. Rather than one longer horizontal incision about the pubic bone, three or four smaller incisions are made. After the procedure, these incisions are closed with absorbable sutures that generally do not have to be removed. Laparoscopy may result in faster recovery time due to the smaller incisions. Pain may be less after a laparoscopy operation, and a quicker return to normal activities may be possible. Doctors do not yet know of the long term success rate of the laparoscopic operation is as good as that of the open Burch colposusoension, but preliminary results appear favourable.

Recovery After Surgery

Recovery after urinary incontinence surgery depends on age, general health, and the type of operation. A lapraroscopically assisted operation or the tape procedures may result in a shorter hospital stay (from one to three days) and a faster recovery at home. Most women have a catheter inserted in the bladder to drain urine it is removed as soon as possible. Pain or discomfort in the abdomen and pelvis may require pain killers. After a laparoscopy, some discomfort or pain may occur in the right shoulder. After general anaesthetic, cough and breathe deeply to keep the lungs clean. With the assistance of a nurse, walk around soon after surgery to improve toe circulation through your legs. Exercise helps to avoid the risk of a blood clot forming in a deep vein in the leg (deep vein thrombosis). You may have some gas pains, nausea or other discomfort as the digestive system returns to normal. Constipation can be a problem in the early postoperative time, particularly when some types of pain killers are taken.

  • No heavy lifting for at least 6 weeks. Following healing, alternative methods of lifting may be learned.
  • No vigorous exercise for at least 6 weeks.
  • Follow your doctor’s advice on showering, driving and returning to work. Your doctor will check on your progress after surgery, answer any questions and arrange follow-up for the removal of the sutures or staples if necessary. It is possible for you to return to your normal sexual activity between four and eight weeks after surgery, if no complications occur. Some couples prefer to wait until after check-up that follows surgery.

Possible Complications of Urinary Incontinence Surgery

As with all surgical procedures, this surgery does have risks, despite the highest standards of practice. While your gynaecologist makes every attempt to minimise risks, complications nay occur that have permanent effects. It is not usual for a gynaecologist to outline every possible side effect or rare complication of a surgical procedure. However, it is important that you have enough information to fully weigh up the benefits and risks of surgery.
The following possible complications are listed to inform and not alarm you. There may be other complications that are not listed. Smoking, obesity, diabetes and other significant medical problems can cause greater risks of complications.


General risks of surgery

  • Cardiovascular risks such as heart attack, blood clots or stroke.
  • Blood clot in a leg vein (deep vein thrombosis, TV) or lung.
  • Uncommonly, infections of the wounds, which is usually treated with antibiotics.
  • Bleeding that may require a return to theatre or a transfusion (about one patient in 100)
  • Risks of anaesthesia

 

Specific risks or urinary incontinence surgery

  • Spasms in the bladder may occur in about six to 15 women in 100. This may cause urge incontinence that usually settles well with time and medical treatment. However, the urge incontinence may be permanent, even though the operation has cured the stress incontinence.
  • In the days after surgery, about two women in 100 have temporary difficulty with passing urine die to tissue swelling and inflammation. A urinary catheter is needed during this period.
  • Difficulty with passing urine that lasts for a few weeks occurs in about two to five women in 100 due to the urethra outlet being elevated. This usually improves gradually over time. In the meantime, it is treated with either a urinary catheter left in the urethra or abdomen, or with intermittent self-catheterisation.
  • Up to five women in 100 have permanent difficulty passing urine. In these cases, there is often a pre-existing weakness in bladder emptying.
  • Further surgery to release a urethral obstruction caused by the surgery may be necessary in a small number of women.
  • A urinary tract infection may develop in about five to 25 women in 100. This is usually treated with antibiotics.
  • Injury to the bowel, urethra, bladder or a ureter during surgery occurs in about one patient in 100. It is usually repaired during the procedure.
  • In about two in 1,000 patients a fistula or connecting channel may form between the bladder and vagina. It can only be repaired with more surgery.
  • Intercourse may be painful for about one to five in 100 women. This may improve over time. Rarely, it may require further surgery.
  • During laparoscopy, a bubble of carbon dioxide (gas embolism) may get into the blood stream. It occurs only rarely and can usually be quickly treated by the anaesthetist and surgeon. It can be life threatening.
  • Tape procedures have been linked to chronic pain in the pelvic area for some patients. In recent years new procedures have had fewer reports of chronic pain.
  • Some types of tapes may cause tissue inflammation, damage or infection many months after surgery. The tapes may need to be surgically removed. This is usually straight forward but some cases can be different.

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