Female stress urinary incontinence and the pelvic floor

Damage to the pelvic floor muscles leads to an altered relationship of the uterus and the urethrovesical unit to the levator plate and creates conditions predisposing to pelvic relaxation associated with stress incontinence. Morphological changes of pelvic floor muscles are age dependent and associated with deterioration of the urethral closure mechanism. Urodynamic assessment and knowledge of the morphology of pelvic floor muscles improves the understanding of pelvic floor function as it relates to the support of the pelvic viscera and the urethral mechanism that maintains continence of urine.     

Female sexual function before and after treatment of urinary incontinence

The prevalence of urinary incontinence is around 20% of healthy middle-aged women. Incontinence causes a negative impact on the quality of life and sexuality. From August 2002 to January 2004, 30 patients (mean age 43 years) with stress urinary incontinence (59%), overactive bladder (15%) and mixed incontinence (26%) answered the ICIQ-SF(International Consultation on Incontinence Questionnarie-Short Form) and FSFI (Female Sexual Function Index) questionnaires before and after treatment for urinary incontinence. The follow-up ranged from 12 to 53 months. Mean ICIQ score was 17 and 7 before and after treatment respectivelly (p<0,001). Overactive bladder showed the worst scores in all domains. The patients who underwent surgery increased their scores of desire (p=0,02), satisfaction (p=0,05) and total score (p=0,02). Thirteen patients which ICIQ was zero increased: desire (p<0,01), satisfaction (p=0,05) and total score (p=0,01). Urinary incontinence significantly affects the quality of life. Therefore sexual evaluation in incontinence patients is recommended.     

Female urinary incontinence: preoperative selection, surgical complications and results

A total of 98 women with stress urinary incontinence underwent surgical repair via 3 different techniques: 38 patients underwent a Burch colposuspension (group 1), 25 underwent a Stamey procedure (group 2) and 35 had a modified Pereyra operation (group 3). The main indication for an operation was clinically unacceptable incontinence, and urodynamic studies were done on all patients with associated stress and urge incontinence or who underwent reoperation. Subtracted bladder pressure recording was an important preoperative screening tool, since patients with high pressure instability did worse surgically than those with a stable bladder or low pressure instability. In patients with detrusor stability similar results were achieved for initial surgery and reoperations. Among the patients with a stable bladder with and without a previous anti-incontinence operation the over-all results were better in groups 1 and 3 than in group 2. Complications were of lesser magnitude in groups 2 and 3 than in group 1.     

Female urinary incontinence treated by transvaginal urethral closure and suprapubic catheter

A new technique for transvaginal closure of the urethra and placement of a suprapubic catheter in 4 patients with total urinary incontinence gave excellent results with all patients remaining dry and accepting the suprapubic catheter. Suspension of the invaginated, closed urethra by sutures, passed through the bladder, is believed to reduce the risk of inadequate healing of the urethra. However, extreme obesity and extensive fibrosis of the periurethral tissue especially with adhesions to the pubic bone are contraindications to the transvaginal approach.     

Female urinary incontinence and artificial urinary sphincter: study of efficacy and risk factors for failure and complications

Background

The artificial urinary sphincter (AUS) has become a commonly used therapy for severe urinary incontinence (UI) due to intrinsic sphincter deficiency (ISD).

Objective

To evaluate retrospectively the efficacy and risk factors for failure and complications of AUS implantation in women with nonneurologic UI.

Design, setting, and participants

From May 1987 to December 2009, 215 women with ISD were treated by AUS implantation, with a mean age of 62.8 yr and a mean follow-up of 6 yr (standard deviation: 5.6 yr). Previous surgical procedures to treat incontinence had been performed in 88.8% of the patients. Urodynamic assessment was required. Patients using only 0 or 1 pad at the end of follow-up were considered continent. The patient's level of satisfaction was evaluated by a global analogue scale and clinical interview.

Intervention

All women had AUS implantation.

Measurements

Patients were evaluated for continence rate, risk factors for failures, and complications.

Results and limitations

At the end of follow-up, 158 patients (73.5%) were continent, and 170 (79%) were satisfied. The redo rate was 15.3% after a mean interval of 8.47 yr for the first redo procedure. Fifteen explantations (7%) were performed. The only risk factor for intraoperative complications (10.7%) was smoking (p < 0.004). Six patients (2.8%) were lost to follow-up. AUS failed to treat incontinence in 51 patients (23.7%) due to defective manipulation in 27.4% of the cases. On multivariate analysis, risk factors for failure were age >70 yr (odds ratio [OR]: 2.46), a history of the Burch procedure (OR: 2.28), or pelvic radiotherapy (OR: 4.37) (p < 0.05).

Conclusions

The place for this safe and long-lasting effective technique in the treatment of UI due to recurrent sphincter deficiency is confirmed. Screening for these risk factors should allow better patient selection.     

Female urinary incontinence health information quality on the Internet: a multilingual evaluation

Introduction and hypothesis

The quality of Internet information on female urinary incontinence is considered variable. No comprehensive analysis exists to support this. We compared the quality of current Internet information for common layperson terminology on female urinary incontinence across four Western languages and a comparative analysis of website sponsors.

Methods

World Health Organization Health on the Net (HON) principles may be applied to websites using an automated toolbar function. We used the Google search engine; 10,200 websites were identified using keywords related to female urinary incontinence and treatments in English, French, German and Spanish. The first 150 websites in each language had HON principles examined, whilst a further analysis of site sponsorship was undertaken.

Results

The total number of websites for each term is variable. “Female sling surgery” had the most websites with approximately 18 million, whereas “colposuspension” had the least with only 159,890 websites. Regardless of language, very few female urinary incontinence websites were HON accredited (p?<?0.0001). Linguistically, French (18 %) and English (16 %) had the greatest percentage of HON-accredited sites. Tertiles (thirds) of the first 150 websites returned the higher percentage of HON-accredited websites (p?<?0.0001). Websites were largely sponsored by physicians/surgeons.

Conclusions

The lack of validation of most female urinary incontinence websites should be appreciated by clinicians. Additionally, discrepancies exist in the quality and number of websites across conditions, languages and also between medical and alternative terms. Clinicians should participate in and encourage the development of informative, ethical and reliable health websites on the Internet and direct patients to them.

     

Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence

PURPOSE: To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI). MATERIALS AND METHODS: A series of 100 consecutive female patients with MUI and UUI were identified from a database. Patients with neurogenic bladder, fistula, urethral diverticulum, prior urologic surgery or known urinary tract obstruction were excluded. All patients were classified according to the urodynamic classification of overactive bladder of Flisser et al. and all patients underwent history, physical examination, validated incontinence questionnaire, 24-hour voiding diary, 24-hour pad test, video urodynamic study (VUDS), and cystoscopy. RESULTS: A significantly higher proportion of patients with UUI exhibited detrusor overactivity at VUDS, (67% of the patients with UUI vs. 24% of the MUI, P < 0.05). Patients with UUI had fewer episodes of incontinence (6.7 vs. 4.2, P < 0.05) with slightly less objective urine loss (24-hour pad test 94 gm vs. 128 g of loss, P < 0.05) and voided at higher pressures (p(det) at Q(max) 21.4 vs. 15.6 cm H(2)O, P < 0.05). Patients in both groups had functional and urodynamic bladder capacities that were not statistically different. CONCLUSIONS: Women with UUI were more likely to exhibit detrusor overactivity but experienced fewer episodes of incontinence and less urinary loss when compared with women who had MUI. The "urge incontinence" component of MUI appears to be different than that of UUI, and suggests that urge incontinence may be overdiagnosed in patients with SUI who misinterpret their fear of leaking (because of SUI) for urge incontinence.     

Female urinary incontinence: The incidence,identification, and characteristics of detrusor instabiiity

One hundred thirty-three women with urinary incontinence, including 51 patients who had undergone unsuccessful surgical treatment, were evaluated urodynamically. A high incidence (55%) of bladder instability was noted, and several patterns of instability were recognized. In 52% of the cases, provocation by erect fast fill and other provocative maneuvers were necessary to unmask the abnormal detrusor activity, and it was also noted that the patient's history did not accurately predict instability. A high incidence (33%) of seemingly inapproprate sphincter electrical silence occurred in those with an unstable bladder and appeared to be the precipitating event of the bladder contraction.     

Female urinary incontinence: a cross-sectional study from a Thai rural area

The aims of this study were to investigate the prevalence and associated factors of female urinary incontinence in a Thai rural area and to investigate the impact of female urinary incontinence on quality of life. A population-based cross-sectional survey was performed from September 2003 to February 2004. A total of 1,126 women completed the questionnaires. The overall prevalence of urinary incontinence was 36.50%, i.e. stress urinary incontinence (33.60%), urge urinary incontinence (11.00%) and mixed urinary incontinence (8.07%). Urinary incontinence adversely affected quality of life; the mixed urinary incontinence group reported significantly greater impairment than the stress and urge urinary incontinence groups. Advancing age, labouring occupation, postmenopausal status, years since menopause, medical diseases, childbirth and vaginal delivery were associated with this problem.     

Estrogen and urinary incontinence

Hormone therapy (HT) has been one of the most commonly used methods to treat postmenopausal disorders including lower urinary tract symptoms such as urinary incontinence (UI). Although it has been suggested that HT improves urinary tract symptoms, little evidence has so far been presented to support this. Recently however, large randomized clinical trials have shown the adverse effects of estrogen on UI and indicate that HT should not be used for prevention or relief of UI in postmenopausal women. Here we review the effects of HT on UI in the light of these clinical trials.     

Pathophysiology of urinary incontinence

Urinary incontinence, or the complaint of involuntary loss of urine, is a debilitating condition of the lower urinary tract with a potentially significant impact on a patient’s physical and mental wellbeing and on their functioning and place in society. Due to the high prevalence of this disorder, the economic burden on healthcare systems worldwide is enormous. Urinary incontinence has a high prevalence in women, but men can be affected as well after a radical prostatectomy or when suffering from chronic urinary retention. Stress, urgency and mixed urinary incontinence are the most common types of urinary incontinence, but other types exist as well. The pathophysiological mechanisms behind these different types of urinary incontinence have been studied extensively. New insights allow for the development of improved diagnostic and therapeutic strategies and ultimately in the reduction of the potentially devastating impact of urinary incontinence on an individual patients’ quality of life. In this review, we explore the current theories on the mechanisms behind urinary incontinence.     

Embryology of urinary incontinence

Congenital incontinence may be divided into primary and secondary types. Primary incontinence refers to the development of a conduit which bypasses the normal sphincter mechanism, while secondary incontinence develops after a congenital outlet obstruction leads to bladder decompensation and overflow. The embryogenesis of the various forms of primary incontinence is described in detail and management is discussed.