Stress Incontinence

People with stress incontinence lose urine involuntarily during physical activities that put pressure on the abdomen.

This type of incontinence is often seen in women after they reach middle age. A weak pelvic floor and a poorly supported uretheral sphincter cause stress incontinence.

Activities commonly associated with stress incontinence include the following:

• Coughing

• Exercising

• Laughing

• Lifting

• Rising from a chair or bed

• Sneezing

Stress incontinence occurs when the bladder neck and urethra do not close properly. When these structures move down and bulge (herniate) through weakened pelvic floor muscles, they are said to be hypermobile.

Herniation, or cystocele, changes the angle of the urethra, which causes it to remain open and allow urine to leak out. There are three classifications of stress incontinence.

• Type I — The bladder neck and urethra are open and slightly hypermobile, and the urethra moves down less than 2 cm when stressed. Type I patients have little or no sign of cystocele.

• Type II — The bladder neck and urethra are closed and hypermobile, and the urethra moves down more than 2 cm when stressed.

  • Patients who have cystocele inside the vagina have Type IIA stress incontinence.

  • When cystocele is outside the vagina, it is classified as Type IIB.

• Type III (severe) — The urethral sphincter is very weak (called intrinsic sphincter deficiency).

Risk factors include childbirth, menopause, and pelvic surgery (e.g., prostatectomy, hysterectomy).

Childbirth

Pregnancy and childbirth can flatten, stretch, and weaken the pelvic floor muscles that support the bladder neck and urethra.

The position of the bladder and urethra may change, bladder control nerves may be damaged, or an episiotomy (incision of the perineum and vagina) may be performed to prevent tearing during vaginal delivery. These complications will weaken the pelvic floor muscles.

If bladder control is lost immediately after childbirth, the pelvic floor muscles may recover within 6 weeks. If continence is not regained, treatment may be required.

Sometimes incontinence develops months or years after childbirth. Women who exercise the pelvic floor muscles (Kegel exercises) are less likely to develop incontinence.

Menopause

At menopause, the ovaries stop producing estrogen. Lack of estrogen results in thinned tissues that line the urethra, a weakened sphincter mechanism that opens and closes the urethra, and weak bladder muscles.

These factors can cause the urethral sphincter to open during physical activity.

Pelvic surgery

Pelvic surgery can weaken and damage the pelvic floor muscles, causing the bladder neck and urethra to drop when abdominal pressure is applied (hypermobility) during physical activity.

Surgical procedures that may affect the pelvic floor muscles include the following:

• Abdominal resection for colorectal cancer

• Complete or partial hysterectomy (removal of the uterus)

• Failed surgery to correct stress incontinence

Causes of Stress Incontinence

Stress incontinence is caused by the following:

• Thinning of the urethral lining

• Weakened bladder and/or pelvic floor muscles

• Weakened urethral sphincter

Signs and Symptoms

Urine leaks during strenuous physical activity

Management of Stress Incontinence

Internal devices

The FemSoft® insert is a disposable, single-use device for the treatment of female stress urinary incontinence. It consists of a narrow silicone tube enclosed in a soft, thin, mineral oil-filled sleeve that forms a balloon at the tip. At the opposite end, the sterile tube and sleeve form an external retainer.

FemSoft® is inserted into the urethra with a disposable plastic applicator. As the device is inserted, the mineral oil in the balloon drains into the external retainer. Once the tip of the device is advanced to the bladder, the oil flows back into the balloon, creating a seal at the neck of the bladder that prevents urine leakage.

FemSoft® is removed and discarded when the patient wants to urinate and afterward, a new device is inserted.

UTI, bacteriuria, urgency, frequency, and nocturia are potential complications.

Vaginal pessaries are silicone or latex devices inserted into the vagina to compress the urethra and support the bladder neck to prevent leakage during strenuous activity. Pessaries are available in different shapes and sizes.

The incontinence ring and incontinence dish shapes are commonly used to treat stress incontinence. Women who experience leakage only during exercise may find that the cube pessary inserted before activity is all that is needed.

A pelvic examination is performed first to make sure there is no infection. An infection must be treated before a pessary can be used.

Pessaries usually are fitted and inserted by a gynecologist and the largest size that can be worn comfortably is usually the most effective. Once in place, the patient is asked to cough to test for leakage.

Frequent follow-up care is required to check for infection, pressure sores, and allergic reaction. If the patient is sensitive to latex or silicone, she cannot use these devices.

Pressure sores are more common in postmenopausal women. Estrogen cream can improve the integrity of the vaginal mucosa. Tissue damage is managed by removing the pessary until the skin heals. Infections are treated with antibiotics.

At each examination, the pessary is removed and cleaned with soap and water. Diligent follow-up is essential for eldery or debilitated patients.

Introl® is a vaginal prosthesis with two prongs that support the bladder neck on either side of the urethra.

It is used for stress and mixed incontinence. The device should not be worn continuously for more than 24 hours without proper cleaning and must be removed to have intercourse.

External devices

The Miniguard Patch® and Impress® are single-use foam pads that are slightly larger than a postage stamp. One side of the patch is covered with adhesive to hold it over the urethral opening and surrounding area.

It fits between the labial folds and provides pressure around the urethral opening to prevent leakage. The wearer simply removes the patch to urinate and puts on a new patch after urination.

Small, round silicone "caps" (e.g., FemAssist®, Bard Cap Sure® Continence Shields) use suction to support the urethral sphincter (muscle that opens and closes the urethra). An ointment is applied to the inner surface to create a vacuum seal that holds the cap in place.

To urinate, the wearer removes the cap, which can be washed with soap and water and reapplied. Some women experience discomfort or irritation with these devices.

External devices for men include penile clamps (e.g., Cunningham clamp) and compression rings.

The penile clamp is a V-shaped casing with a foam cushion that fits over the penis. When closed, the clamp stops the flow of urine. Compression rings fit around the penis and are inflated to pinch off urine flow.

Clamps and rings must be removed every 2 to 3 hours to empty the bladder. Only patients who can adjust them properly and adhere to the voiding schedule should use them. Improper use of these devices can cause penile and urethral tissue damage, penile edema (swelling), pain, and obstruction.

Treatments for Stress Incontinence

Injecting material to increase the bulk around the urethra can improve the function of the urethral sphincter and compresses the urethra near the bladder outlet.

Injectable agents can help women who are not candidates for surgery and have persistent intrinsic sphincter deficiency (very weak urethral sphincter) without urethral hypermobility. Injectable agents also may help men with intrinsic sphincter deficiency that has lasted longer than 1 year.

Injectable materials include collagen (naturally occurring protein found in skin, bone, and connective tissue), fat from the patient's body (autologous fat), and polytetrafluoroethylene (PTFE)and Durasphere™ (synthetic compounds).

• Collagen

  • Collagen is a natural substance that breaks down and is excreted over time. The Contigen® Bard® collagen implant uses a purified form of collagen derived from cowhide.

  • Potential recipients have a skin test 28 days prior to treatment to determine whether or not they are sensitive to the material. Sensitivity is indicated by inflammation at the injection site.

  • A prefilled syringe is used to inject the collagen around the urethra. Some doctors conduct a series of treatments over a few weeks or months.

  • Others instruct patients to return for additional treatment when leakage occurs. Results vary from patient to patient and from physician to physician. Some patients achieve continence for 12 to 18 months and others require more frequent treatment. Some remain dry for 3 to 5 years.

• Autologous fat

  • Autologous fat injections are used to treat intrinsic sphincter deficiency. Fat from the patient's body is gathered by liposuction from the abdominal wall and is injected around the urethra in a simple procedure performed under local anesthesia. Long-term effectiveness of this procedure is not known.

• Polytetrafluoroethylene (PTFE)

  • This synthetic compound in the form of a micropolymer paste is injected into the upper urethra. The PTFE particles spur the growth of fibroblasts (fiber-making cells), which fix the material in the urethral tissue and assist in urethral closure. PTFE is not an approved treatment for incontinence in the United States because PTFE particles may migrate to other parts of the body, such as the lungs, brain, and lymph nodes.

• Durasphere™

  • Durasphere is a water-based gel that contains tiny, carbon-coated beads. Unlike PTFE, this material is not absorbed by the body.

  • The procedure is usually performed under local anesthesia, although some patients may require general anesthesia. A cystoscope is inserted into the urethra, allowing the physician to see the bladder neck area.

  • The gel is injected through a hollow needle into the numbed areas of tissue around the bladder neck. This increases the bulk around the urethral sphincter, allowing it to close enough to help prevent urine from leaking. After treatment, 9 out of 10 women experience improved continence.

Nonsurgical Treatment for Stress Incontinence

• Kegel Exercise

  • Kegel exercises strengthen the pelvic floor muscles (the pubococcygeous muscle group) to improve bladder control for people suffering from stress incontinence.

  • Success of these exercises depends on their proper execution.

  •  First, the muscle group must be located by the patient:

    • Begin urinating and try to stop the flow of urine without tensing the leg muscles.

    • Slow or stop the stream of urine. The muscles holding the urine are the correct muscle group. OR

    • Squeeze the rectal are as if to prevent gas from passing.

  • There are two types of Kegel exercise:

    • Quick contractions—rapidly tighten and relax the sphincter muscle

    • Slow contractions—contract the sphincter muscle and hold to a count of 3, gradually increasing to a count of 10

  • Exercises should be performed several times, every day. Whether the goal is to improve or to maintain bladder control, exercises must be done regularly over a period of 6 to 12 weeks to be effective.

  • Exercises should not be performed while urinating, because urine could be retained.

  • Weighted vaginal cones can help women isolate the pubococcygeous muscles and are held for 15 minutes twice daily, while walking or standing.

• Biofeedback

  • Biofeedback is practiced with Kegel exercise to reinforce proper technique. Patients visualize and identify the pelvic floor and abdominal muscles that are contracted during exercise.

  • A simple instrument records small electrical signals that are produced when muscles contract. The signals are instantly converted into audio and/or visual signs that help patients gain greater control over urinary muscle activity. Weak muscles can be activated on demand, tense muscles can be relaxed, and muscle activity can be coordinated.

• Neuromuscular Electrical Stimulation (NMES)

  • This treatment is used to retrain and strengthen weak urinary muscles and improve bladder control. Electrical stimulation of the pudendal nerve causes pelvic floor and urethral sphincter muscles to contract.

  • A probe is inserted into the vagina (when treating a woman) or the anus (when treating a man) and a current is passed through the probe at a level below the pain threshold, causing a contraction.

  • The patient is instructed to squeeze the muscles when the current is on. After the contraction, the current is switched off for 5 to 10 seconds. Treatment sessions lasts approximately 20 to 30 minutes.

• NeoControl™

  • This therapy is beneficial for women with stress, urge, or mixed urinary incontinence caused by weak pelvic floor muscles. The treatment is delivered through pulsating magnetic fields in the seat of a chair designed by NeoTonus, Inc.

  • Patients sit in the chair for 20 to 30 minutes, twice a week. The magnetic pulses are aimed at the pelvic floor muscles through the seat of the chair and the muscles contract and relax with each magnetic pulse, much like Kegel exercise. It takes about 8 weeks of therapy to achieve some degree of continence.

Surgical Treatment of Stress Incontinence

• Marshall Marchetti Krantz (MMK)

  • This procedure requires an abdominal incision. The bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are elevated to a higher position. The free ends of the stitches are anchored to surrounding cartilage and pubic bone. MMK is no longer a favored technique because there is potential for the development of obstructive adhesions and the incision limits the physician's ability to correct herniation of the bladder into the vagina.

• Burch Colposuspension

  • This vaginal suspension procedure often is performed when the abdomen is open for another purpose, such as abdominal hysterectomy. The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by lateral (sideways) sutures that pass through the vagina and pubic ligaments. (Lateral sutures prevent urethral obstruction and allow the repair of small cystoceles, or hernias.) The vaginal wall and ligament are brought together, and the sutures are tied.

• Needle Suspension

  • Several needle suspension procedures have been developed, each named after its creator (e.g., Stamey, Raz, Gittes); however, the basic technique is the same. Essentially, sutures are placed through the pubic skin or a vaginal incision into the anchoring tissues on each side of the bladder neck and tied to the fibrous tissue or pubic bone.

    • The Stamey technique is performed vaginally or through a small incision above the pubic bone. A nylon suture is used to suspend the urethra on each side and cystoscopy ensures that the urethra and bladder are not injured during the procedure.

    • The Raz procedure corrects urethral and bladder neck hypermobility when there is minimal or no herniation of the bladder into the vagina. An inverted U-shaped incision is made in the vaginal wall and bands of fibrous tissue around the bladder neck and urethra are released. A needle is passed through the incision, and the suspending sutures are pulled, lifting the front of the vagina and urethra.

    • In the Gittes procedure, a small puncture is made above the pubic fat pad. A suture is transferred by a needle through the muscle of the pubic crest to the vaginal wall, where it is looped and drawn back through the puncture. A second suture is made through the puncture to create a strong suspension support. The process is repeated through another puncture made 1.5 to 2 cm from the first site. Both suspending sutures are tied at their puncture sites.

• Sling Procedures

  • Patients with severe stress incontinence and intrinsic sphincter deficiency may be candidates for a sling procedure. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.

  • There are two techniques:

    • percutaneous, which requires a small abdominal incision, and

    • transvaginal, which is performed through the vagina.

  • Percutaneous slings

    • The pubovaginal sling is made of a strip of tissue from the patient's abdominal fascia (fibrous tissue). A synthetic sling may be used, but urethral tissue erosion commonly occurs.

    • An incision is made above the pubic bone, and a strip of abdominal fascia (the sling) is removed. Another incision is made in the vaginal wall, through which the sling is grasped and adjusted around the bladder neck. The sling is secured by two sutures loosely tied to each other above the pubic bone incision, providing a hammock to support the bladder neck.

    • After this procedure, patients generally regain bladder control for more than 10 years. Possible complications include accidental bladder injury, infection, and prolonged urinary retention, which may require chronic intermittent self-catheterization.

  • Transvaginal slings

    • Precision Tack® Transvaginal Anchor System is a device that restores urinary function by returning the urinary anatomy to its proper position in a minimally invasive procedure.

    • No abdominal incision is required and a small incision is made in the vaginal wall. Two small tacks are placed in the pubic bone and a sling is inserted into the vagina and attached to the tacks with sutures. The sling supports the bladder, bladder neck, urethra, and urethral sphincter so urine can flow and be held properly.

• Gynecare TVT™

  • Gynecare TVT™ (tension-free vaginal tape) is a synthetic mesh tape that prevents urine leakage during sudden movement (e.g., laughing, coughing, sneezing) and while exercising by reinforcing the ligaments and tissues that support the urethra. This minimally invasive procedure is used to correct stress incontinence and combined stress and urge incontinence in women.

  • The tape is placed beneath the middle of the urethra in an outpatient surgical procedure that takes 30 to 50 minutes to perform. The procedure is performed under local, regional, or general anesthesia and does not require a urinary catheter. If local or regional anesthesia is used, adjustments can be made during the procedure to ensure that adequate support is provided. Cystoscopy is performed to make sure there has been no injury to the bladder during the procedure. Gynecare TVT does not require anchors or sutures and produces minimal scarring.

  • Recovery from the procedure takes 3 to 4 weeks. Heavy lifting and sexual intercourse should be avoided for 4 to 6 weeks. Normal daily activity can resume within 1 to 2 weeks.

  • Complications are rare and include bleeding; blood vessel, bladder, and bowel injury; and urinary retention. If painful urination (dysuria), bleeding, or other concerns arise, the patient should contact her physician immediately.

  • Newer procedures such as the Monarc™ subfascial hammock and transobturator tape (TOT) also can be used to correct stress incontinence and combined stress and urge incontinence in women. These techniques may result in fewer complications (e.g., blood vessel, bladder, and bowel injury) than other transvaginal procedures.

• Artificial Sphincter

  • An artificial urethral sphincter may help patients who are incontinent after surgery for prostate cancer or stress incontinence, trauma victims, and patients with birth defects in the urinary tract.

  • The device has three components: a pump, a balloon reservoir, and a cuff that encircles and closes the urethra. All three components are filled with fluid (e.g., saline). The cuff is connected to the pump, which is surgically implanted in the scrotum (in men) or the labia (in women). The pump is activated by squeezing or pressing a button. The fluid in the cuff empties into the reservoir, the urethra opens, and the bladder empties. Fluid from the reservoir returns to the cuff, which again closes the urethra.

  • Possible complications include infection, tissue breakdown, and mechanical failure.

Postsurgical Complication

Urethral obstruction is a common complication after surgery for stress incontinence. Symptoms include the following:

• Decreased force of the urine stream

• Hesitancy

• Incomplete bladder emptying

• Irritation or pain during urination (dysuria)

• Recurrent urinary tract infections

• Urinary retention

Urethrolysis involves cutting obstructive adhesions (fibrous tissue bands) that fix the urethra to the pubic bone. When the procedure is performed through an incision in the vagina, it is called transvaginal urethrolysis.

This technique is associated with few complications and permits the correction of vaginal abnormalities. Transvaginal urethrolysis is the most effective procedure for mending urethral obstruction that results from surgical repair of stress incontinence.

Medication

Patients suffering from stress incontinence may benefit from alpha-adrenergic agonists, which stimulate receptors that respond to norepinephrine, a hormone and neurotransmitter.

These agents should be used with caution by patients with high blood pressure (hypertension), overactive thyroid (hyperthyroidism), irregular heartbeat (arrhythymia), or heart pain caused by insufficient oxygen supply to the heart muscle (angina).

Pseudophedrine hydrochloride is also found in cough and cold preparations and antihistamines. Typical dosage is 15-30 mg, three times a day.

Ephedrine, epinephrine, and norepinephrine are alpha-adrenergic agonists that have many effects throughout the body and must be used with caution. Significant side effects include hypertension, tachycardia (rapid heart rate), and arrhythmia (irregular heartbeat).

Hormone replacement therapy (HRT) can restore the health of urethral tissues in postmenopausal women. HRT involves estrogen to heighten bladder outlet resistance by increasing blood flow, muscle tone, and nerve response in the urethra.

Estrogen is given with progestin to avoid the risk for endometrial cancer. A typical dose is 0.3 to 1.25 mg per day. HRT may benefit patients with stress or mixed incontinence.

The above opinionated views and information serves to educated and informed consumer .  The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. .It should not replaced professional advise and consultation.A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions