Dr. med. Dirk Manski



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Stress Urinary Incontinence in Women (1/3)

Definition of stress urinary incontinence

The International Continence Society (ICS) defines urinary incontinence as "the complaint of any involuntary loss of urine". Stress urinary incontinence is urine leakage, which is associated with increased abdominal pressure and insufficient urethral sphincter mechanism. The main symptom of stress urinary incontinence is the loss of urine on exertion, sneezing or coughing.

Epidemiology of stress urinary incontinence

Vaginal deliveries are a risk factor for stress urinary incontinence:

The prevalence of incontinence in nulliparous women is 10%, after cesarean section 16% and in women with vaginal deliveries 21%. Comparative studies between cesarean sections and vaginal deliveries found a different prevalence of stress incontinence: 7% (cesarean sections) vs. 12% (vaginal deliveries).

Age is a risk factor for urinary incontinence:

There is a significant rising prevalence of urinary incontinence with age. For all forms of incontinence, the prevalence is 4.5 to 53% for women, 1.6 to 24% for men, depending on age.

Etiology and Pathogenesis of Stress Urinary Incontinence

Components of the bladder sphincter mechanism:

Components of the bladder sphincter are the urethral closure pressure caused by the sphincter muscles, and active and passive pressure transmission during the elevation of abdominal pressure.

Urethral closure pressure:

Urethral closure pressure is mainly created by the external sphincter muscle (striated muscle) and internal sphincter muscle (smooth muscle) [see section bladder anatomy].

Passive pressure transmission:

If the abdominal pressure rises, additional pressure is applied on the bladder sphincter without muscle contraction of the pelvic floor. The passive pressure transmission is enabled by the connective tissue suspension of urethra, bladder and vagina.

Active pressure transmission:

If the abdominal pressure rises, contraction of the striated muscles of the pelvic floor and bladder sphincter causes an increase in urethral closure pressure.

Causes of Stress Urinary Incontinence:

Any defect causing a reduced urethral closure pressure and/or impaired pressure transmission with rising abdominal pressure will cause stress urinary incontinence. The most common causes of stress incontinence are a hypermobile urethra and/or an intrinsic sphincter deficiency (hypotonic urethra).

Hypermobile urethra:

The caudal displacement of the urethra due to rising abdominal pressure into the extraabdominal compartment leads to lack of passive pressure transmission, opening of the bladder neck and thus to stress urinary incontinence.

The stability of the suburethral connective tissue is a crucial factor for continence under stress. Vaginal deliveries increase the risk of stress urinary incontinence due to damage to the connective tissue, muscle tearing and damage to the innervation of the pelvic floor and sphincter muscles. The defects lead also to pelvic floor deficiency and prolapse of the pelvic organs.

Pelvic organ prolaps is a clinical sign for stress urinary incontinence, but it may also mask the symptom incontinence. The prolapse may cause kinking and obstruction of the urethra. An excessive kinking of the urethra may lead to residual urine and urinary retention. After correction of prolapse, incontinence may become clinically relevant. The effect of hysterectomy on stress incontinence is controversial.

Intrinsic sphincter deficiency :

Insufficiency of the urethral sphincter, regardless of the cause, is called intrinsic sphincter deficiency.

Chronic elevated abdominal pressure:

Diseases or circumstances which elevate the abdominal pressure aggravate existing stress urinary incontinence: e.g. COPD, obesity or carrying heavy loads.

Integral theory of stress urinary incontinence by Petros and Ulmsten:

The integral theory of stress urinary incontinence by Petros and Ulmsten relates symptoms to anatomical defects of the pelvic region. The vagina acts like a hammock under the urethra and bladder and plays a central role in the mediation of urinary continence and in the prevention of urge symptoms. The proximal urethra is the zone of critical elasticity, this elasticity is essential for bladder filling, scarring or distention causes urgency. Depending on the location of the pelvic floor defects, various symptoms and therapeutic consequences may be distinguished.

Integral theory of stress incontinence (Petros and Ulmsten, 1990): description of anatomical defects with clinical symptoms and therapeutic consequences.
Level III Level II Level I
Localization lesion between the bladder neck and symphysis lesion between the bladder neck and cervix / hysterectomy scar lesion between cervix / hysterectomy scar and os sacrum
Defective structures ligamentum pubourethrale, pubococcygeus muscle arcus tendinous fascia pelvis cardial ligaments and uterosacrcal ligaments
Signs and Symptoms stress incontinence stress incontinence, cystocele residual urine, urge symptoms or rectocele / enterocele
Treatment pubovaginal slings (TVT, TOT) Colporrhaphia anterior Colporrhaphia posterior, sacrocolpopexy






Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

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A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.
BJU Int, 2009, 103, 1386-1390


Latthe, P. M.; Singh, P.; Foon, R. & Toozs-Hobson, P.
Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials.
BJU Int, 2010, 106, 68-76


Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.:
[The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
In: Urologe A
44 (2005), Nr. 7, S. W803–18; quiz W819–20

Petros, P. E. & Ulmsten, U. I.
An integral theory of female urinary incontinence. Experimental and clinical considerations.
Acta Obstet Gynecol Scand Suppl, 1990, 153, 7-31.


Quek, P.
A critical review on magnetic stimulation: what is its role in the management of pelvic floor disorders?
Curr Opin Urol, 2005, 15, 231-235


Ward, K. L.; Hilton, P.; K., U. & Group, I. T. T.
Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.
BJOG, 2008, 115, 226-233


Viktrup u.a. 2004 VIKTRUP, L. ; SUMMERS, K. H. ; DENNETT, S. L.:
Clinical practice guidelines for the initial management of urinary incontinence in women: a European-focused review.
In: BJU Int
94 Suppl 1 (2004), S. 14–22


  Deutsche Version: Belastungsinkontinenz der Frau