Urinary Incontinence in Female Patient
and Pelvic Prolapse
Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.
Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g. spina bifida and multiple sclerosis) eventually cause inadequate urinary storage or control.
usually with the progression of age in women we have some degree of weakness of the pelvic floor (muscles of the pelvis) due to childbirth and maybe some degree of vaginal prolapse.
When a condition is identified usually we try with conservative (non surgical methods) to decrease incontinence episodes and let the patient decide if this is significant in order to consider it as a successful treatment.
There are several things patients can do to help improve continence:
- Avoid excessive consumption of diuretics, antidepressants, antihistamines, and cough-cold preparations.
- Perform Kegel Pelvic floor exercises daily. (Link to pelvic floor exercises)
- Practice double voiding (urinate, hold it for a few seconds, urinate again).
- Eat fruits, vegetables, and whole grains daily to prevent constipation.
- Retrain the bladder (urinate only every 3 to 6 hours). (Link to bladder retraining)
- Stop smoking (nicotine irritates the bladder).
Surgical management of Stress Incontinence
When an anatomical condition is identified or after conservative approach failure, then we have to reconsider whether an operation could fix the problem.
For stress and mixed incontinence we have the so called tension free tapes that are placed though the skin on a Day Hospital basis. They aim to support the urethra and give a mechanical obstacle which lasts in time due to the fibrosis that they create around their tract.
They could be placed suprapubically (TVT) or through the trans-obturator foramen (TOT) in various ways.
The urinary bladder stores urine which is coninuously excreted by the kidneys. When the bladder is full the sphincter muscles along the length of the urethra (the tube leading from the bladder) relax and the bladder contracts and empties. Once the bladder is empty, the bladder muscle relaxes and the urethral sphincter closes again.
Urinary incontinence affects up to 15-30% of women and increases with age. Incontinence occurs when the sphincter muscle does not close properly or the bladder contracts when it should not. Inadequate closure of the sphincter may follow damage to the muscles and nerves of the pelvic floor after vaginal delivery. This may be aggravated by the menopause, a chronic cough or heavy physical activity. The patient usually complains of urine loss on coughing or exertion which is called stress incontinence.
Bladder over-activity occurs when the bladder muscle contracts when it should be storing urine, leading to urgency and urge incontinence. This may be due to injury to the bladder`s nerve supply or to a psychosomatic cause associated with anxiety. Occasionally both incompetenc of the sphincter and bladder over-activity co-exist.
Incontinence is not a fatal condition but it can significantly interfere with professional, social, and personal activities with deterioration in the quality of life and sometimes social isolation. It is, therefore, important and worthwhile to have treatment.
A new technique has been devised which ovecomes the modest success rate of pelvic floor exercises and avoids the pain and long hospital stay of more major operations.
This procedure achieves between 85% to 90% success and has little post-perative pain so the patient leaves the hospital either on the same day or on the following day.
It works by supporting the middle of the urethra.
Gynecare TVT ia an exciting new concept. The mesh consists of a permanent Prolene material surrounded by a plastic sheath with a strong needle at either end. A small cut is made in the vagina and the mesh is passed under the middle of the urethra to support it. Both needles emerge through the anterior abdominal wall so that the mesh is accurately positioned.
A fine telescope (cystoscope) is introduced into the bladder to be absolutely sure there is no bladder injury, and then the position is adjusted and needles are removed.
The vaginal and abdominal wounds are then closed and the patient returns to the ward. The operation takes up to 30 minutes. Some pain relief may be necessary and the patient usually passes urine within a few hours and can return home either the same day or the following day.
Published medical papers show that between 86% and 90% of patients are cured at a three year follow-up. (Ulmsten et al 1999, Olsson 1999).
Complications can include bleeding or bladder injury when the needles are passed, difficulty emptying the bladder, urgency and urinary infection. So far there have been no significant long-term side effects.
Questions and Answers
- Am I a candidate for TVT or TOT?
If you complain of stress incontinence and urodynamic studies have shown that urethral sphincter incompetence is present, then this operation is likely to be suitable. It is appropriate for many types of patient, including those who have had previous surgery for incontinence and are overweight. As with any surgery of this kind, the procedure should not be performed during pregnancy and the patient should be counseled that future pregnancies may negate the effects of the surgical procedure and she may again become incontinent.
- Will I have pain after the procedure?
Some mild pain may occur over twenty four to forty eight hours after surgery. This could be controlled by simple pain relief such as aspirin.
- Will I have difficulty emptying my bladder?
A few patients have temporary difficulty and may require an in-out catheter in the ward.
- What is the risk of urinary infection?
This may occur in up to 6% of patients and is treated by antibiotics and an adequate fluid intake.
- When can I play sport?
Usually after 4 to 8 weeks to allow the wounds to heal and the mesh to settle into place.
- When can I have intercourse?
After 4 to 6 weeks.
- Can I return to my usual routine?
Yes after about 1 -2 weeks, but it is wise to avoid unnecessary heavy lifting for 6 weeks.
- When can I drive?
Usually within 1 week of surgery.
- Does the mesh remain there forever?
Yes: evidence form long term follow-ups show that it is inert and remains ther to support the urethra.
- Are there any side effects from this?
Occasionally a portion of the mesh may be exposed but this is uncommon. It is treated by antibiotics, and closure of the wound.
- What happens if the mesh falls and I become incontinent again?
You would need to be investigated with fresh urodynamic tests and treatment decided on the basis of these. Occasionally a new Gynecare TT has to be inserted.
In cases of vaginal prolapse, then a laparoscopic (robotically assisted) procedure is recommended during which the prolapsed organs are pulled back into the pelvis and fixed on the promontory (bone) with a mesh in order to avoid recurrence.