Fachthema

Urinary incontinence in women

Leading Opinions, 28.02.2019

Autor:
Prof. Anis Feki, MD, PhD
Department of Gynecologic and Oncologic Surgery
Gynecology and Urology Unit
Cantonal Hospital of Fribourg, Switzerland
Autor:
Riadh Ben Temime, MD
Department of Gynecologic and Oncologic Surgery
Gynecology and Urology Unit
Cantonal Hospital of Fribourg, Switzerland
Autor:
Fathi Khomsi, MD
Department of Gynecologic and Oncologic Surgery
Gynecology and Urology Unit
Cantonal Hospital of Fribourg, Switzerland
Autor:
Prof. Attila Major, MD, PhD
Department of Gynecologic and Oncologic Surgery
Gynecology and Urology Unit
Cantonal Hospital of Fribourg, Switzerland
Autor:
Prof. Jean Bouquet de Jolinière, MD, PhD
Department of Gynecologic and Oncologic Surgery
Gynecology and Urology Unit
Cantonal Hospital of Fribourg, Switzerland
E-Mail: jean.bouquetdejoliniere@h-fr.ch

Gynäkologie & Geburtshilfe | Urologie & Andrologie

Urinary incontinence in women is not inevitable. Its causes are multiple. Nowadays it is an easy diagnosis if the doctor takes the time to look for it. In this semantics and by extension, we include the urinary disorders of emptying and the need to urinate.

The patient very often does not dare to speak about urinary incontinence when speaking with the gynecologist or with her referring doctor, even less with those around her. This is one of the causes of this «malvivre», especially since very often this pathology occurs in a difficult period in a woman’s life: the menopause. Patients are ashamed of their pathology, hide it from partners, and perhaps undergo an alteration in the quality of their sleep and sexuality.
The anamnesis, a simple questioning on the chronology of the symptoms and their expression, the detailed and simple clinical examination are sufficient in the great majority of the cases to get an idea of the cause and thus the options to manage it. Today, with physiotherapy, pharmacopoeia and surgery 98% of the cases can be treated and managed. More than three times out of four, an outpatient treatment is possible.
In addition, there are simple, non-invasive, reproducible examinations that allow the quantified and scientific evaluation of the problems expressed clinically. Urodynamic with cysto-manometry explores this functional entity represented by the bladder and the urethra. Ambulatory and diagnostic cystoscopy with flexible optics is a true medical advance.
This pathology concerns all treating physicians, gynecologists, urologists, physiotherapists and even midwives.

Anatomical description

The female pelvis remains an «anatomical paradox».
In the standing position, it must remain stable and support the weight of – sometimes – several children, emptying and filling the bladder and rectum.
This dynamic mission is «framed» by a complex muscular aponeurotic system and ligaments in three layers that represent the perineal floor, allowing the suspension of the three pelvic organs: the bladder, the uterus and the rectum.
A simple remark: There is no prolapse in the animal, which is associated with gravitational forces and the plantigrade position like in a woman, who’s exposed to the positional anomalies of her pelvic organs (prolapse), consequences of surgical interventions and pregnancy.
The good knowledge of this anatomy and its functionalities requires the surgical repair criteria, «true specifications», to restore this paradox. It is the only guarantee of surgical success!

Anamnesis

During the consultation the physician has to investigate the complaints and to highlight the symptoms.
Sometimes it’s the patient who comes specifically to check her incontinence problems. It is important to identify some criteria directly related to this pathology:

  • Age: The closer the woman approaches menopause, the more she is exposed to losing her urine. Indeed, the bladder is associated to the genital sphere, especially with the hormonal receptors which regulate the trophicity of the tissues. The loss of their elasticity, their physiological and muscular tone is a facilitating and even aggravating factor regarding urinary incontinence. Is the patient treated with a HRT?
  • Parity: The higher the number of deliveries, the greater the risk of a prolapse. The weight of the children at birth, especially if it exceeds 3500g, the musculoaponeurotic dilapidations resulting from instrumental maneuvers expose to these risks. Age at the time of delivery plays a role. Finally, the systematic episiotomy sometimes practiced on the perineum alter vulvar and perineal musculature, when they are repaired.
  • Metabolic diseases: Diabetes mellitus, especially insulin-dependent diabetes, and obesity are aggravating factors.
  • Neurological diseases: suprapontine forms such as stroke, brain tumors, head trauma, some paralysis (there is no loss of coordination between the detrusor and the urethral sphincter, sometimes lifting the cortical inhibition of the urinary reflex, loss of bladder repletion, or emptying …); pontic causes (the brainstem contains the center of urination and urinary retention), as well as MS, Parkinson’s disease …, sacral and under-sacral causes that can lead to incomplete lesions, ranging from insensitivity to bladder detrusor hyperactivity … (looking for ATCD surgery, spina bifida, ponytail syndrome …), the hyperactive bladder and several iatrogenic drugs: diuretics, anti-depressants, anxiolytics, anti-Parkinson’s …
  • Surgical antecedents (ATCD): previous pelvic surgery, total and subtotal hysterectomy (to be named first), striping, prolapse cure, spinal surgery (discopathy), pelvic oncology surgery, bladder tumor, pudendal surgery, pelvic pain because of surgery …
  • Medical history: urogenital tuberculosis, urogenital schistosomiasis, pathologies related to embryologic abnormalities of the urogenital tree, colonic diseases (Crohn’s, colonic hemorrhage) …
  • Pelvic cancers, vulvar cancers, small post-radiotherapy bladder …
  • Infectious causes: repeated cystitis and urinary tract infections, genital herpes, STD including periurethral HPV condylomas …
  • Tissue causes: vulvar diseases like kraurosis, sclerotic and atrophic lichen, Behçet’s disease, and melanoma
  • Endometriosis is a disease entity that affects the entire pelvis, the bladder, and may be progressive in some cases.
  • Nonspecific stress syndromes sometimes sporadically associated with urinary leak age, urgency with imperative urination …
  • Addictions: alcohol, drugs …

Examination

We have to look for signs of urinary incontinence in a rigorous and systematic way. Urinary incontinence is rarely isolated, almost always intricate.
So, to avoid forgetting anything, we propose an interrogation adapted to each physiological function and a mictional calendar.

  • Filling: Each bladder has its own size, it is necessary to reveal the notion of need to quantify its compliance. A small radial bladder will be filled quickly, with a high urinary frequency. This filling is sometimes directly entangled with an urge to urinate.
  • Emptying:
    -Coughing, sneezing, and bloating: Leaks appear. It must be quantified in drops, jets, stains.
    -Physical strain: More and more patients are practicing sports, jogging and are forced to dress in a certain way, so that they often feel uncomfortable with urinary incontinence. Some women do not practice anymore because they fear to lose urine. Sometimes it happens during a dance, an unusual effort, fitness moves or just walking.
    -Loss of urine during sexual intercourse when forgetting pre-coital bladder emptying
    -Urinary frequency with problems to control the micturition
    -Search for a signal-symptom (cold water, running water, car key, key to open the home or office, cold …), anything related to a «ritual» and an evidence of bladder or urethral instability
    -Bedtime rituals (emptying bladder or not, the last glass of water …) and nocturia (how often), enuresis
    -The positional change from sitting or sleeping into the standing position (often related to an old surgery and striping)
    -Leakage may be concomitant with dysuria-type abdominal thrusts.
  • Post mictional:
    -Search for incomplete emptying signs, late drops

Because of the diversity of the symptoms, urinary incontinence requires a thorough investigation, a study of the symptoms and their assignments to a pathology, with the help of a careful clinical examination.

Clinical examination

The clinical examination for urinary incontinence must be performed during the gynecological examination, requires nothing particular except for the gynecological position of the patient on the examination chair.

  • Any clinical examination starts with an inspection, taking a look for a prolapse by spreading the labia maiora with the fingers (authorization of the patient is required). Integumentary abnormalities of perineal skin should be investigated for lichen vulvar anomalies, kraurosis, Bowen’s disease, condylomas, psoriasis, and vitiligo.
  • Search for isolated, associated or complete prolapse. Under pressure there is either a descent of the bladder (cystocele) linked to an “unfolding” of the anterior perineum or a hysteroptosis (uterine descent), a rectocele (bulging of the rectum in the vagina). These three phenomena can occur each isolated, grouped two by two, or solidary and externalize themselves beyond the vulva itself. Ranked from 1 to 3, we can speak of a complete prolapse, when level 3 is reached. To assess the cystocele, place 2 fingers on the vulvar fork to depress the rectum and ask the patient to push and then cough. In case of urinary leakage, the 2 fingers should correct the leak (Bonnet’s maneuver) by lifting the bladder upwards (correction of the anterior perineum). Other maneuvers exist, but Bonnet’s maneuver is simple to realize and to understand.
  • Neurological examination of the perineum is essential. It consists in asking the patient to close her eyes, using a swab or a tongue depressor, drawing a cross or a circle on the skin that the patient must be able to identify. We are looking for areas of hypoesthesia, sphincters, anesthesia in the saddle (horsetail syndrome), disorders of the contraction of the anal sphincter, contraction of the stimulus of the ano-vulvar area … anal incontinence can be associated and then it’s a matter of proctology.
  • Examine vulva tone by asking the patient to tighten the fingers used for the examination with her vagina.
  • Vaginal and urethral bacteriological specimens with chlamydial search, urea plasma, urealyticum and mycoplasma. A urotube with ECBU can be useful.
  • When abdominal thrusts are present for urination, or a significant cystocele, a post-void residue search may be indicated by a round-trip survey.
  • The pelvic examinations TV/TR complete the examination in search of abdominal or pelvic mass.
  • A pad test (measurement of urinary losses in the protective pad) is very informative. In practice, the total weight of urine lost during the test is assumed equal to the measured weight gain of the collection device.

Paraclinic

Uretero-cystomanometry and urodynamic examination
The principle is based on pressure measurements in the bladder, the urethra, and the difference between the two. This examination, like the female pelvis, is subject to Pascal’s Law on the integral transmission of pressures t Fig. 3: Curve in supine position through liquids.
Furthermore this examination calculates the transmission of full bladder pressures to the urethra, the value of the urethral sphincter and its stability. It studies bladder and urethral function during filling, emptying, exertion, and tries to understand the symptomatology.
The urodynamic apparatus includes a gynecological chair, a robotic system that allows a micro-catheter carrying 2 balloons (one bladder and the other urethral) to enter the bladder, and then remove it by calculating the transmission of pressure. A computer calculates the different values with the aid of specific algorithms and draws the curves (Fig. 1–4).
Bladder filling with physiological saline will make it possible to evaluate the bladder compliance, that is the intrinsic capacity of the bladder to admit a change of volume without a change in the pressure of the detrusor muscle.
Performed for one hour, the patient remains ambulatory. Cystoscopy is complementary to the examination, just as a possible vaginal probe ultrasound. It is helpful for the management to evaluate full urinary bladder leakage. A flowmeter studies the urination at the end of the examination: It is necessary to look for a sub-vesical obstruction knowing that a normal flow must be >15ml/s. An EMG evaluates the bioelectric potentials of skeletal muscles. Thanks to surface electrodes, it records all the electrical activity of the pelvic floor muscles. The study of evoked potentials belongs to specialized services. We can give some main values that will define if there is a sphincter deficiency, vesical and urethral instability, a fault of transmission responsible for the urinary leak often consequence of prolapse.

Findings

  • The average urethral length is 35mm.
  • Finally, ideal and maximum transmission should be 100% knowing that beyond 20%, a defect of pressure transmission will be the cause of a urinary leak.
  • Normal compliance is >30/40ml/ cmH2O.
  • A normal bladder capacity is 400/500ml and the bladder filling determines the 3 needs.
  • After bladder emptying, we talk about post-void residue from 80ml.
  • The «peaks» corresponding to the coughing forces are negative and sometimes cancel out (canceling the closing pressure), the leakage is maximum.

Cystoscopy
Performed outpatient or at the end of urodynamic, it is easily done with a flexible cystoscope. It is painless and can visualize the bladder mucosa, to see the trigone, the ureteral meatus and eliminate a tumor, endometriosis or tuberculosis or bilharzias.

Bacteriology
It is the clinician who will guide the indications that a bacterial research in the urethral meatus and vagina is part of the routine. Specimens can be useful, from ECBU (cytobacteriological urine exam) to urine biochemistry.

MRI and vaginal ultrasound
They provide information about pelvic organs, their relationships and their “conflicts”.

Treatment

There are many possibilities for treating urinary incontinence. Physiotherapy is at least a temporary or complementary solution. The essential thing is the surgery which must remain simple, non-invasive, and functional. A good knowledge of the anatomy is necessary to enable the surgeon to reconstruct a correct anatomy, bearing in mind its functionalities and effectiveness in the long term.
This is the reason why preoperative clinical and paraclinical assessment is essential.
Surgery must take a possible future wish to have children into account, knowing the high rate of recidivism. Current techniques are in most cases performed vaginally, laparoscopically or both.
Medical treatment also has its place. Especially in the treatment of overactive bladder and vesico-urethral instability.
Finally, new techniques appear such as using botulinum toxin by cystoscopy in case in case that drugs show no effects.

Physiotherapy
In cases where there is no prolapse and lack of transmission to correct, physiotherapy sessions can recover proprioception, perineal tone and sphincter.
It is traditional to gain 10 to 20cm of H2O over a dozen sessions. Physiotherapy uses biofeedback and many perineal exercises. Patients learn to control the bladder filling, the first needs and re-educate for urination without waiting for the last moment.
The doctor can explain self-rehabilitation to patients on this model.
In postpartum, the obstetrician and the midwife recommend re-education of the perineum in all cases and especially if there have been performed instrumental maneuvers.

Surgery
For many years, we have found many prolapse correction techniques in the literature. The pathways are multiple, sometimes mixed and associated to each other.
Although it is impossible to describe them all, they must follow simple principles and remain non-traumatic, functional and effective. The approach always depends on the experience of the surgeon in the technique and instrumentation.
According to the indications and the severity of the prolapse, a hysterectomy can be performed, total or simply subtotal with the use of the cervix as a band fixation system.
The principle is always to treat the 3 floors so as to restore a correct pelvic anatomy.
The advent of Mersilene strips or strips based on a titanium structure has disarranged the conventional surgical indications.
Finally, new complications have emerged related to these new materials.

Methods
To correct an urethrocele associated with a transmission defect a TOT or TVT (transobturator or latero-vesical) type strip can be used.

  • A cystocele may require a latero-suspension according to the Dubuisson technique, a paravaginal repair all by laparoscopy and robotics, anterior vaginal colpectomy. The techniques can be combined in the same operating session.
  • A rectocele is treated by posterior colporrhaphy with colpectomy.
  • Complete prolapse can be fully corrected vaginally by associating vaginal hysterectomy with a Richter on the vaginal slice, or even a complementary colpectomy.
  • The international literature is very broad in this area. No technique can claim to be better than another as the results are dependent on the operators.
  • However, the rule remains unchanged: Experience, simplicity, restitution of a normal anatomy, good indications, therefore clinical and paraclinical balance preoperative consistent, little prosthetic material, and especially respect this «pelvic paradox» which combines mobility, flexibility and firmness.

Medical treatment
Most of the time, we find a mixed incontinence that is associated with sometimes even minimal prolapse and a bladder and/or urethral instability. The search for a metabolic cause (diabetes) or neurological or iatrogenic drug is helpful in treating the symptoms. The hyper-contractions of the detrusor muscle caused by the parasympathetic effect of acetylcholine can benefit from numerous anticholinergic drugs on the market.
It is necessary to adapt the daily and nocturnal prescriptions according to the micturition schedule.
Rehabilitation, tips like emptying the bladder in the evening before bedtime, stopping drinking 2 hours before bedtime can help. In rare cases, and when the medications are ineffective, intravenous injection by cystoscopy and above trigonal, botulinum toxin can calm rebellious bladders.

CONCLUSION

Urinary incontinence is common, must be sought and supported. We cannot let the patients suffer as this pathology alters the personal, sexual and social life.
The proposed bibliography is very vast; we recommend a book and access to specialized societies that are referents in the field.

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