WHAT IS STRESS URINARY INCONTINENCE IN WOMEN?
Stress Urinary Incontinence (SUI) is involuntary urinary leakage in women during activities such as coughing, sneezing, lifting, laughing or exercising. It is estimated that greater than 10-20% of women are affected by stress incontinence, yet many do not realize that there are simple, effective treatment options available.
You do not have to be plagued by unwanted urinary leakage. Many women limit their social outings, personal relationships and physical activity due to SUI and its effect on the quality of women’s lives.
HOW DOES A NORMAL BLADDER WORK?
Urine is produced by the kidneys and moved down the ureters to the bladder. As the bladder fills the muscular wall of the bladder (the detrusor muscle) should relax and stretch to accommodate the fluid. When the bladder begins to get full, an urge to pass urine is felt. When it is appropriate, the brain sends a signal to the detrusor muscle to contract and to the urethral sphincter to relax,which allows the bladder to empty. Normal bladder emptying is approximately 5-7 times per day, and 1-2 times at night.
The urethra (tube that carries urine out of the body) and bladder are supported by the pelvic floor muscles, which contract during coughing, sneezing and exercise to prevent leakage. Weakness in the muscles or damage to the bladder neck support can result in leakage.
Causes of stress urinary incontinence can include:
- Pregnancy and vaginal birth
- Obesity
- Chronic cough
- Chronic heavy lifting
- Chronic constipation
- Genetically inherited factors
HOW IS STRESS URINARY INCONTINENCE DIAGNOSED?
Your provider will take a thorough history and ask questions about activities which cause urinary leakage. An examination of the urogenital tract will normally be performed to evaluate for urethral hypermobility, pelvic organ prolapse or other anatomical contributors. Women with stress incontinence may also have problems with urinary urge incontinence or incontinence of feces or gas. Please do not feel embarrassed to discuss these issues with your provider.
WHAT TESTING MAY BE PERFORMED?
A cough test may be performed by your provider during your exam by having you cough while you have a comfortably full bladder.
You may be asked to fill out a voiding or bladder diary, recording how much you drink, as well as the number of times you pass urine and the volume of urine passed each time. A record of the amount of leakage is also kept.
Your provider may recommend urodynamic studies. Urodynamics testing investigates the bladder’s ability to fill and empty, sensation of urge and the type and possible cause of the incontinence.
A Post Void Residual (PVR) ultrasound may be used to determine how much urine is left in the bladder just after voiding.
Urine tests such as a urinalysis or PCR urine culture may be performed to look for a urinary tract infection.
Testing is designed to help in diagnosis and in the development of the best treatment plan for each individual.
WHAT ARE MY TREATMENT OPTIONS?
Your provider will discuss with you the best options for you. They may include:
- Behavior modification, the first line treatment for urinary leakage
- Aiming to drink enough to pass urine 4 to 6 times per day (usually about 60-80 oz, 1.5-2.5 liters, half a gallon)
- Maintaining a healthy weight has been shown to reduce the severity of SUI problems
- Avoiding constipation
- Quitting smoking
- Pelvic floor exercises, which can be an effective way of improving SUI by up to 75%. Like all training, the benefits of pelvic floor exercises are maximized if practice is carried out frequently and regularly over time.
- Continence devices, such as pessaries or Imprezza, which fit in the vagina and help control leakage.
What’s next for women with mild to moderate stress urine incontinence who aren’t surgical candidates, don’t want surgery, are waiting for surgery, aren’t sure if surgical treatment is right for them, or have tried behavior change, pelvic floor exercises, and/or devices without success?
URETHRAL BULKING
Urethral bulking is a simple in office procedure for mild to moderate urinary leakage.
Bulking agents can be injected around the bladder neck at the urethral sphincter to bulk up the tissue there and reduce the caliber of the urethra. There are a variety of different substances that can be injected including fat, collagen and other synthetic collagen like substances. The injection can be performed in the office or at the outpatient surgery center. Light anesthesia such as Nitrous Oxide or light conscious sedation IV may be required for the operation, but many are performed under local anesthetic only. Some burning or stinging when urinating, after the operation, is quite common but short lived. Injections may be repeated on an as needed basis. Discuss with your provider if a particular agent is preferred as considerations and complications will vary depending on the type of bulking agent used.
Slings – The aim of surgery is to stabilize hypermobility at the bladder neck. There are several different ways that this can be done.
Mid-urethral sling procedures – before 1993, the treatment of stress incontinence often involved major abdominal surgery. Today, the most common treatment is a small sling placed at the mid-urethra region. The sling works by supporting the urethra when you cough, sneeze or exercise. This is done by making a small incision in the anterior wall of the vagina, there are several different mid-urethral sling placements, your provider will advise you of the best one for you based on your specific case.
Retropubic slings – these run under the urethra, then behind the pubic bone and exit through two small cuts just above the pubic bone in the lower abdomen.
RETROPUBIC SLING
Transobturator slings run under the mid-urethra and pass out through 2 incisions in the groin.
TRANSOBTURATOR SLING
Single incision slings run under the urethra and are anchored within the tissues. This type of sling has been less well studied to date.
SINGLE INCISION SLING
80-90% of women undergoing retropubic or transobturator sling procedures are cured or have improvement of their stress incontinence symptoms following surgery.
Although stress incontinence procedures are not intended to aid in urge incontinence/overactive bladder (OAB) symptoms, up to 50% of women report noticing some improvement in OAB symptoms following sling surgery. It is important, however, to note that a small percentage of women with OAB, state their symptoms worsened after sling procedures.
Recovery from surgery is typically within 2-4 weeks. Some women may have an aching discomfort in the groin region for a couple of weeks after surgery. You can expect a small amount of vaginal bleeding for 7-10 days following surgery as well.
Many patients will have concerns regarding mesh sling procedures due to recent media coverage of vaginal meshes. It is important to understand that mesh sling procedures have been done safely for decades and the overall risk for mesh complications is less than 5%. You can read more on this subject at: https://www.yourpelvicfloor.org/mesh-mid-urethral-slings/
Autologous fascial sling – This type of sling is made out of tissue from the patient’s own body. The fascia is a layer of strong connective tissue which overlays our musculature. These grafts are typically obtained from the lower abdomen through a small incision. The harvested graft is a strip of fascia 1-3cm wide is placed under the mid-urethra to give support and reduce leakage of urine. This two-step operation is done under anesthesia. The first part is the harvesting of the graft and the second is a small cut made in the anterior wall of the vagina, under the urethra. The strip of fascia is secured underneath the urethra and then passed up to the abdominal wall. The small cut in the vagina is then closed. Fascial slings have similar success rates as do the synthetic mesh slings of approximately 80-90%.
Burch (colposuspension) – For many years, this was considered the gold standard for the management of SUI. It is performed either through a 10-12cm lower abdominal incision (open Burch) or as a laparoscopic (‘key hole’) approach. The surgery involves the passage of 4-6 permanent sutures that suspend the vaginal tissue underlying the bladder to the back of the pubic bone in order to support the bladder neck and urethra and restore continence. Open Burch colposuspension has a success rate similar to that of retropubic slings in long-term follow-up studies, and comparable results can be obtained by skilled surgeons using the laparoscopic approach.
Please feel free to contact our office to make an appointment if you are struggling with stress incontinence.
Base information provided by: IUGR