By Dr. Mário Apolinário
Urinary stress incontinence in women
definition, characterization and treatment
Urinary stress incontinence in women is characterised as involuntary urine loss caused by compromised bladder storage capacity, which is due to inadequate pelvic support or/and urinary sphincter intrinsic defect.
Incidence of stress incontinence
Up to 50% of women over the age of 50 may experience involuntary urinary loss during normal daily activities. This will, in the main, be during activities with increased intra-abdominal pressure, such as physical effort, exercise, sexual activity, laughter or coughing.
Such incidence is also more pronounced in women who have had vaginal childbirth deliveries, which may have weakened the pelvic floor muscles that support the neck of the bladder and urethra, and are in many cases associated with subsequent various grades of vaginal anterior wall prolapse.
After menopause, lack of oestrogen results in the thinning of tissues that line the urethra, a weakened sphincter mechanism and weak bladder muscles. These factors can cause a leakage of the urethral sphincter.
Obesity and chronic bronchitis can also lead to increased abdominal pressure which causes stress incontinence. Urine loss can also be due to pelvic surgery which may weaken and damage the pelvic floor muscles, causing the bladder neck and urethra to drop when abdominal pressure is applied (hypermobility).
Clinical diagnosis
Most urinary leakage happens during the day with normal daily activity. Usually it is not associated with urgency, unless there is concomitant urinary tract infection or inflammatory bladder syndromes such as chronic or acute cystitis.
Nocturnal urinary loss is also rare in pure stress incontinence, so when this happens an overactive bladder should be ruled out.
Vaginal inspection is mandatory in urinary stress incontinence in order to evaluate associated vaginal walls prolapse or gynecological pathology. Urine analysis and urodynamic studies are also needed, to rule out overactive bladder or inflamatory syndromes that have different treatment.
Treatment
Treatment depends on how severe the symptoms are and how much they affect the quality of life of the patient. There is currently no medication for the treatment of urinary stress incontinence. Treatment options available specifically for women with stress incontinence are: Kegel exercises, electrical stimulation, behaviour modification and surgical procedures (mesh slings).
Examples of behaviour changes include losing weight if you are overweight, avoiding food and drinks that irritate the bladder, such as spicy foods, carbonated and alcoholic drinks, and citrus fruits.
Stop smoking if there is chronic cough.
Pelvic muscle training exercises (called Kegel exercises) may help control urine leakage. These exercises keep the urethral sphincter strong and working properly. Biofeedback and electrical stimulation may be helpful for those with light, sporadic losses.
Electrical stimulation therapy uses a low-voltage electrical current to stimulate and contract the correct group of muscles. The current is delivered using an anal or vaginal probe. The electrical stimulation therapy may be done in the doctor’s consulting room or at home. Treatment sessions usually last 20 to 30 minutes and may be done every one to four days.
Surgery (slings)
Surgery is recommended when incontinence requires the use of pads and has an impact on the woman’s quality of life. Vaginal sling procedures are nowadays THE OPTION for treating pure stress incontinence, due to its simplicity and efficiency. Amesh/sling is placed in a transvaginal way, supporting the urethra and preventing its prolapse. In a 10 minute procedure, the transobturator tape TVT (tension free vaginal tape) is passed through the inner thigh, supporting the urethra. This surgery may be done as an outpatient procedure, under local anaesthesia and/or sedation.
Outcome
Behaviour changes, pelvic floor exercise therapy and electrical stimulation usually improve symptoms. However, they will not cure stress incontinence.
Surgery will cure patients in almost all cases of pure stress incontinence.
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Dr Mário Apolinário is a specialist in Urology and a member of the team of Urologists at Hospital Particular do Algarve
