Urinary incontinence in women is a violation of urination, accompanied by the impossibility of arbitrary regulation of emptying the bladder. Depending on the form, it is manifested by uncontrolled leakage of urine under stress or at rest, sudden and uncontrollable urge to urinate, unconscious urinary incontinence. As part of the diagnosis of urinary incontinence in women, gynecological examination, ultrasound of the genitourinary system, urodynamic studies, functional tests, urethrocystoscopy are performed. Methods of conservative therapy may include special exercises, pharmacotherapy, electrical stimulation. In case of inefficiency, sling and other operations are performed.
Urinary incontinence in women is an involuntary and uncontrolled discharge of urine from the urethra due to violations of various mechanisms of miction regulation. According to available data, every fifth woman faces involuntary urine discharge at reproductive age, every third at perimenopausal and early menopausal age, and every second in the elderly (after 70 years).
The problem of urinary incontinence is most relevant for women who have given birth, especially those with a history of natural childbirth. Urinary incontinence has not only a hygienic, but also a medical and social aspect, since it has a pronounced negative impact on the quality of life, is accompanied by a forced decrease in physical activity, neuroses, depression, sexual dysfunction. The medical aspects of this disorder are considered by specialists in the field of theoretical and clinical urology, gynecology, and psychotherapy.
The prerequisites for stress urinary incontinence in women can be obesity, constipation, sudden weight loss, hard physical labor, radiation therapy. It is known that women who have given birth suffer from the disease more often, while the number of births is not so important as their course. The birth of a large fetus, a narrow pelvis, episiotomy, ruptures of the pelvic floor muscles, the use of obstetric forceps – these and other factors are determining for the subsequent development of incontinence.
Involuntary urination is usually observed in menopausal patients, which is associated with age-related deficiency of estrogen and other sex steroids and atrophic changes in the genitourinary system that occur against this background. Pelvic organ surgeries (oophorectomy, adnexectomy, hysterectomy, pangisterectomy, endourethral interventions), prolapse and prolapse of the uterus, chronic cystitis and urethritis contribute.
The direct producing factor of stress incontinence is any tension that leads to an increase in intra-abdominal pressure: coughing, sneezing, brisk walking, running, sudden movements, lifting weights and other physical effort. The prerequisites for the occurrence of urgent urges are the same as with stress incontinence, and various external stimuli (sharp sound, bright light, water pouring from the tap) can act as provoking factors.
Reflex incontinence can develop as a consequence of brain and spinal cord injuries (injuries, tumors, encephalitis, stroke, multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, etc.). Iatrogenic incontinence occurs as a side effect of certain medications (diuretics, sedatives, adrenoblockers, antidepressants, colchicine, etc.) and disappears after the withdrawal of these drugs.
The mechanism of stress urinary incontinence in women is associated with insufficiency of urethral or vesicular sphincters and/or weakness of pelvic floor structures. An important role in the regulation of urination is assigned to the state of the sphincter apparatus – with changes in the architectonics (the ratio of muscle and connective tissue components), the contractility and extensibility of the sphincters are disrupted, as a result of which the latter become unable to regulate urine excretion.
Normally, the continence (retention) of urine is provided by a positive gradient of urethral pressure (i.e., the pressure in the urethra is higher than in the bladder). Involuntary urine discharge occurs if this gradient changes to negative. A prerequisite for voluntary urination is a stable anatomical position of the pelvic organs relative to each other. With the weakening of the myofascial and ligamentous apparatus, the support-fixation function of the pelvic floor is disrupted, which may be accompanied by a lowering of the bladder and urethra.
The pathogenesis of imperative urinary incontinence is associated with a violation of neuromuscular transmission in detrusor, leading to hyperactivity of the bladder. In this case, with the accumulation of even a small amount of urine, there is a strong, unbearable urge to mix.
According to the place of urine excretion, transurethral (true) and extraurethral (false) incontinence are distinguished. In the true form, urine is excreted through the intact urethra; in the false form, from abnormally located or damaged urinary tract (from ectopically located ureters, exstrophic bladder, urinary fistulas). In the future, we will focus exclusively on cases of true incontinence. Women have the following types of transurethral urinary incontinence:
- Stressful – involuntary discharge of urine associated with the failure of the urethral sphincter or weakness of the pelvic floor muscles.
- Imperative (urgent, hyperactive bladder) – unbearable, unrestrained urges caused by increased reactivity of the bladder.
- Mixed – combining signs of stressful and imperative incontinence (a sudden, uncontrollable need to urinate occurs with physical exertion, followed by uncontrolled urination.
- Reflex incontinence (neurogenic bladder) is a spontaneous discharge of urine caused by a violation of the innervation of the bladder.
- Iatrogenic – the intake of certain drugs is caused.
- Other (situational) forms are enuresis, urinary incontinence from overflow of the bladder (paradoxical ischuria), during sexual intercourse.
The first three types of pathology occur in most cases, all the others account for no more than 5-10%. Stress incontinence is classified by degrees: with a mild degree, urinary incontinence occurs with physical exertion, sneezing, coughing; with an average degree – during sudden getting up, running; with a severe degree – while walking or at rest. Sometimes in urogynecology, a classification is used based on the number of sanitary pads used: I degree – no more than one per day; II degree – 2-4; III degree – more than 4 pads per day.
When the stressful form of the disease begins to notice involuntary, without prior urge to urinate, leakage of urine, which happens with any physical exertion. As the pathology progresses, the amount of urine lost increases (from a few drops to almost the entire volume of the bladder), and exercise tolerance decreases.
Urgent incontinence can be accompanied by a number of other symptoms characteristic of an overactive bladder: pollakiuria (increased urination more than 8 times a day), nocturia, imperative urges. If incontinence is combined with the lowering of the bladder, discomfort or pain in the lower abdomen, a feeling of incomplete emptying, a feeling of a foreign body in the vagina, dyspareunia may be noted.
When faced with uncontrolled leakage of urine, a woman experiences not only hygienic problems, but also serious psychological discomfort. The patient is forced to abandon her usual lifestyle, limit her physical activity, avoid appearing in public places and in company, and refuse sex.
Constant leakage of urine is fraught with the development of dermatitis in the inguinal region, recurrent genitourinary infections (vulvovaginitis, cystitis, pyelonephritis), as well as neuropsychiatric disorders – neuroses and depression. However, due to shyness or a false idea of urinary incontinence as an “inevitable companion of age”, women rarely seek medical help with this problem, preferring to put up with obvious inconveniences.
A patient who is faced with the problem of urinary incontinence should be examined by a urologist and gynecologist. This will allow not only to determine the causes and form of incontinence, but also to choose the optimal ways of correction. When collecting anamnesis, the doctor is interested in the prescription of the occurrence of incontinence, its connection with the load or other provoking factors, the presence of imperative urges and other dysuric symptoms (burning, pain, pain). During the conversation, the risk factors are clarified: traumatic childbirth, surgical interventions, neurological pathology, features of professional activity.
An examination is necessarily carried out on a gynecological chair; this allows you to identify genital prolapse, urethro-, cysto- and rectocele, assess the condition of the skin of the perineum, detect genitourinary fistulas, conduct functional tests (straining test, cough test), provoking involuntary urination. Before re-admission (within 3-5 days), the patient is asked to keep a diary of urination, which notes the frequency of injections, the volume of each allocated portion of urine, the number of episodes of incontinence, the number of pads used, the amount of fluid consumed per day.
To assess the anatomical and topographic relationships of the pelvic organs, gynecological ultrasound, ultrasound of the bladder is performed. Of the laboratory methods of examination, the most interesting are general urine analysis, urine sampling for flora, smear survey microscopy. Methods of urodynamic examination include uroflowmetry, filling and emptying cystometry, intraurethral pressure profilometry – these diagnostic procedures allow to assess the state of sphincters, differentiate stress and urgent urinary incontinence in women.
If necessary, the functional examination is supplemented by methods of instrumental assessment of the anatomical structure of the urinary tract: urethrocystography, urethroscopy and cystoscopy. The result of the examination is a conclusion reflecting the form, degree and causes of incontinence.
Treatment of urinary incontinence in women
If there is no gross organic pathology causing incontinence, treatment begins with conservative measures. The patient is recommended to normalize weight (in case of obesity), give up smoking, which provokes a chronic cough, exclude heavy physical labor, and follow a caffeine-free diet. At the initial stages, exercises aimed at strengthening the pelvic floor muscles (Kegel gymnastics), electrical stimulation of the perineal muscles, and BOS therapy can be effective. With concomitant neuropsychiatric disorders, the help of a psychotherapist may be required.
Pharmacological support for a stressful form of incontinence may include the appointment of antidepressants (duloxetine, imipramine), topical estrogens (in the form of vaginal candles or cream) or systemic HRT. For the treatment of imperative incontinence, M-cholinolytics (tolterodine, oxybutynin, solifenacin), alpha-blockers (alfuzosin, tamsulosin, doxazosin), imipramine, hormone replacement therapy are used. In some cases, the patient may be prescribed intravesical injections of botulinum toxin type A, periurethral injection of autogyre, fillers.
The surgery of stress urinary incontinence in women has more than 200 different techniques and their modifications. The most common methods of operative correction of stress incontinence today are sling operations (TOT, TVT, TVT-O, TVT-S). Despite the differences in the technique of execution, they are based on a single general principle – fixing the urethra with a “loop” of inert synthetic material and reducing its hypermobility, preventing urine leakage.
However, despite the high efficiency of sling operations, 10-20% of women develop relapses. Depending on the clinical indications, it is possible to perform other types of surgical interventions: urethrocystopexy, anterior colporaphy with bladder reposition, implantation of an artificial bladder sphincter, etc.
Prognosis and prevention
The prognosis is determined by the causes of development, the severity of the pathology and the timeliness of seeking medical help. Prevention consists in the rejection of bad habits and addictions, weight control, strengthening of the press and pelvic floor muscles, control of defecation. An important aspect is careful management of childbirth, adequate treatment of urogenital and neurological diseases. Women who are faced with such an intimate problem as urinary incontinence need to overcome false modesty and seek specialized help as soon as possible.