The term “incontinence” in the academic sense of the word – it’s an involuntary loss of urine through the external urethral orifice. In this definition, however, does not include other causes of involuntary loss of urine, such as vesico-vaginal fistula and ectopic meatus.
Schemes symptomatic classification instead of using anatomical terms allows us to give the most accurate definition and assessment of urinary incontinence in women. There are three main types of urinary incontinence that can be discerned, gathering a thorough medical history: stress, total (total) is enforced.
Stress incontinence — sudden urination because of the actions that result in increased intra-abdominal pressure. Coughing, lifting weights, breathing and laughter – a typical situation that can cause stress incontinence. In accordance with modern views, it is believed that intra-abdominal pressure transmitted to the bladder, is not balanced by an equal pressure transmitted to the urethra as the bladder neck and urethra protrudes (like a hernia) because of attenuation (loss of strength) of the tissue in the small pelvis.
Forced incontinence — a sudden imperative urge to urinate, accompanied by discharge of urine; incontinence is accompanied by varying degrees of success in controlling the severity of incontinence. The amount of lost urine varies from a teaspoon to full volume of the bladder. The volume of urine in the bladder is not a determinant of the suddenness of the impulse, and the patient notice that often small amounts can cause immediate (mandatory) the urge. If the patient is able to hold urine, they baffled a small amount of urine is passed and frequently occurring new the urge after a short time.
Full incontinence — in this case, there was an absolute inability to hold urine in the bladder, the patient constantly wet, despite the efforts made. When full wetting is continuously (day and night) used plain napkins.
THE HISTORY AND PHYSICAL EXAMINATION
History taking and physical examination are the most important components of diagnosing urinary incontinence. Medical history begins with questions about the duration and severity of incontinence and have already occurred attempting to surgically correct stress incontinence. The aim is to identify avoidable factors in the behavior of the patient or in the environment and in determining any neurological diseases or diseases of internal organs, underlying urinary incontinence or contributing to it. Special attention should be paid to the beginning and type of incontinence (e.g., stress, forced, full or mixed), the position of the patient in which the urine, contributing to the symptoms, the frequency of urination at night and measures (e.g., planting diaper, etc.).
Mixed symptoms and involuntary stress urinary incontinence is noted in almost 60% of women and approximately 30% of women is found an isolated form of involuntary incontinence. The sensation of bladder filling, pelvic prolapse (“heaviness” in the vagina or protrusion), vaginal discharge or symptoms of lack of estrogen production (dryness and itching) are important signs that you should pay attention during history taking. A detailed gynecological history must include information about surgical procedures, childbirth, infections, trauma, radiation therapy. It is also necessary to ask the patient about previous injuries to the pelvis, surgery on the spine used medications, eating habits, sex life and bowel movements, etc.
Diary of urination are important in quantifying and documenting the number of losing urine. In the diary should be marked with the number taken per os fluids and urine, imperative urges, the time of urination and any physical activity associated with episodes of incontinence.
Physical examination should be thorough and focused not only on the bladder and the urethra. During the inspection we need to assess the mental and physical capacity of the patient. Functional status of the patient may play a major role in the physical abilities of the elderly person to use the toilet in time to prevent incontinence. On examination, the abdomen is necessary to pay attention to postoperative scarring, the lesion and the signs of damage and to determine the degree of filling of the bladder (palpation). In General neurologic examination should pay attention to the sensitive and motoric innervation of the lower torso and crotch. Motor and sensory branches to the bladder and urethral sphincter come from the sacral segments of the spinal cord (S1-S4). During the physical examination it is important to assess the sensitivity of the skin of the perineum, the motor function of the anal sphincter with arbitrary reduction and bulbocavernosus reflex. Bulbocavernosus reflex is absent in 20% of healthy women. It is necessary to examine the back and spine to identify scarring and asymmetry, as well as to evaluate the sensitivity and reflexes in the lower extremities.
You need a consistent examination of the pelvic organs. Before that, the patient should empty the bladder. Be sure to assess the condition of the vaginal epithelium, indicating a hormonal background (for example, the surface is shiny, dry, smooth and thin), as in some cases of stress urinary incontinence in elderly women is shown only substitutive treatment with estrogen. It is necessary to specify the localization and appearance of the external opening of the urethra. Open and maximized the external opening of the urethra may indicate the presence of non-functioning urethra.
One half mirrors the Grave impose on the back wall of the vagina and explore the front wall of the vagina at rest, when coughing and when performing the Valsalva index. Then the plate is rotated mirror, inspect the back wall of the vagina at rest and during straining. Inspect the cervix, determine the state of the surrounding tissues and the position of the uterus. If the uterus has been removed, examine the position and strength of the vaginal “cuff”, again at rest and when straining. On closer inspection you can identify the omission of the anterior vaginal wall (cystocele – hernia of the bladder), povyshennogo the mobility of the proximal segment of the urethra, uterine prolapse, vaginal fornix after the removal of the uterus, bulging of the perineum between the utero-sacral ligaments (enterocele) or protrusion of the rectum into the vagina (rectocele). Slight defects can be detected during the re-examination of the patient in the standing position.
A catheter, No. 14 French scale (Carrera) from red rubber is injected into the bladder and measure the amount of residual urine. Syringe 60 ml without the plunger is attached to the catheter, and the bladder is slowly filled with sterile water. With this procedure is determined by urodynamics ad oculus. Record the volume of liquid that produces the first sensation of fullness of the bladder and imperative urge to urinate. After filling the bladder catheter is removed and repeat stress tests (cough, straining) to detect excessive mobility of the urethra and prolobbirovat bladder into the vagina (cystocele).
The table presents the standard classification used by urologists to characterize the types of stress incontinence, which is marked by a physical examination. It is important to note whether there is a leakage of urine immediately after an episodic increase in intra-abdominal pressure. The cough may provoke spasm (instability) of the bladder, if there is a short period between a cough and diuresis. This can lead to a false diagnosis of genuine stress urinary incontinence. If the flow of urine is not observed in the supine position, it is necessary to repeat the test in a standing position. When complaints of stress incontinence and absence of objective confirmation a thorough examination of the patient.
Common urine analysis, bacteriological examination and susceptibility testing of isolated bacteria to antibiotics, and urine Cytology should be performed to exclude infection or malignancy (e.g., carcinoma in situ) as a cause of urinary incontinence.
Bladder infection should be treated to instrumental manipulation on the bladder or urethra (cystoscopy or urodynamics study). Creatinine serum is an indicator of renal function. Its content must be determine in patients with large residual urine volume after urination or with severe cystocele.
Cystoscopy is used to diagnose the onset of pain in the bladder during its filling, the increased mobility of straining, determine the location of the obstruction and hematuria etc. When in history or the detection of red blood cells in the urine require cystoscopy to exclude bladder tumors, stones or foreign bodies.
X-ray examination performed for the diagnosis of type III stress urinary incontinence (open bladder neck at rest or dribbling of urine with minimal increase in intra-abdominal pressure transmitted to the bladder) or prolapse of the pelvic organs (moderate or pronounced). Radiological methods are also used for information about the obstruction of the urethra resulting from the previous surgery for urinary incontinence. Voiding cystourethrography (radiograph performed during the act of urination) is used to study the bladder filled rentgencontrastnam substance while the patient is standing, nutriiveda, coughing and peeing. Voiding cystourethrography also informal about the presence of vesicoureteral reflux, diverticulum, and the amount of residual urine after urination. The neck of the bladder is opened when a sudden spasm of the bladder, and as for the fluoroscopic examination it is impossible to distinguish between anatomic failure of the proximal urethra (bladder neck) and sudden spasm of the bladder, to measure pressure in the bladder during the study are often injected with a small catheter.
Registration of bladder pressure and voiding cystourethrography produced at the same time. Simple urodynamic study is performed to improve the accuracy of diagnosis and selection of rational treatment of urinary incontinence. In the diagnosis of urinary incontinence through urodynamic test, it is necessary that the phenomenon of incontinence was reproduced during the study. Cystometrogram records the pressure in the bladder at the time when the bladder is filled at a constant speed, usually 40 to 60 ml/min. Volume of liquid at the moment of appearance of the first feeling of fullness first the urge to urination and bladder record the total and note on cystometrogram. A sudden spasm of the bladder, while the patient tries to hold urine, is perfectly visible and is regarded as an involuntary contraction of the bladder with a sense of urgency or urge incontinence, or without it. When a sudden sensation of imperativeness urinary urgency associated with involuntary spasm registered on cystometrogram, and incontinence is documented, the patient’s involuntary urinary incontinence is secondary to involuntary bladder spasms (detrusor instability). Washing, the sound of the water stream, Bouncing on the heels can cause involuntary incontinence of urine during the process of research.
In adult bladder can hold 400 to 600 ml of urine, and the pressure will be less than 12 cm of water. article Slow, gradual increase in intra — cystic pressure as you fill the bubble indicates weak compliance of its walls (fibrosis), usually noted after radiation therapy of pelvic organs in malignant tumors of the female genital organs, or in violation of the peripheral innervation of the bladder. In normal anatomical relationship (and surrounded by healthy tissue) closes the urethra during increased intra-abdominal pressure. If the urethra is damaged (radiotherapy, trauma, multiple operations) is broken or its innervation, it is not closed when changing intra-abdominal pressure.
THE CHOICE OF MEANS FOR THE TREATMENT OF STRESS INCONTINENCE
Exercises and routines to the pelvic organs, drug therapy, coaching manipulation on the bladder, vaginal pessaries, electrical stimulation, surgery – all are used when the diagnosis of stress urinary incontinence.
Exercises for pelvic floor muscles if performed correctly strengthen the muscles of the anus, and give the effect, according to some reports, 70% of cases. Mentioned muscles form a supportive “hammock” that lifts the pelvic organs, including the bladder and the urethra. Thorough patient education is key to the success of exercises for the pelvic floor muscles. Women should be trained in which muscle should be tense, as well as the duration and frequency of the voltage on the optimal scheme; the statement simply is not an adequate form for the proper training of patients with urinary incontinence. The doctor inserts two fingers of one hand into the vagina of the patient, and places his other hand on her belly and asks to strain the muscles, as if she’s trying to stop urination. The doctor notes an isolated contraction of the muscles of the pelvic floor without tension of abdominal muscles. An exercise in contraction – relaxation of the pelvic floor muscles perform on the “four accounts” for each contraction for 5 min at least 2 times a day.
The method of biological feedback and other instrumental methods with the measurement of the pressure in a muscular contraction can visually enhance the effectiveness of this technique. Cones of different weights entered into the vagina, help the patient to learn how to stretch specific muscles to hold the cone. These cones shall be retained in the vagina for 15 minutes 2 times a day while walking or when the vertical position of the body. Election to exercise the necessary muscles using electrical stimulation of the pelvic floor musculature through the electrode placed in the vagina.
For treatment monitoring stress urinary incontinence using oestrogen and ?-agonists. Stimulated contraction of the muscles should help close the urethra during stressful actions. Most often used phenylpropanolamine, which is found in many medicines to treat colds that we see in pharmacies (Ornade®, Spansule® — Smithkline Beecham Pharmaceuticals, Entex®LA – Procter & Gamble Pharmaceuticals and Tavist-D®). Replacement therapy in female patients after menopause contributes to the increase in the thickness of the mucous membrane of the urethra and vagina. It is believed that estrogens increase the factor of tightness created by the mucous membrane in the urethra, while its walls are closed with increasing intraabdominal pressure. Traditionally, the training of the bladder used to control (manage) the urgency of urination and involuntary incontinence. Studying the diary of urination, the doctor prescribes the patient about the fixed time interval at which it is recommended to urinate; usually these recommendations are “tied” to shaping the schedule of urination. If the patient urinates every hour, the interval between urinations installed in 45 minutes She offered to only urinate at a set time. Each week, the time interval is increased by 15 minutes; eventually the force of urination control by supporting cortical effects on gallbladder mechanism of sensations. In combination with exercise for the pelvic floor bladder training is an excellent initial treatment for 40-year-old patients with newly started stress urinary incontinence in combination with the sometimes occuring elements of involuntary incontinence.
For treatment monitoring stress urinary incontinence using vaginal pessaries, and diaphragms. They support the base of the bladder and prevent the increased mobility of its neck and urethra during sudden increases in intra-abdominal pressure.
Surgical treatment methods should be discussed, if it is clear that the patient has stress urinary incontinence and conservative therapies are not able to result in cure. There are 6 main options, containing about 100 surgical techniques. The choice of method is within the competence of the urologist.
Narrowing of the anterior part of the vagina used to reduce the severity and eliminate the cystocele, which prolabium through the front wall of the vagina. This technique gives unreliable long-term results in the treatment of stress urinary incontinence, if not performed surgery aimed at restoring normal supporting effect of the surrounding tissues to the neck of the bladder. The best follow-up result was obtained when performing abdominal potadromous urethropexy. Pasadenabuy options surgical intervention is indicated for increased mobility of the urethra with the proximal sphincter functioning or no apparent cystocele (for example, type I stress urinary incontinence).
Pereira has published the results of his method (transvaginal method stitch) in 1959, followed by numerous modifications (Stamey, Gittes, rat), although its basic principles remain the same. Areas of tissue on each side of the bladder neck to hem blind or through an incision in the vaginal wall to the tissues located in the suprapubic space. Here the sutures are fixed to the fascia of the rectus muscle or the bone nadkostnitsej. In comparison with abdominal pasadenabuy operations described in the method of the procedure and the postoperative period is shorter. In some centers, this operation is carried out on an outpatient basis.
For the treatment of stress urinary incontinence there are a number of techniques. A thorough history, physical examination along with simple diagnostic procedures lead to accurate diagnosis. Conservative methods of treatment should be explained to the patient and applied to surgical – disease state and a poorer quality of life and often persist to a large extent after the surgery.
With the failure of treatment with oral medication, but if indicated for surgical treatment may be the technique of use of the catheter. With the monthly rotation of the catheter it is possible to avoid the development of infection. The second factor that prevents ascending infection is hermetically closing the system.
Family doctors must be able to document and correct diagnosis of stress urinary incontinence, as well as pick up recommendations for exercises for the pelvic floor muscles, prescribe drug therapy per os. In history,attesting to the involuntary urinary incontinence, and the absence of incontinence in the stress trial during the examination, the family doctor should consider the exclusion of infection or carcinoma in situ. The constant presence of symptoms of disease in the absence of infection and failure when trying to treat stress urinary incontinence exercises or pharmacology justify the direction of the patient to a urologist for examination and decision of a question on expediency of surgical interference.
METHODS FOR THE TREATMENT OF INVOLUNTARY URINARY INCONTINENCE
The inability to delay urination when the urge suddenly arises is called induced urinary incontinence. Forced incontinence can be caused different causes, including neurological disorders (multiple sclerosis, urinary tract infections). In most cases of involuntary incontinence and detrusor instability cannot find significant neurological etiology. With age, the muscles of the bladder are prone to instability or poorly controlled contractile activity, To prevent or delay sudden contractions of the bladder use of anticholinergic and antispastic drugs. In the treatment of involuntary urinary incontinence most commonly used oral medications such as oxybutynin (Ditropan® — Marion Merrill Dow), propantheline bromide (pro-BanthAne® — Roberts).