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Stress incontinence

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Stress incontinence

What Is It ?

Stress incontinence is the type of urinary incontinence that occurs when a small amount of urine leaks out during jumping, coughing, running, sneezing, or other types of activity that cause pressure on the bladder. Women are more likely than men to experience stress incontinence. This is often due to pregnancy, childbirth, and menopause -- all conditions that can cause changes to the pelvic floor muscles that support the bladder. Many women experience more stress incontinence in the week before menstruation. Researchers believe that lower levels of estrogen just before menstruation may cause a weakening of the muscle pressure around the urethra, which leads to urine leakage.

Pathophysiology: In women, physical changes resulting from pregnancy, childbirth, and menopause often contribute to stress incontinence. Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels. In female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance.

Treatment

Noninvasive/minimally invasive

  • Weight loss: Weight loss in overweight women reduced stress incontinence, in women with a Body Mass Index (BMI) over 25 and at least 10 episodes of urinary incontinence per week. With exercise and restricted diet they had a 70% or greater reduction in overall incontinence episodes.
  • Exercises: One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage. Patients younger than 60 years old benefit the most. The patient should do at least 24 daily contractions for at least 6 weeks.It is possible to assess pelvic floor muscle strength using a Kegel perineometer.Increasingly there is evidence of the effectiveness of pelvic floor muscle exercise (PFME) to improve bladder control. For example, urinary incontinence following childbirth can be improved by performing PFME.
  • Electrical stimulation: Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This can stabilize overactive muscles and stimulate contraction of urethral muscles.
  • Biofeedback: Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles.
  • Pessaries: A pessary is a medical device that is inserted into the vagina. The most common kind is ring shaped, and is typically recommended to correct vaginal prolapse. The pessary compresses the urethra against the symphysis pubis and elevates the bladder neck.
  • Surgery: Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried.
  • Slings: The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine, porcine) or the patients' own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a "backboard" or "hammock" of support under the urethra. According to published peer-reviewed studies, these slings are approximately 85% effective. There is a great variety of slings that have been marketed in the U.S. Three of the most common are the Tension-free Transvaginal Tape (TVT), The Trans-obturator Tape (TOT).
  • Tension-free transvaginal (TVT) sling: The tension-free transvaginal| (TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra.The 20-minute outpatient procedure involves two miniature incisions and has an 86–95% cure rate.
  • Urethral Bulking agents: A variety of materials have been historically used to add bulk to the urethra and thereby increase outlet resistance. This is most effective in patients with a relatively fixed urethra. Blood and fat have been used with limited success. The most widely used substance, gluteraldehyde crosslinked collagen (GAX collagen) proved to be of value in many patients. The main downfall was the need to repeat the procedure over time.
  • Artificial urinary sphincter: In rare cases, a surgeon implants an artificial urinary sphincter. A fluid fills and expands the sac, which squeezes the urethra closed. By pressing a valve implanted under the skin, the artificial sphincter can be deflated. This removes pressure from the urethra, allowing urine from the bladder to pass.