Stress incontinence refers to urine leakage that occurs in moments when there is a sudden abdominal strain such as coughing, sneezing, squatting down or running. The amount leaked may range from a few drops of urine to a large gush, depending on how severe the condition is. This can adversely affect the lifestyle of those affected and become a social or hygienic issue.
Stress incontinence is usually caused by a weakening or damage to the pelvic floor muscles, nerves or to damage or loss of connective tissue support of the bladder neck and urethra. Other causes include injury to the urethral sphincter, urethral mucosal thinning due to loss of blood supply and scarring of tissues. Even ageing and low female hormone levels can contribute to the problem. Obesity and conditions that cause frequent abdominal straining like chronic cough or constipation make it worse.
Grade 2 (moderate): Leakage occurs when there is moderate abdominal straining such as running or carrying heavy articles. There may be a need to use pads and the frequency and amount of leakage is greater than grade 1. One’s lifestyle can be affected as exercising , sports or even certain daily chores can cause leakage.
Grade 3 (severe): Leakage occurs when there is very mild straining like standing up from a sitting or lying down position. One may need to use pads all the time as the leak episodes are frequent the amount leaked can be quite large. This often leads to social or hygiene issues.
Treatment for stress incontinence is dependent on the grade of stress incontinence and can be broadly divided into the following categories :
Conservative treatment usually involve the methods described below and are suitable for women with grade 1 or 2 stress incontinence who have mild to moderate leakage. They can also be for patients who are unfit for surgery or do not desire to undergo any form of surgical treatment.
- Pelvic floor exercises to train pelvic floor muscles so as to strengthen them. This can be taught by either the urologist or the physiotherapist.
- Biofeedback where patients are undergo programs to teach them to lhow to use their pelvic floor muscles and to do their pelvic floor exercises effectively. This is can be done using visual aids, electrical stimulation or even manually but the urologist or physiotherapist.
- Prophylactic voiding is advised. Patients are taught to go to the restroom at regular intervals so that they will not leak when they have a sudden increase in abdominal pressure eg: coughing and sneezing.
- Changes in lifestyle may be necessary such as weight loss and smoking cessation.
- Treatment for precipitating factors such as chronic cough or constipation is often necessary.
SURGERY FOR STRESS INCONTINENCE
In general, surgical correction for stress incontinence is offered to patients who have not improved with conservative treatment or who desire to have a better quality of life. For patients with grade 3 or severe incontinence, surgery may be offered at the outset as convervative measures are often not adequate.
TYPES OF SURGERY FOR STRESS INCONTINENCE
- The traditional method for SUI surgery is colposuspension whereby the paravaginal tissue is held up with sutures to the ileopectineal ligament. This operation can be done either open, laparoscopically or with robotic assistance.
- Increasing support under the urethra. Surgery may involve lifting up the urethra or to bulk up the sphincter muscle so that the closure mechanism improves. For urethral slings, patients have a continence rate of 80-90% one year after surgery. However, continence rate decreases with time. The urethral slings can be either synthetic or natural. The natural slings are made using the patient’s own tissue (either strong tissue from the abdomen or thigh). This is best done at the advice of a specialist.
- Injection of bulking agents into the peri-urethral tissue has been used with an aim to improve urethral closure. This technique is less invasive and is better tolerated by patients. However, repeated injections are often required to maintain continence and the overall success rate is only 30%.
- Surgical insertion or injection of synthetic materials into the lower urinary tract can have potentially serious complications. Some injected materials have been shown to migrate to distant organs e.g. brain and lungs. Foreign materials (eg the urethral sling) can incite chronic inflammation resulting in peri-urethral abscess formation and erosions into the urinary tract. Urinary tract obstruction can lead to voiding dysfunction and urinary retention.
- Additional surgeries to correct pelvic organ prolapse may also be necessary.