October 31, 2014


URINARY INCONTINENCE

Overview Classification Therapy for urge incontinence Therapy for stress incontinence Conclusion Faculty


THERAPY FOR STRESS INCONTINENCE

In contrast to urge incontinence, treatment of stress incontinence focuses less on bladder behavior than on the structure and function of the bladder and sphincter valve. Kegel's exercises designed to improve pelvic muscle strength have in important role in mild degrees of stress incontinence and in maintaining health and function of the lower urinary tract. For more significant degrees of exertional leakage many options are available. These include temporary devices to support, close or plug the urethra, injection of Urethral bulking agents into the bladder neck and sphincter area to help its closure, and surgical procedures to restore function of the valve mechanism.

Stress incontinence is thought to result from either loss of support for the bladder neck and sphincter area or intrinsic damage to the urethra and sphincter itself. Again, each of these entities may be present singly or in combination, and accurate diagnosis is important for treatment planning. Many procedures done previously, such as the Kelly plication and bladder suspension of the Raz, Stamey and Peyreyra type, have not shown satisfactory durability to warrant their use.

Surgical procedures for restoring continence can be performed through an abdominal incision, laparoscopically, or through a vaginal approach. The most reliable of these procedures in women are the Burch colpocystourethropexy and the Pubovaginal sling. The sling procedure places a strong material beneath the urethra and bladder neck to provide strength to the sphincter valve and restore its function. Results show excellent durability with low complication rates for patients of all ages. For males with significant stress incontinence, the favored surgical therapy is placement of an Artificial Urinary Sphincter. This is a mechanical device designed to replace the sphincter valve. It provides closure of the valve on a continuous basis and is opened by squeezing a small pump implanted beneath the skin of the scrotum. This allows unrestricted voiding, after which the device closes automatically.

Urethral bulking agents

Part of the mechanism of stress incontinence involves failure of the sphincter valve to form a seal adequate to hold back leakage. This lack of sphincter closure is due to changes in the muscular wall and lining of the urethra. A minimally invasive therapy for this condition involves the injection of a bio-compatible material into the sphincter area to help its closure. The material used is similar in type and technique to that used by plastic surgeons in treating facial wrinkles and contouring. The procedure can be performed in the office under a local anesthetic and is well tolerated. A cystoscope is inserted into the urethra and used to direct the injection into the appropriate site.

In the majority of cases, 2-3 sessions are necessary to achieve a satisfactory result. These sessions are usually done at 4-6 week intervals. The rate of improvement in continence is 60-70% while the overall cure rate (complete dryness) is lower (15-25%). Results are generally poor in men suffering from incontinence as a result of radical prostatectomy.

Reference:
1. McGuire EJ, et al: Periurethral collagen injection for male and female sphincteric incontinence: indications, techniques, and result. World J Urol. 15(5):306, 1997.


Pubovaginal sling

A sling operation is currently the most effective therapy for significant stress urinary incontinence due to weakness of the urethral sphincter. This procedure requires 1-2 hrs. of operative time and an overnight stay in the hospital. Through a vaginal approach, small incisions are made beneath the bladder neck and urethra.


Creation of submucosal tunnel in anterior vaginal wall.


Allograft fascia for sling

A strong and durable material from the body called fascia is placed beneath the bladder neck to provide support when pressure is placed on the bladder from a sneeze, cough, exercise or other activities.

This fascia is obtained from the thigh (through an additional small incision), abdomen (through an incision over your pubic bone) or from a donor. A catheter placed through the urethra or the abdominal wall is usually left in place overnight or for a few days following surgery.

Results are immediate but a healing period of modified activities is usually recommended for 4-6 wks. This operation has a success rate of over 90% and has excellent durability.

Reference:
  1. Chaikin D, et al: Results of pubovaginal sling for stress incontinence: a prospective comparison of 4 instruments for outcome analysis. J Urol. 1999 Nov;162(5):1670-3.
  2. Wright EJ, et al: Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency. J Urol. 1998 Sep;160(3 Pt 1):759-62
  3. Carr LK, Walsh PJ, Abraham VE, Webster GD.: Favorable outcome of pubovaginal slings for geriatric women with stress incontinence. J Urol. 1997 Jan;157(1):125-8.
Artificial Urinary Sphincter

The artificial urinary sphincter (AUS) is a hydraulic bio-compatible device with 3 components

There is a fluid filled reservoir roughly the size of a golf ball that is implanted in the groin area next to the bladder. A pump device about the size and shape of the thumb is placed inside the scrotum in front of one of the testicles. The last piece is a circular inflatable cuff that is placed around the urethra and sphincter area.

When activated, the cuff compresses the urethra with sufficient pressure to withstand forces associated with most activities. When one has the usual sensation of a full bladder, the pump in the scrotum is pressed between the fingers twice to allow the cuff to open. Voiding is completed in the normal fashion and the device automatically closes over 1-2 minutes. Implantation of this device generally requires a 2 hour surgery and an overnight stay in the hospital. The device is left inactivated for a period of 4-6 weeks following implantation to allow for successful healing and recovery. After this waiting period the device is turned on and results are immediate. The materials in the AUS are durable for a period of 7-10 years. If they wear out, they can be replaced as an outpatient with a 40-60 minute operation. The AUS is associated with significant improvement in quality of life in the majority of men with significant stress urinary incontinence.

Reference:
1. Haab, F et al: Quality of life and continence assessment of the artificial urinary sphincter in men with minimum 3.5 years of followup. J Urol. Aug;158(2):435, 1997.

 

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