Alanna Matheson is 45 years old, she presents 'wanting to talk about her bladder problems'. Over the last 12 months Alanna has had difficulty controlling her urine flow when she coughs and sneezes. It has been problematic over the last few weeks as she has a 'bout of bronchitis' with a particularly bothersome cough. She has now started wearing pads, because she is worried that she will 'leak' if she coughs and she is wet all the time. She has also stopped playing netball because she is embarrassed by the leakage.
Alanna has symptoms of stress incontinence - involuntary leakage with exertion. She has difficulty controlling her urine flow when she coughs and sneezes. This has led to her stopping playing sport. Obesity, respiratory conditions and medications such as alpha-blockers may contribute to her symptoms.
| Type of incontinence | Pathophysiology | Symptoms |
|---|---|---|
| Common | ||
| Stress incontinence | Lack of bladder neck support and/or poor urethral closure | Involuntary leakage on effort or exertion, coughing and or sneezing |
| Urge incontinence: detrusor overactivity/overactive bladder syndrome (previously called detrusor instability/unstable bladder) | Failure of cortical inhibition of sacral reflex arc Idiopathic - anxiety, coffee intake and cold weather are said to influence symptoms Neurogenic (upper motor neuron lesion, ie multiple sclerosis, spinal trauma and cerebral vascular accidents) ?urethral obstruction after surgery |
Urgency: compelling desire to void, accompanied by fear of leakage and/or discomfort Day time frequency Urge incontinence: involuntary loss or urine associated with a strong desire to void Nocturia: awoken at night one or more times to void Nocturnal enuresis: bedwetting |
| Less common | ||
| Retention with overflow | Over-distension of bladder following surgery or delivery Urethral obstruction from a pelvic mass or faecal impaction Drugs or neurological disease |
Dribble incontinence, symptoms of the overactive bladder and of voiding difficulty |
| Fistula | Less developed countries: prolonged obstructed labour and pressure necrosis of bladder base and vagina. More developed countries: pelvic surgical complications, radiation, advanced pelvic surgery |
Uncontrollable continuous leakage |
The bladder is a hollow retroperitoneal pelvic organ composed of smooth muscle situated behind the pubic symphysis. Bladder function can be divided into the storage and voiding phases. The bladder is designed to store urine at low pressures less than 15cmH2O and when socially convenient, to achieve efficient complete voiding. A normal first sensation of bladder filling is noted at between 150 and 250 ml, followed by a first desire to void with a strong desire to void at about 400-600 ml (bladder capacity).
Continence is maintained by several mechanisms that allow urethral pressure to exceed bladder pressure:
In general terms, in the majority of cases of incontinence, the bladder pressure exceeds the urethral pressure because the sphincter mechanism is weak (urodynamics stress incontinence) or because the detrusor pressure is excessively high (detrusor overactivity).
Stress incontinence is due to pelvic floor dysfunction - resulting in a lack of support of bladder neck and impaired pressure transmission to proximal urethra - the factors that maintain positive urethral closure pressure at rest are inadequate when there is increased intra-abdominal pressure - so that urine loss is triggered by activities that cause a rise in intra-abdominal pressure (eg coughing, sneezing, jumping, lifting).
Pelvic floor dysfunction results in a lack of support of bladder neck and impaired pressure transmission to proximal urethra. The focus of pelvic floor muscle training is to build the strength, endurance, speed and the coordination of the pelvic floor muscles in different situations. In some women, more training is needed to enable them to contract their pelvic floor with appropriate coordination. An appropriately trained physiotherapist can assist in pelvic floor training.
Other measures would include:
Urodynamics studies can vary from simple cystometry (where bladder pressures alone are measured) to complex cystometry where multiple pressures are measured with computer analysis and imaging. Urodynamics are useful to differentiate genuine stress incontinence and detrusor overactivity, particularly when the history is unclear. Mandatory when invasive or surgical treatments are considered. Performed by inserting a catheter and distending the bladder with fluid. Pressures can then be measured with filling and voiding. Increased pressure is noted with detrusor overactivity and not with USI, which is only increased at being full.
Non-surgical options which could be considered in patients who are either not-suitable for surgery or where an intermediate solution is required (women who have not completed child bearing) would be anti-incontinence pessaries which supports the urethra or bladder neck, injectable periurethral bulking agents, or even a simple intravaginal tampon in minor cases.
Surgical Options:
| Procedure | Details |
|---|---|
| Colposuspension | Open or laparoscopic elevation of the bladder neck by suspending the vaginal fornices to the iliopectineal ligament. This was the gold standard until the advent of the mid-urethral sling which achieved similar efficacy rates without the morbidity of abdominal surgery. |
| Synthetic mid-urethral slings | Use of a sling of tissue inserted vaginally under the mid-urethra (not the bladder neck) to provide pressure transmission and urethral closure. Advent of safe synthetic slings such as TVT (tension free vaginal tape) have made this more popular. Can also be done as a day case. The tape is passed either side of the midline to the lower anterior abdominal wall. A newer procedure passes the tape through the transobturator foramen (Monarc trans obturator tape procedure). |
| Bio-injectables/urethral bulking agents | Injected cystoscopically to add bulk to urethral tissue and improve urethral mucosal coaptation. The indication for this treatment is intrinsic sphincter deficiency where the urethral closure pressure is less than 20cm H2O, or where other surgical treatments have failed. |