Investigating urinary incontinence

Urinary incontinence and other bladder disorders belong to the most common female diseases. Investigation should always start with simple measures. A problem-oriented history and a differentiated clinical examination, eventually complemented with search for infection, miction calendar and assessment of residual urine most often lead to a rather precise diagnosis and to the initiation of a primarily conservative treatment. If primary therapy is unsuccessful stepwise integration of additional diagnostic measures like cystoscopy, ultrasound, X-ray and urethrocystometry is indicated. Surgical interventions in particular demand, in the authors' view a foregoing urodynamic examination. Execution of the investigations, interpretation of the results and their impact on recommendations for therapy are explained.     

Surgery for urinary incontinence

Burch colposuspension remains the most effective surgical procedure for stress urinary incontinence with a continence rate, which shows better longevity than other methods of treatment. Sling procedures have a comparable continence rate to colposuspension and there appears to be little reduction in continence over time. It is expected that the tension-free vaginal tape will eventually supersede the open Burch colposuspension as the preferred method of primary incontinence surgery principally because it is a minimal-access procedure and medium-term data suggest similar effectiveness to colposuspension. Initial reports on the trans-obturator tape, which minimises bladder and vascular trauma, are encouraging but longer term results remain uncertain. Although the injectable agents have a lower success rate than other procedures, they may still have a role when other procedures have failed due to their low morbidity. Anterior colporrhaphy and needle suspension procedures should no longer be offered as treatments for stress urinary incontinence.The surgical options for detrusor activity should be considered when pharmacological options have been exhausted. Appropriate patient selection is crucial when choosing which surgical option would be most suitable, especially as many of these procedures carry with them a significant risk of morbidity. Some surgical options are becoming less invasive and modern developments, such as intravesical botulinum toxin injection may in future become a first line treatment option for detrusor overactivity.     

Post prostatectomy urinary incontinence

The specific incidence rate of post prostatectomy incontinence is difficult to ascertain. However, regardless of the type of prostatectomy, whether it be transurethral, radical retropubic or radical perineal prostatectomy, or the nature of the prostatic disease, several risk factors are common to all. The most significant risk factors include pre-existing detrusor and/or sphincter dysfunction, increasing age, and surgical expertise. Management options include behavioral techniques, pharmacologic therapy, surgical intervention, and other supportive measures. While no definitive preventive measures can be recommended at this time, reducing the incidence of post prostatectomy urinary incontinence should be the goal.     

Surgical management of urinary incontinence

Surgery for stress incontinence is selected according to specific problems in each patient. Patients with ISD can be identified and selected for sling surgery or collagen injection therapy. Other patients may be managed successfully by retropubic urethropexy, either open or laparoscopic. Diagnostic evaluation should be thoughtful and extensive, with good correlation of findings and presenting symptoms to apply therapy in a specific manner to each patient.     

Nonsurgical therapies for urinary incontinence

Many nonsurgical treatments for incontinence are available and all offer benefit to some patients. Patients with mild to moderate incontinence usually benefit the most from these modalities and, for many, it may obviate the need for surgery. Several factors influence the success of nonsurgical treatments for incontinence. Most important is the patient's motivation and ability to comply with the therapy. Selection of therapy appropriate for a given patient is, therefore, important. Compliance is better when the patient has a better understanding of the therapy and expected results. When appropriate, combinations of therapy may be very useful.     

An introduction to urinary incontinence

Urinary incontinence is most frequently associated with the elderly, particularly women, and is often thought of as inevitable. However, orthopaedic nurses encounter incontinence as a response to alterations in orthopaedic health. This article reviews the types of urinary incontinence, with emphasis on those which may most directly result from orthopaedic problems. It will also help the nurse differentiate between types of incontinence in a way that will clarify appropriate interventions.     

Non-surgical management of urinary stress incontinence

This article reviews the non-surgical approach to urinary stress incontinence. As the cost of medical care increases and the waiting lists for surgical operations grow bigger, non-surgical management of incontinence takes on importance. The cure rates or improvement of quality of life with conservative management of urinary stress incontinence are not as good as with the surgical approach but it is an option which may be used in selected patients. Whenever a patient or the health care provider embarks upon the non-surgical options, consideration should be given to the success rates of the modality, either used alone or in combination. The motivation and compliance of patient is important, individuals who have realistic expectations from non-surgical management of urinary stress incontinence usually have the best result.Recent literature was reviewed and an attempt has been made to present an objective assessment for all the modalities currently available for the incontinent woman. It is necessary to stress the need for the use of a combination of modalities for better results when non-surgical approach is used as the first line option. It is also important to be empathetic and supportive of such women as they usually have an extremely poor self esteem, are depressed and reclusive.     

Reflex electrical stimulation for urinary incontinence

Our previous observations have shown that the electrical stimulation of muscles is prevalently reflex. One of the advantages of reflex stimulation is that it activates not only a limited number of motor units, but rather a number of muscles connected by the same reflex from a single stimulation site. Consequently, it is not necessary to place electrodes into the muscle to be activated. They can be put elsewhere provided that the same effect is obtained and that it is more convenient for the patient. Such an opportunity arises when treating urinary incontinence which involves not only the urethral sphincter but also the group of synergistic muscles of the pelvic floor. Our experiments with several patients suffering stress incontinence have shown that indirect stimulation of the levator ani with a vaginal stimulator and especially of the anal sphincter with an anal stimulator affects the urethral sphincter in the same way as direct stimulation. These findings are significant since they enable us to use external instead of implantable stimulators. External stimulation is worth trying in all cases of stress incontinence where conservative measures have failed. In our cases, the results have been very satisfactory.     

Collagen injection therapy in the treatment of urinary incontinence

Impairment from depression and its impact on productivity are of profound societal importance. We report the results of an evaluation of depression and academic impairment in university students, using standardized measures. Sixty-three students completed the Beck Depression Inventory and the work role section from the Social Adjustment Scale-Self Report. Academic impairment, manifested as missed time from class, decreased academic productivity, and significant interpersonal problems at school, was seen in 92% of the students. More severe depression was related to a higher level of impairment. At all levels of depression, affective impairment-inadequacy, distress, and disinterest in school-was more prevalent than was academic impairment. The risk of academic impairment became likely at only moderate-to-severe levels of depression. Discussing the implications of depression with students and aggressively pursuing both medication and nonmedication therapies are essential in preventing the high morbidity associated with untreated depression.     

The colposuspension operation for urinary incontinence

Forty-two patients with urinary incontinence and related symptoms were treated by colposuspension. Two patients were lost to follow-up and the results of surgery in the remaining 40 patients are presented and discussed. The place of vaginal surgery in women with urinary symptoms is also discussed.     

Diagnosis and management of female urinary incontinence

Urinary incontinence affects an estimated 13 million Americans of which 85% are women. It is an embarrassing and lifestyle limiting condition for which effective treatment is available. Health care providers should be alert to the signs and symptoms of UI and pursue its etiology. Those patients who fail medical therapy, in whom the etiology for the incontinence is unclear, or those patients with concomitant cystocele, enterocele, or rectocele, should be referred to an incontinence specialist.     

Treatment of stress urinary incontinence in women

Involuntary urinary leakage due to a rise in abdominal pressure caused by stress (cough, laugh, change in position, walking, running or carrying heavy weight) is a clinical entity often experienced by women. Management can be based on physical therapy techniques, drugs or surgery but indications and results to be expected are still very largely debated. Cure of an underlying condition such as obesity, or chronic bronchitis may be sufficient in some cases and others may benefit from "preventive" physical therapy to reinforce the perineum after difficult pregnancy and delivery. Alpha-stimulating drugs have also been proposed to increase sphincter tone. Surgery gives the best results. Several procedures have been proposed, usually based on classical retropubic colposuspension and aponevrosis loops. Success rate is approximately 80 to 90% although the lack of a sufficient understanding of the underlying mechanism involved, makes it impossible to predict outcome. Results in women with recurrent incontinence are less satisfactory.     

Pelvic organ prolapse and stress urinary incontinence

Pelvic organ prolapse presents a wide array of distressing symptoms to the female patient. Stress urinary incontinence is often considered a normal phenomenon of aging and tolerated for years before seeking medical attention. A detailed history outlining specific complaints and a targeted pelvic examination can usually elucidate the anatomic problems responsible for producing symptoms. Nonsurgical therapy can be initiated, often with great improvement in symptoms. If the results are not satisfactory, the patient can be referred for further evaluation and possible surgical intervention.