Stress incontinence

Stress incontinence is a major women health problem , characterized by involuntary escape of urine in raising intra-abdominal pressure as during laughing, sneezing and straining , that escape occur when there is complete absence of micturation desire .

Stress incontinence causes

Normally there is sphincter between urethra and urinary bladder that has anterior and posterior angles , these angles lead to make that sphincter closed under normal conditions , also the proximal part of the urethra lies intra abdominally , that create pressure and made the intra urethral pressure more than the intra vesical pressure and finally the female is under continence condition.

what happening in stress incontinence that many females has repeated vaginal deliveries , that lead to over stretch or damage of fascia that surround neck of the bladder , beside these deliveries lead to weakening of the supporting muscles surround bladder neck .

stress incontinence occurs also in menopause women , due to reduction of fascia surround bladder neck as it estrogen dependent and also decrease or atrophy of mucosa inside urethra .

There are other stress incontinence causes , as it occur after operations as in cases of repair of cystocele , and also it can occur due to congenital weakness of sphincter and as aside effects of some anti hypertensive drugs as it affect autonomic control of sphincter .

Stress incontinence types

There are two main types of stress in continence , first is Genuine stress incontinence and the other is detrusor instability .

Genuine stress incontinence

Genuine stress incontinence or anatomic stress incontinence , occur when the bladder pressure exceed the intra urethral pressure in absence of any detursor muscle contraction. That type of incontinence has agradual onset as it occur after on or two deliveries , escape of urine occur synchronous with increase in abdominal pressure , usually with few drops of urine.

Detrusor muscle instability

That type of incontinence occur due to involuntary contraction of detrusor muscle ( bladder muscle) , that contraction may be idiopathic or secondary to neurological lesions , diabetes or urinary tract infections . In that type the incontinence , female has a history of weak bladder even before pregnancy , it also may be associated with manifestation of diabetes , enuresis and urinary tract infection as frequency , usually in that type there are escape of larger amount of urine

Mixed type: mixed between Genuine type and detrusor muscle .

In all stress incontinence types , there are grading of incontinence , that grade is mild , moderate and severe stress incontinence .

Stress incontinence treatment

Before actual treatment , diagnosis should be confirmed by taking complete history and in that history patient must know which type of incontinence he has ,after taking history examination should be done to him

Stress incontinence examination

First when the patient in standing position  , doctor asked her to cough and so seeing the escape of urine , as there are some cases in which stress incontinence may be hidden as in case of empty bladder ! , also in cases of large cyctocele  , other investigation done to confirm diagnosis and asses  the type of incontinence like:

Urodynamic studies :

In that study there is measuring of pressure insider both bladder and urethra and calculating urethral closure pressure , that study differentiate between both types of incontinence especially before surgery or after unsuccessful surgery .

Cystourethrograghy :

That type take an image to both urethra and bladder , and it is diagnostic if it show funneling shape of bladder neck in anterior posterior view , or shows loss of angle between bladder and urethra in lateral view.

After confirming diagnosis by history , examination , and investigation , treatment of stress incontinence has two man subdivision , First non -surgical treatment and in case of failure , the other option is surgical treatment

1. Non-surgical treatment

Females must modifies in their life style by having scheduled fluid consumption , avoid alcohol , smoking and drinking caffeine products , also have scheduled toiling .

In menopause women , they should receive Hormonal replacement therapy under physician control to balance the atrophy that occur .

Doing kegel ‘s exercises , which strength the pelvic floor , also electrical stimulation of plevic floor muscles are advised .

2. Surgical treatment

The options of  in stress incontinence surgery are : repair of sphincter ,or fixation of sphincters

• Repair of sphincter

Repairing sphincter by suturing it by a special suturing called kelly’s sutures , in that operation suturing of fascia around bladder neck to reinforce it  , that operation called kelly’s suture operation , other operation called kennedy’s operation , in which there lysis of fibrosis and adhesion around bladder neck .

• Fixation of sphincter

There are multiple operations like :

1. Marshall Marchetti Krantz operation : in that operation there is suturing the fascia around bladder neck to the posterior aspect of pubic bone .

2. Burch operation : suturing the fascia around bladder neck and vaginal wall to the pectineal part of inguinal ligament.

3. Tension free vaginal tape

4. Sling operations : they are  mainly  done in recurrent cases , as Aldridge operation (fascial sling) , in which sling is prepared from the rectus sheath , passed below the bladder neck and sutured ti the anterior abdominal wall , in pereya operation that sling made of nylon threads .

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