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HEALTH AND WELLNESS 1/2015
WELLNESS AND HEALTH
CHAPTER XXVII
Developmental Age Research Department, Institute of Public Health,
Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
Zakład Badań Wieku Rozwojowego, Wydział Nauk o Zdrowiu,
Uniwersytet Jana Kochanowskiego w Kielcach
EWA ZIĘBA, PAULINA ZIĘBA, GRAŻYNA NOWAK-STARZ
Diagnosis and treatment of female stress urinary incontinence
Rozpoznanie i leczenie wysiłkowego nietrzymania moczu u kobiet
Key words: stress urinary incontinence, urodynamic testing, TVT operation
Słowa kluczowe: wysiłkowe nietrzymanie moczu, badanie urodynamiczne, operacji
TVT
INTRODUCTION
Urinary incontinence (UI) is a common ailment, usually shamefully concealed,
which might occur in anyone, regardless of gender or age. For that reason the disease
is often not treated or the treatment is undertaken too late. Although it is not a lifethreatening disease, it significantly worsens the conditions of functioning of patients,
leading to physical disability, and sometimes even psychiatric. The quality of life is
reduced not only in terms of professional life, social, family, physical, and mental but
also in terms of sexual life. UI hampers many life activities, career plans, social contacts and worsens considerably the well-being of patients. It leads inevitably to isolation of the patient from the environment and reduces self-respect [1].
The variety of clinical forms of urinary incontinence is a significant problem in its
differential diagnosis, and requires to apply accurate diagnostic tests, a thorough history and examination in order to determine objectively the type of urinary incontinence. A comprehensive examination of the lower urinary tract includes the medical
history of the patient, analysis of the urination diary, physical examination, assessment of residual urine and lower urinary tract imaging. Simultaneous pressure measurement along with lower urinary tract imaging is referred to as video urodynamics.
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The diagnostics of urinary incontinence should be initiated with a medical history
of the patient, which should be targeted and based on questionnaires enabling us to
assess the current symptoms [2]. Any assessment of the dysfunction of the lower urinary tract should be started with the history. Primary diagnosis also includes a physical examination, a cough test, evaluation of urinary retention after urination, analysis
and alternatively urine culture and evaluation of the 24-hour voiding diary.
The physical examination is the next step in the effort urinary incontinence diagnostics. The patient’s neurological condition is particularly important as well as
changes in the organs of the pelvis minor rated through a gynaecological examination
[3]. The neurological examination is to assess the functional efficiency of neurons
innervating the urethra, bladder and pelvic floor muscles.
The patellar reflex and Achilles tendon reflex examinations make the sympathetic
innervation assessment (Th11 to L2) possible. The sympathetic innervation (S2-S4)
and the vulvar nerve (S2-S4) are examined by evaluating the bulbar-cavernous reflex.
The sacral reflex (bulbar-cavernous), which is the contraction of the anal sphincter
muscle in response to stimulation of the clitoris or surrounding area around the anus,
excludes the neurological defect related to the spinal roots of the spinal cord as a cause
of urinary incontinence. Gynaecological examination focuses on the evaluation of the
pelvis minor organs and hypoestrogenism [4,5]. The POPQ (Pelvic Organ Prolapse
Quantification) scale is used for evaluating the statics of the sexual organs. The POPQ
is a research tool which is more objective than the Badan-Walker scale hitherto applied. A detailed examination of the external genitals provides information on the integrity of the apparatus supporting and stabilizing the sex organs and the lower section
of the urinary tract [6].
The gynaecological examination allows us to assess the state of the connective
tissue of the ligament system of the vagina and urethra. Subsequently visualizing the
vaginal wall and measuring their length during the Valsalva test, one can state which
of the supporting elements is damaged and does not fulfil its function.
The rectovaginal septum , centrum tendineum of the perineum and the mobility of
the uterine cervix during tenesmus are also subject to evaluation[7]. Due to a wide
variety of symptoms in many cases, objective and fully controlled tests must be applied in order to determine the form of the disease. Macroscopic evaluation of the
urine sample allows us to specify the infection in the urinary tract and eliminate hematuria.
Sanitary towel tests make it possible to exclude or confirm bacteriuria and then
indicate conducting the urine culture and the antibiogram. An essential source of data
is the urination diary, time intervals between urination and unintentional urination
episodes. The last parameter can be also assessed by measuring the weight of sanitary
towels, used by the patient [8].
The sanitary towel test allows us to identify questionable cases of urinary incontinence and to quantify the severity of the symptoms. In addition, it is used to monitor
the course of therapy. The cough test in the recumbent or erect position is performed
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Ewa Zięba, Paulina Zięba, Grażyna Nowak-Starz
by the patient directly after emptying the bladder. The stress cough test in the recumbent or erect position is performed with a full bladder (sensation of the patient, ultrasonography, bladder content assessment after the test and after administering into the
bladder 300 to 350 ml of physiological saline) [9].
The stick test is used in the diagnostics of the stress urinary incontinence. It allows
us to demonstrate the hypermobility of the bladder neck and the proximal section of
the urethra. After entering the urethra with a sterile, gel-coated hygienic stick the patient is told to perform the Valsalva test. Change in the inclination angle by more than
30 degrees indicates the loss of proper support of this section of the urinary tract.
The next step is the urodynamic examination, which is one of the components of
the comprehensive examination of the lower urinary tract and is to answer the question
how the bladder and urethra act at the phase of storing, emptying and transporting
urine and what interrelationships exist between the detrusor and urethra. This examination makes the direct assessment of the lower urinary tract function possible by
measuring physiological parameters [10].
The urodynamic study is carried out in three stages: uroflowmetry, cystometry,
and urethral profilometry. Uroflowmetry consists in measuring the pace of urine flow
during micturition. A further diagnostic step consists in conducting the cystometric
test. It is a provocative test in which a catheter is introduced into the bladder, fluid is
administered through the catheter and the activity of the bladder detrusor is observed
by measuring the intra bladder pressure.
The uniqueness of this test is in its general availability, which does not require
specialized equipment. The ultrasound scanner has extensive diagnostic capability.
Using a high-resolution intravaginal head one can observe the dynamics of the spatial
relations of the bladder neck and urethra. Demonstrating the absence of adhesion of
the mucosa closing the light of these anatomic structures may indicate the presence of
stress urinary incontinence [11].
The choice of the right method of treating stress urinary incontinence depends on
the results of additional tests. The diagnosis and treatment should be started with the
least invasive process and safest for the patient, and the information provided in the
patient’s history and voiding diary should be analyzed at the beginning of the case
study. In the case of treatment and diagnostic proceedings, the therapy should be applied in a multifaceted and interdisciplinary manner.
It should involve the participation of a therapist, psychologist and community
nurse. The goal of the treatment is not only the control of the patient over urinary
incontinence, but also significant improvement in the well-being, quality of life and
functioning in social life [12].
The aim of the study was to assess the most common risk factors, the evaluation
of the diagnostic methods and the effectiveness of the selected methods for the treatment of stress urinary incontinence in females.
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MATERIALS AND METHODS
The study included 285 patients, treated in the years 2005-2014 due to stress urinary incontinence in the Department of Gynaecology of the Regional Hospital in
Kielce.
The medical documentation was used in the study. The evaluation of the diagnostic methods and the applied methods of treatment of the stress urinary incontinence
was carried out on the basis of the documentation. The most common risk factors
leading to urinary incontinence in patients were analyzed and their influence on the
quality of life. The cause of stress urinary incontinence was analyzed in relation to
age, body mass index (BMI), and the type of work, obstetric history and the date of
the last menorrhea.
The material obtained was ordered using the descriptive analysis. The elements of
the studied population were grouped in terms of particular variants of analyzed features. The results were analyzed using independent chi-square tests (assuming the significance level of p=0,05). The results obtained were subjected to statistical analysis
and a graphical presentation of data using the Excel spreadsheet.
RESULTS
The numerical strength and the average age of the total group of patients studied
in the given years were determined after analyzing the data available in the medical
documentation.
Table. 1. Numerical strength and the average age of the patients examined
Year
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Numerical
strength
of the group
N
%
11
3,85
13
4,56
20
7,01
22
7,71
23
8,07
29
10,17
33
11,57
41
14,38
45
15,78
48
16,84
285
100
Average
age
57,45
57,4
55,45
58,80
59,9
60,1
58,33
55,5
53,5
52,2
56,83
According to the obtained data the average age of all the patients treated for stress
urinary incontinence in the years 2005/2014 was 56.83. On the basis of the independence chi-square test it was found that there was no correlation between age and the
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prevalence of symptoms of the disease ( x2=0,376 < x20,05=3,841). The data on the
patients’ education was also obtained from the documentation.
The examination involved the dependence of the education level of the patients
and the occurrence of symptoms of stress urinary incontinence. On the basis of the
dependence chi-square test it was discovered that there is no correlation between the
education level and the occurrence of symptoms of stress urinary incontinence (
x2=2,302 < x20,05=3,841).
Stress urinary incontinence was diagnosed on the basis of the medical history and
other available diagnostic methods, which are presented in Table 2.
Table. 2. The number of patients who were diagnosed using the following
diagnostics methods
n
Medical
history
285
100%
Cough
test
285
100%
Gynaecological
examination
285
100%
Voiding
diary
246
86,31%
Sanitary Urodynamic
towel test examination
156
246
54,73%
86,31%
According to the information collected from each patient, the most common cause
of stress urinary incontinence was the obstetric past history, the number of spontaneous deliveries above two- 124 patients (43.5%). The next most common risk factor
was the nature of work, manual labour- 114(40%). The patients performed the same
type of work.
Another factor involved patients with overweight and improper life style- 12 patients (4.21%). Subsequently in 11(3.85%) of women urinary incontinence was caused
by menopause, in 10 (3.5%) urinary tract infections were indicated as the cause of UI.
Gynecological operations were the cause of urinary incontinence in 9 patients
(3.15%). In the remaining 5 patients (1.75%) it was difficult to identify an unambiguous cause of UI.
All the patients who were examined and experienced stress urinary incontinence
were given treatment adequate to the severity of the disease, namely: 246 (86.32%)
TVT tape surgeries were performed, whereas the remaining 39 patients (13.68%) were
given conservative therapy, mainly with pharmacotherapy combined with pelvic floor
exercises.
The cough test was carried out during the surgery in each of the operated patient.
In the case of coexistence of cysto-or rectocoele, simultaneously the reconstructive
operation of the front or back wall of the vagina was performed. In 143 patients
(50.17%) the anterior vaginal wall plasty was performed, in 25 (8.77%) the reconstruction of the anterior and posterior walls of the vagina was carried out, and in
14(4.91%) the posterior vaginal wall plasty.
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8,77%
4,91%
13,70%
22,45%
50,17%
1. Conservative therapy
2. TVT operation
3. TVT operation combined with anterior vainal wall plasty
4. TVT operation combined with posterior vaginal wall plasty
5. TVT operation combined with posterior vaginal wall plasty
Fig 1. The type of applied therapy of stress urinary incontinence in the years
2000-2009
The cough test conducted during the surgery was positive in 3 patients(1.21%).
The remaining patients did not show this pathology. Stress urinary incontinence was
found in 15 patients (6.09%), with filled bladder, but it was far less severe than it was
before the surgery. Of the entire group 3 (1.21%) patients had no improvement of
urinary continence after the TVT surgery. In the remaining patients there was no leakage of urine during physical stress (92.68%).
6,09% 1,21%
1. Total improvement
2. Partial improvement
92,68%
3. No improvement in urine
continence after the surgery
Fig. 2. Evaluation of the effectiveness of the operational treatment of stress
urinary incontinence
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Immediately following the surgery only 13 (5,28%) patients reported urinary incontinence. Minimal and occasional incontinence was declared by 7 patients (2.84%),
urinary incontinence with variable intensity was reported by 6 patients (2.43%). The
remaining 220 patients (89.43%) reported complete continence immediately after the
operation. On the basis of the test of independence chi-square it was found that there
was no relationship between the age of the patient and the effectiveness of the surgical
treatment of stress urinary incontinence ( x2=0,468 < x20,05=3,841).
5,28% 2,43%
1.Full urinary continence
2,84%
2. Minimal urinary
incontinence
3. Urinary incontinence
symptoms
4. Urinary incontinence
with variable intensity
89,43%
Fig. 3. The effect of surgical treatment of stress urinary incontinence
immediately following the operation
Analyzing the intra-operative complications occurring during the surgery it was
found that in 19(7.72%) patients the walls of the bladder were slightly injured, 17
(6.91%) patients had an infection of the urinary tract. Only in two cases (0.81%) there
was urinary retention due to too tight application of the tape and in the remaining
patients ,i.e. 208 (84.55%) there was no complications throughout the procedure.
7,72%
6,91%
0,81%
1. No complications
2. Minor injury to the bladder
wall
3. Urinary tract infections
4. Urine retention
84,55%
Fig. IV. Intra-operative complications
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In the examined group 39 patients (13.68%) , whose severity of symptoms and
the clinical form of the disease was a contraindication to surgery, were treated using
conservative methods. In 30 patients (10.52%) estrogen therapy was applied in combination with pelvic floor muscles training, and in the remaining 9 (3.15%) the therapy
involved mainly changing life style and introducing exercises to strengthen the pelvic
floor muscles.
The outcomes of both therapies were 100% effective, because as many as 7 patients (2.45%) experienced improvement or regression of uncomfortable symptoms of
urinary incontinence, 13 patients (4.56%) described the improvement as incomplete.
In the examined group19(6.66%) women declared that the therapy was effective.
Although urinary incontinence is not perceived as a dangerous or life-threatening
disease, it is a serious problem and has a significant impact on the quality of life. The
disruptive nature of this disease considerably lowers it. As it is clear from the medical
records collected from the patients during the anamnesis, almost all the patients determined the level of quality of life as low or average.
The occurring symptoms such as pain, burning sensation, personal hygiene problem, and the problem with spending a longer time outside home obviously hamper
everyday functioning. The results before and after treatment are presented in Table 3.
Table. 3. Evaluation of discomfort before and after treatment
Evaluation of discomfort
related to SUI
Major discomfort
Average discomfort
Minor discomfort
No discomfort
Total
Number of patients
Before treatment After treatment
N
%
n
%
88
30,87
8
2,8
189
66,33
20
7,03
8
2,8
37
12,98
0
0
220
77,19
285
100%
285
100%
DISCUSSION
Urinary incontinence in women is a common problem both medical and social. In
the vast majority of clinical studies the problem of urinary incontinence is associated
with the aging process and the involutionary changes within genitourinary system due
to hypoestrogenism. One of the most important factors responsible for the occurrence
of stress urinary incontinence are vaginal deliveries, especially births of children
weighing more than 4000g. The majority of studies show that 2 or more vaginal childbirths are particularly significant risk factors for stress urinary incontinence.
The operation of urinary incontinence using a tension free tape in a short time after
the surgery leads to improving the comfort of life through disappearance of uncon-
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trolled flow of urine and a reduced number of uresis. This study showed a high effectiveness of the TVT operation, which correlates with the results of studies of Ceddrowski K., W.Sawicki, Śpiewakiewicz, B [13]. The scientific research and the present study show that the women’s assessment of the improved quality of life after the
TVT operation is very high and remains at the same level regardless of time after the
operation when the evaluation was conducted. One can assume that the short and longterm effects of the operations are good. The TVT operation seems to be safe, and very
effective.
The mental state, quality of life, improvement of daily functioning are the most
important benefits of surgical correction of defects leading to urinary incontinence.
This is undoubtedly related to a much better control of the uresis process, decreased
urinary frequency, micturition reduction during the night rest, fewer episodes of urinary bladder infections. The complications described are rare, the most common is
the perforation of the bladder wall in about 10% of cases, which does not leave extensive consequences and only
requires to maintain the catheter in the bladder for 4 days.
The effectiveness of the treatment of the stress urinary incontinence with the available methods was evaluated in the study. The study shows that the surgery brings the
best results. These results are comparable with the studies of other authors [14]. The
most common intra-operational complication in the examined group of patients involved breaking the continuity of the bladder walls during the TVT (7.72%) operation.
These outcomes are consistent with the observations of other authors Płachta Z., Adamski A., Jankiewicz K [15].
In the conducted study only two patients experienced postoperative urinary retention (0.81%). In the available literature this complication occurs more frequently. The
urinary tract infections were diagnosed in 6.91% of patients, whereas other authors
observed this complication in 2.5% to 10.9% of patients [16,17]. Some authors, apart
from the above-mentioned complications, also notice the erosion of the tape in the
vagina, bladder or urethra (about 8%), however this study does not show such cases.
This study showed the discomfort of symptoms related to stress urinary incontinence. In as many as 99.2% of the patients the symptoms included pain, burning
sensation, poor hygiene and problems with staying outside the house longer, which
did not allow them to function normally thereby reducing the quality and comfort of
life [18]. In addition to physical ailments, urinary incontinence is related to problems
of psychological nature.
Depressed mood and lack of self-confidence create a large distance which obviously makes social contacts more difficult. When comparing the results of the author’s
studies with the results of other authors the percentage of women suffering from urinary stress incontinence is comparable [19]. Although there is no method that eliminates the symptoms in a hundred per cent, it may be argued that in the majority of
cases it is the surgical corrections that meet the expectations of the patients and the
doctors in terms of the treatment of stress urinary incontinence.
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CONCLUSIONS
1.
The most common and important risk factor for stress urinary incontinence in
women is the obstetric history- number of vaginal spontaneous deliveries, above
two.
2.
Of all the available methods of diagnosing stress urinary incontinence , the most
helpful is the community and family history.
3.
TVT surgery is the most effective form of treatment for stress urinary incontinence.
4.
The most frequent intra-operational complication, although not dangerous, is the
perforation of the bladder.
5.
Application of tension-free vaginal tape results in improved control of micturition
and its reduced frequency also at night, which considerably enhances the comfort
and quality of life of the operated patients.
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ABSTRACT
Urinary incontinence (UI) is a common affliction , usually concealed with shame,
which might occur in anyone, regardless of gender or age. Therefore this ailment is
not often treated or the treatment is undertaken too late. Although it is not a life-threatening disease it significantly worsens the conditions of patients’ functioning, leading
to physical disability, and sometimes even to mental incapacity. The quality of life is
reduced including not only the professional, social, family, physical, and psychological aspects of life, but also the sexual. The purpose of this study was to investigate
the most common risk factors ,diagnostic methods applied, and estimate the effectiveness of selected methods of treatment for stress urinary incontinence in female population. The research method of this study was the analysis of the medical documentation, which includes the information on 285 patients treated for stress urinary incontinence in the Department of Gynaecology, Regional Hospital in Kielce. The results
are presented as percentage in a descriptive and graphic form. The study shows that
stress urinary incontinence is a serious social problem. A family and community history is very important in the diagnostics of this disease, which pre-defines the most
important risk factors for stress urinary incontinence, which affected the health of the
examined patient. The effectiveness of the surgical treatment of stress urinary incontinence is much higher than effectiveness of the conservative treatment methods,
which was stated on the basis of a considerable improvement in the quality and comfort of life of the patients and regression of the majority of additional symptoms associated with stress urinary incontinence. Of all the available methods of diagnostics of
SUI, the most helpful is the community and family history and the urodynamic examination. The TVT operation is a safe and the most effective method of treating stress
urinary incontinence.
STRESZCZENIE
Nietrzymanie moczu (NTM) jest powszechnie występującą, na ogół wstydliwie
ukrywaną dolegliwością, mogącą wystąpić u każdego, niezależnie od płci i wieku. Z
tego powodu schorzenie często nie jest leczone lub leczenie podejmowane jest zbyt
późno. Mimo, że nie jest chorobą zagrażającą życiu, znacznie pogarsza warunki funkcjonowania chorych prowadząc do niesprawności fizycznej, a czasem i psychicznej.
Jakość życia ulega obniżeniu nie tylko w aspekcie zawodowym, społecznym, rodzinnym, fizycznym, psychologicznym, ale także seksualnym. Celem pracy była ocena
najczęściej występujących czynników ryzyka, zastosowanych metod diagnostycznych oraz efektywność wybranych sposobów leczenia wysiłkowego nietrzymania
moczu u kobiet. Metoda badawcza jaką się posłużono była analiza zarchiwizowanej
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dokumentacji medycznej, zawartych w niej danych dotyczących w szczególności diagnostyki i leczenia schorzenia. Obserwacji poddano 285 pacjentek leczonych z powodu wysiłkowego nietrzymania moczu w Oddziale Ginekologii Wojewódzkiego
Szpitala zespolonego w Kielcach. Przeprowadzone badanie wykazało, że wysiłkowe
nietrzymanie moczu stanowi poważny problem społeczny. Bardzo ważną rolą w diagnostyce stanowi wywiad środowiskowy-rodzinny, na podstawie którego można
wstępnie określić najważniejsze czynniki ryzyka, które wpłynęły na stan zdrowia badanej pacjentki. Skuteczność operacyjnego leczenia wysiłkowego nietrzymania moczu znacznie przewyższa leczenie metodami zachowawczymi, co stwierdzono na
podstawie znacznej poprawy jakości i komfortu życia badanych pacjentek oraz ustąpienia większości dodatkowych dolegliwości związanych z wysiłkową formą nietrzymania moczu. Spośród wszystkich dostępnych metod diagnostyki wysiłkowego nietrzymania moczu, najbardziej pomocny jest wywiad środowiskowy-rodzinny oraz badanie urodymaniczne. Operacja TVT jest bezpieczną i najbardziej skuteczną metodą
leczenia wysiłkowej postaci nietrzymania moczu.
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Artykuł zawiera 29570 znaków ze spacjami + grafika

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