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Urogynecology

The field of Urogynecology is dedicated to the treatment of women with pelvic floor disorders such as urinary or fecal incontinence and prolapse (bulging or falling) of the vagina, bladder and/or the uterus.

Urinary incontinence (leakage of urine) is a very common condition affecting at least 10-20% of women under age 65 and up to 56% of women over the age of 65. While incontinence also affects men, it occurs much more commonly in women.

The causes of incontinence are multifactorial and may involve factors both within and outside the lower urinary tract. Urologic, gynecologic, neurologic, psychologic, environmental, and iatrogenic factors may all play a role. Several potentially reversible causes may contribute to transient as well as to chronic incontinence.

Urinary incontinence refers to the inability to stop urine from flowing from the body. It often indicates that the urethra cannot close completely, making it unable to prevent urine from leaking from the bladder.

What is Stress Urinary Incontinence?

Stress urinary incontinence, or SUI, occurs when urine leaks from the bladder when pressure is exerted in the abdominal area. It can occur when the muscles supporting the urethra or bladder have been weakened. It can make it hard to live a normal life; those with this condition have a difficult time doing simple things such as climbing the stairs, laughing, or sneezing without experiencing urine leakage.

It’s nothing to be ashamed of. Just as some lose their ability to see or hear, the urinary tract can stop working perfectly for some people. It is a perfectly natural occurrence and it is no reason to be embarrassed.

Many people think that SUI is a condition associated mainly with aging. This cannot be farther from the truth: SUI affects women young and old. A number of factors could be the culprit, including pregnancy, vaginal childbirth, menopause, gynecologic surgeries, and even strenuous exercise. And, no matter how much you’d want it to, it won’t get better on its own.

Normal urination consider as follow:

The ability to hold urine and maintain continence is dependent on normal function of the lower urinary tract, the kidneys, and the nervous system. Additionally, the person must possess the physical and psychological ability to recognize and appropriately respond to the urge to urinate.

The process of urination involves two phases: 1) the filling and storage phase, and 2) the emptying phase. Normally during the filling and storage phase, the bladder begins to fill with urine from the kidneys.

The bladder stretches to accommodate the increasing amounts of urine. The first sensation of the need to urinate occurs when approximately 200 ml of urine is stored. The healthy nervous system will respond to this stretching sensation by alerting you to the need to urinate, while also allowing the bladder to continue to fill.

The average person can hold approximately 350 to 550 ml of urine. The ability to fill and store urine properly requires a functional sphincter muscle, controlling output of urine from the bladder, and a stable bladder wall muscle (the detrusor muscle).

How SUI is treated:

The good news is that SUI is 85%-90% treatable. Most of those who suffer from it can return to normal, active lives.

After a patient has been diagnosed with SUI through urodynamic testing, all of the surgical options available are discussed. The two most commonly used treatment methods are the sling procedure and the Burch procedure, which are the most effective options available according to the American Urology Association. The urodynamic study and physical examination will determine which procedure is best for each patient.

Mixed Incontinence

Many people have symptoms of both stress incontinence and urge incontinence. This combination is often referred to as mixed incontinence. Many studies show that mixed incontinence is a more common type of incontinence in older women.

Symptoms of Mixed Incontinence

Because mixed incontinence is typically a combination of stress and urge incontinence, it shares symptoms of both. You may have mixed incontinence if you experience the following symptoms:

  • Leaking urine when you sneeze, cough, laugh, do jarring exercise, or lift something heavy.
  • Leaking urine after a sudden urge to urinate, urinating while you sleep, after drinking a small amount of water, or when you touch water or hear it running.

Causes of Mixed Incontinence

Mixed incontinence also shares the causes of both stress incontinence and urge incontinence.

Stress incontinence often results when childbirth, pregnancy, sneezing, coughing, or other factors lead to weakened muscles that support and control the bladder or increase pressure on the bladder, causing urine to leak.

Urge incontinence is caused by involuntary actions of the bladder muscles. These may occur because of damage to nerves of the bladder, the nervous system, or muscles themselves. Such damage may be caused by certain surgeries or diseases such as multiple sclerosis, Parkinson’s disease, diabetes, stroke, or an injury.

Other medical conditions, such as thyroid problems and uncontrolled diabetes, can worsen symptoms of incontinence, as can certain medications such as diuretics.

Diagnosis of Mixed Incontinence

If you have problems with incontinence, it’s important to speak with your doctor, who can diagnose the type of incontinence you have and devise a treatment plan. Your doctor may have you keep a diary for a day or more as a record of when you urinate — purposely or not. You should note the times you use the toilet and the amount of urine (your doctor may have you use a special measuring pan that fits in the toilet seat) and when you leak. You may also record fluid intake.

Your diary entries along with answers to your doctor’s questions will help make the diagnosis. These questions may include:

  • How often do you go to the bathroom?
  • When you get to the bathroom, do you have trouble starting or stopping the flow of urine?
  • Do you leak urine constantly or only during certain activities?
  • Do you leak urine before you get to the bathroom?
  • Do you experience pain or burning when you urinate?
  • Do you get frequent urinary tract infections?
  • Have you had a back injury?
  • Do you have a medical condition such as Parkinson’s or multiple sclerosis that could interfere with bladder function?

Your doctor may also perform a physical examination and look for signs of damage to the nerves that supply the bladder and rectum. Depending on the findings of the examination your doctor may refer you to a neurologist (a doctor who specializes in diagnosing and treating diseases of the nervous system) or perform tests.

These may include:

  • Bladder stress test. Your doctor checks to see if you lose urine when coughing. This could indicate stress incontinence.
  • Catheterization. After having you empty your bladder, the doctor inserts a catheter to see if more urine comes out, meaning you are unable to empty your bladder completely.
  • Urinalysis and urine culture. Lab technicians check your urine for infection, other abnormalities, or evidence of kidney stones.
  • Ultrasound. An imaging test is performed to visualize inner organs such as the bladder, kidneys, and ureters.

If the diagnosis is still not clear, your doctor may order urodynamic testing. This can help provide information on bladder contractions, bladder pressure, urine flow, nerve signals, and leakage.

Another test used to confirm a diagnosis is cystocopy, which examines the inside of the bladder and urethra with a small scope called a cytoscope.

Detrusor overactivity is the most common cause of UI in the elderly, occurring in 40% to 70% of those who present to the physician with complaints of incontinence. Patients with detrusor overactivity have early, forceful detrusor contractions, which occur well before the bladder is full. This creates its clinical hallmark “the abrupt sensation that urination is imminent, whether or not leakage ensues” and frequency. Patients with detrusor overactivity describe frequent losses of small to moderate volumes of urine. The PVR urine volume is typically normal (<51 mL). Detrusor overactivity can be found in conditions of defective central nervous system inhibition or increased afferent sensory stimulation from the bladder. Examples of disorders, which impair the ability of the brain to send inhibitory signals, include strokes, masses (tumor, aneurysm, hemorrhage), demyelinating disease (multiple sclerosis), Alzheimer’s disease, and Parkinson’s disease. Increased afferent stimulation from the bladder can result from lower urinary tract infections (cystitis), atrophic urethritis, fecal impaction, or uterine prolapse. Benign prostatic hyperplasia is a common cause of detrusor overactivity in men. It can also produce symptoms of urinary outflow obstruction. Impaired detrusor contractility alone is an uncommon cause of UI, though it occurs in patients with diabetic neuropathy, spinal stenosis, and spinal cord injury. It has been diagnosed in conjunction with detrusor overactivity in almost one third of nursing home patients. Patients with detrusor hyperactivity with impaired contractility experience urge symptoms, but the PVR urine volume is high (>100 mL).

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