Stress Incontinence Treatment India
A sudden involuntary release of urine caused by muscular strain, accompanying laughing, sneezing, coughing and exercise seen primarily in older women with weakened pelvic musculature. Also called "stress urinary incontinence".
The ability to hold urine and control urination depends on the normal function of the lower urinary tract, the kidneys, and the nervous system. You must also have the ability to recognize and respond to the urge to urinate.
The average adult bladder can hold over 2 cups (350ml - 550 ml) of urine. Two muscles are involved in the control of urine flow:
The sphincter, which is a circular muscle surrounding the urethra. You must be able to squeeze this muscle to prevent urine from leaking out.
The detrusor, which is the muscle of the bladder wall. This must stay relaxed so that the bladder can expand.
In stress incontinence, the sphincter muscle and the pelvic muscles, which support the bladder and urethra, are weakened. The sphincter is not able to prevent urine flow when there is increased pressure from the abdomen (such as when you cough, laugh, or lift something heavy).
Stress incontinence may occur as a result of weakened pelvic muscles that support the bladder and urethra or because of a malfunction of the urethral sphincter. The weakness may be caused by:
Injury to the urethral area
Surgery of the prostate or pelvic area
Stress urinary incontinence is the most common type of urinary incontinence in women. Stress incontinence is often seen in women who have had multiple pregnancies and vaginal childbirths, and whose bladder, urethra, or rectal wall stick out into the vagina (pelvic prolapse).
Chronic coughing (such as chronic bronchitis and asthma)
Dietary measures can be instituted, with identification of items that can be modified. Reduction in consumption of caffeinated beverages and alcoholic drinks should be encouraged. Fluid restriction in patients without chronic medical problems, such as cardiovascular, renal, or endocrinologic disease, can be attempted. Timed voiding to prevent - filling the bladder to a capacity that causes urine loss should be undertaken with the use of a urine diary. The diary can also facilitate discussion between patient and clinician as therapy progresses.
Pelvic floor muscle exercises or Kegel exercises have been found to be extremely helpful in patients with mild to moderate forms of incontinence. Focused repetitive voluntary contractions of the levator ani muscles (pubococcygeus, coccygeus, and iliococcygeus) created by having the patient contract or "squeeze" the muscle as if to prevent the passage of rectal gas is an effective therapy. The contractions exert a closing force on the urethra and increase muscle support to the pelvic organs. Repetitions, with each contraction held for 3-5 seconds alternated with periods of relaxation, should be begun at 45-100 repetitions daily, results for cure or improvement of bladder control (reduction in urine loss) can be up to 75%.
Biofeedback is an adjunct to pelvic floor exercises that is used to facilitate the patient's comprehension of the proper muscles to contract. By using a pressure catheter and myographic monitoring, a visual or auditory signal of the physiologic response can be provided to the patient to help refine exercise skills. Using surface electromyography on the perineum to measure levator contraction and a pressure monitor in the vagina or rectum to indicate abdominal pressure, the patient can be instructed to preferentially contract the pelvic floor without concomitant abdominal contraction. Studies using a variety of techniques demonstrate a 54-95% cure rate or improvement in SUI. The efficacy of this modality is highly dependent on patient motivation and compliance. Pelvic floor muscle exercises with or without biofeedback require continued implementation and practice or effectiveness will wane.
As an alternative to active patient contraction of the levator muscles, electrical stimulation of the muscles via small electrical currents can be used to help both SUI and mixed incontinence. Using intravaginal or transrectal electrodes with stimulators, the pelvic muscles automatically contract and are thereby artificially "trained". When used long term, weakened muscles are strengthened and innervation re-established during activation. Experiences with the devices are variable, but they generally show a positive impact on incontinence and acceptable patient tolerance.
Intravaginal devices or pessaries to correct the anatomic deficits associated with stress incontinence have long been used to address this vexing problem. Pessaries, traditionally used for treatment of genital prolapse, have also been shown to have a potential role in supporting the bladder neck and urethra and preventing stress incontinence. Many pessary devices designed to fit within the vagina and elevate the bladder neck are available. Continence can often be achieved because many devices adequately obstruct the bladder neck and urethra. As with all intravaginal devices, maintenance is essential to avoid urinary obstruction and vaginal erosion if the pessary is too compressive.
Occlusive devices are commercially available. External devices, such as urethral plugs that are placed over the external urethral meatus or internal occlusive devices placed transurethrally with an internal balloon are available and have been shown to be partially helpful in reducing wetting episodes.
Surgical treatments are offered for moderate to severe incontinence. Urinary incontinence is not a life-threatening condition, and the decision to operate is based on the patient's symptoms and the impact on daily life. Many patients are able to tolerate slight urine loss, and what often provokes a desire for treatment is an increase in loss above a tolerable threshold. If medical management to improve bladder control is possible and symptoms are reduced to below this threshold, then medical management is most desirable. If not, surgery should be considered.
At least 130 operative procedures are there for treatment of female urinary stress incontinence. Common to most surgical procedures is restoration of bladder neck support by elevation of the urethrovesical junction. Some procedures reconstruct bladder neck supports and provide a stable suburethral layer -
Anterior repair: Anterior colporrhaphy with Kelly plication is one of the oldest methods of surgical correction, introduced in 1914. Used for anterior vaginal defects (Cystocele), the technique involves vaginal dissection of the epithelium below the bladder and bladder neck, identifying the perivesical fascia and pubocervical fascia, and plicating each side over the midline. The Kelly plication involves specific support at the bladder.
Needle urethropexy: Since the introduction of this procedure in 1957 by Armand Pereyra and its modifications with contributions by Thomas Lebherz, needle urethropexy has become a fixture in anti-incontinence surgery. Vaginal incision, dissection and mobilization of periurethral tissues enter into the space of Retzius (retropubic space), and passage of a needle ligature carrier from a small abdominal incision into the vaginal incision. The periurethral tissues and fascia are identified, secured with delayed absorbable suture, and brought through retropubically and secured above the abdominal rectus fascia. In this manner the bladder neck is elevated and continence restored. The procedures appear to be effective initially, with cure rates of approximately 80-85% with variable follow-up.
Abdominal retropubic colpopexy: First, suspend the periurethral and paravaginal tissue at the level of the urethrovesical junction, and second, use a firm point of attachment for fixation of these suspension sutures. In the MMK procedure, the sutures are fixed to the periosteum of the pubic bone, and in the Burch procedure, the iliopectineal ligament (Cooper's ligament). The Burch colposuspension has become the first choice for treatment of patients with hypermobility of the bladder neck and genuine SUI.
A laparoscopic approach to Burch colposuspension offers the benefit of minimally invasive surgery with the same level of efficacy. With the laparoscopic approach, hospital stay and postoperative recovery are minimized. Using the transperitoneal or preperitoneal approach, this method has demonstrated cure rates comparable to the open procedure. Success rates with variable follow-up range between 87% and 97%.
Suburethral slings: The suburethral sling was one of the original surgical procedures developed for correction of SUI. The SUI concept of restoring continence is that of encircling the urethra with supportive tissue either from the patient or foreign material. Contemporary techniques have used a patient's own fascia harvested from the leg or rectus fascia, or donor fascia in the form of cadaveric fascia lata. Cure rates of suburethral sling procedures for genuine stress incontinence vary from 70-95%. Variations in sling material and technique have made cure rates among sling techniques difficult to interpret. Furthermore, most studies vary in the definition of cure and may not distinguish between cure and improvement.
Midurethral slings: The latest modification of the sling is the use of tension-free vaginal mesh made of polypropylene placed at the level of the midurethra. Use of tension-free vaginal tape (TVT) was developed as a minimally invasive technique for surgical correction of genuine SUI. The initial study had an 84% cure rate in 75 women with 2-year follow-up. Considerable data now support a high subjective cure of 85-93% and objective cure rate of 75-85% with up to 7-year follow-up.
Because of the success of TVT, numerous other devices using the same principles and technique have been introduced. All use a polypropylene mesh but have different designs of delivery needle/trocar, mesh construction, and sheath type.
The newest variation of the midurethral sling is the transobturator approach. Instead of retropubic passage, the sling is passed through the obturator foramen laterally. This creates a more lateral point of fixation. The purported advantage is reduction in bladder, bowel, or major vascular injury because this method avoids the space of Retzius and does not traverse the peritoneal space.
Treatment For Stress Incontinence at Delhi, India
Treatment depends on how severe the symptoms are and how much they interfere with your everyday life.
There are four major categories of treatment for stress incontinence:
Pelvic floor muscle training
Surgical treatment is only recommended after the exact cause of the urinary incontinence has been determined. Most of the time, your doctor will try bladder retraining or Kegel exercises before considering surgery.
Anterior vaginal repair
Artificial urinary sphincter is a surgical device used to treat stress incontinence mainly in men (rarely in women)
Retropubic suspensions are a group of surgical procedures done to lift the bladder and urethra. They are done through a surgical cut in the abdomen. The Burch colposuspension and Marshall-Marchetti-Krantz (MMK) procedures differ based on the structures that are used to anchor and support the bladder
Tension-free vaginal tape
Vaginal sling procedures are often the first choice for the treatment of uncomplicated stress incontinence in women (it is rarely done in men). A sling made of synthetic material is placed so that it supports the urethra