Incontinence

Incontinence is a condition when the patient is not able to control his or her urination. This is a very common problem that affects both women and men and affects negatively their quality of life.

Diagnosis of urinary incontinence and its basic examination

Medical history
A medical history is the most important part of the examination for the urinary incontinence. The doctor will ask questions not only about leakage of urine, strong urge to urinate but also about your diseases, childbirth, medicines you take, conditions you work in, sports you play, etc. It is easier to answer these questions if the patient uses a bladder diary or targeted questionnaire 48 hours before the appointment (must be completed even at night) that helps to obtain valuable information related to the patient’s fluid intake.

Laboratory tests
These examinations include chemical examination of the urine, urinary sediment, urine culturing or a swab from the vagina and urethra.

Urodynamic examination
It is the examination, in which the catheter is used to fill the urinary bladder. The doctor thus monitors the pressure in the bladder and urethra and considers the relationship between them. At the end of the examination the patient urines into a special toilet adapted to measure the speed of the urine flow (uroflowmeter).

 

Supplementary examination

Gynaecological examination
The gynaecologist assesses pelvic floor muscle strength and descent of the anterior or posterior vaginal wall.

PW test, weighing of liners
Before and after an hour-long physical activity the liners are weighed. It is thus possible to determine the quantity of fluid escaping especially during the physical activity.

Ultrasound
The ultrasound probe is held firmly against the underbelly. A full bladder makes the ultrasound picture clearer.

X-ray or CT
These examinations are used for detection of any possible stones in the urinary tract.

Urethrocystoscopy
Using an endoscopic device the doctor can very easily perform an outpatient examination. He inserts a small specialized tube with a camera at the end through the urethra into the bladder and assesses the medical condition of the patient. He focuses on the mucosal tissue of the urinary tract.

Urethral calibration
When the doctor suspects narrowing of the urethra he uses a special tool to measure the urethral diameter.

 

Incontinence treatment

Conservative strategies
The conservative treatment includes behavioural changes in the patient’s lifestyle (weight loss, no smoking, drinking coffee and limitation of heavy physical activity), physiotherapy and treatment (urinary sphincter training exercises, pelvic floor muscles training exercises, electrostimulation including vaginal electrical stimulation of the pelvic floor muscles, overcoming the urge - bladder drill, practising going to the toilet, biofeedback, neuromodulation and neurostimulation techniques etc.), vaginal cones, urinary drainage catheter or urinary catheter inserted through the abdominal wall into the bladder, use of incontinence aids, prosthetic aids (clamp on the penis, urinal, vaginal support pessaries), pharmacotherapy (inhibits muscle bladder contractions, increases the bladder capacity, strengthens the closure mechanism). Delivery of estrogen in women in the period of transition (HRT) improves blood flow and thus the function of the tissue in the urethra, vagina and the base of the bladder.

 

Surgical treatment
If more conservative strategies do not help, it is recommended for medium-serious and serious cases of incontinence to undergo a surgery. The surgical treatment is in the majority of cases related to the stress incontinence. There are performed surgeries to support the urethra and bladder neck, sling procedures and bladder neck suspension procedures. Nowadays, the experts call the standard surgical treatment of stress urinary incontinence in women minimally invasive techniques – the tension-free transvaginal (TVT) sling procedure and the transobturator tape (TOT) sling procedure. These procedures replace the previously preferred open surgeries. Furthermore, it is possible to apply different substances (teflon, collagen, or autologous fat) in the bladder neck that help to close the urethra and bladder neck.

Based on improvements and achievements in pharmacotherapy related to urge urinary incontinence (used anticholinergic drugs to suppress the contraction of the bladder muscle tension), the invasive treatment of these difficulties is undergone only when the conservative treatment options are all applied without success. The doctor can for example use the option of intravesical drugs suppressing hyperactivity of the bladder. The invasive method of treatment includes for example the application of the botulinum toxin into the bladder wall. In case of the failure of this less invasive treatment the doctor may perform surgeries to increase bladder capacity by means of the intestinal segment.

Men patients suffering from stress incontinence acquired after prostate surgery are treated during the first year conservatively. Physiotherapy together with medications often completely removes or significantly suppresses incontinence within one year. In patients with persistent incontinence the treatment is more complicated and at a higher level the patient usually has to undergo a surgery. The injection surgery is the simplest but least effective method. Recently, the most widely used method is to insert collagen under the mucous membrane of the urethra. The objective is to close the lumen of the urethra and thus stop leakage of the urine without preventing urination. It is a safe, well-tolerated and easily repeatable treatment. However. it should be noted that effectiveness of this treatment is limited and its efficiency tends to decrease with time.

Another treatment option is a sling surgery and insertion of the so-called artificial sphincter. A sling implant usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial or the patient’s own tissue that is placed under the urethra (beneath the scrotum) and mechanical compression thus prevents leakage of the urine. The success rate is above 75%. According to current experiences the male sling seems to be a good alternative to the artificial sphincter that is considered to be the worldwide standard solution in case of a persistent incontinence in men after prostatectomy. The advantages of a sling surgery are the acquisition costs that are significantly smaller than those of the artificial sphincter. Insertion of an artificial sphincter or sling may, however, have some risks. The most serious risks include the mechanical damage followed by the loss of sphincter function, infections in the area around the sphincter or erosion induced by the pressure on the walls of the urethra, which requires the surgical revision. There is also the risk of a partial incontinence and the possibility of a surgical revision including necessity to remove the artificial sphincter during the first years after insertion due to these complications.