Stress incontinence was clearly defined in the first standardized nomenclature definition by ICS (1975): involuntary intraurethral incontinence occurring during increased abdominal pressure is called stress incontinence. In the absence of contraction of the detrusor muscle during an increase in abdominal pressure, abdominal pressure is transmitted to the bladder causing an increase in intravesical pressure, and incontinence that occurs when bladder pressure is greater than urethral pressure and urethral closure pressure is negative is called true stress incontinence.
Although stress incontinence can occur in both sexes and at any age, true stress incontinence almost always occurs in women, and true stress incontinence in men is extremely rare.
True stress incontinence accounts for 29.82% of patients with signs and symptoms of stress urinary incontinence. Age is mostly between 21-60 years old, with an average of 44.8 years. The incidence has been reported to be proportional to the number of deliveries.
(A) Medical history
1, history of childbirth, trauma.
2, history of obstructed labor, pelvic and other surgical procedures, bowel habits.
(II) Physical examination
1, physical examination, heavy patients first smell the odor of urine, wet underwear, some perineum eczema and dermatitis. After urination, a comprehensive genitourinary examination is then performed.
2. During the lower abdominal examination and vaginal examination, pay attention to the presence or absence of masses. If there is a mass, conduct a post-catheterization examination, and if there is a large amount of residual urine or chronic urinary retention, stress urinary incontinence may be a group of symptoms and signs of overflow incontinence.
3, perineal and vaginal examination, pay attention to the presence of scarring, the remains of perineal lacerations, uterine, bladder, urethra and rectal bulge, these signs are indicative of weakness and injury of the bladder, urethra support tissue and pelvic floor tissue. However, those with the above signs do not necessarily have the presence of true stress incontinence.
4, vaginal examination, pay attention to whether there is atrophy of the vaginal mucosa, scarring and contracture in the vagina, these not only provide an important basis for diagnosis, but also have important value for the selection of treatment.
5.Stress urinary incontinence test, this test is very important and must be meticulous. First, inject 100-150ml of sterile isotonic saline into the bladder, and in the lithotomy position, ask the patient to cough hard and continuously for several times, and while coughing, observe whether there is flowing and spraying urine from the urethra. If so, the stress incontinence test was positive. If it is negative, the patient should cough continuously in a sitting and standing position, and if there is incontinence, the test is still positive. If it is negative, further examination is required, fill the bladder with sterile isotonic saline, and then continue the stress incontinence test in the lithotomy/sitting and standing positions, respectively, and incontinence found in either position is considered positive.
6, pressure incontinence test positive, Mashall-Marchett test, also known as bladder neck elevation test. The method is to inject 250 ml of sterile isotonic saline into the bladder, take a lithotomy position, the right middle finger and the index finger are inserted into the anterior vaginal wall and placed on either side of the urethra, the bladder neck is pushed upward to the top, the patient is instructed to cough continuously and observe whether the urethral orifice flows urine, if the urine flows when coughing before the test, and the urine does not flow when coughing during the test, the bladder neck elevation test is positive. In the past, a positive test was considered to be true stress incontinence and was used as an indication for the Marshall-Marchett-Krantz procedure. It is important to note that when performing this test, the examiner’s finger pressure should be directed to elevate the bladder neck and not to compress the urethra. Otherwise, the results cannot be accurately determined. Therefore, a positive bladder neck elevation test alone cannot be used as a basis for the diagnosis of true stress incontinence or as an indication for the selection of the Marshall-Marchett-Krantz procedure. It can only be used as a reference.
7, Q-tip test (Q-tiptest): This test, also known as the lever test, is a test used to roughly reflect the angle of the bladder urethra and the mobility of the urethra. A lever with an undamaged tip is placed in the urethra about 4 cm and its tip reaches the level of the bladder neck. The patient is asked to cough repeatedly, if the support tissue of the bladder neck and urethra is normal, and the position and mobility of the urethra is normal, the lever inserted into the urethra only has a slight up and down swing, and the angle between the lever and the horizontal line of the body is -5º~+10º, if the swing amplitude before and after pressure is large, greater than 30º, it means that the bladder neck and urethra mobility is large, then it can be diagnosed as true stress urinary incontinence.
(C) Outpatient information
1, laboratory tests: routine urinalysis, quantitative culture of bacteria in the middle segment of urine, should be routinely performed.
(D) Continuing examination items
1, cystourethrography: lateral cystourethrography can only show the relationship, shape and position of the bladder neck and urethra well. With conventional methods, the urethra overlaps with the bladder neck and bone tissue such as the pelvis and femur, and the images of the bladder and urethra are blurred and do not meet the diagnostic requirements, so special methods are needed to show the images of the bladder and urethra well. A catheter is inserted and 150 ml of water-soluble contrast agent heated to 37°C is injected into the bladder after draining the urine to show the whole bladder. Then 15ml of iodine oil heated to 37°C is injected into the bladder, and the iodine oil is attached to the bladder base to show the bladder base and bladder neck. The catheter is removed and a sterilized metal ball chain is gradually fed into the urethra through the urethral orifice. The image of the ball chain indicates the shape and position of the urethra, and the end is held with a small clip to prevent the ball chain from slipping into the bladder. The X-ray images of the three different substances are of different depths and thus show the bladder, bladder floor, neck and urethra. Then, lateral cystourethrography was performed in the prone and standing positions and lateral cystourethrography was performed in different positions with forceful breath holding to increase abdominal pressure (Valsalvamaneuver). The morphology and position of the bladder and urethra were compared and observed in different positions and under different conditions such as normal breathing and forceful breath-holding.
2.Urodynamic examination.
(1) Cystometry Many bladder diseases can cause stress urinary incontinence, while simple true stress urinary incontinence, bladder function is normal, so symptomatic stress urinary incontinence caused by abnormal bladder function can be excluded by cystometry, such as motor urge incontinence, low compliance bladder, and overflow incontinence. The indicators of simple true stress incontinence cystometry are normal, with zero residual urine, bladder void pressure below 10 cmH2O, filling pressure of the detrusor muscle below 25 cmH2O, no detrusor muscle without inhibitory contraction, and normal compliance. However, motor urge incontinence has no inhibitory contraction of the forced urinary muscles, and overflow incontinence, in addition to low bladder compliance, can have filling pressures of the forced urinary muscles as high as 52,0±29,54 cmH2O and a large amount of residual urine, which is not found in other types of stress incontinence. In addition, in those with hypertonic detrusor dysfunction, the voiding detrusor pressure is particularly high for other types of stress urinary incontinence that are not present.
(2) Static urethral manometry static urethral manometry is of greater diagnostic value for true stress urinary incontinence, and the diagnostic value of each parameter is described below.
① anatomical urethral length: the relationship between true stress urinary incontinence and anatomical urethral length is not uniformly recognized. The results of our measurements are not significantly different from those of other types of stress incontinence, and the diagnostic significance is not significant.
Functional urethral length: Due to differences in the methods and instruments used for measurement, the reported values of the results of true stress urinary incontinence vary among scholars, but the shortening compared to normal values is significant. All scholars believe that functional urethral length shortening is one of the main indicators for the diagnosis of true stress urinary incontinence.
(iii) Maximum urethral pressure: It is now agreed that a decrease in maximum urethral pressure is one of the main indicators for the diagnosis of true stress urinary incontinence. The maximum urethral pressure in true stress urinary incontinence is lower than normal.
In mild cases, it can overlap with normal values, and then it is not easy to distinguish. In this case, a comparison between lying and standing urethral manometry is performed after bladder filling. In normal cases, the maximum urethral pressure in the standing position is greater than that in the horizontal position, while the maximum urethral pressure in the vertical position is lower than that in the horizontal position for true stress incontinence.
④ Maximum urethral closure pressure: low maximum urethral closure pressure is another important indicator for the diagnosis of true stress urinary incontinence.
(E) Diagnosis
The most significant symptom of simple true stress incontinence is unexplained unintentional finding of incontinence weeks or months after childbirth or trauma. Uncontrollable flow of urine during coughing, sneezing, laughing, physical activity and sudden increase in abdominal pressure. In some cases, there is no sensation of urine flow, and the flow is realized only when one feels dampness in the underwear. Some of them occur immediately after difficult birth, trauma, pelvic surgery, etc., and are clearly related to trauma. Some are not directly related to the above conditions. In those who occur during pregnancy and around menopause, it is mostly related to a decrease in estrogen levels. In those with constipation habits, it may be related to constipation. The symptoms are usually milder in the lying position and worsen after rising.
The degree of true stress incontinence, in addition to the degree of incontinence can be more accurately recorded with electronic flow urine monitor, generally clinically based on the impact on the patient’s life is divided into three degrees: ① mild: general activity without incontinence, no incontinence at night, only when the abdominal pressure suddenly increased, occasional incontinence, do not need to carry diapers; ② moderate: when standing up and moving, there is frequent incontinence, need to carry diapers (3) Severe: urinary incontinence when standing up or changing position in the prone position, which seriously affects the patient’s life and social activities. Severe true stress incontinence not only brings the patient life, health, social and work, but also brings mental anguish and pain to the patient. Due to frequent urinary incontinence, with the smell of urine, and therefore reluctant to approach others, reluctant to participate in social activities, afraid to sit in other people’s bed and chair, afraid of ridicule, appear to be withdrawn and low self-esteem. Some even lose the relationship between husband and wife and family harmony, which will further increase the mental suffering of the patient.
The typical clinical manifestations combined with physical examination and urodynamic examination can make a clear diagnosis.
Clinical Types
Green is divided into the following two types according to the imaging changes on X-ray: Type I: Type I is characterized by a normal axis of urethral imaging, but the bladder floor loses its horizontal state, thus the posterior angle of the vesicourethra is greater than 110º, resulting in a funnel-shaped bladder floor and neck, and the angle of urethral tilt is within the normal range. When pressure is applied, the contrast agent enters the proximal segment of the urethra, or the entire urethra is contrasted and overflowed by the urethral orifice, i.e., incontinence. Type II: Type II is characterized by a change in the urethral axis from inclined to horizontal due to excessive urethral mobility, in addition to the loss of the bladder floor to a horizontal state. As a result, the posterior angle of the bladder urethra is greater than 110º, and the bladder neck and bladder floor are funnel-shaped while the angle of urethral tilt is greater than 45º. When pressure is applied, the contrast is seen to fill the entire urethra. Most of this type has the bladder neck and urethra prolapsed from the pelvic floor.
(F) Treatment principles
The treatment of true stress urinary incontinence is varied, and the efficacy reported varies, but regardless of which method is chosen, the following principles should be followed.
1, the diagnosis must be exact, true stress urinary incontinence, otherwise misdiagnosis and mistreatment will occur, and even cause serious consequences.
2, should be a comprehensive examination of the signs found to determine the cause of the onset of each patient, the cause of the first non-surgical treatment.
3, the mild degree is appropriate to take non-surgical treatment.
4. Obese and elderly patients should be treated non-operatively first. Or use non-surgical treatment as preoperative preparation, and then operate after adequate preparation.
5.Know the theoretical basis and treatment principles of various types of surgical treatment, and choose the surgical treatment method that is in line with the cause of the disease.
Pre-operative preparation
Due to the continuous development of new sling surgery, obesity and chronic cough are no longer contraindicated for surgery, but routine preoperative preparations such as skin preparation, clean bowel washings and prophylactic application of antibiotics are necessary.
Treatment options
1.Non-surgical treatment
(1) To strengthen the pelvic floor muscle exercise method is to ask the patient to regularly and consciously perform the stretching and contracting exercises of the anal and perineal muscles every day to enhance the tension of the pelvic floor muscles and urethral muscles and improve the muscles’ reactive contraction force to the action of pressure. In mild cases, it can improve the symptoms, and in severe cases, it can improve the efficacy of the procedure. So it is both a treatment method and can be used as preoperative preparation.
(2) Functional electrical stimulation therapy Functional electrical stimulation therapy has two types of electrodes, anal pessary and vaginal pessary. It is stimulated by electric current to enhance the urethral closure function. The mechanism.
(i) stimulation of the efferent fibers of the pubic nerve to enhance the function of the levator muscle and other pelvic floor muscles and the transverse muscle around the urethra to increase urethral closure pressure.
(ii) Stimulation of the afferent fibers of the pubic nerve, through the connection of neurons to the sacral medullary forceps nucleus, to inhibit the excitability of the forceps nucleus, and then through the pelvic nerve to the forceps muscle, to inhibit the contraction of the forceps muscle.
(3) The electrical stimulation impulse goes up to the thoracolumbar segment, which excites the sympathetic neurons, and the α-adrenergic receptors cause contraction of the bladder neck and the proximal segment of the urethra, further increasing the urethral closure function. α-adrenergic excitation and bladder floor relaxation increase the closure of the bladder neck.
(3) Pharmacological treatment Pharmacological treatment has two purposes.
(1) increase urethral resistance: use drugs to increase the contractile function of the urethra and increase urethral closure pressure. Such as oral ephedrine.
② Enhance the tension of the pelvic floor with drugs to plump up the atrophied supporting tissues: such as the application of estrogen. It is suitable for true stress urinary incontinence caused by estrogen deficiency in menopausal women and other causes. It can make the epithelium of the atrophied urethra caused by estrogen deficiency proliferate and enhance the closing function of the urethra, and it can also enrich the vascular network under the mucosa of the urethra and increase the urethral pressure and urethral closing pressure, which can be cured or improved. Oral estrogen, which has more side effects. Using estrogen paste preparation coated in the vagina can make the urethral mucous membrane epithelial cells proliferate.
2.Surgical treatment
There are more than 100 surgical modalities for the treatment of stress urinary incontinence, which can be summarized into four categories.
(1) postpubic bladder urethral suspension
(2) bladder neck pin suspension
(3) Anterior vaginal wall repair
(4) New type of sling surgery
(vii) Efficacy
With the continuous application of new materials and technologies and the development of new sling surgery, the results of surgical treatment for stress urinary incontinence have been very satisfactory.
Exploring the causes of surgical failure to improve the efficacy of surgery has been an issue of discussion for many years. Some of the known causes of failure are summarized as follows.
1, obesity, chronic cough, as a high-risk factors for surgical failure, the coexistence of two factors, surgical failure rate that is up to 50% or more, such patients should strictly grasp the indications, and fully do a good job of preoperative preparation.
It is not uncommon for surgical failure to result from a wrong diagnosis, and many cases of motor urge incontinence are misdiagnosed as true stress incontinence and are treated surgically.
3, The surgery did not elevate the bladder neck and urethra and did not restore them to their normal position. Or inadequate preparation before surgery and improper treatment after surgery, such as coughing and increased abdominal pressure, etc., tore the sutures off and led to surgical failure.
4.Multiple injuries to the bladder neck and urethra during surgery, which reduces the function of urethral closure.
5, surgical failure due to surgical hematoma, infection, and urethral fibrosis.
Since the incisions of the new sling surgery are all in the perineum, attention should be paid to the cleanliness and hygiene of the perineum after discharge, and sexual life should be avoided in the near future.