Stress incontinence, also known as tension incontinence, is a disease in which urine flows involuntarily due to increased intra-abdominal pressure, urethral sphincter relaxation and incompetence when standing upright or walking. When it occurs in adolescents, it is mostly due to congenital sphincter deficiency or poor function; in middle-aged patients, it is mostly due to injury and hypotonia caused by production; in elderly patients, it is caused by muscle atrophy; in addition, weakness after prolonged illness, malnutrition, diabetes, etc. can also lead to the occurrence of this disease.
This kind of incontinence often occurs in women when the muscles or local gods at the bottom of the pelvis are often injured during pregnancy or after childbirth, resulting in the relaxation of these muscles, or when there is a problem with the command pathway of nerve injury. In women, the decrease in female hormones after menopause also causes the muscles at the bottom of the pelvis to relax, leading to this type of incontinence is also seen in women after menopause.
The purpose of the diagnosis of stress incontinence is to confirm that the incontinence is caused by increased abdominal pressure.
1.Take a medical history
Learn about the various causes associated with stress incontinence, such as childbirth, trauma, pelvic surgery, etc. Understand the impact of urinary incontinence on the patient’s life. Also, it should be understood whether there are symptoms of difficulty in urination and whether there is overactivity of the forced urinary muscles.
2.Symptoms
Urine leaks out of the urethra involuntarily when coughing, laughing, sneezing, or lifting heavy objects. It can be clinically divided into three degrees: degree I: urinary incontinence when coughing, sneezing, lifting heavy objects and other abdominal pressure increases; degree II: urinary incontinence when standing or walking; degree III: urinary incontinence in both upright or lying positions.
3.Physical examination
① Measure the length of urethra: insert a balloon catheter, inject 20ml of water into the balloon, gently pull it to the inner urethral opening and calculate the length of urethra. The normal length of the urethra in women is about 4 cm. If the urethral length is shortened in the standing position or shortened in both the standing and lying positions, there is a possibility of stress urinary incontinence.
②Bladder neck lift test: the patient takes a truncated position, increases abdominal pressure when the bladder is full, and urine flows out; at this time, the index finger and middle finger are inserted into the vagina, and the urethra is lifted upward on both sides of the bladder neck, which is positive if the urine flow is aborted.
③Swab test: used to determine the degree of urethral prolapse. A swab is inserted into the urethra after routine sterilization in the truncated bladder position. The angle of swab activity should not be >30° in normal people with and without stress, if >30° it indicates weak bladder and urethral support tissue.
4, bladder manometry except neurogenic bladder and to solve the degree of urinary incontinence.
Diagnosis.
Diagnostic criteria for stress urinary incontinence.
1, normal urinalysis and negative urine culture.
2, Normal neurological examination.
3, Weak anatomical support (swab test, x-ray or urethroscopy).
4, Confirmation of overflowing urine under pressure (pressure test or cotton pad test).
5, Normal intravesical manometry map or urethral intravesical pressure (normal residual urine volume, normal bladder volume and sensation; no involuntary detrusor contraction).
Other auxiliary examinations.
1. Urodynamic examination
Normal forced urinary muscle reflex, significant increase in maximum urinary flow rate during stress incontinence, significant decrease in intravesical pressure during voiding, intravesical pressure is 5.9-7.8kPa in mild cases, 2.5-5.9kPa in moderate cases, and below 1.96kPa in severe cases. urethral pressure decreases, and the maximum urethral pressure decreases significantly, and its urethral closure pressure decreases after shifting from the prone to the standing position.
2.Leakage point pressure (LPP) measurement
Put the manometry tube into the bladder and fill the bladder, record the pressure in the bladder when urethral leakage occurs, and this pressure is the leakage point pressure. Most of the mild cases are higher than 11.8kPa and most of the severe cases are lower than 5.88kPa.
3, Maximum functional bladder capacity and residual urine measurement are normal.
4.Urethral cystogram
The normal posterior bladder angle should be 90° to 100°, with the upper urethral axis and the vertical line in the upright position, forming an inclined urethral angle of about 30° and the bladder neck above the lower border of the pubic symphysis. In stress urinary incontinence, the posterior urethral angle of the bladder disappears, the bladder neck is lower than the inferior border of the pubic symphysis, the urethral tilt angle increases, the bladder neck is funnel-shaped and sags, and the urethral axis undergoes different degrees of downward and backward rotation.Green divides it into two types: type I, where the urethral axis is normal but the posterior urethral bladder angle increases; type II, where the posterior urethral angle of the bladder disappears, and the urethral tilt angle increases when the abdominal pressure increases by lowering and twisting the urethra Increased urethral tilt angle >45°, sometimes >90°, weak bladder neck related support tissue, severe symptoms and difficult treatment. McGurie has since proposed the name Type III for stress incontinence associated with decreased function of the intrinsic urethral sphincter.
Treatment principles
Non-surgical treatment.
Perineal muscle training, contraction of the anal and urethral sphincters, three times a day, 15-30 times each, for at least six months. , estrogen preparations can be given to elderly patients.
Surgical treatment.
Currently, bladder neck suspension is the most effective. The methods of bladder neck suspension are trans-pubic posterior bladder neck and urethral suspension and trans-vaginal bladder neck suspension to increase the angle between the bladder neck and urethra.