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. When the bladder pressure is greater than the urethral pressure and the urethral closure pressure is negative, the incontinence that occurs is called genuine stress urinary incontinence (GSUI).
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 incontinence. Age is mostly between 21-60 years, with a mean of 44.8 years. The incidence has been reported to be proportional to the number of deliveries.
I. Medical history
1, history of childbirth, trauma
2, history of obstructed labor, pelvic surgery, stool habits
Second, physical examination
1. On physical examination, heavy patients first smell the odor of urine, wet underwear, and some have eczema and dermatitis in the perineum. After urination, a comprehensive examination of the genitourinary system will be 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 to perform stress incontinence test in the lithotomy/sitting and standing positions, respectively, and if incontinence is found in either position, it is positive.
6, when the stress incontinence test is positive, the Mashall-Marchett test, also known as the 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 bladder neck and urethra support tissue is normal, the urethra position and mobility is normal, the lever inserted into the urethra only slightly swing up and down, the angle between the lever and the horizontal line of the body is -5º ~ +10º, if the swing 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.
Third, continue the examination items
1, cystourethrography.
Lateral cystourethrography can only show the relationship, shape and position of the bladder neck and urethra in a good way. 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 (Valsalva maneuver). 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) Bladder manometry: many bladder diseases can cause stress incontinence, while simple true stress incontinence, bladder function is normal, so symptomatic stress incontinence caused by abnormal bladder function can be excluded by bladder manometry, such as motor urge incontinence, low compliance bladder, overflow incontinence, etc. 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.
(2) Static urethral manometry: Static urethral manometry has a 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 measured by various scholars differed, but the shortening compared to the normal value was very significant. All scholars agree 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 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 may 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.
④Maximum urethral closure pressure: low maximum urethral closure pressure is another important indicator for the diagnosis of true stress urinary incontinence.
IV. Diagnosis
The most significant symptom of simple true stress incontinence is unexplained unintentional incontinence found weeks or months after childbirth or trauma. The uncontrollable flow of urine occurs 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 urinary incontinence, in addition to the degree of incontinence that can be more accurately recorded with an electronic flow urinary monitor, is generally clinically classified into three degrees according to the impact on the patient’s life.
(1) Mild: no incontinence under general activity, no incontinence at night, only occasional incontinence when abdominal pressure increases suddenly, and those who do not need to carry diapers;
(2) Moderate: frequent urinary incontinence when standing up and moving around, and those who need to carry diapers to live;
(3) Severe: Incontinence occurs 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.
V. 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 urethra, 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 urethral tilt angle 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.
VI. Treatment principles
There are various methods of treatment for true stress urinary incontinence, 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 principle of various surgical treatments, and choose the surgical treatment method that is in line with the cause of the disease.