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Stress urinary incontinence

  The definition of stress urinary incontinence proposed by the International Continence Society is: the sudden increase in abdominal pressure leads to involuntary urine leakage, which is not caused by detrusor contraction pressure or bladder wall tension pressure. Its characteristics are no urinary incontinence in normal conditions, but automatic urine leakage when abdominal pressure suddenly increases. For example, when coughing, laughing, sneezing, jumping, or lifting heavy objects, the phenomenon of involuntary leakage of urine from the urethral orifice.

Table of Contents

1. What are the causes of stress urinary incontinence?
2. What complications can stress urinary incontinence easily lead to
3. What are the typical symptoms of stress urinary incontinence
4. How to prevent stress urinary incontinence
5. What laboratory tests are needed for stress urinary incontinence
6. Dietary taboos for patients with stress urinary incontinence
7. Conventional methods of Western medicine for the treatment of stress urinary incontinence

1. What are the causes of stress urinary incontinence?

  1. Etiology

  Stress urinary incontinence is divided into two types. More than 90% is anatomical stress urinary incontinence, caused by relaxation of the pelvic floor tissues; about 10% or less is due to urethral sphincter dysfunction, which is congenital or of unknown cause.

  1. Pregnancy and vaginal delivery are the main causes of stress urinary incontinence. During pregnancy and delivery, excessive compression of the pelvic floor muscles by the presenting part of the fetus, the use of vacuum extraction and breech extraction, and increased abdominal pressure after delivery can all lead to relaxation of the pelvic floor tissues. A multivariate regression analysis of a case-control study by Van found that stress urinary incontinence is not related to the second stage of labor of the first child, but is significantly associated with forceps delivery. Persson found that the occurrence of stress urinary incontinence is significantly associated with the age of first delivery, the number of deliveries, the birth weight of the fetus, and perineal anesthesia.

  2. Urethra and vagina surgery Procedures such as anterior and posterior vaginal wall repair, radical hysterectomy for cervical cancer, and resection of urethral diverticula can all destroy the normal anatomical support of the urethra and bladder.

  3. Dysfunction Congenital lack of support or inadequate nerve supply around the bladder and urethra, which is a cause of disease in young women and nulliparas. Postmenopausal women, due to the decline in estrogen, cause the submucosal veins of the urethra and bladder trigone to become thinner, blood supply to decrease, and mucosal epithelium to regress. The superficial epithelial tissues of the bladder and urethra become less tense, the muscles and fascia around the urethra atrophy, and urinary incontinence occurs. Salinas also found that although the menopausal state is related to the occurrence of stress urinary incontinence, the risk of occurrence does not increase with age, and the risk of stress urinary incontinence after 52 years of age disappears. The onset before menopause is often due to malnutrition and weakness, leading to atrophy of the muscles and fascia at the neck of the urethra and bladder, resulting in urinary incontinence.

  4. Pelvic mass When there is a large mass in the pelvic cavity, such as uterine fibroids or ovarian cysts, it leads to increased abdominal pressure, the position of the bladder-urethra junction is lowered, and urinary incontinence occurs.

  5. Body weight Many studies have reported that the occurrence of stress urinary incontinence is related to the increase in the patient's body mass index (BMI).

  6. Cyclic stress urinary incontinence The symptoms of stress urinary incontinence are more pronounced in the second half of the menstrual cycle, which may be related to the relaxation of the urethra caused by progesterone.

  II. Pathogenesis

  Stress urinary incontinence is classified into two types: high bladder neck mobility type and urethral sphincter dysfunction type. The former accounts for more than 90%, while the latter is less than 10%. The pathogenesis of stress urinary incontinence is not yet clear. No hypothesis has been widely accepted, but possible mechanisms include the following:

  1. To maintain an effective micturition mechanism with reduced urethral resistance, two factors are required: complete urethral internal structure and sufficient anatomical support. The integrity of the urethral internal structure depends on the resistance produced by the urethral mucosal apposition and urethral closure pressure. Urethral mucosal apposition is formed by mucosal folds, surface tension of secretions, and submucosal venous plexus, which can prevent urinary leakage when sealed. Urethral closure pressure comes from the tension of submucosal vessels and muscles. An increased urethral closure pressure results in greater resistance and can control micturition. The relaxation and injury of pelvic floor tissues lead to reduced urethral resistance. Studies have found that in the case of increased abdominal pressure, neuro-muscular conduction disorders cannot cause a reflexive increase in urethral pressure. This type of stress urinary incontinence is classified as a urethral sphincter dysfunction type.

  2. In individuals with a well-functioning micturition mechanism due to the pressure relationship between the urethra and bladder, the pressure in the proximal urethra is equal to or higher than the intravesical pressure. When abdominal pressure increases, the pressure is evenly transmitted to the bladder and 2/3 of the proximal urethra (located within the abdominal cavity), thereby maintaining the urethral pressure equal to or higher than the intravesical pressure, and urinary incontinence does not occur. Conversely, patients with stress urinary incontinence, due to pelvic floor relaxation, have 2/3 of the proximal urethra located outside the abdominal cavity. At rest, the urethral pressure decreases (still higher than the intravesical pressure), but when abdominal pressure increases, the pressure can only be transmitted to the bladder and not to the urethra, making the urethral resistance insufficient to counteract the bladder pressure, leading to urinary leakage. This explains the pathogenesis of stress urinary incontinence with high bladder neck mobility.

  3. Anatomical Relationship between Urethra and Bladder The normal posterior angle of the urethra and the bottom of the bladder should be 90° to 100°, and the urethral axis forms an angle of about 30° with the vertical line of the standing position. In patients with stress urinary incontinence, due to the relaxation of the pelvic floor tissues, the bottom of the bladder moves downward and backward, gradually causing the posterior angle of the urethra and bladder to disappear and the urethra to shorten. This change is like the initial stage of micturition, and once abdominal pressure increases, it can trigger involuntary urination. In addition to the disappearance of the posterior angle of the urethra and bladder, the urethral axis also rotates, increasing from the normal 30° to more than 90°. This also explains from one side the pathogenesis of bladder neck hyperactivity in stress urinary incontinence.

  Petros explained the pathogenesis of stress urinary incontinence from the hypothesis of the normal urethral and bladder neck closure mechanism: The closure of the urethra is caused by the contraction of the anterior part of the pubococcygeus muscle to form what is called a 'hammock'. The formation of the 'hammock' is transmitted by the posterior part of the vaginal canal behind the pubourethral ligament. The closure of the bladder neck, called 'knotting', is mediated by the posterior part of the vaginal canal behind the pubourethral ligament and completed by the common contraction of the 'lifting and supporting structure'. The 'lifting and supporting structure' refers to the transverse muscle of the rectum and the longitudinal muscle around the anus. The measurement of the posterior fornix muscle of the vagina confirms this hypothesis. In women without urinary incontinence, the contraction of the 'lifting and supporting structure' causes the vagina to reach the X point, the contraction of the pubococcygeus muscle pulls the vagina forward to form a 'hammock', and closes the urethral cavity. If there is relaxation of the vaginal wall, and the contraction of the pubococcygeus muscle exceeds the fixed distance and cannot reach the conversion point Ⅺ, the urethra cannot be closed and urinary incontinence occurs.

2. What complications can stress urinary incontinence easily lead to

  80% of patients with stress urinary incontinence have cystocele, but about half of the patients with cystocele have stress urinary incontinence. Secondly, it should be distinguished from infectious urinary incontinence, which is usually due to urinary frequency and urgency after urinary system infections such as urethritis and cystitis. Therefore, patients (especially female patients) may develop urinary incontinence due to urgency caused by inflammatory stimulation.

3. What are the typical symptoms of stress urinary incontinence

  The purpose of the diagnosis of stress urinary incontinence is to confirm that urinary incontinence is caused by increased abdominal pressure.

  1. Medical History

  Understand various causes related to stress urinary incontinence, such as childbirth, trauma, pelvic surgery, etc., and understand the impact of urinary incontinence on the patient's life. At the same time, it should also be understood whether there are symptoms of difficulty in urination and whether there is detrusor overactivity.

  2. Symptoms

  Urinary incontinence may occur involuntarily from the urethral orifice during coughing, laughing, sneezing, or lifting heavy objects. Clinically, it can be divided into three degrees: Degree I: Urinary incontinence occurs during coughing, sneezing, or lifting heavy objects when abdominal pressure increases; Degree II: Urinary incontinence occurs during standing or walking; Degree III: Urinary incontinence occurs in both an upright or lying position.

  3. Physical Examination

  (1) Measure the urethral length: Insert a balloon catheter, fill the balloon with 20ml of water, gently pull it to the urethral orifice, calculate the urethral length. The normal length of the female urethra is about 4cm. If the urethral length shortens when standing, or shortens in both supine and lying positions, there is a possibility of stress urinary incontinence.

  (2) Cervical elevation test: The patient takes the lithotomy position, when the bladder is full, increase abdominal pressure, and urine flows out. At this time, insert the index and middle fingers into the vagina, elevate the urethra upwards on both sides of the bladder neck, and if the urine flow stops, it is positive.

  (3) Cotton swab test: Used to judge the degree of urethral prolapse. Take the lithotomy position, perform routine disinfection, and insert a cotton swab into the urethra. In normal people, the angle of cotton swab movement should not be greater than 30° under both stressed and non-stressed conditions. If it is greater than 30°, it indicates that the bladder and urethral supporting tissues are weak.

4. How to prevent stress urinary incontinence

  1. Good attitude

  Maintain an optimistic and open-minded attitude, face success, failure, pressure, and烦恼 with a positive and peaceful mindset, and learn to regulate one's mood and emotions.

  2. Prevent urethral infection

  Develop the habit of wiping hands with toilet paper from front to back after urination and defecation to avoid urethral infection. Before sexual intercourse, both partners should wash the external genitalia with warm water, and the female partner should empty her urine immediately after intercourse and clean the external genitalia. If urinary pain and frequency occur after intercourse, anti-urinary tract infection drugs can be taken for 3~5 days, which can quickly cure the inflammation in the early stage.

  3. Regular sexual life

  Research shows that women who continue to have regular sexual life after menopause can significantly delay the physiological degeneration of the ovaries in synthesizing estrogen, reduce the incidence of stress urinary incontinence, and at the same time prevent other senile diseases, improve health levels.

  4. Strengthen physical exercise

  Strengthen physical exercise, actively treat various chronic diseases. Conditions such as emphysema, asthma, bronchitis, obesity, and large abdominal tumors can cause increased abdominal pressure leading to urinary incontinence. It is necessary to actively treat these chronic diseases, improve the overall nutritional status. At the same time, appropriate physical exercise and pelvic floor muscle exercises should be performed. The simplest method is to do 45~100 times of anal and perineal contraction and lifting exercises before getting out of bed in the morning and after going to bed at night, which can significantly improve the symptoms of urinary incontinence.

  5. Rational diet

  Diet should be light, eat more fiber-rich foods, and prevent abdominal pressure increase induced by constipation from triggering stress urinary incontinence.

5. What laboratory tests are needed for stress urinary incontinence?

  1. Urodynamic examination:The detrusor reflex is normal, the maximum urine flow rate increases significantly during stress urinary incontinence, and the bladder pressure during micturition decreases significantly. In mild cases, the bladder pressure is 5.9~7.8kPa, in moderate cases it is 2.5~5.9kPa, and in severe cases it is lower than 1.96kPa. The urethral pressure decreases, and the maximum urethral pressure decreases significantly. After changing from a supine position to an upright position, the urethral closure pressure decreases.

  2. Determination of Leakage Point Pressure (LPP):Insert the pressure measuring tube into the bladder and fill the bladder, record the bladder pressure when urinary leakage occurs through the urethra, this pressure is the leakage point pressure, which is generally higher than 11.8kPa in mild cases and lower than 5.88kPa in severe cases.

  3. Maximum functional bladder capacity and residual urine measurement

  4. Urethral bladder造影:The normal posterior angle of the bladder should be 90°-100°, the axis of the upper urethra is perpendicular to the vertical line of the standing position, forming an approximate 30° urethral tilt angle. The bladder neck is higher than the inferior margin of the pubic symphysis. In stress urinary incontinence, the posterior angle of the bladder and urethra disappears, the bladder neck is lower than the inferior margin of the pubic symphysis, the urethral tilt angle increases, the bladder neck is funnel-shaped and下垂, the urethral axis rotates downward and backward to varying degrees, Green divided it into two types: Type I, the urethral axis is normal, but the posterior urethra bladder angle is increased; Type II, the posterior urethra bladder angle of the bladder disappears, the urethra descends when the abdominal pressure increases, twists to increase the urethral tilt angle, the urethral tilt angle is greater than 45°, sometimes greater than 90°, the supporting tissue of the bladder neck is weak, the symptoms are severe, and the treatment is difficult. After this, McGurie proposed to name the stress urinary incontinence related to the decline of the intrinsic sphincter function of the urethra as Type III.

6. Dietary taboos for patients with stress urinary incontinence

  Therapeutic diet for stress urinary incontinence:

  1. Ten dates, steam and cook to eat every day.

  2. Five dates, 50g of euryale, cook porridge to drink.

  3. Schisandra 10g, black sesame 10g, prepared rehmannia 10g, add an appropriate amount of brown sugar and boil in 500ml of water for oral administration.

7. Conventional methods of Western medicine for the treatment of stress urinary incontinence

  1. Treatment

  1. Non-surgical treatment

  (1) Pelvic floor muscle training: By correctly contracting the anal sphincter, vaginal sphincter, and urethral sphincter, the tension of the pelvic floor muscles is strengthened, and the degree of downward displacement of the urethra and bladder is reduced. Method: Contract the anal sphincter 10-20 times every half hour, each time lasting more than 3 seconds.

  (2) Acupuncture or electrical stimulation therapy: Acupuncture at acupoints such as Guanyuan, Qihai, Sanyinjiao, Zusanli, etc., select 1-2 acupoints each time, or use anal electrodes, vaginal electrodes to stimulate the pelvic floor muscles to achieve the therapeutic purpose.

  (3) Medication: ① Drugs to inhibit detrusor contraction: Tertroline 2mg, twice a day; flavoxate 200mg, three times a day. ② Drugs to increase urethral resistance: Ephedrine (ephedrine) 25-50mg, four times a day; propranolol 10-20mg, three times a day. ③ Estrogen: Suitable for postmenopausal or estrogen-deficient patients. Diethylstilbestrol 1-2mg, once a day;尼尔雌醇6mg, 1-2 times a month.

  (4) Submucosal injection therapy through the urethra: Special Teflon cream, collagen, biological glue, or autologous fat tissue is injected into the submucosa and muscular layer of the posterior urethra or bladder neck, narrowing and elongating the urethral lumen to close the internal urethral orifice. This method is suitable for stress urinary incontinence caused by dysfunction of the internal urethral sphincter.

  2. Surgical treatment

  (1) Vaginal anterior wall repair: A longitudinal incision is made from 1 cm below the urethral orifice to the bladder neck. The vaginal walls are separated, and the soft tissues on both sides of the bladder neck and urethra are sutured with a round needle and silk thread in a mattress suture to strengthen the posterior wall of the bladder and urethra. This procedure is suitable for patients with mild symptoms who require simultaneous repair of vaginal anterior wall prolapse or hysterectomy.

  (2) Postpubic Cystourethral Suspension: Make a median incision in the lower abdomen, fully mobilize the retropubic bladder, bladder neck, and part of the urethra. Suture the surrounding tissue of the urethra with the retropubic fascia or pubic superior ligament, so that the bladder neck and urethra are lifted to achieve the suspension effect. In recent years, laparoscopic technology has been widely used for this procedure, also known as Burch vaginal wall suspension surgery.

  (3) Cystourethral or Urethral Suspension: Through abdominal-vaginal combined incision, wrap a strip of autologous biomatrix (such as the anterior aponeurosis of the rectus abdominis, fascia lata, etc.) or artificial material [such as TVT, prolene mesh (prolenemesh)] around the urethra or bladder neck, and suspend and fix it on the muscles and fascia of the lower abdominal wall to compress the urethra and bladder neck, and enhance the urethral closure function. This procedure is suitable for patients with all types of stress urinary incontinence and is currently recognized as one of the procedures with the best long-term efficacy.

  (4) Endoscopic Cystourethral Suspension (Stamey Procedure, also known as Long Needle Cystourethral Suspension): Make a 1cm incision 2 fingers above the superior margin of the pubic symphysis, 3cm away from the midline, and insert a special long needle through this incision. Under the guidance of the index finger inside the vagina, pass through the vaginal wall at the junction of the bladder neck and urethra, and pull out a 2号线 from the small hole of the needle head. Use the same method to insert the long needle parallel to the aforementioned nylon line and pull out the other end of the nylon line. Perform the same operation on the opposite side. Lift the two nylon lines, restore the posterior angle of the bladder and urethra, and tie a knot outside the rectus sheath. This procedure has a shallow incision, minimal trauma, and is safe, accurate, and reliable, suitable for most female patients with stress urinary incontinence, especially for overweight women and those who have failed surgery. However, the long-term efficacy is not very ideal.

  II. Prognosis

  With the aging of the population and the improvement of medical level, people's requirements for the quality of life have also increased accordingly. Stress urinary incontinence is a disease that can be cured. Surgery is considered the standard treatment for stress urinary incontinence. Successful surgery for strictly selected patients can reach 80% to 90% correction rate. If there is improvement after taking medication or the possibility of standard surgery is not high, the modification of surgery will achieve a higher success rate.

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