Sexually Transmitted Diseases - I. I. Mavrov 2005

Diseases of the Reproductive Organs of Various Etiologies
Urinary Incontinence

Urinary incontinence (incontinentia urinae) is the involuntary leakage of urine from the Urethra without prior urgency. It is classified into absolute, relative, spurious (overflow), and nocturnal incontinence.

Absolute urinary incontinence is a continuous form of leakage where urine does not accumulate in the bladder, but instead flows out constantly, drop by drop, without any urge to urinate. This condition is caused by total epispadias or bladder exstrophy.

Relative urinary incontinence is a condition where urine is partially retained in the bladder. It is observed in partial epispadias, postpartum bladder trauma, impaired bladder innervation accompanied by sphincter paralysis, as well as in Brain AND SPINAL cord disorders.

Spurious urinary incontinence refers to the involuntary leakage of urine through a fistula resulting from developmental anomalies, bladder injuries, or ureteral damage. In spurious incontinence, constant leakage occurs alongside normal acts of urination. This phenomenon is frequently seen in vesicovaginal fistulas or ureteral ectopia, where the ectopic ureteral orifice may open into the Vagina, vaginal vestibule, or urethra.

Nocturnal enuresis (bedwetting) is involuntary urination during Sleep. As a rule, it is observed up to the age of 16. Through the gradual development of higher Central Nervous system (CNS) Functions and appropriate toilet training, children acquire voluntary control over urination both day and night by the age of 2 to 3 years. However, some children suffering from neurotic traits under METABOLISM/18.html">The Influence of psychological factors, CNS-damaging infectious diseases in their medical history, or other causes continue to experience enuresis.

Relative urinary incontinence is the most common form, with stress urinary incontinence (SUI) being one of its primary types.

Stress urinary incontinence (SUI) is the involuntary loss of small amounts of urine from the urethra during increases in intra-abdominal pressure (e.g., physical exertion, coughing).

SUI is rooted in pelvic floor Muscle dysfunction, as well as weakness of the bladder and urethral sphincters, which arise from anterior vaginal wall prolapse (cystocele, urethrocele), uterine prolapse, trauma, prior surgeries, or prostatectomy in men, among other causes. It can also manifest as uncontrolled or involuntary urination resulting from the irritation of nerve fibers located in the urogenital mucosa, the sacral reflex arc, or central Autonomic nervous system centers.

Associated symptoms of SUI include the patient's inability to control urination during strong urges or a sensation of bladder fullness, leakage triggered by or unstoppable during laughter, sneezing, or heavy lifting, as well as intermittent and unpredictable leakage of small (and sometimes substantial) amounts of urine caused by distraction, sleep, or emotional stress.

SUI significantly restricts patients' daily activities, often forcing them to change occupations or leave their jobs altogether. In a domestic Setting, their lives are burdened by the discomfort of constant urinary leakage and its secondary complications (Skin maceration, inflammation, local and systemic infections, sexual dysfunction, unpleasant odor, etc.). All of this takes a heavy psychological toll, triggering neuroses and depressive states. In some cases, these patients require psychiatric consultation.

The Etiology AND Pathogenesis are linked to psychosomatic disorders, early manifestations of neurological strain, local irritation of the mucosa and neuromuscular apparatus, medications affecting the autonomic nervous system, and certain anatomical alterations (such as funnel-shaped dilation of the bladder neck). These factors presumably create a mismatch between urethral sphincter contraction or relaxation and detrusor contractions. Urinary incontinence is observed in multiparous women, those who have undergone traumatic vaginal deliveries, and patients with anterior vaginal wall prolapse. During menopause, women may experience urinary incontinence caused by impaired detrusor and bladder sphincter tone resulting from hormonal dysfunction.

Clinical manifestations. Absolute incontinence is characterized by continuous urine leakage, whereas relative incontinence presents during physical exertion.

Diagnosis is a rather complex task. Determining the causes of urinary incontinence involves analyzing patient history, radiological imaging, cystourethroscopy, and cystometry (using carbon dioxide and Water).

Patient evaluation begins with a detailed urological and gynecological history. The clinician establishes the relationship between leakage and physical strain, assesses the severity and frequency of involuntary episodes, quantifies the volume of urine leaked, and identifies triggers (such as strong urges or a full bladder).

Next, an objective physical examination is performed. The external genitalia and urethra are inspected (both at rest and during straining). The pelvic Organs are examined, the pelvic profile is assessed, and treatable conditions responsive to medical therapy are identified. Post-void residual urine volume is measured. Estrogen deficiency is evaluated, and the cotton swab test, stress test, and neurological assessments of pelvic floor sensation and muscle tone, as well as the Bonney test, are conducted. Additional Laboratory tests (urinalysis, urine culture, urogenital swab cultures, etc.) are performed. If bladder capacity permits, cystoscopy is carried out.

Several studies have established that approximately 50% of healthy, parous women experience occasional urinary leakage during straining in the absence of any anatomical defects (Z. Wolin, 1969). Even after successfully performed plastic surgeries, this phenomenon persists in many women due to the Functional Anatomy OF the female pelvis (specifically, altered relationships between intra-abdominal pressure and pressures within the bladder and urethra).

An Objective Examination aimed at identifying any comorbidities that could impact Treatment outcomes—such as chronic Diseases of the Urogenital System or Lungs, or obesity—is mandatory. A neurological examination (bulbocavernosus and pubocavernosus Reflexes) is also necessary to evaluate the status and function of the anal sphincter.

Important pathogenetic factors of female urinary incontinence include urethral length, the urethrovesical angle, the anatomical relationship between the bladder neck and lower Urinary Tract, and the loss of urethral mobility. Alterations in the urethrovesical angle and urethral inclination angle are the most frequent causes of urinary incontinence. Cystography is employed to identify anatomical abnormalities or changes in urethral angles.

The cotton swab test is used to assess the severity of anatomical pelvic floor disorders. A thin probe tipped with a cotton applicator and lubricated with anesthetic gel is inserted along the entire length of the urethra. The angle between the probe axis and the horizontal plane is then measured during maximal straining. The more the urethral position shifts due to Connective Tissue support failure, the greater this angle will be. Consequently, pelvic profile systems allow clinicians to evaluate the degree of support apparatus relaxation.

If an objective pelvic examination reveals urinary leakage during physical exertion or coughing, the stress test is considered positive; however, this finding alone does not allow for a definitive diagnosis of SUI. To confirm this, the Bonney test is performed: the Tissues lateral to the bladder neck are elevated toward the pubic bone. The patient is then asked to strain or cough again. If no leakage occurs during this maneuver, a diagnosis of stress urinary incontinence is confirmed, indicating The Need for a surgical Procedure aimed at reinforcing the supportive structures.

Cystometric studies evaluate the accommodation capacity of the detrusor muscle as the bladder fills without a rise in intravesical pressure (isotonic compliance). The test involves the gradual instillation of carbon dioxide or isotonic saline solution into the bladder while continuously recording intravesical pressure. Normally, intravesical pressure does not rise until a volume of 300–600 mL is reached. Once this threshold is attained, either a Micturition-associated detrusor contraction occurs, or the patient begins to report pain.

To diagnose urinary tract disorders, clinicians utilize urethroscopy (to detect urethritis, trigonitis, or diverticula); uroflowmetry (to assess urinary tract patency and excretory function); and urethral pressure profilometry to evaluate the functional status of the sphincter.

Treatment. For mild to moderate stress urinary incontinence, conservative therapy is prescribed. This approach is also indicated for patients at high surgical risk—such as those with comorbidities (Bronchial Asthma, diabetes, Heart disease)—as well as elderly women with a history of unsuccessful prior surgeries who failed to achieve the expected benefit. Medical treatment is initiated only after ruling out conditions that require surgical intervention.

Alpha-adrenergic agonists and anticholinergic (parasympatholytic) agents are recommended, as they can exert a direct effect by increasing urethral pressure and alleviating pathological symptoms. Conversely, antihypertensive, antipyretic, and psychotropic drugs that affect the autonomic nervous system significantly lower the urinary retention threshold.

Menopausal urinary incontinence is treated with estrogen replacement therapy; postpartum and postmenopausal administration increases intraurethral pressure by improving the elasticity and thickness of the urethral mucosa, enhancing smooth muscle tone in the bladder and its neck, increasing urethral muscle sensitivity, and restoring normal bladder sphincter function. Preparations such as Rigevidon, Bisecurin, Non-Ovlon, and Ovidon can be utilized for this purpose.

For adequate estrogenization of the vaginal and urethral tissues, estriol is used, exerting a local effect on the mucosa of the vagina, Urinary Bladder, and its musculature. An appropriate estrogenic effect can be achieved by applying an estrogen-containing cream to the vaginal vestibule and the anterior vaginal wall several times a week.

For urinary incontinence, long-acting androgens such as Sustanon-250 and Omnadren-250 are recommended (D. V. Kan, 1986). The action of these drugs is attributed to their high anabolic effect, which enhances the tone of the bladder Muscles.

Electrostimulation of the pelvic floor and urethral muscles using devices such as Amplipulse and others has been successfully employed. Vibrational massage of the lumbosacral region, copper Electrophoresis to increase bladder tone, and rectal electrostimulation are recommended. Electrostimulation of the bladder muscles using sinusoidal modulated currents is also utilized. Dynamic sphincterotonization is performed via a specialized vaginal electrode. Physiotherapeutic Methods are particularly effective when combined with therapeutic exercise.

Anatomical changes causing urinary incontinence can be corrected through various Surgical methods. The approach to Surgical treatment must be strictly individualized.

A number of original surgical Procedures have been developed, which can be divided into the following groups: 1) surgeries restoring normal vesicourethral anatomy via a vaginal approach; 2) various modifications of retropubic uretropexy; 3) surgeries correcting vesicourethral anatomy and fixing the musculoligamentous apparatus via a combined approach; 4) various modifications of so-called sling operations.

Surgical Treatment of stress urinary incontinence yields good results in 90% of cases over a 2-year period, and in 50–85% of cases within 5 years postoperatively, given that the pathogenic factors continue to operate even after surgery (R. Symmonds, 1972).

Management of patients suffering from mild stress urinary incontinence or those who have undergone surgery includes training in self-monitoring and pelvic exercises, adequate estrogenization of supporting tissues, and treatment of urinary tract infections.

One of the primary directions in the Prevention of stress urinary incontinence is the avoidance of genital and perineal trauma: proper Management of Labor, and regular gymnastic exercises during Pregnancy and the postpartum period. Timely and proper medical care in cases of perineal rupture, as well as the correction of postpartum and postoperative trauma consequences, is of great importance.