Dr. med. Dirk Manski



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Stress Urinary Incontinence in Women (3/3)

Treatment of Stress Urinary Incontinence (SUI)

Conservative treatment:

Weight reduction, regular micturition to avoid a full bladder, pelvic floor exercises and topical (vaginal) estrogen treatment are conservative treatment options of stress urinary incontinence.

Drug Therapy for SUI:

Drug therapy for pure stress incontinence has not been promising until recently. The first promising substance is duloxetine. Anticholinergic treatment is the option of first choice if mixed stress incontinence with overactive bladder symptoms or overactive detrusor action is present.

Duloxetine:

Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SSRI) on spinal level and reinforces the strength of the sphincter contraction. Duloxetine may achieve a reduction of incontinence episodes by 50–60% (vs. 20–40% in the placebo group). Dosage and side effects, see section pharmacology of duloxetine. Duloxetine is approved for treatment of mild stress urinary incontinence in Europe. Duloxetine failed the US approval for stress urinary incontinence amidst concerns over liver toxicity and suicidal events.

Electromagnetic Stimulation of the Pelvic Floor Muscles:

Perineal nerves are stimulated by an electromagnetic chair, this leads to a contraction of the pelvic floor. The treatment option is used for stress incontinence, overactive bladder, and in the mixed incontinence. Randomized trials could only demonstrate a small and temporary treatment effect with electromagnetic stimulation of the pelvic floor (Gilling et al, 2009) (Quek, 2005).

Periurethral Injections:

Collagen, teflone, silicone, polydimethylsiloxane, or autologous fat are used for periurethral injections to improve sphincter function. In the long term, however, poor cure rates are reported (30–40%). If the periurethral injection is successful in the short term, the prognosis for a definitive cure with surgery (e.g. TVT, see below) is good.

Surgical Treatment of Female Stress Urinary Incontinence

Suprapubic and Abdominal Approach:

The Burch colposuspension has success rates of 70% in the long term. Any other (less invasive) treatment options have to compete with this success rate, unfourtunately controlled trials are often not available. However, a significant decrease of abdominal procedures in favor of vaginal procedures is observable.

Burch colposuspension:

The paravaginal fascia is attached to the arcus tendineus ligament with mattress sutures which elevate the urethra and bladder neck. The Burch colposuspension can also be performed laparoscopically with fewer side effects, the success rate is somewhat lower (Dean et al, 2006).

Abdominal sacrocolpopexy:

Abdominal sacrocolpopexy is suitable to repair level 1 defects, to treat descensus of the uterus and to restore functional vaginal length and the vaginal axis. The vaginal cuff is mobilized and fixed to the os sacrum with a prolene mesh. The Y-shaped net extends into the anterior and posterior compartments, but the safety of these nets is controversial (see below). Surgery can be done with a laparoscopic or open approach.

Vaginal Approach for the Surgical Treatment of SUI:

The vaginal approach with alloplastic meshes is most commonly used for surgical treatment of stress urinary incontinence, but the safety of these nets is controversial (see below).

Alloplastic Midurethral Slings:

All steps of the operation are carried out by a vaginal approach with the patient in lithotomy position. A small incision of the anterior vaginal wall is done to enable minimal dissection of the urethra. Two stab incisions for the urethral sling exit points are created suprapubic (TVT) or near the origin of the gracilis muscle (TOT). A 1 cm wide urethral sling is placed around the midurethra using a special needle device and exiting at the two stab incisions. Wound healing and scarring leads stability of the urethra and restores pressure transmission to the urethra with rising abdominal pressure. Details of the surgical techniques and complications see chapter urologic surgery section alloplastic midurethral slings.

Suprapubic alloplastic midurethral slings have been first described as tension free vaginal tape (TVT) (Ulmsten et al, 1998). TVT showed comparable 5-year results in randomized trials compared to the Burch colposuspension (Ward et al, 2006). Meanwhile, several medical companies with different sling material and surgical technique are present on the market [fig. alloplastic vaginal midurethral sling].


figure alloplastic vaginal midurethral sling  

Suprapubic alloplastic midurethral sling. With kind permission of American Medical Systems, Minnetonka, Minnesota, USA.


Transobturator slings are known by the acronym TOT (transobturator tape). Randomized studies showed comparable results for TOT vs. TVT, however, long-term results are lacking (Latthe et al, 2010). As with suprapubic alloplastic midurethral slings, several medical companies with different sling materials and surgical techniques are present on the market [fig. Transobturator midurethral sling (TOT)].


Transobturator midurethral sling (TOT). With kind permission of American Medical Systems, Minnetonka, Minnesota, USA.
fig. Transobturator midurethral sling or transobturator tape (TOT).

Minimally invasive alternatives to TVT or TOT are short midurethral devices (short tapes), which are inserted via a single vaginal incision and are anchored in the paraurethral tissue and pelvic floor muscles. Controlled studies with long term results are not available.

Pubovaginal Sling Procedure:

The pubovaginal sling procedure was only rarely performed after the development of the alloplastic midurethral slings, but the surgical technique is experiencing a certain renaissance due to the dangers of alloplastic material. A Pfannenstiel incision is used for suprapubic approach, and autologous fascia material is harvested from the rectus sheath (1.5×10 cm). The urethra is exposed via a vaginal incision (comparable to TVT, see above). The fascia graft is grasped at both ends with a strong suture, the ends of the suture are passed on both sides from vaginal to suprapubic with the help of a Stamey needle. The graft is positioned like a TVT tape. The graft is fixed by tying of the two ends of the sutures above the rectus sheath and with additional sutures to the paraurethral tissue. Compared to alloplastic slings, the pubovaginal sling procedure has somewhat poorer healing rates with regard to urinary incontinence, but complications from alloplastic material is avoided.

Vaginal surgery for pelvic floor insufficiency:

Procedures against urinary incontinence mentioned above can be combined with pelvic floor reconstruction, see section pelvic floor insufficiency.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Dean, N. M.; Ellis, G.; Wilson, P. D. & Herbison, G. P.
Laparoscopic colposuspension for urinary incontinence in women.
Cochrane Database Syst Rev, 2006, 3, CD002239


Gilling, P. J.; Wilson, L. C.; Westenberg, A. M.; McAllister, W. J.; Kennett, K. M.; Frampton, C. M.; Bell, D. F.; Wrigley, P. M. & Fraundorfer, M. R.
A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.
BJU Int, 2009, 103, 1386-1390


Latthe, P. M.; Singh, P.; Foon, R. & Toozs-Hobson, P.
Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials.
BJU Int, 2010, 106, 68-76


Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.:
[The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
In: Urologe A
44 (2005), Nr. 7, S. W803–18; quiz W819–20

Petros, P. E. & Ulmsten, U. I.
An integral theory of female urinary incontinence. Experimental and clinical considerations.
Acta Obstet Gynecol Scand Suppl, 1990, 153, 7-31.


Quek, P.
A critical review on magnetic stimulation: what is its role in the management of pelvic floor disorders?
Curr Opin Urol, 2005, 15, 231-235


Ward, K. L.; Hilton, P.; K., U. & Group, I. T. T.
Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.
BJOG, 2008, 115, 226-233


Viktrup u.a. 2004 VIKTRUP, L. ; SUMMERS, K. H. ; DENNETT, S. L.:
Clinical practice guidelines for the initial management of urinary incontinence in women: a European-focused review.
In: BJU Int
94 Suppl 1 (2004), S. 14–22


  Deutsche Version: Belastungsinkontinenz der Frau