stress incontinence
Introduction
Introduction to stress urinary incontinence The stress incontinence proposed by the International Continence Society (ICS) is defined as: a sudden increase in abdominal pressure leads to involuntary discharge of urine, not caused by detrusor systolic pressure or tension of the bladder wall against urine. of. It is characterized by no enuresis in the normal state, and the urine automatically flows out when the abdominal pressure suddenly increases. Such as coughing, laughing, sneezing, jumping, when the heavy objects are transported, the urine involuntarily leaks from the urethra. basic knowledge The proportion of illness: 18% Susceptible people: no special people Mode of infection: non-infectious Complications: bladder bulging
Cause
Causes of stress urinary incontinence
(1) Causes of the disease
Stress urinary incontinence is divided into two types, more than 90% of which are anatomical stress urinary incontinence, which is caused by pelvic floor tissue relaxation; less than 10% is urethral sphincter type stress urinary incontinence, which is congenital or unexplained.
1. Pregnancy and vaginal delivery: the main cause of stress urinary incontinence, during pregnancy and childbirth, the fetal first exposed to the pelvic floor muscles excessive compression, the use of fetal head suction and breech traction and other vaginal surgery delivery, postpartum abdominal pressure increase Higher can cause pelvic floor tissue relaxation, multiple regression analysis of Van's group of case-control studies found that stress urinary incontinence was not associated with the second stage of labor extension of the first child, but was significantly associated with forceps delivery, Persson found stress urinary incontinence The incidence was significantly associated with primiparity, parity, fetal birth weight, and perineal anesthesia.
2. urethra, vaginal surgery: anterior and posterior vaginal wall repair, cervical cancer radical surgery, urethral diverticulectomy, etc. can destroy the normal anatomical support of the urethra bladder.
3. Dysfunction: Insufficient support or congenital insufficiency of congenital bladder and urethra is a cause of young women and unmarried women. Postmenopausal women have thinned submucosal veins in the urethra and bladder triangle due to estrogen decline. Reduced blood supply and mucosal epithelial degeneration, decreased tension in the superficial epithelium of the urethra and bladder, atrophy of the urethra and surrounding pelvic floor muscles, and urinary incontinence. Salinas also found that although menopausal status is associated with stress urinary incontinence, the risk is not As the age increases, the risk of stress urinary incontinence disappears after the age of 52. Premenopausal symptoms are often due to malnutrition, weak constitution, urethral bladder neck muscles and fascia atrophy and urinary incontinence.
4. Pelvic mass: When there is a huge mass in the pelvic cavity, such as uterine fibroids, ovarian cysts increase abdominal pressure, bladder urethra junction position is reduced and urinary incontinence.
5. Weight: Many reports have reported that the occurrence of stress urinary incontinence is associated with an increase in the patient's body weight index (BWI).
6. Periodic stress urinary incontinence: The symptoms of stress urinary incontinence in the second half of menstruation are more obvious, which may be related to the relaxation of urethra by progesterone.
(two) pathogenesis
Stress urinary incontinence is classified into bladder neck hyperkinesis and urethral sphincter disorder. The former accounts for more than 90%, and the latter is less than 10%. The pathogenesis of stress urinary incontinence is still unclear. The hypothesis is widely accepted, but the possible mechanisms include the following:
1. Reduced urethral resistance: Maintaining an effective mechanism for controlling the urine requires two factors: the complete internal structure of the urethra and adequate anatomical support. The integrity of the internal structure of the ureth is determined by the resistance of both the urethral mucosa and the urethral closure. The urethral mucosa is formed by mucosal folds, surface tension of the secretions and submucosal venous plexus. The closed seal can prevent leakage of urine. The urethral closure pressure comes from the tension of the submucosal blood vessels and muscles. The urethral closure pressure is increased and the resistance is high. It can control urination, relaxation of pelvic floor tissue and reduce urethral resistance. Some studies have found that neuromuscular conduction disorder can not reflexively cause an increase in urethral pressure when abdominal pressure is increased. This type of stress urinary incontinence is urethra. Internal sphincter disorder type.
2. Pressure relationship of urethral bladder: those with good urinary control have a proximal urethral pressure equal to or higher than the intravesical pressure. When the abdominal pressure increases, the abdominal pressure is transmitted to the bladder and 2/3 proximal urethra (in the abdominal cavity). ), so that the urethral pressure remains equal to or higher than the intravesical pressure, so no urinary incontinence occurs. On the contrary, patients with stress urinary incontinence cause 2/3 proximal urethra to move outside the abdominal cavity due to pelvic floor relaxation. When the urethral pressure is reduced (still higher than the intravesical pressure), but when the intra-abdominal pressure increases, the pressure can only be transmitted to the bladder and can not be transmitted to the urethra, so that the urethral resistance is not enough to resist the bladder pressure, causing urine overflow, explaining The mechanism of the occurrence of stress urinary incontinence in the bladder neck with high mobility.
3. Anatomical relationship of the urethra bladder: the posterior angle of the normal urethra and the bottom of the bladder should be 90°100°, and the inclination angle of the urethra formed by the vertical line of the upper urethra axis and the standing position is about 30°. In patients with stress urinary incontinence, due to The pelvic floor tissue is loose, the bottom of the bladder is displaced downwards and backwards, and the posterior horn of the urethra is gradually disappeared, and the urethra is shortened. This change is like the initial stage of urination. Once the intra-abdominal pressure increases, it can induce involuntary urination. In addition to the disappearance of the posterior horn of the urethra, the urethral axis also rotates, increasing it from a normal 30° to greater than 90°. This also explains the mechanism of stress urinary incontinence of bladder neck hyperkinesia from one side.
Petros elaborated on the mechanism of stress urinary incontinence from the hypothesis of normal urethra and bladder neck closure mechanism: the closure of the urethra is caused by the contraction of the anterior portion of the pubic muscle to form a so-called "hammock", which is formed by the pubic urethra. The part of the vagina after the ligament is the transmission medium, and the closure of the bladder neck is called knuckle knot. It is based on the part of the vagina behind the pubic urethra and is completed by the common contraction of the lifting support structure. "Support structure" refers to the lateral muscle of the rectum and the longitudinal muscle around the anus. The measurement of the posterior vaginal myoelectric EMG confirms this hypothesis. In women without urinary incontinence, the "lifting support structure" contract causes the vagina to reach X point. The pubic muscle contraction pulls the vagina forward to form a "hammock", and closes the urethral cavity. If the vaginal wall is loose, the pubic muscle contraction exceeds a fixed distance and the transition point XI cannot be reached, and the urethra cannot be closed to cause urinary incontinence.
Prevention
Stress urinary incontinence prevention
Good mentality
Be optimistic, open-minded, with a positive and peaceful attitude, laugh at the successes, failures, stresses and annoyances in life and work, and learn to adjust your mood and mood.
2. Prevent urinary tract infections
After getting into the urine, the habit of going to the back to wipe the toilet paper to avoid infection of the urethra. Before sex, the husband and wife first wash the vulva with warm water. After sexual intercourse, the woman immediately empties the urine and cleans the vulva. If urinary pain and frequent urination occur after sexual intercourse, you can take anti-urinary tract infection drugs for 3 to 5 days, and cure quickly in the early stage of inflammation.
3. Regular sex life
Studies have shown that menopausal women continue to maintain a regular sex life, can significantly delay the physiological degeneration of ovarian synthetic estrogen function, reduce the incidence of stress urinary incontinence, while preventing other senile diseases and improve health.
Complication
Stress urinary incontinence complications Complications, bladder bulging
80% of patients with stress urinary incontinence have bladder bulging, but about half of patients with bladder bulging have stress urinary incontinence.
Symptom
Stress urinary incontinence symptoms common symptoms sneezing children enuresis
The purpose of the diagnosis of stress urinary incontinence is to confirm that urinary incontinence is caused by an increase in abdominal pressure.
1. Ask about medical history
Understand various causes related to stress urinary incontinence, such as childbirth, trauma, pelvic surgery, etc., to understand the impact of urinary incontinence on the patient's life, at the same time, should also know whether there are symptoms of dysuria and the presence or absence of detrusor overactivity.
2. Symptom
Cough, laugh, sneeze, urine involuntarily leaking from the urethra when carrying heavy objects, the clinical can be divided into three degrees: I degree: cough, sneezing, heavy weight and other abdominal pressure increase when urinary incontinence occurs; II Degree: standing, urinary incontinence during walking; III degree: urinary incontinence when standing upright or lying.
3. Physical examination
1 urethral length: insert balloon catheter, 20ml water injection, gently pull to the urethra, calculate the length of the urethra, the normal length of the female urethra is about 4cm, such as the urethra length shortened or standing, when lying Both are shortened, there is the possibility of stress urinary incontinence;
2 bladder neck lift test: the patient takes the lithotomy position, increases the abdominal pressure when the bladder is filled, and has urine flowing out; at this time, the index finger and the middle finger are inserted into the vagina, and the urethra is lifted up on both sides of the bladder neck, such as the flow of urine. That is positive;
3 cotton swab test: used to determine the degree of urethral sag, take the bladder lithotomy position, insert a cotton swab in the urethra after routine disinfection, the normal person's angle of cotton swab activity under stress and no stress should not > 30 °, if > 30 ° indicates that the bladder and urethral support tissue are weak.
Examine
Examination of stress urinary incontinence
1. Urodynamic examination: normal detrusor reflex, maximum urinary flow rate during stress urinary incontinence, intravesical pressure during urination was significantly reduced, mild intravesical pressure was 5.9 ~ 7.8kPa, moderate is 2.5 ~ 5.9 kPa, the severity was less than 1.96 kPa, the urethral pressure decreased, the maximum urethral pressure decreased significantly, and the urethral closing pressure decreased from the supine position to the standing position.
2. Leakage point pressure (LPP) measurement: put the pressure tube into the bladder and fill the bladder, record the intravesical pressure when the urethra leaks urine. This pressure is the leaking point pressure, which is mostly higher than 11.8 kPa. The severity is mostly below 5.88 kPa.
3. The maximum functional bladder capacity and residual urine were normal.
4. Urethral cystography: normal bladder posterior angle should be 90 ° ~ 100 °, the vertical line of the upper urethra axis and standing position, forming a urethral tilt angle of about 30 °, the bladder neck is higher than the lower edge of the pubic symphysis, pressure In urinary incontinence, the posterior horn of the bladder urethra disappears, the bladder neck is lower than the lower edge of the pubic symphysis, the urethral tilt angle increases, the bladder neck is funnel-shaped and sag, the urethral axis occurs to a different extent, backwards, Green will Divided into two types: type I, the urethral axis is normal, but the posterior urethra bladder angle is increased; type II, the posterior urethra angle disappears, the urethra decreases when the abdominal pressure increases, the urethral tilt angle increases, and the urethral tilt angle is >45°. Sometimes >90°, the bladder neck related support tissue is weak, the symptoms are severe, and the treatment is difficult. McGurie later proposed that the stress urinary incontinence associated with the decline of the urethral sphincter function is named type III.
Diagnosis
Diagnosis and identification of stress urinary incontinence
diagnosis
Diagnostic criteria for stress urinary incontinence:
1. Urine analysis was normal and urine culture was negative.
2. The nerve examination is normal.
3. Anatomical support is weak (swab test, X-ray or urethroscopic examination).
4. Confirm that there is an overflow of urine under pressure (pressure test or cotton pad test).
5. Intravesical pressure measurement or normal intraurethral pressure (residual urine volume, bladder volume and normal feeling; no involuntary detrusor contraction).
Differential diagnosis
1. Overactive bladder: refers to the syndrome of urinary frequency, urgency and urge incontinence caused by involuntary contraction of the detrusor when the bladder is filled. The symptoms are similar to those of stress urinary incontinence, but the bladder neck lift test is negative. Bladder urethra angiography showed normal posterior urethral urethra, urodynamic examination showed normal urethral pressure; bladder detrusor pressure increased, hyperreflexia.
2. Overflow urinary incontinence: refers to the involuntary urination that occurs when the bladder is over-expanded. The patient may have no urinary sensation. There is still a lot of residual urine in the bladder after urination. Therefore, it is also called chronic urinary retention or pseudo-urinary incontinence. Urinary incontinence is often secondary to benign prostatic hyperplasia, diabetic neuropathy and spinal cord injury.
3. True urinary incontinence: Due to dysfunction of the bladder neck sphincter and urethral sphincter, urine continuously dripping from the urethra, the patient has no urinary sensation, and the bladder is always in an empty state.
4. Neurogenic urinary incontinence: It is a urinary tract dysfunction caused by nervous system diseases, which is common in cerebrovascular diseases, Parkinson's disease and spinal cord injury. Depending on the type of disease, the urgency of detrusor hyperreflexia may occur. Two types of urinary incontinence or reflex urinary incontinence.
5. Urethral diverticulum: more common in women, because the sputum is filled with urine after urination, so when the erect walking or force, the urine can flow out, its performance is similar to stress urinary incontinence, but the urethral diverticulum patient shows urinary leakage Urine; urinary anterior wall of the vagina may have cystic masses, urine or pus outflow can be seen in the swollen mass, and diverticulum can be seen in urethroscopic and urethral pressure angiography.
6. Bladder bulging: a history of urinary incontinence, accompanied by lower abdominal and perineal bulge, check the bladder residual urine, vaginal anterior wall bulging when forced, bladder urethra angiography showed urethral posterior horn and urethral tilt angle are in the normal range Within the bladder, the symptoms of vaginal anterior wall repair were improved, while stress urinary incontinence did not improve significantly after surgery.
7. Urine leakage: urine leaks through the pupil around the urethra rather than through the urethra. It is common in ureteral ectopic opening, vesicovaginal fistula, ureterovaginal fistula and other diseases. By asking about medical history, detailed physical examination, finding leaking urine. The specific part is generally not difficult to identify.
