Urinary incontinence often impairs quality of life significantly more than other chronic diseases such as hypertension, diabetes mellitus or depression.1–4 Despite identical symptoms, there are various types of urinary incontinence that have different causes and, therefore, require different therapeutic approaches. Based on case histories alone, the correct diagnosis is given in only 30% of cases, showing that exact urological diagnostics are necessary so that the correct therapy can be instituted.
Urinary incontinence can be classified by:
Stress urinary incontinence in women
IIn women with stress urinary incontinence, the urethral closure mechanism becomes ineffective and is unable to withstand increased intra-abdominal pressure. This means that events such as coughing, sneezing, laughing and physical activity cause loss of urine. It is an isolated problem of the pelvic floor; bladder function is completely unaffected. A distinction is drawn between genuine diagnoses and non-genuine diagnoses, associated with concomitant pathologies. Genuine stress incontinence is characterized by intact anatomy of the pelvis and a regular preserved angle between bladder neck and urethra. However, the non-genuine type also exists, for example caused by a prolapse of the anterior vaginal wall in association with a rotatory descent of the bladder.
Possible causes of deficiency of the urethral sphincter include:
long-term intense use of the pelvic floor muscles during pregnancy
overstretching and injury to the pelvic floor during childbirth
changes in the anatomy of the pelvis that result in the bladder and urethra having a more caudal position, thus making appropriate sphincter function impossible (such as may occur, for example, after hysterectomy or childbirth but may also be due to idiopathic insufficiency of the pelvic floor)
excessive overloading of the pelvic floor as a consequence of chronic obstructive pulmonary disease, chronic constipation, regularly lifting of heavy weights or obesity.
Endoscopy in patients suffering from urinary incontinence typically shows normal bladder capacity and absence of detrusor trabeculation. Digital evaluation of the pelvic floor often identifies hypotonic muscles that cannot be contracted consciously, or to only a very limited extent, resulting in urinary leakage during activities such as coughing. The patient can easily relax the sphincter and the urodynamic findings reveal a stable detrusor muscle and a negative closure pressure of the urethra during coughing. A level of physiological micturition is then evaluated using uroflowmetry.
Additionally, there is often a sensory urge to urinate when in a vertical position. This is accompanied by reduced functional bladder capacity, which can be identified from a voiding diary kept by the patient or by urodynamic testing.
Various accompanying pathologies of the pelvic floor compartments can often be misdiagnosed as urinary incontinence, such as a cystocele, an enterocele or a rectocele. According to the 2004 therapeutic guidelines of the International Consultation on Incontinence (ICI) and the World Health Organization (WHO), conservative treatment options should be completely explored before progressing to more radical therapy.5
With professional training, the pelvic floor can be efficiently strengthened and the patient can learn to consciously and intentionally control the sphincter. Support can be mediated via intravaginal electrical stimulation probes or via the more convenient use of extracorporeal magnetic stimulation. Magnetic chair therapy is characterized by a higher intensity and depth of tissue penetration than electrical stimulation. In addition to strengthening the muscles, stimulation treatment facilitates the physical perception of the muscles that are to be trained.6 Similarly, to improve awareness of the pelvic floor and to control the pelvic floor muscles, electromyography-supported training or biofeedback therapy is used. The drug duloxetine is currently available and enables the muscle tone of the external sphincter to be measured by urodynamics and improves sphincter ability during urine storage in the bladder.7 Further supplements to conservative therapy include the local use of oestrogen. The trophic effect of oestrogen on the epithelium and connective tissue collagen of the urethra increases the concentration of adrenergic receptors in the smooth muscle and, thus, the closing competence of the sphincer.8
This multimodal therapeutic approach makes it possible to restore continence and can also ensure anatomical changes of the pelvic floor in the sense of elevation of the bladder neck, which can be demonstrated using MRI.9–14
Surgery is necessary only if conservative therapy has not been successful or has not resulted in sufficient improvement in symptoms. A wide range of different interventions are now available, from which the optimal method can be chosen and fully customized for each individual patient. While continence rates after the classical techniques without alloplastic material (fascial sling plasty, Burch colposuspension and sacrocolpopexy, which is performed following concomitant prolapse of the anterior vaginal wall) and after implantation of alloplastic tapes [tension-free vaginal tape (TVT) and transobturator tape (TOT), or their modifications and various meshes] are comparable, differences in complication rates have to be taken into consideration. Techniques that involve the use of alloplastic tapes can be complicated by malposition of the tape and its consequences, by impaired cohabitation, obstructive voiding dysfunction and de novo urge in up to 30% of patients.15–29 The rate of complications after mesh implantation is much higher than after sacrocolpopexy with or without synchronized Burch colposuspension. In addition to the de novo urge and the obstructive urinary symptoms, erosion of the anterior vaginal wall occurs in 17% of patients and impairment of cohabitation in 30–73% of patients.30–35 The complications of these procedures are often difficult to remedy because the alloplastic material is usually only partially removed and often causes damage to the surrounding tissue. Thus, for several years it has been recommended that the use of meshes be reserved for secondary surgery in the event of prolapse recurrence. The classical methods, without alloplastic materials, are currently used in addition to the open surgical technique as well as minimally invasive Da Vinci robotic-assisted laparoscopic surgery.
Anterior colporrhaphy, by definition, is not a surgical technique to cure urinary incontinence. From a purely technical viewpoint, it is not possible to correct the anatomical position of the bladder and proximal urethra to the extent that continence is restored.
Stress urinary incontinence in men
Stress urinary incontinence in men is usually iatrogenic. It may be the result of accidental damage to the external sphincter during transurethral resection of the prostate (in addition to the inevitable violation of the internal sphincter). Alternatively, it may manifest as post-prostatectomy incontinence after surgical treatment of prostate carcinoma or after treatment of invasive bladder cancer with radical cystoprostatectomy and orthotopic neobladder. Even if the integrity of the external sphincter is preserved, 17–83% of patients suffer mild to severe stress urinary incontinence immediately after surgery.36,37 The type of surgical intervention is of importance as protection of the nerves on at least one side and some degree of preservation of bladder neck anatomy seems to be preventive.36,37
The pathophysiological background of urinary incontinence indicates that it is a complex disorder of the pelvic floor and auxiliary muscles that are necessary for the sufficient closure of the lower urinary tract. The causative components can exist alone or in combination, such as:
lack of awareness of the pelvic floor
lack of controllability and, therefore, lack of activation of the continence-guaranteeing muscles
muscular weakness or untrained condition of the pelvic floor owing to natural lack of use prior to the removal of the prostate
contracted muscles of the pelvic floor and the auxiliary muscles supporting continence
failure to cope with tumour with consequent anxiety and depression.
A typical diagnostic result is physiological function of the bladder in the presence of an insufficient closure mechanism and accidental leakage of urine during increased intra-abdominal pressure or during physical activity.
Similar to stress urinary incontinence in women, professionally guided pelvic floor exercises are used therapeutically in men. In addition, electrical stimulation (or extracorporeal magnetic stimulation) electromyographically based training or biofeedback training are used therapeutically; off-label use of duloxetine is also reported. With these therapeutic options used in combination, it is possible to reduce the rate of postoperative incontinence within 12 months to 3–23%.36 Failure to achieve continence within a year, despite pelvic floor exercises, is often because conventional physiotherapy is non-specific and non-intensive and utilises preprinted brochures.38,39 A recent study on early continence after 3 weeks of inpatient urological rehabilitation with additional osteopathy reported a success rate of 30%.37 Our own data from 2010–2012 show that with an average of 5 days’ urological outpatient rehabilitation including specially designed intensive pelvic floor power training and psychosomatic or psycho-oncological support, a continence rate of 77% is achievable after 4 weeks.
Preoperative pelvic floor exercises can significantly reduce post-prostatectomy incontinence,40–42 and our own data show that it is possible to achieve continence with only 1–5 preoperative training days in combination with an optimized surgical technique. We found a continence rate of 44% immediately after removal of the indwelling catheter. Furthermore, 80% of the patients who were not immediately continent became so between 3 days and 4 weeks postoperatively. However, less intensive, conventional physiotherapy seems not to have a positive impact on the postoperative continence rate.43–45
With respect to the success rate achievable with professional and intensive education regarding the pelvic floor, the recommendation for surgical treatment should be provided very cautiously and surgery should be conducted no earlier than 1 year postoperatively. Because of sex-specific anatomy, the range of the invasive options differs in men and women. Minimally invasive adjustable techniques are available, such as Pro-ACT balloons, Argus sling and the Reemex system as well as the classic Scott Sphincter or American Medical Systems (AMS) 800 and the developing Flow Secure, which is adaptable to different pressures. The success rate of minimally invasive procedures is 80–85% and of the AMS sphincter is 85–95%. Explantation is often unavoidable owing to infection or erosion in 10–13% of cases, despite the system used. If an artificial sphincter is inserted, surgical intervention is usually required after 5–10 years in order to replace the defective components such as the cuff placed around the bulbar urethra.
Overactive bladder and urinary urge incontinence
The overactive bladder is characterized by an imperative and non-suppressible need to empty the bladder that cannot be delayed. In cases of overactive bladder or urge urinary incontinence, an involuntary loss of urine takes place before the sufferer can reach the toilet. The underlying hyperactivity of the detrusor muscle can be caused by different pathogenetic mechanisms; thus, the failure rate of anticholinergic therapy and even of intravesical botulinum neurotoxin injection is comprehensible.46–48
Detrusor muscle overactivity may be due to an anatomical infravesical obstruction that, in men, originates from obstructive hyperplasia of the prostate, caused by bladder neck sclerosis or by urethral stricture. In women, the obstruction can arise from congenital or acquired stenosis of the urethral meatus, bladder neck tightness or sclerosis, or a bend in or narrowing of the urethra due to a rotatory descent of the bladder or following incontinence surgery.
In both sexes, bladder overactivity can be caused by an infravesical functional obstruction. As a result of an acquired detrusor–external sphincter dyscoordination, a functional or dynamic stenosis of the proximal urethra can develop that also may cause accompanying symptoms such as recurrent urinary tract infections or the chronic pelvic pain syndrome. The development and persistence of these functional or so-called somatoform overactive bladders may have a psychosomatic cause, and this has to be taken into account. Unconscious anxiety, unrecognized depression, partnership conflicts, disturbance of self-demarcation and emotional or sexual abuse are often responsible. The underlying aetiology is a continuously increased inner tension that is reflected in an increased muscular tone of the pelvic floor.49
Coital incontinence is not just an expression of stress urinary incontinence but quite often coexists with bladder overactivity. It seems to be due to unconscious and defensive pressing in a caudal direction because of difficulties in the relationship with the partner.50,51
The idiopathic overactive bladder is characterized by the absence of obstructive voiding dysfunction and is likely to be caused by age-related changes in the receptors of the bladder.
Typical endoscopic diagnostic findings include an early first sensation of urination and a reduced functional bladder capacity and detrusor muscle trabeculation of varying degrees. Moreover, a subvesical obstruction may be recognized. It is important to distinguish, especially in women, between a distal stenosis of the distal urethra, i.e. stenosis of the urethral meatus, and dynamic stenosis of the proximal urethra, i.e. acquired or habitual overactivity of the external sphincter. Digital evaluation of the pelvic floor reveals hypertonic muscles and little or no conscious controllability, and voluntary relaxation is either barely possible or not possible at all. A typical detrusor–external sphincter dyscoordination of varying degrees, obstructive micturition sometimes followed by residual urine, is noted using uroflowmetry. The urodynamics picture is of a stable detrusor with sensory or motoric urge. In women, normal to increased urethral closure pressure may lead to the diagnosis of concomitant pathologies of the different pelvic floor compartments, such as a cystocele, rectocele or enterocele, which must be taken into consideration before instituting appropriate therapy.
Anatomical bladder capacity measured while the patient is under anaesthesia is usually normal or even increased once a previous infrequent voiding syndrome has passed. Reduced capacity resulting from a fibrotic bladder of low compliance is rarely found and is mostly observed in women who have suffered from recurrent urinary tract infections for many years.
The treatment of an overactive bladder and urge urinary incontinence depends on the patient’s specific pathogenetic background. The anatomically related stenosis of the urethral meatus is corrected surgically by meatoplasty; internal Otis urethrotomy, used previously, is now obsolete. Similarly, obstructive hyperplasia of the prostate and the urethral stricture in men are surgically removed.
The type of overactive bladder that arises from a functionally related obstructive voiding dysfunction can be successfully treated by professionally guided pelvic floor exercises. The patients learn voluntary sphincter relaxation and conscious or coordinated micturition. The combination of relaxing pelvic floor exercises with training supported by electromyography or biofeedback therapy and with concomitant psychosomatic support is often successful and additional psychotherapy is rarely required.49 The transient use of alpha-adrenergic antagonists is helpful while the administration of an anticholinergic gives no, or unsatisfactory, improvement but may be tried as an additional step towards pelvic floor education.46–48 Intravesical botulinum neurotoxin injection is contraindicated in principle but may be a therapeutic option in a few well-chosen and individual cases. This option has to be discussed very carefully with the patient, who must accept the requirement for intermittent postoperative self-catheterization.
The idiopathic overactive bladder in elderly patients represents the domain of drug therapy with anticholinergics administered orally or transdermally. Significant differences in the pharmacokinetics of the available preparations, in terms of effect, tolerability and optimal indication, must be taken into consideration as this is a very sophisticated option that offers an individually customizable range of therapies. Thus, therapeutic success may be achieved at the first attempt or only after trying several anticholinergic agents. In addition to purely symptomatic drug therapy, professionally instructed bladder training and neuromodulating electrical or magnetic stimulation of the bladder are encouraged.52 In this way, many patients learn once again to control their bladder despite their age, and drug therapy can often be terminated after 3–6 months. If no improvement is noted, the anticholinergic can be continued as long as the patient continues to tolerate the drug.
In cases of therapeutic resistance to anticholinergics despite a reliable and possibly verified diagnosis, or in cases of intolerance of various preparations, the minimally invasive technique of intravesical botulinum neurotoxin injection of the bladder is useful and may be carried out as a short inpatient intervention. In contrast to the treatment of neurogenic hyperreflexive bladder, the dosage differs for each individual and is to be identified according to the results of previously performed urological diagnostics. Carried out by an experienced practitioner, this minor surgical intervention is virtually free of adverse events and reduces bladder activity no more than desired. The effect persists for an average of 9–12 months; further reinjections can be carried out easily if necessary. In our own patients treated from 2005 to 2008, bladder activity normalized permanently in 30% of patients so that no further botulinum neurotoxin injection or other therapy was necessary. Thus, the injection acted to train the bladder: because micturition habits were normalized during the effective period, patients learned to empty their bladder in an appropriate manner.
Mixed urinary incontinence
The combination of sphincter or pelvic floor insufficiency and an overactive bladder is described as mixed urinary incontinence. This pathology is of importance when deciding on appropriate treatment. Those options associated with aggravation of urgency symptoms or with a risk of postoperative de novo urge, such as TVT/TOT surgery or mesh implantation in concomitant vaginal prolapse, are contraindicated. It is fundamentally important to distinguish whether the urge component is sensory or motoric on the basis of functional diagnostics to explore whether there is an actual or motoric urge concerning the mixed urinary incontinence presented. The sensory urge sometimes accompanies stress urinary incontinence owing to bladder neck insufficiency and, therefore, is also cured by TVT/TOT surgery with no contraindication.
Overflow urinary incontinence
Overflow urinary incontinence describes a feature that is often found in connection with urinary urgency incontinence in men caused by infravesical obstruction. Obstructive voiding dysfunction caused by bladder neck sclerosis, obstructive hyperplasia of the prostate or urethral stricture progresses to decompensate of bladder function followed by high volumes of residual urine. This development often goes unnoticed by the patient until the occurrence of overflow urinary incontinence, and injury to the upper urinary tract may occur before the patient seeks medical attention.
Therapeutic surgical removal of the subvesical obstacle, and thus the abolition of decompensated bladder dysfunction, is required in cases of overflow urinary incontinence. Today, various alternative methods, such as the GreenLight laser, are available in addition to the classical transurethral resection and open adenomectomy; the choice is made on an individual basis depending on the prostate volume and morbidity of the patient.
Urinary incontinence in children
The causes of urinary incontinence in children are similar to those of dynamic stenosis of the proximal urethra in the adult, i.e. acquired functional or somatoform bladder dysfunction, and, therefore, similar therapeutic approaches are applied. It is essential that the doctor’s behavioural and motivational measures are translated into language the child understands so that the child can work up the necessary personal responsibility and initiative for normalization of the bladder function. Child-friendly and multimodal pelvic floor education will enable the child to learn appropriate micturition and reduce pathogenically increased internal tension, and thus to control bladder function.53–58 Accompanying urinary tract infections or a high-pressure reflux are not triggers of urinary incontinence in children but are always a result of involuntarily postponed micturition. Early detection and treatment of the obstructive voiding dysfunction are important to avoid chronic damage to the upper urinary tract. Pathophysiologically, urinary leakage is a manifestation of a lack of maturity or of self-regulatory disorder, which is quite often the result of a disturbed mother–child relationship or the need for satisfaction; thus, treatment requires both special urological and psychosomatic knowledge.53,59
Neurogenic urinary incontinence
Neurogenic urinary incontinence results from a disturbed innervation of the lower urinary tract. This can be caused by damage to the central nervous system and spinal cord or by damage to the peripheral nerves passing through the pelvis to supply the urinary organs and the pelvic floor. The pathogenetic sources are extremely varied; they may be congenital, such as meningomyelocele, or acquired, such as Parkinson’s disease, multiple sclerosis, traumatic spinal cord injury, herniated disc, spinal stenosis, stroke or spinal metastases of carcinomas. Depending on the underlying cause and the specific location of the lesion in the nervous system, the innervation of either the bladder or the sphincter or both can be affected, and various dysfunctions of both may result.
Ensuring that patients have a sufficient urological supply is as important as treating the underlying neurological diseases. Approximately 70% of patients with multiple sclerosis cite urological symptoms as the decisive factor limiting their quality of life.60 In addition, every urinary tract infection may trigger a new episode of multiple sclerosis and, conversely, increased intravesical pressure may impair spasticity.
The urological symptoms of nephrogenic urinary incontinence are diverse and can be very mild or associated with very dangerous and rapidly progressive failure of renal function. Accordingly, the diagnosis and successful treatment of neurogenic urinary incontinence requires very specialized neuro-urological knowledge. Only then is it possible to increase the quality of life of patients in terms of improved bladder control and continence and to guarantee permanent protection of the vulnerable upper urinary tract.