Urinary incontinence and prolapse

Female urinary incontinence and prolapse are common conditions. While not life-threatening, they can have a considerable impact on the quality of life of those who suffer from them.
It is estimated that 25 per cent of women wait more than five years to seek treatment because they are embarrassed or assume that their symptoms are an inevitable consequence of childbirth and ageing.

h4. Aetiology
The urethra, vagina and rectum pass through the levator ani muscles of the pelvic floor. These muscles support the pelvic organs and augment urinary and faecal continence as well as accommodating parturition and sexual function.
The major risk factor for prolapse and incontinence is childbirth and increasing parity. Following a first birth, a woman is four times more likely to develop a prolapse and the risk rises to 11 times with four or more deliveries.
Symptoms include backache, a bulge in the vagina with a sensation of “something coming down”, urinary frequency, voiding difficulty with incomplete emptying and problems evacuating their bowels. Sexual dysfunction is often an associated problem.
Lower urinary tract (LUT) function can be compromised by urethral sphincter incompetence, resulting in stress urinary incontinence (SUI); the overactive bladder (OAB), with symptoms of urinary frequency, urgency, urge incontinence, nocturia or nocturnal enuresis, or a mixture of both. Recurrent urinary tract infections (RUTI), particularly in the elderly, may also lead to incontinence.
h4. Management of urinary incontinence
Pelvic floor muscle contractility and symmetry can be assessed by vaginal examination, including the strength and endurance of each ‘squeeze’. Hypermobility of the midurethra may imply sphincter incompetence. SUI may be demonstrated by means of the cough stress test on a full bladder.
A cystocele, rectoenterocele, uterine or vault descent should be assessed and graded simultaneously. Examination may detect abnormal pelvic masses or constipation, which may impair voiding and exacerbate prolapse and incontinence.
Urodynamic testing provides objective evidence of LUT dysfunction while ultrasound imaging of the pelvis can reveal residual volumes, bladder diverticulae, urethral sphincter volumes, bladder wall thickness and pelvic masses.
Treatment for the OAB includes advice on fluid intake and avoidance of urinary stimulants. Behavioural therapies including bladder training, biofeedback and electrical stimulation are very effective in inhibiting detrusor contractions and are enhanced by the use of anticholinergic medications.
Pelvic floor muscle exercise (PFME) is the first line of treatment for women with stress urinary incontinence. Success rates of up to 70 per cent can be achieved in well-motivated women with mild to moderate incontinence. Surgery for SUI has been revolutionised by innovative, less invasive procedures such as the tension-free vaginal tape (TVT).
Used in place of the Colpo-suspension, it is performed as a day-case procedure with success rates of up to 81 per cent at seven years. Previous procedures, especially anterior repairs and needle suspensions, are no longer appropriate for SUI.
Intraurethral plugs, intravaginal tampons, pessaries and extraurethral devices are helpful where leakage occurs in isolated circumstances. Bulking materials injected into the tissues around the urethra may also improve urethral closure under conditions of stress.
h4. Management of pelvic organ prolapse
Shelf or ring pessaries may provide temporary relief from prolapse prior to surgical correction or can be a more enduring measure when surgery is inappropriate. In the case of a more severe prolapse, reconstructive surgery is required to both resolve symptoms and restore the pelvic floor supports. Site-specific defects can now be identified and repaired to a higher standard.
Vaginal vault reconstruction may be performed either abdominally or per vaginam with the use of mesh material to reinforce the pelvic floor mechanisms. Success rates for these procedures are in the region of 80 per cent with significant improvement in quality of life.