Urinary incontinence
Urinary continence is the ability to postpone urination to carry out this act in conditions of hygienic-social convenience [1]Urology. Francesco Porpiglia. Minerva Medica Editions. 2015. Any involuntary loss of urine, beyond quantity (even if it's just one drop), However, it has recently been foundhyena defined “urinary incontinence”[2]Abrams, Paul, et al. – The standardization of terminology of lower urinary tract function. Report from the standardization sub-committee of International Continence Society. – Textbook… Continue reading.
CLASSIFICATION OF DIFFERENT TYPES OF INCONTINENCE:
Incontinence is classified in three types:
- Urinary incontinence from effort: involuntary loss of urine in response to physical exertion or a sudden increase in intra-abdominal pressure that occurs during activities such as sneezing or coughing[3]Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32., jump, lift weights, LAUGH, make efforts, do physical exercise[4]Harris, Shauna, Stephen W. Leslie, and John Riggs. -Mixed urinary incontinence.- StatPearls -Internet-. StatPearls Publishing, 2024..
- Urinary incontinence from urgency: involuntary loss of urine associated with urgency[5]Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32..
- Urinary incontinence Mr: is given by the combination of the first two. It is a urinary incontinence that is elected under effort and that presents itself with the characteristic of urgency.
Storing urinary incontinence (IUS)
Urinary continence in stress situations is mainly guaranteed by the integrity of the anatomical support structures of the bladder and urethra (the endopelvic band, with its lateral attacks on the tendon arch, the elderly muscle of the anus and the front vaginal wall) and from the efficiency of the urethral sphincter[6]https://www.aiugstudies.it/lineeguida/commissione1/2/. Pathopathology of urgent urinary unconstitution – M.meschia, P. Piparies, U. Gattei, F. Baruffi, P. Cavoretto service… Continue reading. The surgical interventions for IUS generally aim to restore a support to the bladder and urethra.
At present, It is therefore believed that the pathogenesis of the ius is mainly due to factors that induce anatomical changes in those structures that contribute both directly and indirectly to the urination function. The most influential among these factors are aged, pregnancies, obesity and constipation ([7]Which, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicine 59.1 – 2022 – 5..
Several theoretical models have been designed to explain the anatomical-functional mechanisms of urinary continence, which were also fundamental to refine the rehabilitation approaches. Among these models the most interesting are the “Amaca theory” e the “Theory of transmission of intra-abdominal pressures” e[8]Which, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicine 59.1 – 2022 – 5..
The "Amaca theory" refers direct reference precisely to those anatomical support structures to support the bladder and the urethra to which we have already referred. This theory has in fact identified in Elegant muscle of the anus, in the front vaginal wall, in the pelvic band but also in PUBO-UTRAL LINK, The main elements of a support structure to Amaca whose validity is fundamental to urinary control.
Based on “Amaca theory”, In patients with stress urinary incontinence, a sudden increase in abdominal pressure by overcoming the existing pressure in the’ Uretra would cause an involuntary urine escape due to an anatomical support deficiency of the urethra and bladder neck. In the presence of valid anatomical support, The increase in pressure would lead to a physiological compression of the urethra and bladder neck against solid support, determining its closure.
According to this theoretical model, The IUV would not be so much due to an inadequate transmission of the abdominal pressure forces to the urethra, as for the loss of the anatomical support of the urethra and the bladder neck.
According to the “Theory of transmission of intra-abdominal pressures“, The ius would instead be related to a reduction in the transmission of the abdominal pressure to the bladder and the proximal urethra. This reduction of transmission has a close link with posture. For this reason, the re -education of posture is often an integral part of the rehabilitation of the ius.
It has not yet come to a complete understanding of the mechanisms involved in the genesis of this phenomenon. E’ It has been shown that during the effort an increase in simultaneous intra -minultual pressure occurs to the increase in abdominal pressure and all this in order to guarantee the closure of the urethra and maintain a positive urethrovascular pressure gradient. Although the concept of the pressure transmission represents an important observation, The anatomical-physiological bases on which it is based are difficult to understand. In fact Enhorning, In the early 1960s, he hypothesized that the transmission of the abdominal pressure to the urethra occurs whenever the latter lies in the field of abdominal pressures, Above a theoretical pelvic floor, However, it is shown that there is poor correlation between the anatomical position of the urethra and urinary incontinence from effort[9]https://www.aiugstudies.it/lineeguida/commissione1/2/. Pathopathology of urgent urinary unconstitution – M.meschia, P. Piparies, U. Gattei, F. Baruffi, P. Cavoretto service… Continue reading.
Main causes/risk factors of stress urinary prourcency
Proproblems following childbirth (episiotomy).
The episiotomy (o perineotomy) it is a surgical incision of the perineum that can be made during vaginal birth to facilitate the exit of the fetus from the vaginal orifice.
The surgical incision can be midline (longitudinal), lateral and medio-lateral depending on the direction of the cut which is decided by the surgeon from time to time based on how the birth appears. The midline incision is the least invasive and causes fewer short-term complications, medium and long term.
Episiotomy in some places is done routine, to reduce the risk of perineal lacerations in women and the complications that these may cause (urinary incontinence, feces, sexual dysfunctions) and to facilitate childbirth, thus reducing risks to the fetus. From a systematic review of the literature published in 2005 [10]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. But, it emerged that there is currently no evidence to support the benefits traditionally attributed to routine episiotomy for women's health. From this review it appears that in fact the outcomes of the’routine episiotomy they can be considered worse when compared to outcomes from birth without episiotomy.
The scientific evidence[11]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. derived from clinical studies suggest that the immediate results of routine episiotomy on women's health, including the severity of the perineal tear, pain and the use of painkillers, are no better than those relating to the restrictive use of this practice (it means applying it only in cases where the need to carry out surgery is evident because childbirth is difficult and not regardless of the situation). Clinical studies to date[12]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. highlight the lack of benefits of routine episiotomy for the prevention of fecal and urinary incontinence or pelvic floor relaxation. It has also been found that pain during intercourse is more common among women who have undergone episiotomy.
Menopause or hormonal dysfunction
The decrease in estrogen and collagen that occurs with menopause, it reduces the elasticity of the detrusor muscle and induces atrophic changes in the pelvic floor muscles[13]trash, Abdulmaged M., et al. – Role of androgens in female genitourinary tissue structure and function. Implications in the genitourinary syndrome of menopause.- Sexual Medicine Reviews 6.4… Continue reading, thus creating a predisposition to urinary incontinence (IU).
Results of a systematic review[14]God, Ahmad Hasan, et al. – The Link Between Menopause and Urinary Incontinence: A Systematic Review.- Cureus 16.10 2024 – e71260. of the scientific literature that has investigated the link between menopause and UI, published in 2024, have highlighted the complexity and variability of UI in postmenopausal women:
in fact, the prevalence of UI in this population group varies, depending on the different studies selected by this review, from the 13,6% [15]Singh S, Baranwal K, Wound I, Khan IA, Bajpai S – Sociodemographic determinants of urogenital morbidities among menopausal women in rural areas of Eastern Uttar Pradesh. Cureus. 2023, 15 … Continue reading all’84,4%[16]Morals and, Delgado JL, Carmona F, et al. – Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study. Climacteric. 2018, 21 – … Continue reading. According to some of these authors [17]Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51. the most frequent problem during menopause would be UI e, specifically, l'Exercise UI would seem to constitute the typology more widespread [18]Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51..
Severe obesity and/or excessive weight changes.
The prevalence of obesity is increasing worldwide, with significant negative implications on health. Obesity is associated with low-grade systemic inflammation and the release of proinflammatory cytokines. This context alters collagen metabolism and, in combination with increased intra-abdominal pressure, contributes to the development of UI. Weight loss can reduce UI and, Non-motor symptomsn those patients who present a clear overweight condition, should be included among the objectives of a therapeutic project aimed at the rehabilitation of UI[19]Doumouchtsis, S. K., J. Loganathan, and V. Pergialiotis. – The role of obesity on urinary incontinence and anal incontinence in women. A review. – BJOG: An International Journal of… Continue reading.
Diabetes.
Diabetes can cause UI through several mechanisms[20]Feeney, Catherine, et al. – Lower urinary tract dysfunction in adult patients with mitochondrial disease.- Neurourology and urodynamics 39.8 – 2020 – 2253-2263., among which:
- l’hyperglycemia. This causes an increase in urine volume and an increase in the activity of the detrusor muscle, with time, undergoes alterations that determine a dysfunctional condition.
- The diabetic cytopathy and the damage to the detrusor nerve
Chronic bronchitis and asthma.
UI is more common among patients with COPD (Chronic Obstructive Pulmonary Bronchopathy) that among people who are not affected and lThe prevalence of UI increases with increasing severity of the disease.Chronic cough in fact, which is a very common symptom in COPD, involves greater stress on the pelvic floor due to continuous sudden increases in intra-abdominal pressure, thus undermining its stability.
The specific scientific literature on this topic states that “Urinary incontinence screening should be considered in patients with COPD and generally with impaired lung function[21]Burge, Angela T., et al. – Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease. A questionnaire survey.- Physiotherapy 103.1 – 2017 – … Continue reading”.
Pelvic or abdominal surgeries.
All those interventions that risk compromising the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system can be a potential cause of UI. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
Very intense sporting activity.
Exertional UI is considered the most commonpelvic floor dysfunction in female athletes[22]Dieter, Alexis A., Maggie F. Wilkins, and Jennifer M. Wu. – Epidemiological trends and future care needs for pelvic floor disorders. – Current Opinion in Obstetrics and Gynecology 27.5… Continue reading[23]Goldstick, Orly, and Naama Constantini. – Urinary incontinence in physically active women and female athletes. – British journal of sports medicine 48.4 – 2014 – 296-298.[24]Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – … Continue reading.
A systematic literature review with meta-analysis carried out in 2020[25]Pires, Thelma, et al. – Prevalence of urinary incontinence in high-impact sport athletes. A systematic review and meta-analysis. – Journal of Human Kinetics 73 – 2020 – 279. he highlightedthat the prevalence of exertional UI among female athletes is equal to 20,7% is thatin high impact sports on average it reaches 25,6%. Thehigher prevalence was observed in volleyball: 75,6%.
The most plausible explanation for thesehigher rates is that intense physical activity involves repeatedsudden and/or prolonged increases in intra-abdominal pressure and in the long termthey can weaken the pelvic floor, compromising its tightness[26]Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – … Continue reading[27]Santos, Keyla Mara, et al. – Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes.- International urogynecology journal 30 – 2019 – … Continue reading[28]Dosde Mattos Lourenco, Thais Regina, et al. – Urinary incontinence in female athletes. A systematic review. – International urogynecology journal 29 – 2018 – 1757-1763..
Heavy work activities.
The same considerations made for very intense sporting activities apply.
Trauma to the coccyx or pelvis.
In some cases, UI can be the consequence of trauma to the coccyx[29]Stude, David E., Thomas F. Bergmann, and Bradley A. Finer. -A conservative approach for a patient with traumatically induced urinary incontinence. – Journal of Manipulative and physiological… Continue reading or the pelvis[30]Pachcinski, Olaf, et al. – Treatment of female stress urinary incontinence after pelvic trauma.- GYNECOLOGY 95.5 – 2024 – 416-417.[31]with earrings, Bora, Yakup Kordan, and Turgut Alkibay. – Urinary incontinence after pelvic trauma: a case report. – International Urology and Nephrology 32 – 2001 – 363-365. that has compromised the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
MAIN CAUSES OF EMERGENCY URINARY INCONTINENCE:
Neurological disorders.
…
Chronic inflammatory forms of the bladder
When the bladder is inflamed, “reacts before its actual filling, giving a stimulus that cannot be controlled by the voluntary muscles which can lead to urine loss in women of all ages, but especially in postmenopausal women[32]https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza“.
Menopause or hormonal dysfunction.
Estrogen hormones help regulate the functioning of the neurotransmitters responsible for the stimulation/inhibition mechanisms that underlie urination[33]https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza.
Spinal pathologies:
Radicolopathy[34]Captain, Hulagu, et al. – The association between urinary incontinence and low back pain and radiculopathy in women. – Open access Macedonian journal of medical sciences 4.4 – 2016 … Continue reading. E’ A statistically significant correlation was found between both radiculopathies and unspecified UI and emergency UI.
Low back pain[35]Eisenstein, S. M., D. J. Engelbrecht, and W. S. El Masry. – Low back pain and urinary incontinence. A hypothetical relationship. – Spine 19.10 – 1994 – 1148-1152.. E’ A rare association between severe low back pain and urge incontinence was found, not explainable on the basis of any conventional neurological or genitourinary pathology.
Stenosis of the lumbar spinal canal[36]Gandhi, Jason, et al. – Neuro-urological sequelae of lumbar spinal stenosis. – International Journal of Neuroscience 128.6 – 2018 – 554-562.. Narrowing of the spinal canal at this level can damage the nerve structures contained within it. In this case, symptoms affecting the genitourinary system may occur, including emergency UI.
Spina bifida
Spina bifida is a congenital pathology due to an incomplete closure of one or more vertebrae of the spine and the membranes surrounding the spinal cord. Depending on the structures involved, it is called occult bifid, meningocele and myelomeningocele.
Trauma to the coccyx or pelvis.
Traumas that compromise the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system can lead to dysfunction. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
REHABILITATION OF URINARY INCONTINENCE
The rehabilitation of urinary incontinence falls within the field of pelvic floor rehabilitation and makes use of the synergy between different types of interventions:
- Behavioral education
- Manual therapy
- Therapeutic exercises
- Aids for: muscle strengthening; perineal massage; treatment of deep trigger points; containment of prolapses
- Instrumental therapy
Note
| ↑1 | Urology. Francesco Porpiglia. Minerva Medica Editions. 2015 |
|---|---|
| ↑2 | Abrams, Paul, et al. – The standardization of terminology of lower urinary tract function. Report from the standardization sub-committee of International Continence Society. – Textbook of Female Urology and Urogynecology. CRC Press, 2010. 1098-1108 |
| ↑3, ↑5 | Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32. |
| ↑4 | Harris, Shauna, Stephen W. Leslie, and John Riggs. -Mixed urinary incontinence.- StatPearls -Internet-. StatPearls Publishing, 2024. |
| ↑6 | https://www.aiugstudies.it/lineeguida/commissione1/2/. Pathopathology of urgent urinary unconstitution – M.meschia, P. Piparies, U. Gattei, F. Baruffi, P. Cavoretto Specialized Service of Uruoginecology Department of Obstetrics and Gynecology, University of Milan Institute L. Mangiagalli, Via della Commenda 12, Milano |
| ↑7, ↑8 | Which, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicine 59.1 – 2022 – 5. |
| ↑9 | https://www.aiugstudies.it/lineeguida/commissione1/2/. Pathopathology of urgent urinary unconstitution – M.meschia, P. Piparies, U. Gattei, F. Baruffi, P. Cavoretto Specialized Service of Uruoginecology Department of Obstetrics and Gynecology, University of Milan Institute L. Mangiagalli, Via della Commenda 12, Milano |
| ↑10, ↑11, ↑12 | Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. |
| ↑13 | trash, Abdulmaged M., et al. – Role of androgens in female genitourinary tissue structure and function. Implications in the genitourinary syndrome of menopause.- Sexual Medicine Reviews 6.4 – 2018 – 558-571. |
| ↑14 | God, Ahmad Hasan, et al. – The Link Between Menopause and Urinary Incontinence: A Systematic Review.- Cureus 16.10 2024 – e71260. |
| ↑15 | Singh S, Baranwal K, Wound I, Khan IA, Bajpai S – Sociodemographic determinants of urogenital morbidities among menopausal women in rural areas of Eastern Uttar Pradesh. Cureus. 2023, 15 – e46677. 10.7759/cureus.46677 |
| ↑16 | Morals and, Delgado JL, Carmona F, et al. – Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study. Climacteric. 2018, 21 – 167-73. 10.1080/13697137.2017.1421921 |
| ↑17, ↑18 | Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51. |
| ↑19 | Doumouchtsis, S. K., J. Loganathan, and V. Pergialiotis. – The role of obesity on urinary incontinence and anal incontinence in women. A review. – BJOG: An International Journal of Obstetrics & Gynaecology 129.1 -2022 – 162-170. |
| ↑20 | Feeney, Catherine, et al. – Lower urinary tract dysfunction in adult patients with mitochondrial disease.- Neurourology and urodynamics 39.8 – 2020 – 2253-2263. |
| ↑21 | Burge, Angela T., et al. – Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease. A questionnaire survey.- Physiotherapy 103.1 – 2017 – 53-58. |
| ↑22 | Dieter, Alexis A., Maggie F. Wilkins, and Jennifer M. Wu. – Epidemiological trends and future care needs for pelvic floor disorders. – Current Opinion in Obstetrics and Gynecology 27.5 – 2015 – 380-384. |
| ↑23 | Goldstick, Orly, and Naama Constantini. – Urinary incontinence in physically active women and female athletes. – British journal of sports medicine 48.4 – 2014 – 296-298. |
| ↑24, ↑26 | Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – Acta Obstet Gynecol Port 9.1 – 2015 – 56-64. |
| ↑25 | Pires, Thelma, et al. – Prevalence of urinary incontinence in high-impact sport athletes. A systematic review and meta-analysis. – Journal of Human Kinetics 73 – 2020 – 279. |
| ↑27 | Santos, Keyla Mara, et al. – Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes.- International urogynecology journal 30 – 2019 – 693-699. |
| ↑28 | Dosde Mattos Lourenco, Thais Regina, et al. – Urinary incontinence in female athletes. A systematic review. – International urogynecology journal 29 – 2018 – 1757-1763. |
| ↑29 | Stude, David E., Thomas F. Bergmann, and Bradley A. Finer. -A conservative approach for a patient with traumatically induced urinary incontinence. – Journal of Manipulative and physiological therapeutics 21.5 – 1998 – 363-367. |
| ↑30 | Pachcinski, Olaf, et al. – Treatment of female stress urinary incontinence after pelvic trauma.- GYNECOLOGY 95.5 – 2024 – 416-417. |
| ↑31 | with earrings, Bora, Yakup Kordan, and Turgut Alkibay. – Urinary incontinence after pelvic trauma: a case report. – International Urology and Nephrology 32 – 2001 – 363-365. |
| ↑32, ↑33 | https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza |
| ↑34 | Captain, Hulagu, et al. – The association between urinary incontinence and low back pain and radiculopathy in women. – Open access Macedonian journal of medical sciences 4.4 – 2016 – 665. |
| ↑35 | Eisenstein, S. M., D. J. Engelbrecht, and W. S. El Masry. – Low back pain and urinary incontinence. A hypothetical relationship. – Spine 19.10 – 1994 – 1148-1152. |
| ↑36 | Gandhi, Jason, et al. – Neuro-urological sequelae of lumbar spinal stenosis. – International Journal of Neuroscience 128.6 – 2018 – 554-562. |