Urogynecology

What is urogynecology?

The ability to control urination in women is dependent on complex function of the nervous system, urinary bladder, urethra and pelvic floor. Any defect in this system can lead to urinary incontinence. This is a very common occurrence in women, which can usually be treated using a range of conservative and surgical treatments. The field that deals with these problems in women is called urogynecology.

Urogynecology is a relatively new field within gynecology, which began to develop some 25 years ago, and is one of the four fields included within gynecology (obstetrics, fertility, oncogynecology and urogynecology).

About 20% of women over the age of 18 suffer from this problem, which constitutes an international health issue from which some 50 million women suffer in the Western world.

How does urinary incontinence come about?

The urinary bladder is a complex organ. It is a muscular sac whose function is to store urine without exertion, without leakage, and to enable urination to occur in a complete manner when voluntarily initiated. In order to meet these requirements, the bladder requires proper anatomical support and normal function of the muscular and nervous systems in the bladder and the urethra.

Normal closure of the urethra (serving as a valve for the urinary bladder) is achieved through the combination of two mechanisms – one “internal” and one “external”. The “external” mechanism includes the system of pelvic floor muscles and its connective tissues that support the bladder and urethra. This system generates support for the urethra and responds to day-to-day activities performed by the woman that cause increased intra-abdominal pressure (coughing, laughing, sneezing and physical activity) and enables the urethra to be closed. If this support mechanism is damaged, there is loss of support of the urinary bladder and urethra, with the development of a condition called anatomic hypermobility of the urethra and bladder. For many women, this loss of support is sufficiently severe to cause loss of closure of the lower urinary tract during activities that increase intra-abdominal pressure, and urine leakage occurs on exertion.

The “internal” mechanism that contributes to the closure of the urethra is composed of the muscular system and the nervous system, constituting the “urethral sphincter”. Impairment of damage of this system could of itself cause inability of the urethra to serve as a closure valve against urine leakage.

Definitions and types of urinary incontinence in women

Disorders of urination include: disorders of urine storage (involuntary urine leakage – such as “stress urinary incontinence” and “overactive bladder”) and disorders of emptying and of sensation (urgency, frequency and pain).

Urinary incontinence is generally defined as “a complaint of any involuntary urine loss”. 5-10 percent of older women (from age 55) have severe urinary incontinence in their everyday lives, causing a dramatic and negative change in their quality of life. Many women in this group suffer deterioration in their self confidence. Urinary incontinence is an international phenomenon, and it is estimated that about one third of adult women (over the age of 40) suffer from urinary incontinence at least once a week. In spite of the difficulty and the impairment in quality of life, many women avoid discussing and revealing these disorders. Some feel embarrassment or shame and suffer in silence; others do not bring the topic up due to the incorrect perception that treatment is ineffective.

The extent to which the woman is bothered by this is influenced by many factors, such as cultural values, expectations, living environment and physical activity. Urinary incontinence can almost always be improved and even cured by simple means. Therefore, if the urinary incontinence is perceived by the woman as disturbing, an investigation can and should be performed, and treatment offered.

The common types of urinary incontinence in women are:

• Stress urinary incontinence (in some 50% of women suffering from urinary incontinence),
• Urge incontinence (overactive bladder syndrome- some 20%)
• Mixed incontinence (stress urinary incontinence and symptoms of overactive bladder syndrome) occurring in combination in the same woman (some 30%).

Stress urinary incontinence occurs during episodes of increased intra-abdominal pressure that appear in everyday life, such as coughing, sneezing or physical activity, in which the pressure exerted on the urinary bladder is much higher than the pressure closing the urethra. Stress urinary incontinence is the most common type of urinary incontinence in women, is not a problem of older age and is particularly common in young and middle aged women.

Active women are anticipated to suffer more from symptoms of stress urinary incontinence. The common physical activities that could cause urine loss are: jumping, running, dancing, brisk walking and sports activities such as a game of tennis, i.e. routine daily activities. Many women are forced to abandon physical activities such as jogging, dancing and aerobic exercise when they experience stress urinary incontinence. Limiting these activities can reduce the problem of incontinence, but at the expense of impaired quality of life.

Even though stress urinary incontinence is the most common type of incontinence in women, urge incontinence (“overactive bladder syndrome”) is the most common type of urinary incontinence in older women, and is defined as involuntary loss of urine that occurs together with or preceded by a sensation of urgency to urinate. These women may experience increased frequency of urination during the day and at night. This problem is caused by uncontrolled contractions of the urinary bladder, and constitutes a manifestation of a defect of the neural control of the urinary bladder.

What are the causes of a defect of the neural control of the urinary bladder?

Among the causes, one may list pregnancy and vaginal delivery, the genetic quality characteristics of the pelvic tissues, obesity and age. The genetic factor that is responsible for the quality of the connective tissue that supports the urinary bladder and urethra has a significant role in the occurrence of the problem in some women. Pregnancy and childbirth could expose women to stress urinary incontinence, the mechanism in this case being damage to the supportive tissue at the pelvic floor and to the urethral sphincter mechanism – as a result of vaginal delivery. This is explained by damage to and stretching of muscle fibers, connective tissue and nerves of the lower urinary tract and pelvic floor. Additional factors that make things worse are smoking and respiratory problems that cause chronic coughing.

At this stage, there is no method for preventing the problem, although it has been claimed that planned Caesarian deliveries may reduce the rate at which the problem occurs.

Assessment and treatment of urinary incontinence

Before recommendations can be made for treatment, an investigation must be carried out, which includes assessment of the severity of the incontinence and the degree to which this impairs daily life and the degree of impairment to the quality of life, including on occasion a urodynamic investigation. Such an investigation is performed in accordance with the woman’s particulars, and is not necessarily required before beginning treatment.

The treatment of involuntary leakage of urine in women may be conservative or surgical, and the therapeutic approach is based on the clinical findings and the degree of disturbance felt by the woman.

It is possible to start with simple measures such as lifestyle changes- e.g. setting fixed times for urinating, cutting down on caffeine consumption, quitting smoking and losing weight. A further simple measure is physiotherapy of the pelvic floor muscles, which can be offered as a first line of conservative treatment for women suffering from urinary incontinence. There is also medicinal treatment for stress urinary incontinence, which works by strengthening the urethral sphincter mechanism.

The most significant treatment of the “overactive bladder syndrome” and of stress urinary incontinence is medicinal treatment using a group of medicines that relax the muscular wall of the urinary bladder. These medicines block receptors in the muscular wall of the urinary bladder, thus reducing contractions and relieving symptoms of urgency, frequency and the need to urinate during the night.

If conservative treatment of stress urinary incontinence is not effective or if there is considerable leakage, as occurs in active middle aged women, the recommended treatment is surgical treatment, in the form of minimally invasive surgery to repair the urethral sphincter mechanism. This operation is called TVT (tension free vaginal tape) implantation.

In this novel surgical technique, which was developed at the end of the 90’s (and which constituted a revolution in this medical field), a synthetic tape is implanted under the mid urethra via the vagina in a minimally invasive operation; an 80-90% complete cure rate of stress urinary incontinence can be achieved. This operation can also help symptoms of the overactive bladder syndrome. This operation constitutes an impressive breakthrough in the past decade as it is minimally invasive- i.e. minimal intervention and penetration into the woman’s body (figure attached), with high efficacy and a high safety profile.

Additional modes of treatment are injection of substances around the urethra to treat stress urinary incontinence, or injection of Botox to the urinary bladder and application of electrical stimulation in severe cases of overactive bladder syndrome.

The significant changes that have occurred in the field in recent years are the introduction of the use of tiny synthetic mesh implants (TVT) to treat stress urinary incontinence, and improved understanding of medicines for the treatment of overactive bowel syndrome.

One may anticipate that the next decade will bring developments and improvements in the field of minimally invasive implants and in the ability to provide more effective medicines. Also, it is possible that treatments will be introduced that are based on the use of stem cells, which is currently in its initial stages.

Position of the TVT (tension free vaginal tape) for correction of stress urinary incontinence, implanted via the vagina and supporting the mid urethra, seen in a side view of the pelvis.