Incontinence is the loss of bladder or bowel control. It affects women of all ages. It is NOT a disease. It is NOT a part of being a woman. It is NOT a consequence of getting old. The statistics are: one out of four women over the age of 40 experiences some degree of incontinence. Over 13 million Americans are affected by it . A patient may dribble only a few drops when they laugh, cough, or sneeze (usually they quickly cross their legs or sit down). They may leak constantly or empty their entire bladder without any warning. Therefore, the problem has social implications. They may stop leaving the house, going for car rides, exercising, or having sexual intercourse. It has been estimated that approximately 2% of health care costs in the U.S. are spent on incontinence-related care. Usually, patients will start out using Mini or Maxi pads and may progress to using adult diapers. The cost of these products is about £1.00 each. If a patient uses 2-3 a day, the expense can amount to £730 to £1,095 per year.
Medical costs due to the problem of incontinence are estimated at $10 billion per year in the United States. Currently, the Agency for Health Care Policy and Research recommends a non-surgical attempt in nearly all patients with stress incontinence. There are different types of incontinence: Stress, Urge, Overflow or a combination of types. The most common type is stress urinary incontinence (SUI). Stress urinary incontinence is the involuntary loss of urine with physical activity such as coughing, sneezing, laughing, jogging or aerobics.The trauma of childbirth and aging cause a partial interruption in the nerve impulse route (denervation), resulting in a decrease or even no transmission of impulses through the pathways to the pelvic floor muscles. The muscle tissue so denervated, atrophies and becomes weaker.
The levator ani muscles support the pelvic organs and forms the platform to which the pelvic ligaments are attached. Delayed conduction of impulses to the pelvic floor muscles are seen in women with SUI.
At the level of the urethra, urinary continence exists when pressure in any part of the urethra is the same or greater than the pressure in the bladder. Conversely, when the pressure is lower in the urethra than in the bladder, urinary incontinence occurs.
Stress urinary incontinence may be due to intrinsic sphincter deficiency (ISD), affecting patients with impaired sphincter function. For women with ISD and a lack of urethral mobility, periurethral bulking agents such as collagen injections provide a successful alternative to abdominal or vaginal surgery.
Genuine stress incontinence (GSI), one of the most common causes of stress urinary incontinence is primarily due to hypermobility of the urethra. An alternative to surgery for the woman with GSI due to hypermobility of the urethrovesical junction, is the use of an incontinence pessary. “The pessary restores continence by stabilizing the bladder base, allowing proper pressure transmission to the urethra, and by active enhancement of urethral resistance through significantly increased urethral functional length and closure pressure.”
Pessaries are used therapeutically as an alternative to surgical repair in those patients where surgery is contraindicated. Frail elderly women, those with major health problems, young women who plan to have more children in the future as well as those women who refuse to have surgery, are all candidates for pessary use.
Pessaries are also used preoperatively as a test in patients with marked cystocele, vaginal vault prolapse, or procidentia to determine if, when these conditions are corrected with a pessary, the patient develops stress incontinence. This will help determine if correction of the urethrovesical junction defect at the time of surgery for prolapse should be performed.
The type of pessary you choose for a given patient is determined by the anatomic defect and the symptoms exhibited by the patient.
All incontinence pessaries should be fit before the patient empties her bladder.
A diagnostic test is performed to help determine if the patient would benefit from an incontinence pessary.
This is known as the Marshall-Marchetti, or Modified Mayo Test.
1. Patient with a full bladder standing in an erect position is asked to cough.
2. If short spurts of urine escape simultaneously with each cough, SUI is suggested.
3. The bladder neck is elevated with one finger on each side of the urethra and the patient is asked to cough.
4. If there is no loss of urine when the patient coughs, the test is considered to be positive and the patient would benefit from using a pessary device.
Experience has shown that in order to properly fit a pessary, you should have at least one of each of the four most commonly used sizes in any given pessary.
Fit patient with the largest size pessary that can be inserted without causing any undue patient discomfort.