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Urinary Incontinence, Non-Surgical AestheticTreatments©By Dr. Nadia Yousri, OB&GY&Sexual Wellness

Updated: Oct 25

By Dr. Nadia Yousri, FRCOG, MRCOG, PhD & MSc, DFSRH, OB&GY Surgeon, Sexual Medicine & Aesthetic Regenerative Gynaecology Consultant, published on 21/02/2021. Copyrights© are fully reserved to www.drNYaesthetics.com©®


Introduction:

Urinary incontinence is when urine leaks involuntarily from the bladder 1, 2. The severity ranges from occasionally leaking to having an urge to urinate that’s so sudden and strong leak before reaching toilet in time. Urinary incontinence has a negative impact on the woman’s quality of life that could severely restrict her daily activities. Many women are unable to play sport, run, jump, sneeze or cough without the embarrassment of being incontinent and obliged to use panty liners all the time.

Urinary incontinence is a problem in up to 40% of women, that happens commonly after childbirth and menopause but may affect women of all ages during life situations.





What are the types of urinary incontinence?


(A) Stress Urinary Incontinence (SUI): Urine leaks on straining (i.e Valsalva’s Maneuver that is the sudden rise of intraabdominal pressure) or exertion of pressure on the bladder, like in coughing, sneezing, laughing, or exercising typically leads to urine leakage involuntarily.

it usually caused by weakness in the support of the bladder neck or urethral sphincter (weak pelvic floor muscles with prolapse/sagging of the pelvic organs. The pelvic floor muscles are controlling the urine outflow and becomes weak after childbirth (mechanical or due to direct birth injuries) or at menopause (with atrophy of the supporting tissues as a result of aging process & declining levels of Oestrogen/Feminine hormone).


(B) Urge incontinence (UI): urine leakage after a sudden urge/desire to pass urine but you leak on your way to toilet. This is could be caused by lower urinary tract infection or bladder stone or due to dysfunction in bladder control mechanism so the bladder wall contracts overpowering your voluntary control & overcoming the urethral closing pressure (formed by the urine tube/bladder neck angle /sphincter muscle resting tone) causing some urine to leak through the urine tube opening (the urethra) against the will & without being able to stop it (called Overactive Bladder OAB, Detrusor Instability). OAB causes might be nerve damage from injury or pelvic surgery, bladder stones, diabetes, kidney disease, side effects of some drugs, and neurologic disorders like Parkinson's disease, stroke, or multiple sclerosis. But often, the cause of OAB is a mystery!


(C) Total incontinence: (Interstitial Cystitis), when the bladder fails to store urine because of the walls are not able to expand to accommodate the normal capacity of urine storage volume (~250 ml), which causes you to pass urine constantly or have frequent leaking. This is usually due to chronic inflammatory conditions affecting the bladder wall called Interstitial Cystitis that has controversial etiology.


(D) Urinary incontinence that happen due to chronic irritation of the base of the bladder as caused by Atrophic changes in the bladder wall at menopause (Senile Trigonitis) or due to constant mechanical pressure on the bladder base by an enlarged fibroid uterus limiting the storage capacity or by presence of pocket of residual urine. (In Pregnancy, the growing uterus constantly exerts pressure on the bladder, therefore there is tendency to frequent urination or even urine leakage during pregnancy).


E) Overflow incontinence is the involuntary release of urine due to a weak bladder muscle or to blockage, thence the bladder becomes overly full, and leaks even though the person feels no urge to urinate. overflow incontinence is more common in men than women. The most common cause in men is an enlarged prostate, which impedes the flow of urine out of the bladder. Other possible causes of overflow incontinence include:

  • Blockages of the urethra (the tube that carries urine from the bladder to outside the body) from tumors, urinary stones, scar tissue, swelling from infection, or kinks caused by dropping of the bladder within the abdomen

  • Weak bladder muscles, which are unable to squeeze the bladder empty

  • Injury of nerves that affect the bladder

  • Nerve damage from diseases such as diabetes, alcoholism, Parkinson's disease, multiple sclerosis, back problems/back surgery, or spina bifida

  • Medications, including some anticonvulsants and antidepressants, that affect nerve signals to the bladder.

Urinary incontinence: Causes? Here is a variety of factors 1, 2:

Surgery: some women who have hysterectomy or prolapse repair suffer from incontinence afterwards.

Pregnancy and childbirth: a vaginal delivery can cause damage to pelvic nerves and muscles, resulting in an overactive bladder. Instrumentally assisted delivery (by forceps or Suction Ventouse) leads to stretch of the pelvic supportive ligaments and connective tissue with loss of elasticity-weakness and sagging of the bladder neck with the uterus or the vaginal walls. (Cystocele, Cysto-urothrocele)

Obesity: excess body weight increases abdominal pressure which in turn increases bladder pressure and mobility of urethra.

Menopause: menopause can cause the pelvic floor muscle to weaken and the bladder lose its elasticity.

Chronic cough: by causing the pelvic floor muscle to relax momentarily and leakage of urine.

Chronic constipation an over-full bowel (due to constipation) can press on the bladder, reducing the amount of urine it can hold.

Gynecological factors like uterovaginal prolapse (sagging) or pressure by large tumors like fibromyomas or an ovarian cyst or in distortion caused by endometriosis.



Urinary Incontinence, How, Who to do the Assessment? By Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant


It is prudent to identify the type/cause of urinary incontinence accurately in order to devise the suitable treatment plan. The assessment ideally should be carried out by a highly qualified & experienced OB&GY Specialist/Consultant who is knowledgeable on the standards of ICS & able to have a holistic & specialized "Uro-Gynae Evaluation", select cases' suitablity to a matching procedure(s) & personalise the treatement plan to maximise the success rate.


Urinary Incontinence, What Does Assessment entail?


Taking full medical history: demographic, Obstetric, Gynaecological including info on lifestyle or daily habits, etc

Urine analysis: it is an office procedure or at the lab where a mid-stream urine sample is checked for signs of infection, traces of blood or other abnormalities.


Bladder diary: record of how much you drink and urinate for several days and whether you had an urge to urinate.

Post-void residual measurement: using ultrasound machine to measure the amount (volume) of urine leftover remained in your bladder following urination.


Cystometry, Uroflowmetry, Urodynamic studies; that is the bladder function tests using very fine catheters threaded into to the urine tube to measure the pressure changes inside the bladder wall and interpreted against the changes in pressure inside the tammy (intraabdominal pressure) gauged by another fine catheter that is passed through the back passage opening. The graphs of both pressures are recorded during urine provocation tests and during passing urine.


Urinary Incontinence; What Are the Treatment Options?


(A) Conservative- life style Recommendations

1- Do pelvic floor exercise (Kegel’s exercises) to strengthen pelvic floor muscles.

2- Stop smoking & treat chronic coughing that puts strain on pelvic floor muscles

3- Reducing the amount caffeine & spicy food [NICE guidelines 123]

4- Bladder training

- Avoid lifting which puts strain on pelvic floor muscles.

- lose excess weight since being overweight cause pressure of fatty tissue on your bladder.

- Treat constipation promptly to preserve pelvic floor muscles.


(B) Medicinal Treatment

Anticholinergics are the most common OAB medications. You take them by mouth at least once a day. Topical Oestrogen; vaginal rings, tablets, or creams are also prescribed to treat women's OAB symptoms.


(C ) Surgical interventions: As indicated, advised & performed by an experienced Gynaecologist after full clinical assessment & counselling about the success rate, risks, potential complications, and recurrence rate.

Prolapse treatment procedures include anterior colporrhaphy, posterior colporrhaphy or colpoperineorrhaphy, autologous sling grafts (artificial mesh procedures are prohibited), laparoscopic colposuspension, (vaginoplasty) with or without hysterectomy, others like Clam’s procedure, etc.


(D) Minimally invasive/ office procedures: Cystoscopic Neurotoxin injection (Botulinum A) 3-7 into the bladder muscle wall [intravesical] at partially paralyzes it to ease overactivity but leaves enough control. Also, can use injection of sclerotic fillers into the bladder neck.


(E) Non-surgical options

An initial full Gynaecological assessment by an expert Gynaecologist is crucial for case selection. These non-surgical procedures are strongly advised & recommended to be performed by the efficient Gynaecologist who knows best in the microanatomy & physiology of this feminine area. Hence, The experienced Gynaecologist knows best; capable to select the ideal procedure to achieve the highest possible success rate according to the individual variations and circumstances.


1- Non- Surgical “Aesthetic”/Regenerative Gynaecology Procedures, What are they?

i-Laser treatment8-10

Laser therapy has been proven to be successful in treating disorders affected by collagen damage by promoting the synthesis of collagen in the connective supporting endopelvic fascia/tissues around the bladder outlet with excellent safety record.

Laser therapy stimulates blood flow to the affected areas, bringing healing and rejuvenation to the pelvic floor muscle, vaginal walls and urethra. The increased blood flow and better tissue tone leads to a better urinary function.

A laser beam is aimed at the area to stimulate the body’s healing repose and production of collagen and elastin which are essential components of healthy cells.


ii-Radiofrequency treatment 11, 12,

A temperature-controlled radiofrequency generating machines are used for treatment of mild to moderate urinary incontinence (as selected by an experienced Gynaecologist) that help tightening the underlying connective & supportive tissues of the vagina, urethra and tissues beneath the bladder.


iii-Platelets’ Rich Plasma injection 13-15

The autologous platelet-rich plasma (PRP) wether the one known as “O” Shot or Urethral PRP injection are safe and effective in increasing urethral resistance and improving SUI. PRP could be an alternative treatment modality for male and female patients with moderate SUI due to non-neurogenic causes.


iv- Other Autologous Cell grafts: like Stem Cell Therapy & ESWT 16-20

ADSC: adipose-derived stem cell or BMSCs: bone marrow-derived mesenchymal stem cell or human umbilical cord blood stem cells (HUCBs) and total nucleated cells (TNCs) are directly & locally injected into the urethra/ bladder neck in SUI. Studies showed that the median improvement rate of intrinsic sphincter deficiency after ADSCs, MDSCs, TNCs, HUCBs injections were 88%, 77%, 89%, 36% (improvement rate: 1-2 pads) at a mean (range) follow-up of 6 (1-72) months. The cell sources, methods of cell processing, cell number, and implantation techniques differed considerably between studies. Most of the periurethral injections were at the 3, 5, 7, and 9 o'clock positions and for submucosa were at the 4, 6, and 8 o'clock positions. No significant postoperative complications were reported.

Recently ESWT is found very useful in treatment of intractable cases of Interstitial Cystitis in both genders



Prepared by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant©


Dr. Nadia YOUSRI,

FRCOG, MRCOG, PhD, MSc & DFFP in OB&GY & Regenerative Sexual Aesthetics Consultant Expert & Cosmetic Specialist


YouTube: Dr. Nadia Yousri: https://youtu.be/PdTObUhTnyo



References


1-Urinary Incontinence in Women: A Review, Emily S Lukacz 1, Yahir Santiago-Lastra 2, Michael E Albo 2, Linda Brubaker. JAMA, 2017 Oct 24;318(16):1592-1604.

2- Urinary incontinence in women. A Review, Lauren N Wood &, Jennifer T Anger, BMJ. 2014 Sep 15;349: g4531.


3- OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. Cindy L Amundsen etal, JAMA, 2016 Oct 4;316(13):1366-1374

4- OnabotulinumtoxinA vs Sacral Neuromodulation for Urgency Incontinence. Blok BF, .JAMA. 2017 Feb 7;317(5):534-535..

5-OnabotulinumtoxinA vs Sacral Neuromodulation for Urgency Incontinence. McCauley JF, Gonzalez HM, Osborn DJ. JAMA. 2017 Feb 7;317(5):535.

6-Re: OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. Cornu JN. Eur Urol. 2017 Jun;71(6):988-989.

7-Re: OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. Wein AJ. .J Urol. 2017 Jun;197(6):1524-1525.


8-BotulinumtoxinA for overactive bladder. [No authors listed]. Med Lett Drugs Ther. 2013 Apr 15;55(1414):31-2


9-Open-label study evaluating outpatient urethral sphincter injections of onabotulinumtoxinA to treat women with urinary retention due to a primary disorder of sphincter relaxation (Fowler's syndrome).Panicker JN, Seth JH, Khan S, Gonzales G, Haslam C, Kessler TM, Fowler CJ.BJU Int. 2016 May;117(5):809-13.


10-Fractional CO(2) laser for treatment of stress urinary incontinence.

Behnia-Willison F, Nguyen TTT, Mohamadi B, Vancaillie TG, Lam A, Willison NN, Zivkovic J, Woodman RJ, Skubisz MM..Eur J Obstet Gynecol Reprod Biol X. 2019 Jan 11;1:100004


11-Laser Therapy in the Treatment of Female Urinary Incontinence and Genitourinary Syndrome of Menopause: An Update.

Franić D, Fistonić I. Biomed Res Int. 2019 Jun 4;2019:1576359


12-Laser therapy for the restoration of vaginal function.

Gambacciani M, Palacios S. Maturitas. 2017 May; 99: 10-15.


13-Radiofrequency for the treatment of stress urinary incontinence in women.

Dillon B, Dmochowski R.Curr Urol Rep. 2009 Sep;10(5):369-74.


14-Noninvasive Vaginal Rejuvenation: Radiofrequency Devices.

Hoss E, Kollipara R, Fabi SSk. inmed. 2019 Nov 1;17(6):396-398


15-Promising impact of platelet rich plasma and carbon dioxide laser for stress urinary incontinence. Behnia-Willison F, Nguyen TTT, Norbury AJ, Mohamadi B, Salvatore S, Lam A.Eur J Obstet Gynecol Reprod Biol X. 2019 Oct 22;5:100099


16-A pilot study: effectiveness of local injection of autologous platelet-rich plasma in treating women with stress urinary incontinence. Long CY, Lin KL, Shen CR, Ker CR, Liu YY, Loo ZX, Hsiao HH, Lee YC. Sci Rep. 2021 Jan 15;11(1):1584.


17-Therapeutic Efficacy of Urethral Sphincter Injections of Platelet-Rich Plasma for the Treatment of Stress Urinary Incontinence due to Intrinsic Sphincter Deficiency - A Proof of Concept Clinical Trial. Jiang YH, Lee PJ, Kuo HC. .Int Neurourol J. 2021 Jan 19. doi: 10.5213/inj.2040272.136. Online ahead of print.PMID: 3350412

https://pubmed.ncbi.nlm.nih.gov/33504126/


18-Stem cell applications in regenerative medicine for stress urinary incontinence: A review of effectiveness based on clinical trials.

Barakat B, Franke K, Schakaki S, Hijazi S, Hasselhof V, Vögeli TA. Arab J Urol. 2020 Apr 17;18(3):194-205


19-Cell therapy for stress urinary incontinence: Present-day frontiers.

Vinarov A, Atala A, Yoo J, Slusarenco R, Zhumataev M, Zhito A, Butnaru D. J Tissue Eng Regen Med. 2018 Feb;12(2): e1108-e1121


20- Interstitial Cystitis-new promising indication for the extracorporeal shock wave therapy? Steffi Kabisch, Dirk Fahlenkam. Urology, 1st Edition March 2013 by H. Tisellius.



Internal Links:

-Vaginal Tightening, Which Treatment for Vaginal Laxity?

https://www.drnyaesthetics.com/post/603aa94bc036e20015db0df2/edit


External links

1-Overactive Bladder: https://www.webmd.com/urinary-incontinence-oab/ss/slideshow-overactive-bladder


2-Urinary Incontinence & Pelvic Organ Prolapse in Women: Management. NICE Guidelines [NG 123], Published date: 02 April 2019, updated 24 June 2019. https://www.nice.org.uk/guidance/ng123


3- Botulinum Toxin for an Overactive Bladder (Scientific Impact Paper No. 42): Royal College of Obstetricians & Gynaecologists: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/sip42/


4-British Society of Urogynaecology (BSUG); BotulinumA Injections To Treat Overactive Bladder; Patient Information Leaflet: https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Botox-BSUG-Dec-2019.pdf


5- British Society of Urogynaecology (BSUG); Urethral Debulking To Treat Stress Urinary Incontinence. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Urethral%20bulking%20BSUG%20Mar%202018.pdf


6-British Society of Urogynaecology (BSUG); Obesity: Effect on the Pelvic Floor, Risk for Surgery. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/info-leaflets/Obesity%20and%20the%20plevic%20floor%20BSUG%20July%202017.pdf


7-Transvaginal Mesh Repair of Anterior or Posterior Vaginal Wall Prolapse. NICE Interventional Procedures Guidance [IPG 599], Published date: 15 December 2017. https://www.nice.org.uk/guidance/ipg599


8- British Society of Urogynaecology (BSUG); Autologous Facial Slings To Treat Stress Urinary Incontinence. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Autologous%20fascial%20sling%20BSUG%20Mar%202018-2.pdf


9-Menopause Matters: https://www.menopausematters.co.uk/tree.php


10-British Society of Urogynaecology (BSUG); https://pcwhf.co.uk/resources/british-society-of-urogynaecology-patient-information-leaflets/


11-Management of Bladder Pain Syndrome. Royal College of Obstetricians & Gynaecologists-Green-top Guidelines, number 70, published on 09 December 2016).

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg70/


12-International Incontinence Society: https://www.ics.org/


13-National Institute for Health and Care Excellence (NICE); Surgery for Stress Urinary Incontinence, Patient Decision Aid. https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress-urinary-incontinence-patient-decision-aid-pdf-6725286110


14-Royal College of Obstetricians & Gynaecologists (RCOG); Recovering After Mid Urethral Sling Operation for Stress Urinary Incontinence. Patient Information. https://www.rcog.org.uk/en/patients/patient-leaflets/mid-urethal-sling-operation-for-stress-urinary-incontinence/


15- Royal College of Obstetricians & Gynaecologists (RCOG); Recovering After Pelvic Floor Repair Operation for Stress Urinary Incontinence. Patient Information https://www.rcog.org.uk/en/patients/patient-leaflets/pelvic-floor-repair-operation/




Internal Links:

1-Vaginal Tightening, Which Treatment for Vaginal Laxity?

https://www.drnyaesthetics.com/post/603aa94bc036e20015db0df2/edit


2-Gynaecology

https://www.drnyaesthetics.com/post/5faacaa77620370017d93ced/


3-Pain During Intercourse (Dyspareunia)-Non-Surgical Treatment

https://www.drnyaesthetics.com/post/5fab09b8770a8b001734ebaa/

4-Pregnancy Stretch Marks-The Tigress' Pattern!©

https://www.drnyaesthetics.com/post/5ce0df4ab8c6b601f51f838e/


5- Why Aesthetic Gynaecology procedures are best performed by a Gynaecologist©

https://www.drnyaesthetics.com/post/why-aesthetic-gynaecology-procedures-are-best-performed-by-a-gynaecologist


6- Can erectile dysfunction really be cured with soundwaves https://www.dailymail.co.uk/health/article-8732429/Can-erectile-dysfunction-really-cured-soundwaves.html


Published by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant©

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