Urinary Incontinence in the Young Woman: Treatment Plans and Options Available

Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study

OBJECTIVE

To investigate the pelvic floor changes in primiparas with postpartum stress urinary incontinence (SUI) after vaginal delivery using pelvic floor MRI.

MATERIALS AND METHODS

Fifty-two women were enrolled in the primiparous stress urinary incontinent (PSUI) group and 51 in the primiparous continent (PC) group. Thirty nulliparas were also recruited as the nulliparous control (NC) group. Levator ani muscle (LAM) injury, levator hiatus area (LHA), H-line, M-line, the distance from the bladder neck and cervix to the pubococcygeal line (B-PCL and U-PCL), levator plate angle, the anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, functional urethral length, and a bladder neck funnel were evaluated on MRI images. Univariate and multivariate logistic regression analyses were used to explore anatomical predictors for SUI.

RESULTS

The primiparas in the PSUI group showed more obvious LAM injuries than in the PC groups (p = 0.001). LAM function assessment: the PSUI group had larger LHA and shorter B-PCL and U-PCL than the other groups during straining. Assessment of urethral mobility and function: the PSUI group had larger anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, and shorter functional urethral length than the other two groups (all p < 0.05). Up to 88.5% of primiparas in the PSUI group showed bladder funnel (p < 0.001). The logistic regression analysis showed that retrovesicourethral angle, functional urethral length, and the presence of bladder funnel were significantly associated with postpartum SUI (p < 0.05).

CONCLUSIONS

Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel may be anatomical predictors for SUI in the early postpartum period. Urethral sphincter dysfunction plays an essential role in developing postpartum SUI.

CRITICAL RELEVANCE STATEMENT

This study used several measurements to reflect the anatomical structure and functional changes of the pelvic floor to identify the best anatomical predictors associated with postpartum stress urinary incontinence (SUI), aiming to provide new insights into treatment strategies for postpartum SUI.

KEY POINTS

• Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel are more commonly seen in primiparas with SUI. • The combination of retrovesicourethral angle, functional urethral length, and bladder funnel had the highest diagnostic performance in predicting postpartum SUI (AUC=0.947). • Urethral sphincter dysfunction may be the main pathophysiological foundation in SUI development.

Therapeutic massage in women with stress urinary incontinence: a pilot study

Background: Stress incontinence affects 25–60% of women of all ages and causes constant discomfort, significantly lowering quality of life. The most common causes of urinary incontinence are weakened sphincter muscles or bladder failure. Aim of the study: The aim of this study was to assess the effectiveness of therapeutic massage therapy for stress urinary incontinence and to determine whether therapeutic massage can restore the normal function of the bladder sphincters. Material and methods: The study involved eleven women with a diagnosis of primary stress urinary incontinence, aged 50–79 years. The women attended therapeutic massage sessions twice a week for four weeks. A sanitary pad test was performed before starting and immediately after ending the therapy to verify its effectiveness. Results: In eight women, the amount of urine that leaked decreased after therapy. This result was statistically significant (p = 0.02). In three cases, urine leakage was reduced to zero. Conclusions: Therapeutic massage, acting locally, improves the function of the bladder sphincters, their flexibility and the ability to contract and relax. Massage eliminates or significantly reduces the symptoms of stress urinary incontinence.

Regenerative potential of human dental pulp stem cells in the treatment of stress urinary incontinence: In vitro and in vivo study

OBJECTIVES

To evaluate the regenerative potential of human dental pulp stem cells (hDPSCs) in an animal model of stress urinary incontinence (SUI). SUI, an involuntary leakage of urine, is due to physical stress involving an increase in bladder pressure and a damage of external urethral sphincter affecting muscles and nerves. Conventional therapies can only relieve the symptoms. Human DPSCs are characterized by peculiar stemness and immunomodulatory properties and might provide an alternative tool for SUI therapy.

MATERIALS AND METHODS

In vitro phase: hDPSCs were induced towards the myogenic commitment following a 24 hours pre-conditioning with 5-aza-2'-deoxycytidine (5-Aza), then differentiation was evaluated. In vivo phase: pudendal nerve was transected in female rats to induce stress urinary incontinence; then, pre-differentiated hDPSCs were injected in the striated urethral sphincter. Four weeks later, urethral sphincter regeneration was assayed through histological, functional and immunohistochemical analyses.

RESULTS

Human DPSCs were able to commit towards myogenic lineage in vitro and, four weeks after cell injection, hDPSCs engrafted in the external urethral sphincter whose thickness was almost recovered, committed towards myogenic lineage in vivo, promoted vascularization and an appreciable recovery of the continence. Moreover, hDPSCs were detected within the nerve, suggesting their participation in repair of transected nerve.

CONCLUSIONS

These promising data and further investigations on immunomodulatory abilities of hDPSCs would allow to make them a potential tool for alternative therapies of SUI.

Effects of RSC96 Schwann Cell-Derived Exosomes on Proliferation, Senescence, and Apoptosis of Dorsal Root Ganglion Cells In Vitro

Background

Stress urinary incontinence is a common condition in women and can be associated with peripheral nerve injury. Exosomes. derived from Schwann cells, can enhance the regeneration of axons of the peripheral nervous system. This study aimed to investigate the effects of RSC96 Schwann cell-derived exosomes in a novel in vitro model of dorsal root ganglion (DRG) cell injury induced by cyclic mechanical strain (CMS).

Material/Methods

RSC96 Schwann cells and DRG cells were cultured in vitro. CMS in DRG cells involved mechanical stretch trauma with 5333 μ strain. ExoQuick-TC polymer was used to precipitate exosomes from RSC96 Schwann cell culture medium and identified by nanoparticle tracking analysis, electron microscopy, and Western blot for detection of CD9 and tumor susceptibility gene 101 (Tsg101) protein. Cultured DRG cells were treated with RSC96 Schwann cell-derived exosomes, followed by measurement of cell viability, proliferation, senescence, and apoptosis using the cell counting kit-8 (CCK-8) assay, senescence-associated beta-galactosidase (SA-β-gal) staining, and Hoechst 33258 (blue) fluorescence nucleic acid staining using flow cytometry.

Results

Mechanical stretch with 5333 μ strain for 8 hours at 1 Hz decreased the activity of cultured DRG cells. RSC96 Schwann cell-derived exosomes promoted cell proliferation and significantly inhibited apoptosis and senescence of DRG cells following injury induced by CMS.

Conclusions

An in vitro model of DRG cell injury induced by CMS, showed that RSC96 Schwann cell-derived exosomes had a protective effect. The effects of Schwann cell-derived exosomes on peripheral nerve injury, including in stress urinary incontinence, require future in vivo studies.

An overlooked effect of systemic anticholinergics: alteration on accommodation amplitude

AIM

To investigate the effect of oral solifenacin succinate, tolterodine-L-tartarate and oxybutinin hydrochloride (HCl) on accommodation amplitude.

METHODS

Female overactive bladder syndrome (OAB) patients who were planned to use oral anticholinergics, patients that uses solifenacin succinate 5 mg (Group I, n=25), tolterodine-L-tartarate 4 mg (Group II, n=25), and oxybutinin HCl 5 mg b.i.d (Group III, n=25) and age matched healthy female subjects (Group IV, n=25) were recruited and complete ophthalmological examination and accommodation amplitude assessment were done at baseline and 4wk after initiation of treatment.

RESULTS

The mean age of 100 consecutive female subjects was 51.6±5.7 (40-60)y and there were no statistically significant difference with regard to the mean age (P=0.107) and baseline accommodation amplitude (P=0.148) between study groups. All treatment groups showed a significant decrease in accommodation amplitude following a 4-week course of anticholinergic treatment (P=0.008 in Group I, P=0.002 in Group II, P=0.001 in Group III), but there was no statistically significant difference in Group IV (P=0.065).

CONCLUSION

A 4-week course of oral anticholinergic treatment have statistically significant effect on accommodation amplitude. Clinicians should avoid both overestimating this result, as this would unnecessarily restrict therapeutic possibilities, and also underestimating it which may lead to drug intolerance.

Age-stratified trends in 20 years of stress incontinence surgery in Australia

BACKGROUND

Stress urinary incontinence (SUI) is a common, debilitating condition in Australian women. Since its introduction in 1998-1999, the less invasive mid-urethral sling (MUS) procedure has become the new standard for surgical correction of SUI and overall numbers of continence procedures increased. Trends since 2009 have not been analysed.

AIMS

To identify patterns in the surgical treatment of women with SUI in Australia from January 1994 to December 2014 stratified by age.

MATERIALS AND METHODS

Gender- and age-specific data from Medicare Australia between January 1994 and December 2014 were extracted and the patterns of SUI surgery analysed for the 20-year period. Data on gynaecologists and urologists performing MUS and colposuspension were collected from Department of Human Services.

RESULTS

Following the introduction of MUS, total SUI operations increased with the peak in 2002, a plateau between 2006 and 2011, and a new decline from 2012 onwards. There has been a sustained 51.7% increase in total SUI operations in 75- to 84-year-old women, and a 105.2% increase in women aged over 84. However, SUI operations in 45- to 64-year-olds decreased below pre-MUS baseline in 2014.

CONCLUSIONS

Mid-urethral sling has become the standard SUI procedure being performed in Australia since its introduction in 1999. SUI operations have increased each year for patients aged over 65, with the greatest increase seen in patients aged over 84 - indicating expanded eligibility for SUI surgery in older women. However, since 2010, there has been a fall in SUI operations to below the pre-MUS baseline.

Postmenopausal overactive bladder

Bladder storage symptoms have a severe impact on many areas as regards the quality of life including health-related, social, psychological and working functions. Pharmacotherapy of lower urinary tract stores (LUTS) has been developed to optimize neural control of the lower urinary tract in pathologic states. The bladder can be overactive or underactive. Overactive bladder (OAB) is highly prevalent and is associated with considerable morbidity, especially in aging population. Therefore, an effective treatment of OAB must result in a meaningful reduction in urinary symptoms. Pharmacotherapy for the OAB must be individualized based on the degree of bother, medication side-effect profile, concomitant comorbidities and current medication regimen. Antimuscarinic agents will continue to represent the current gold standard for the first-line pharmacological management of OAB. Alternatively to antimuscarinic therapy, β3-adrenergic receptor agonists, due to their efficacy and favorable adverse event profile, are a novel and attractive option of pharmacological treatment of overactive bladder symptoms. A combination of selective antimuscarinic and β3-adrenergic receptor agonists, agents with the different mechanism of action, gives a new treatment option for the patient with OAB according to its harms profile. A number of putative novel therapeutic agents is under clinical evaluations that may ultimately provide alternative or combination treatment options for OAB in the nearest future.

Female urinary incontinence: effective treatment strategies

Urinary incontinence is a dysfunction that tremendously affects women's quality of life, involving social, emotional and economic aspects. Although various treatments for urinary incontinence have been described, it is important to know which of them are truly effective. This review seeks to determine the current available therapies for women with stress urinary incontinence and overactive bladder syndrome, based on the best scientific evidence.