Tension-free Vaginal Tape

Urinary Incontinence

The Risk factors are better known.

There are congenital factors: pelvic floor disorders are less common among black and asian women.

Among the established factors :

  • Obstetrical trama is at the forefront.
  • Pelvic surgery.
  • The pelvic hypertension induced by obesity, constipation or a chronic cough.
  • Menopause.

The care of incontinent patients must undergo a clinical exam and urodynamic :

Urinary incontinence is often multifactorial and sometimes complex. Before any treatment, patients must undergo a clinical exam and urodynamics.
The examination of the patient is crucial in finding the onset mode, the leakage occurance and the functional impairment caused by them. It also identifies other urinary problems that may be associated.
An associated anal incontinance will be systematically checked for.
The clinical exam searches for genital prolapse and the tipping over of the urethrovesical junction from a cough. Urinary leakage while coughing with a full bladder is quantified.
Bonney’s manœuvre, reducing the scale with two fingers placed on either side of the urethra, can predict whether surgery will be effective.
We also quantify the levator muscles of the anus and carry out a perineal neurological exam.
The urodynamic examination will help confirm and quantify the evidence produced by the clinical examination. The test takes about 10 minutes, it is not painful, it entails introducing a probe of small caliber equipped with pressure sensors inside the bladder to measure intravesical and intra-sphincter pressure with a full bladder, at rest and whilst coughing.

After the clinical and urodynamic, three distinct pathologies must be instigated despite their frequent complexity.

  • Stress urinary incontinence from mobility of the urethrovesical junction: is the most common case that we see. During a physical examination, we find a urine leak with coughing and Bonney positive maneuvers. The urodynamic examination is intended to eliminate an unknown instability.
  • Vesical instability: the clinical picture is characterized by unusually frequent urination, the urgent need to urinate accompanied by leaks that often resemble real urination.

The clinical exam searches for involuntary leakages during bladder filling and possible leaks related to the effort. A cytobacteriological urinary analysis is done systematically to eliminate a urinary infection. Cystoscopy is performed to remove an irritating intravesical element. The urodynamic examination is crucial when it highlights peaks of uncoordinated detrusor muscle.

  • Sphincter deficiency: is most often caused by neuromuscular decay of the urethral sphincter by surgical or obstetrical trauma most often found in their history.

There are also neurodegenerative diseases such as multiple sclerosis (MS) or diabetes that may be responsible for the degradation of the urethral sphincter. Finally, certain medication such as neuroleptics may be the cause of sphincter dysfunction.
Clinical examination picks up on major incontinence, permanent day and night. Urodynamic examination confirms sphincter deficiency.

Treatment must be perfectly adapted to the mechanism involved

  • For stress urinary incontinence caused by hypermobility of the urethrovesical junction: When incontinence is mild, treatment is usually started with kinesitherapy of the vesico-sphincter.

When kinesitherapy is ineffective or the incontinence is considered severe, surgical treatment is required. There are a variety of techniques, classified schematically into two groups; the “sling” and “suspension” of the bladder. At present a Swedish technique has replaced all the other conventional techniques : the “Tension-free Vaginal Tape” TVT developed by Dr Ulmsten. This technique involves placing a synthetic mesh sling in position under the urethra, the sling is passed on each side of the urethra behind the pubis to the anterior abdominal wall 1 or 2 cm above the pubis (TVT), or to the root of the thigh through the obturator foramen of the pelvis (TOT or TVT-O).

Tension-free Vaginal Tape

Tension-free Vaginal Tape

TVT-O

TVT-O

This sling works by restoring the support of the urethra.

  • Treatment of urinary incontinence from vesical instability:
    it is often a combination of several therapeutic approaches tailored to each patient that will improve the symptoms:

    • Lifestyle and dietary rules
    • Anticholinergic
    • Behavioural therapy
    • kinesitherapy with electrical stimulation strengthening the pelvic floor and vesical biofeedback

When the vesical instabilities are resistant to all treatments outlined above, we can propose sacral neuromodulation.

  • Treatment of urinary incontinence due to sphincter deficiency:
    In the case of a minor sphincter deficiency associated with another mechanism of incontinence, kinesitherapy is important.

When incontinence is important in terms of volume of leakage, the therapeutic problem is more complex as surgery, preferably a suburethral sling, has mixed results.
The artificial urinary sphincter has helped thousands of patients out of their urinary handicap.

ARTICLES:

  • Pelvic Surgery : Urinary incontinence
    Article written by Jacques Raiga*, Christian Saussine**, Paul Barakat* , Pascal Calmelet*,
    Elisabeth Castel**, Didier Jacqmin**, Jean Philippe Brettes* le 29/04/2002
    *Department of Obstetrics and Gynecology, Civil Hospital of Strasbourg
    **Department of Urology, Civil Hospital of Strasbourg
  •  An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence
    U. Ulmsten, L. Henriksson, P. Johnson and G. Varhos
    International Urogynecology Journal
    Volume 7, Number 2, pages 81-86, 1996