Urinary incontinence in women

Quite often, prolapse of the genital organs is accompanied by stress urinary incontinence (SUI) and cystocele. The main cause of cystocele is weakening of the pubocervical fascia, divergence of the cardinal ligaments, and a defect of the detrusor muscle itself. The formation of cystocele is accompanied by prolapse of the anterior vaginal wall, the urethrovesical segment and, accordingly, urination disorders.

Urinary incontinence is a pathological condition in which voluntary control over the act of urination is lost, and a complaint of any involuntary leakage of urine.

Epidemiology

Women's shyness and attitude to the problem as an integral sign of aging leads to the fact that the figures do not reflect the prevalence of the disease, but it should be noted that 50% of women aged 45 to 60 have ever noted involuntary urinary incontinence. In a study conducted in the USA, out of 2000 women over 65, urgent urination occurred in 36% of respondents. According to D. Yu. Pushkar (1996), the prevalence of urinary incontinence among women is 36.8%, according to I. A. Apolikhina (2006) - 33.6%.

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Causes female urinary incontinence

The leading cause of urinary incontinence is considered to be childbirth: stress urinary incontinence is observed in 21% of women after spontaneous childbirth and in 34% after the use of pathological obstetric forceps.

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Pathogenesis

It has now been proven that pathological childbirth plays a major role in the development of this disease. Involuntary urine leakage often occurs after difficult childbirth, which was protracted or accompanied by obstetric operations. A constant companion of pathological childbirth is trauma to the perineum and pelvic floor. However, the occurrence of urinary incontinence in women who have not given birth and who have not even had sex forced us to reconsider the issues of pathogenesis. Numerous studies have shown that urinary incontinence is accompanied by a pronounced disorder of the occlusal apparatus of the bladder neck, changes in its shape, mobility, and the "bladder-urethra" axis. S. Raz believes that urinary incontinence should be divided into two main types:

• a disease associated with dislocation and weakening of the ligamentous apparatus of the unchanged urethra and urethrovesical segment, which is referred to as anatomical urinary incontinence;
• a disease associated with changes in the urethra itself and the sphincter apparatus, leading to a disruption of the function of the sphincter apparatus.

Stress urinary incontinence is combined with genital prolapse in 82% of cases, mixed incontinence - in 100%.

A positive urethral pressure gradient (the pressure in the urethra exceeds the intravesical pressure) is considered a condition for urine retention. In case of urinary incontinence and urinary dysfunction, this gradient becomes negative.

The disease progresses under the influence of physical activity and hormonal disorders (a decrease in estrogen concentration during menopause, and in women of reproductive age, a significant role is played by fluctuations in the ratio of sex and glucocorticoid hormones and their indirect effect on α- and β-adrenoreceptors). Connective tissue dysplasia plays an important role.

In the genesis of genital prolapse and urinary incontinence, a decisive role belongs not only to the total number of births, but also to the peculiarities of their course. Thus, even after uncomplicated births, 20% of women show a slowdown in distal conduction in the pudendal nerves (in 15% of cases - transient). This gives grounds to assume that during childbirth the lumbosacral plexus is damaged, resulting in paralysis of the obturator, femoral and sciatic nerves and, as a consequence, incontinence of urine and feces. Moreover, incontinence of urine and feces after normal births is explained by muscle stretching or damage to perineal tissues due to a disruption in the innervation of the pelvic floor sphincter muscles.

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Forms

JG Stronglaivas and EJ McGuire developed a classification in 1988 that has since undergone numerous additions and modifications. This classification is recommended for use by the International Continence Society (ICS) and is generally accepted.

International Classification of Urinary Incontinence

• Type 0. At rest, the bottom of the bladder is above the pubic symphysis. When coughing in a standing position, a slight rotation and dislocation of the urethra and the bottom of the bladder are determined. When its neck is opened, spontaneous release of urine is not observed.
• Type 1. At rest, the bottom of the bladder is above the pubic symphysis. When straining, the bottom of the bladder descends by approximately 1 cm, and when the neck of the bladder and urethra open, urine leaks involuntarily. Cystocele may not be detected.
• Type 2a. At rest, the bottom of the bladder is at the level of the upper edge of the pubic symphysis. When coughing, there is a significant drooping of the bladder and urethra below the pubic symphysis. With a wide opening of the urethra, spontaneous release of urine is observed. Cystocele is determined.
• Type 26. At rest, the bottom of the bladder is below the pubic symphysis. When coughing, a significant prolapse of the bladder and urethra is determined, which is accompanied by pronounced spontaneous release of urine. Cystourethrocele is determined.
• Type 3. At rest, the fundus of the bladder is slightly below the upper edge of the pubic symphysis. The neck of the bladder and the proximal urethra are open at rest in the absence of detrusor contractions. Spontaneous urine leakage is observed due to a slight increase in intravesical pressure. Urinary incontinence occurs with loss of the anatomical configuration of the posterior vesicoureteral angle.

As can be seen from the classification given, in urinary incontinence types 0, 1 and 2 there is a dislocation of the normal urethrovesical segment and the proximal part of the urethra, which is often accompanied by the development of cystocele or is its consequence. These types of urinary incontinence are called anatomical incontinence.

In case of type 3 incontinence, the urethra and bladder neck no longer function as a sphincter and are more often represented by a rigid tube and a cicatricially altered urethrovesical segment.

The use of this classification allows standardizing approaches to such patients and optimizing the choice of treatment tactics. Patients with type 3 urinary incontinence require the formation of additional support for the urethra and bladder neck, as well as the creation of passive urinary retention by compression of the urethra, since the sphincter function in these patients is completely lost.

Urinary incontinence is divided into true and false.

• False urinary incontinence is the involuntary release of urine without the urge to urinate, which may be associated with congenital or acquired defects of the ureter, urethra and bladder (bladder exstrophy, absence of its anterior wall, total epispadias of the urethra, etc.).
• The classification of true urinary incontinence according to the definition of the International Continence Society ICS (2002) is presented as follows.
  • Stress urinary incontinence, or stress urinary incontinence (SUI), is a complaint of involuntary leakage of urine when straining, sneezing, or coughing.
  • Urge urinary incontinence is the involuntary leakage of urine that occurs immediately after a sudden, strong urge to urinate.
  • Mixed urinary incontinence is a combination of stress and urge urinary incontinence.
  • Enuresis is any involuntary loss of urine.
  • Nocturnal enuresis - complaints of loss of urine during sleep.
  • Overflow urinary incontinence (paradoxical ischuria).
  • Extraurethral urinary incontinence is the release of urine outside the urethra (typical of various urogenital fistulas).

Overactive bladder (OAB) is a clinical syndrome characterized by a number of symptoms: frequent urination (more than 8 times a day), imperative urges with (or without) imperative urinary incontinence, nocturia. Urgent urinary incontinence is considered a manifestation of overactive bladder.

Urgent urinary incontinence is an involuntary leakage of urine due to a sudden, strong urge to urinate, caused by an involuntary contraction of the detrusor during the filling phase of the bladder. Detrusor overactivity may be due to neurogenic causes and idiopathic causes, when neurogenic pathology is not established, as well as a combination of both.

• Idiopathic causes include: age-related changes in the detrusor, myogenic and sensory disturbances, and anatomical changes in the position of the urethra and bladder.
• Neurogenic causes are the result of suprasacral and supraspinal damage: consequences of circulatory disorders and damage to the brain and spinal cord, Parkinson's disease, multiple sclerosis and other neurological diseases leading to impaired innervation of the detrusor.

Classifications considering symptoms of urgency from the position of the doctor and the patient, proposed by A. Вowden and R. Freeman in 2003.

Scale for assessing the severity of clinical manifestations of imperative symptoms:

• 0 - no urgency;
• 1 - mild;
• 2 - average degree;
• 3 - severe degree.

R. Freeman classification:

• I usually can't hold my urine;
• I hold my urine if I go to the toilet immediately;
• I can "finish speaking" and go to the toilet.

This scale is actively used to assess the symptoms of detrusor overactivity. Symptoms of overactive bladder and urgent incontinence must be differentiated from stress urinary incontinence, urolithiasis, bladder cancer, and interstitial cystitis.

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Diagnostics female urinary incontinence

The purpose of diagnostic measures is to establish the form of urinary incontinence, determine the severity of the pathological process, assess the functional state of the lower urinary tract, identify possible causes of incontinence, and select a correction method. It is necessary to focus on the possible connection between the occurrence and increase in symptoms of incontinence during the perimenopause.

Examination of patients with urinary incontinence is carried out in 3 stages.

Stage I - clinical examination

Most often, NMPN is found in patients with genital prolapse, so it is especially important to assess the gynecological status at the 1st stage: examination of the patient in a gynecological chair, when it is possible to identify the presence of prolapse and prolapse of the internal genital organs, assess the mobility of the bladder neck during a cough test or straining (Valsalva test), the condition of the skin of the perineum and the vaginal mucosa.

When collecting anamnesis, special attention should be paid to identifying risk factors: childbirth, especially pathological or multiple, heavy physical work, obesity, varicose veins, splanchnoptosis, somatic pathology accompanied by increased intra-abdominal pressure (chronic cough, constipation, etc.), previous surgical interventions on the pelvic organs, neurological pathology.

Clinical examination of patients with incontinence must necessarily include laboratory examination methods (primarily clinical urine analysis and urine culture for flora).

The patient should be asked to keep a urination diary for 2 days, where she records the amount of urine released per urination, the frequency of urination per 24 hours, notes all episodes of urinary incontinence, the number of pads used, and physical activity. A urination diary allows for an assessment of urination in a familiar environment for the patient, and filling it out over several days provides a more objective assessment.

For differential diagnosis of stress and urgent urinary incontinence, it is necessary to use the specialized questionnaire by P. Abrams, AJ Wein (1998) for patients with urination disorders.

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Functional tests

Allows visual confirmation of urinary incontinence.

Cough test: the patient with a full bladder (150-200 ml) in a gynecological chair is asked to cough: three coughing thrusts 3-4 times, in between the series of coughing thrusts a full breath. The test is positive if urine leaks during coughing. This test has received wider application in clinical practice. A connection between a positive cough test and the incompetence of the internal urethral sphincter has been proven. If urine does not leak during coughing, the patient should not be forced to repeat the test, but other tests should be performed.

Valsalva test or straining test: a woman with a full bladder in a gynecological chair is asked to take a deep breath and, without releasing the air, strain: in case of urinary incontinence, urine appears from the external opening of the urethra under strain. The nature of urine loss from the urethra is recorded visually and carefully compared with the force and time of straining. In patients with genital prolapse, the cough test and Valsalva test are performed with a barrier. The posterior spoon of the Simps speculum is used as a barrier.

One-hour pad test (60-minute step test): First, the initial weight of the pad is determined. The patient then drinks 500 ml of water and alternates between different types of physical activity (walking, picking up objects from the floor, coughing, going up and down stairs) for an hour. After 1 hour, the pad is weighed and the data is interpreted:

• an increase in the weight of the pad by less than 2 g - no urinary incontinence (stage I);
• increase by 2–10 g - urine loss from weak to moderate (stage II);
• increase by 10–50 g - severe loss of urine (stage III);
• weight gain of more than 50 g - very severe urine loss (stage IV).

A test with a tampon applicator inserted into the vagina in the area of the bladder neck. The results are assessed in the absence of urine leakage during provocative tests with the applicator inserted.

"Stop test": the patient is asked to urinate with the bladder filled with 250-350 ml of sterile 0.9% sodium chloride solution. As soon as a stream of "urine" appears, after a maximum of 1-2 seconds, the patient is asked to stop urinating. The volume of urine excreted is measured. Then the patient is asked to finish urinating and the amount of "urine" excreted is measured again. In this modification of the "stop test", it is possible to evaluate: the real efficiency of the inhibitory mechanisms - if more than 2/3 of the injected liquid remains in the bladder, then they function normally, if less than 1/3 - 1/2, then slowly, if "urine" remains in the bladder <1/3 of the injected volume, then the mechanisms inhibiting the act of urination are practically impaired. A complete absence of inhibitory reflexes is manifested in the fact that the woman is unable to stop the act of urination that has begun. The ability to spontaneously interrupt the act of urination allows us to judge the contractile capacity of the striated muscles of the pelvic floor, which participate in the formation of the sphincter system of the bladder and urethra (m. bulbospongiosus, m. ischiocavernosus and m. levator ani), as well as the state of the sphincter apparatus of the bladder. The "stop test" may indicate not only the inability of the sphincter to contract voluntarily, but also the inability of the overactive detrusor to retain a certain volume of urine.

Stage II - ultrasonography

Ultrasound examination (US) performed through perineal or vaginal access allows obtaining data corresponding to clinical data and, in most cases, limiting the use of radiological examinations, in particular, urethrocystography.

The diagnostic capabilities of transvaginal ultrasonography are quite high and have an independent value for specifying the dislocation of the urethrovesical segment and diagnosing sphincter insufficiency in patients with stress incontinence. With perineal scanning, it is possible to determine the localization of the bottom of the bladder, its relation to the upper edge of the pubis, measure the length and diameter of the urethra along its entire length, the posterior urethrovesical angle (β) and the angle between the urethra and the vertical axis of the body (α), assess the configuration of the neck of the bladder, the urethra, the position of the neck of the bladder in relation to the symphysis.

With three-dimensional reconstruction of the ultrasound image, it is possible to assess the condition of the inner surface of the mucous membrane, the diameter and cross-sectional area of the urethra in cross-sections in the upper, middle and lower thirds of the urethra, examine the neck of the bladder “from the inside”, and visualize the internal “sphincter” of the bladder.

Stress urinary incontinence in two-dimensional scanning is manifested by an ultrasound symptom complex: dislocation and pathological mobility of the urethrovesical segment, most demonstratively manifested in the rotation of the angle of deviation of the urethra from the vertical axis (α) - 200 or more and the posterior urethrovesical angle (β) during a straining test; a decrease in the anatomical length of the urethra, expansion of the urethra in the proximal and middle sections, an increase in the distance from the neck of the bladder to the pubis at rest and during the Valsalva test.

Characteristic signs of sphincter insufficiency in three-dimensional reconstruction: the cross-sectional diameter of the urethra is more than 1 cm in the proximal section, a decrease in the width of the muscular sphincter to 0.49 cm or less, deformation of the urethral sphincter, the ratio of the numerical values of the cross-sectional area of the urethra and the width of the sphincter is more than 0.74 cm. Also characteristic is the picture of a funnel-shaped deformation of the urethrovesical segment with a minimally expressed sphincter, with a maximum ratio of the cross-sectional area of the urethra and the width of the sphincter (up to 13 with a norm of 0.4–0.7).

Stage III - urodynamic study

Indications for a comprehensive urodynamic study (CUDS): the presence of symptoms of urgent urinary incontinence, suspicion of a combined nature of the disorder, lack of effect from the therapy, discrepancy between clinical symptoms and the results of the studies, the presence of obstructive symptoms, the presence of neurological pathology, urinary dysfunction that has arisen in women after surgery on the pelvic organs, "relapses" of urinary incontinence after anti-stress operations, proposed surgical treatment of urinary incontinence.

KUDI is considered an alternative method for diagnosing urethral instability and detrusor overactivity, which allows for the development of correct treatment tactics and avoidance of unnecessary surgical interventions in patients with overactive bladder.

Urodynamic examination includes uroflowmetry, cystometry, and profilometry.

Uroflowmetry is a measurement of the volume of urine excreted per unit of time, usually expressed in ml/s, an inexpensive and noninvasive method of examination, which is a valuable screening test for the diagnosis of voiding dysfunction. Uroflowmetry should be performed as a first-line examination. It can be combined with simultaneous recording of bladder pressure, detrusor, abdominal pressure, sphincter electromyography and registration of cystourethrograms.

Cystometry is the recording of the relationship between the bladder volume and the pressure in it during its filling. The method provides information regarding the bladder's adaptation to an increase in its volume, as well as the central nervous system's control of the micturition reflex.

The urethral pressure profile allows us to evaluate the functions of the urethra. The function of urine retention is due to the fact that the pressure in the urethra at any moment exceeds the pressure in the bladder. The urethral pressure profile is a graphical expression of the pressure inside the urethra at successive points along its length.

Additional research methods

Cystoscopy is indicated to exclude inflammatory and neoplastic lesions of the bladder.

Before the initial stage of examination, all patients undergo a general urine and blood test and a standard biochemical blood serum test. If signs of urinary infection or erythrocyturia are detected, the examination is supplemented by a bacteriological urine test and nystourethroscopy to exclude bladder neoplasms. If signs of urinary infection are detected, the first stage is its treatment. A properly conducted patient survey is of great importance for identifying various forms of urinary incontinence.

Vaginal examination in patients with urinary incontinence allows us to determine:

• the size of the vagina, the condition of the mucous membrane and the nature of the discharge (macroscopic signs of colpitis or atrophic changes in the mucous membrane);
• the presence of cicatricial deformation of the vagina and urethra (as a result of previous surgeries or radiation therapy);
• size of the anterior vaginal fornix;
• position of the urethra and bladder neck;
• the presence and form of cystocele and urethrocele;
• position of the cervix and body of the uterus;
• the presence of hypermobility of the bladder neck and proximal urethra during straining (indirect signs of sphincter insufficiency even in the absence of involuntary urine leakage during coughing or straining);
• involuntary leakage of urine when coughing or straining.

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Treatment female urinary incontinence

There are numerous methods for treating stress urinary incontinence, which can currently be divided into two large groups: conservative and surgical.

The preference for one or another treatment method is determined by the cause of the disease, the anatomical disorders that have arisen, and the degree of urinary incontinence.

Conservative methods:

• exercises to strengthen the pelvic floor muscles;
• estrogen therapy;
• alpha-sympathomimetics;
• pessaries;
• removable urethral obturators,

Surgical methods:

• suprapubic approach:
• Marshall–Marchetti–Krantz operation;
• Operation Church;
• vaginal access:
• Figurnov's operation;
• Raz bladder neck suspension;
• needle suspension according to Stamey;
• Gunes needle suspension;
• needle suspension according to Peery;
• anterior vaginal wall sling;
• TVT (tension-free vaginal tape) operation;
• laparoscopic suspension.

In patients with type 2 urinary incontinence, the main goal of surgical treatment is to restore the normal anatomical position of the organs by moving and fixing the urethrovesical segment in a normal topographic-anatomical position.

Patients with type 3 urinary incontinence require additional support for the urethra and bladder neck, as well as passive urinary retention by compressing the urethra, since the sphincter function in these patients is completely lost.

In case of insufficiency of the sphincter apparatus of the urinary bladder, the following types of surgical interventions are currently used:

• sling operations with flaps from the anterior vaginal wall;
• fascial slings (auto- or artificial);
• injection of a substance (collagen, autofat, Teflon);
• artificial sphincters.

The essence of all sling interventions is to create a reliable "closure mechanism" that does not involve the restoration of the damaged sphincter apparatus, but leads to the so-called passive retention of urine by compression of the urethra. Formation of a sling (loop) around the neck of the bladder and proximal urethra also restores their normal anatomical location. During these operations, the urethra is lengthened, the posterior vesicoureteral angle is corrected, the angle of inclination of the urethra to the pubic symphysis is reduced while simultaneously lifting the neck of the bladder.

Treatment of overactive bladder

The goal of treatment is to reduce the frequency of urination, increase the intervals between urinations, increase the capacity of the bladder, and improve the quality of life.

The main method of treating overactive bladder is considered to be treatment with anticholinergic drugs, mixed-action drugs, α-adrenergic receptor antagonists, antidepressants (tricyclic or serotonin and norepinephrine reuptake inhibitors). The most well-known drugs are: oxybutynin, tolterodine, trospium chloride.

Anticholinergic drugs block muscarinic cholinergic receptors in the detrusor, preventing and significantly reducing the effect of acetylcholine on the detrusor. This mechanism leads to a decrease in the frequency of detrusor contractions during its hyperactivity. Currently, five types of muscarinic receptors are known (M1–M5), of which two are localized in the detrusor: M2 and M3.

Tolterodine is a competitive muscarinic receptor antagonist with high selectivity for bladder receptors over salivary gland receptors. Good tolerability of the drug allows its long-term use in women of all age groups. Detrusitol is prescribed at 2 mg twice daily.

Trospium chloride is an anticholinergic drug, which is a quaternary ammonium base, which has a relaxing effect on the smooth muscles of the detrusor of the bladder both due to the anticholinergic effect and due to a direct antispasmodic effect due to a decrease in the tone of the smooth muscles of the bladder. The mechanism of action of this drug is the competitive inhibition of acetylcholine on the receptors of postsynaptic membranes of smooth muscles. The drug has ganglionic blocking activity. The active substance of the drug - trospium chloride (quaternary ammonium base) is more hydrophilic than tertiary compounds. Therefore, the drug practically does not penetrate the blood-brain barrier, which contributes to its better tolerability, ensuring the absence of side effects. The drug is prescribed 5-15 mg 2-3 times a day.

Oxybutynin is a drug with a combined mechanism of action, since along with anticholinergic activity it has antispasmodic and local anesthetic effects. The drug has a pronounced effectiveness against all symptoms of overactive bladder and is prescribed at 2.5-5 mg 2-3 times a day. Like other anticholinergic drugs, oxybutynin can cause side effects associated with the blockade of M-cholinergic receptors in various organs; the most common of these are dry mouth, constipation, tachycardia. The elimination or reduction of the severity of the latter can be achieved by individual dose selection.

Alpha-blockers are indicated for infravesical obstruction and urethral instability:

• tamsulosin 0.4 mg once a day in the morning;
• terazosin at a dose of 1–10 mg 1–2 times a day (maximum dose 10 mg/day);
• prazosin 0.5–1 mg 1–2 times a day;
• alfuzosin 5 mg once daily after meals.

Tricyclic antidepressants: imipramine 25 mg 1-2 times a day.

Selective serotonin reuptake inhibitors:

• citalopram at a dose of 20 mg once at night;
• fluoxetine 20 mg in the morning or in two doses: in the morning and at night. The duration of therapy for OAB and urgent urinary incontinence determines the intensity of symptoms and, as a rule, its duration is at least 3-6 months. After discontinuation of the drugs, symptoms recur in 70% of patients, which requires repeated courses or continuous treatment.

The effectiveness of treatment is assessed based on the urination diary data, the patient's subjective assessment of her condition. Urodynamic studies are performed according to indications: in patients with negative dynamics against the background of the therapy, in women with neurological pathology. All postmenopausal patients are simultaneously given hormone replacement therapy in the form of Estriol suppositories in the absence of contraindications.

Treatment of stress urinary incontinence

Non-surgical treatment methods are indicated for patients with mild urinary incontinence. The most effective method for treating stress urinary incontinence is surgical intervention. Currently, preference is given to minimally invasive sling operations using synthetic prostheses - urethropexy with a free synthetic loop (TVT, TVT-O).

In case of stress urinary incontinence combined with cystocele, partial or complete prolapse of the uterus and vaginal walls, the main principle of surgical treatment is considered to be restoration of the normal anatomical position of the pelvic organs and pelvic diaphragm by abdominal, vaginal or combined approaches (extirpation of the uterus with colpopexy using own tissues or synthetic material). The second stage is colpoperineolevatoroplasty and, if necessary, urethropexy with a free synthetic loop (TVT, TVT-O).

Treatment of mixed urinary incontinence

Complex forms of urinary incontinence include stress incontinence combined with genital prolapse and detrusor overactivity, as well as recurrent forms of the disease. There is still no clear approach to treating patients with mixed incontinence and genital prolapse, which constitute the most severe contingent of patients.

The necessity of surgical intervention in such patients is a controversial issue. Many researchers believe that a long course of drug therapy with anticholinergic drugs is necessary, others argue for the need for combined treatment: surgical correction of the stress component and subsequent drug treatment. Until recently, the effectiveness of correction of incontinence symptoms in such patients did not exceed 30–60%.

Etiologically, the insufficiency of the urethral sphincter has much in common with the prolapse of female genitalia; they are almost always combined with each other. According to domestic obstetricians and gynecologists, genital prolapse is diagnosed in 80% of patients with stress urinary incontinence and in 100% of cases in patients with mixed incontinence. Therefore, treatment principles should include the restoration of the sphincter mechanisms of the urethra, the disturbed anatomy of the small pelvis, and the reconstruction of the pelvic floor.

The decision on the need for surgical treatment of patients with mixed urinary incontinence occurs after 2-3 months of conservative treatment. This period is sufficient to assess the changes occurring during therapy.

The scope of the operation depends on the concomitant gynecological disease, the degree of genital prolapse, age and social activity of the woman. The most preferred method of correction of stress incontinence is urethropexy with a free synthetic loop (TVT-O). An important factor for achieving good functional results in patients with complex and mixed forms of incontinence is not only the timely diagnosis of unrealized sphincter insufficiency, but also the choice of gynecological surgery that corrects the genital prolapse itself. According to a number of researchers, the probability of disappearance of clinical manifestations of imperative urinary incontinence after surgical correction of prolapse is almost 70%.

The effectiveness of surgical treatment in patients with mixed and complex forms of urinary incontinence was assessed by the following parameters: elimination of urgency symptoms, restoration of normal urination and restoration of impaired anatomical relationships of the pelvic organs and pelvic floor. The criteria for a positive evaluation of the operation also include the patient's satisfaction with the treatment results.

In the absence of pronounced genital prolapse, treatment of patients with mixed urinary incontinence begins with taking antimuscarinic drugs. All postmenopausal patients are simultaneously recommended to take hormone therapy in the form of local application of suppositories or cream containing the natural estrogen estriol (Estriol).

After conservative therapy, about 20% of patients report significant improvement in their condition. Karram MM, stronghatia A. (2003) concluded that the combination of stress urinary incontinence and detrusor instability should initially be treated with medication, which may reduce the need for surgical intervention.

Preliminary therapy with M-anticholinergics and nootropic agents (piracetam, nicotinoyl gamma-aminobutyric acid) creates the preconditions for restoring the normal mechanism of urination by improving the contractile ability of the detrusor, restoring blood circulation in the bladder and urethra.

In case of pronounced prolapse and prolapse of internal genital organs (IGP), obstructive urination and unrealized sphincter insufficiency, it is advisable to initially perform correction of genital prolapse and anti-stress surgery, after which the issue of the need for drug treatment should be decided. The optimal choice of treatment tactics, and therefore, obtaining the highest results, depends on the quality of preoperative diagnostics and clarification of the primary-effect relationship of the combined pathology.

An analysis of factors that provoke incontinence showed that there were no nulliparous patients with complex and mixed incontinence, all patients had 1 to 5 births in their anamnesis. The frequency of perineal ruptures during childbirth is 33.4%. Among the features of the course of childbirth, it is noteworthy that every 4th patient gives birth to a child weighing more than 4000 g.

The course of the underlying disease is aggravated by the presence of various gynecological extragenital diseases in patients. Most often, patients with complex and mixed incontinence have cardiovascular diseases (58.1%), chronic gastrointestinal diseases (51.3%) and respiratory diseases (17.1%), endocrine pathology (41.9%). The frequency of osteochondrosis of various parts of the spine is 27.4%, in addition, neurological diseases (history of acute cerebrovascular accident, cerebral atherosclerosis, Alzheimer's disease) are detected in 11.9%. A fairly high frequency of varicose veins (20.5%), hernias of various localizations (11.1%) indicate a systemic failure of connective tissue in patients with mixed incontinence.

Combined genital pathology is detected in 70.9% of patients. The most frequently diagnosed are uterine myoma (35.9%), adenomyosis (16.2%), and ovarian cystitis (100%).

The combination of organic pathology with the disposition of the pelvic organs determines the diversity of clinical manifestations. The most common complaints are the sensation of a foreign body in the vagina, incomplete emptying of the bladder, imperative urge to urinate, urinary incontinence with an imperative urge, urinary incontinence during physical exertion, nocturia.

Ultrasonography (two-dimensional scanning and 3D) allows to detect signs of urethral sphincter failure (wide and short urethra, minimal bladder capacity, funnel-shaped deformation of the urethra), which is regarded as "unrealized" sphincter insufficiency, which is restored after correction of genital prolapse in 15.4% of patients with complete/incomplete uterine prolapse. It is ultrasound with three-dimensional image reconstruction that allows to avoid erroneous surgical tactics. In cases where there is a combination of genital prolapse with pronounced cystocele and sphincter insufficiency, during vaginal examination only OiVVPO is determined, according to KUDI - obstructive type of urination. If we do not take into account the ultrasound and 3D image reconstruction data, then, as a rule, the scope of surgical intervention is limited to the operation correcting the genital prolapse, and in the postoperative period, with the restoration of normal anatomical relationships of the organs, the mechanism of urethral obstruction disappears and the possibility appears for the clinical realization of symptoms of urinary incontinence under stress caused by sphincter insufficiency. The manifestation of incontinence symptoms in this case is regarded as a relapse and insufficient effectiveness of surgical treatment.

Indications for surgical treatment of patients with a mixed form of incontinence are significant genital prolapse, the presence of a gynecological disease requiring surgical treatment, insufficient effectiveness of drug treatment and the predominance of symptoms of stress incontinence.

Correction of genital prolapse is performed using both abdominal and vaginal access. If necessary, hysterectomy is performed as a "basic" operation. During laparotomy, the vaginal dome is fixed with an aponeurotic, synthetic flap or by means of the uterine ligament apparatus. Vaginopexy does not complicate the operation, is physiologically justified, allows for simultaneous repositioning of the bladder and rectum, restoration or improvement of impaired functions of the pelvic organs. The operation does not lead to severe intra- and postoperative complications and significantly reduces the frequency of relapses.

Colpoperineolevatoroplasty is a mandatory 2nd stage of genital prolapse correction; anti-stress surgery (free synthetic loop urethropexy: TVT or TVT-O) is performed at the same time.

Vaginal access allows for simultaneous elimination of both genital prolapse and symptoms of stress urinary incontinence.

When performing vaginal hysterectomy, it is recommended to use synthetic prolene prostheses (Gynemesh soft, TVM-total, TVM-anterior, TVM-posterior). Uretropexy with a free synthetic loop (TVT or TVT-O) is performed simultaneously.

Symptoms of overactive bladder persist after surgery in approximately 34% of patients.

The effectiveness of combined surgical treatment using anti-stress technology with a free synthetic loop was 94.2% with an observation period of up to 5 years.

Indications for consultation with other specialists

In the presence of diseases of the central and/or peripheral nervous system, a consultation with a neurologist, endocrinologist, and in some cases, a consultation with a psychologist is indicated.

Forecast

The prognosis for life is favorable.

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