Urinary incontinence in women

Enough prolapse of the genitals is accompanied by urinary incontinence with tension (NNPN) and cystocele. The main cause of cystocele is a weakening of the poubocervical fascia, a discrepancy of the cardinal ligaments, as well as a defect of the detrusor muscle proper. The formation of cystocele is accompanied by the lowering of the anterior wall of the vagina, the urethro-vesic segment and, accordingly, a violation of urination.

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

Epidemiology

The shyness and attitude of women towards the problem as an inherent feature 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 years have ever noticed involuntary urinary incontinence. In a study in the United States of America, of the 2000 women aged above 65 years, urgent urination took place in 36% of the respondents. According to D.Yu. Pushkar (1996), the incidence of urinary incontinence among women is 36.8%, according to IA. Apolikhina (2006) - 33.6%.

[1], [2], [3], [4], [5], [6], [7], [8], [9],

Causes of the urinary incontinence in women

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

[10], [11], [12], [13]

Pathogenesis

At present, it is proved that in the development of this disease the main role is played by pathological births. Involuntary discharge of urine occurs more often after difficult births that have been protracted or accompanied by obstetric operations. A constant companion of pathological births is trauma of the perineum and pelvic floor. However, the occurrence of urinary incontinence in nulliparous women and even those who did not live sexually forced to reconsider pathogenesis. Numerous studies have shown that with urinary incontinence, there is a marked disruption of the bladder neck closure, 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 loosening of the ligament apparatus of the unchanged urethra and the urethrozic segment, which is attributed to anatomic incontinence;
• a disease associated with changes in the urethra and the sphincter apparatus itself, leading to a disruption in the function of the closure device.

Urinary incontinence in tension is combined with prolapse of the genitals in 82% of cases, mixed - in 100%.

The condition for urine retention is the positive gradient of urethral pressure (the pressure in the urethra exceeds the intravesical pressure). If urination and urinary incontinence are disrupted, this gradient becomes negative.

The disease progresses under the influence of physical activity and hormonal disorders (a decrease in the concentration of estrogens in menopause, and in women of reproductive age, a significant role belongs to the fluctuations in the ratio of sex and glucocorticoid hormones and their indirect effect on α- and β-adrenergic receptors). Dysplasia of connective tissue plays an important role.

In the genesis of genital prolapse and urinary incontinence, the decisive role is played not only by the total number of births, but also by the peculiarities of their course. So, even after uncomplicated births, 20% of women show a slowing of the distal conductivity in the pudend nerves (in 15% of cases, a transient one). This suggests that the lumbosacral plexus is damaged in childbirth, as a result of which paralysis of the obturator, femoral and sciatic nerves develops and as a consequence of it, the incontinence of urine and feces. Moreover, urinary and fecal incontinence after normal delivery is due to muscle stretching or damage to the perineal tissue due to impaired innervation of the pelvic floor muscle sphincters.

[14], [15], [16], [17]

Forms

JG stronglaivas and EJ McGuire in 1988 developed a classification, which subsequently underwent numerous additions and changes. This classification is recommended for use by the international society of urine retention (1CS) and is generally accepted.

International classification of urinary incontinence

• Type 0. At rest, the bottom of the bladder is above the lone articulation. When coughing in the standing position, slight rotation and dislocation of the urethra and the bottom of the bladder are determined. When opening his neck, spontaneous excretion of urine is not observed.
• Type 1. At rest, the bottom of the bladder is above the pubic articulation. When straining, the bottom of the urinary bladder falls approximately 1 cm, when the neck of the bladder and the urethra are opened, involuntary urine is released. Cystocele may not be defined.
• Type 2a. At rest, the bottom of the bladder is at the level of the upper edge of the lone articulation. When coughing, there is a significant pubescence of the bladder and urethra below the pubic articulation. With a wide opening of the urethra, spontaneous excretion of urine is noted. It is determined by cystocele.
• Type 26. At rest the bottom of the bladder is below the pannus joint. When coughing is determined a significant omission of the bladder and urethra, which is accompanied by a pronounced spontaneous release of urine. Cystourethroce is determined.
• Type 3. At rest, the bottom of the bladder is slightly below the upper edge of the lone articulation. The bladder neck and the proximal urethra are open at rest in the absence of detrusor cuts. Spontaneous excretion of urine is noted due to a slight increase in intravesical pressure. Urinary incontinence occurs when the anatomical configuration of the posterior vesicourethral angle is lost.

As can be seen from the above classification, with incontinence of types 0, 1 and 2, a normal urethrovesic segment and proximal part of the urethra dislocation occur, which is often accompanied by the development of cystocele or its consequence. These types of urinary incontinence are called anatomic incontinence.

In case of type 3 incontinence, the urethra and the neck of the bladder do not function more like a sphincter and are more often represented by a rigid tube and a scar-modified urethrovesical segment.

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

Urinary incontinence is divided into true and false.

• False urinary incontinence - involuntary discharge of urine without urination to urinate, can be associated with congenital or acquired defects of the ureter, urethra and bladder (bladder exstrophy, absence of its anterior wall, total epispadia of the urethra, etc.).
• The classification of true urinary incontinence as defined by the International Society for Urine Retention ICS (2002) is as follows.
  • Stress incontinence, or urinary incontinence (NNPN), is a complaint about involuntary leakage of urine with tension, sneezing or coughing.
  • Urge incontinence is an involuntary leakage of urine that occurs immediately after a sudden urge to urinate.
  • Mixed urinary incontinence is a combination of stressful and urgent urinary incontinence.
  • Enuresis is any involuntary loss of urine.
  • Nocturnal enuresis - complaints of loss of urine during sleep.
  • Urinary incontinence from overflow (paradoxical ishuria).
  • Extra-urinary incontinence - excretion of urine in addition to the urethra (characteristic of various urogenital fistula).

The hyperactive bladder (GMS) is a clinical syndrome characterized by a number of symptoms: frequent urination (usually 8 times a day), imperative urges with (or without) mandatory urinary incontinence, nocturia. Urgent incontinence of urine refers to the manifestation of a hyperactive bladder.

Urge incontinence is an involuntary leakage of urine, due to a sudden sharp urge to urinate caused by an involuntary contraction of the detrusor during the bladder filling phase. Detrusor hyperactivity can be a consequence of neurogenic causes and idiopathic, when neurogenic pathology is not established, and also by their combination.

• Idiopathic causes include: age changes in the detrusor, myogenic and sensory disorders, as well as anatomical changes in the position of the urethra and bladder.
• Neurogenic causes are the result of suprasacral and supraspinal injuries: consequences of circulatory disorders and brain and spinal cord injuries, Parkinson's disease, multiple sclerosis and other neurological diseases that lead to a violation of the detrusor innervation.

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

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

• 0 - there is no urgency;
• 1 - light degree;
• 2 - medium degree;
• 3 - severe degree.

Classification of R. Freeman:

• I usually can not hold urine;
• I hold 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 hyperactivity. Symptoms of a hyperactive bladder and urgent incontinence must be differentiated from urinary incontinence with stress, urolithiasis, bladder cancer, interstitial cystitis.

[18], [19], [20], [21], [22]

Diagnostics of the urinary incontinence in women

The purpose of diagnostic measures is to determine the form of urinary incontinence, to determine the severity of the pathological process, to assess the functional state of the lower urinary tract, to identify possible causes of incontinence, and to choose the correction method. It is necessary to focus attention on the possible relationship between the onset and the intensification of symptoms of incontinence during the perimenopause.

The examination of patients with incontinence is carried out in 3 stages.

Stage I - clinical examination

Most often, NMPP is found in patients with genital prolapse, therefore it is especially important to assess the gynecological status at the first stage: examination of the patient in the gynecological chair, when it is possible to identify the presence of pustules and prolapses of the internal genital organs, assess mobility of the bladder neck with a cough test or naturation (Valsalva test), the state of the skin of the perineum and the mucous membrane of the vagina.

When collecting an anamnesis, special attention should be paid to finding out the risk factors: birth, especially pathological or multiple, heavy physical work, obesity, varicose disease, splenchnoptosis, somatic pathology, accompanied by increased intra-abdominal pressure (chronic cough, constipation, etc.), previous surgical intervention on the pelvic organs, neurological pathology.

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

It should be suggested that the patient maintains a diary of urination for 2 days, where she records the amount of excreted urine for one urination, the frequency of urination in 24 hours, notes all incidents of urinary incontinence, the number of pads used and physical activity. Diary of urination allows you to assess urination in a familiar environment for patients, and filling it for several days gives a more objective assessment.

For differential diagnosis of stress and urgent urinary incontinence, a specialized questionnaire of P. Abrams, AJ Wein (1998) should be used for patients with urinary disorders.

[23], [24], [25], [26], [27]

Functional tests

Allow to visually prove the presence of urinary incontinence.

Cough test: a patient with a full bladder (150-200 ml) in the position on the gynecological chair is offered to cough: three cough thrust 3-4 times, in intervals between the series of coughing jolts full breath. The sample is positive for urine leakage when coughing. This test has become more widely used in clinical practice. A positive cough test was correlated with the failure of the internal urethral sphincter. If you do not cough up urine, do not force the patient to repeat the test, but perform other tests.

Valsalva test or test with straining: a woman with a full bladder in the position on the gynecological chair is offered to take a deep breath and, without letting out air, to stiffen: urine incontinence with tension from the external hole of the urethra appears urine. The character of loss of urine from the urethra is recorded visually and carefully compared with the force and time of strain. In patients with genital prolapse, the cough test and the Valsalva test are carried out with a barrier. As a barrier use a back spoon mirror on the Simpsu.

One-hour interlining test (60-minute step test): first determine the initial mass of the gasket. Then the patient drinks 500 ml of water and within an hour alternates various types of physical activity (walking, lifting objects off the floor, coughing, lifting and descending the stairs). After 1 hour, the gasket is weighed and the data interpreted:

• an increase in the weight of the lining by less than 2 g - urinary incontinence is not (stage I);
• an increase of 2-10 g - loss of urine from mild to moderate (stage II);
• an increase of 10-50 g - a severe loss of urine (stage III);
• increase in weight by more than 50 g - very severe loss of urine (IV stage).

A sample with a tampon-applicator inserted into the vagina in the neck of the bladder. Evaluation of the results is performed in the absence of leakage of urine in provocative samples with an inserted applicator.

"Stop test": a patient with a bladder filled with 250-350 ml of sterile 0.9% sodium chloride solution is offered to urinate. As soon as a jet of "urine" appears, a maximum of 1-2 seconds, the patient is asked to stop urinating. Measure the volume of the selected. Then they propose to finish the urination and again measure the amount of the allocated "urine". In this modification of the "stop-test" you can estimate: the actual efficiency of the braking mechanisms - if more than 2/3 of the fluid enters the bladder, they function normally, if less than 1/3 -1/2, then slower if "urine" "Remains in the bladder <1/3 of the injected volume, then practically the mechanisms that inhibit the act of urination are violated. The complete absence of inhibitory reflexes is manifested in the fact that a woman is not able to stop the beginning of an act of urination. The ability to spontaneously interrupt the act of urination allows us to judge the contractual ability of the striated pelvic floor muscles involved 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. "Stop-test" may indicate not only the inability of the sphincter to arbitrary reduction, but also the inability of a hyperactive detrusor to retain a certain volume of urine.

II stage - ultrasonography

Ultrasound (ultrasound), performed by perineal or vaginal access, allows you to obtain data that correspond to clinical and in most cases limit the use of radiological studies, in particular urethrocystography.

The diagnostic capabilities of transvaginal ultrasonography are high enough and are of independent importance for clarifying the dislocation of the urethrovesic segment and the diagnosis of sphincter insufficiency in patients with stress incontinence. With crotch scanning, it is possible to determine the localization of the bottom of the bladder, its ratio to the upper edge of the womb, measure the length and diameter of the urethra all the way, the posterior urethrovesic angle (β) and the angle between the urethra and the vertical axis of the body (α), evaluate the configuration of the neck of the bladder, the urethra, the position of the neck of the bladder in relation to the symphysis.

With the 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 on transverse sections in the upper, middle and lower third of the urethra, examine the neck of the bladder "from within," visualize the internal "sphincter" of the bladder.

Stress 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 the urethra deviation from the vertical axis (α) - 200 and more and the posterior urethrovesic angle (β) in the strain test; a decrease in the anatomical length of the urethra, an expansion of the urethra in the proximal and middle sections, an increase in the distance from the neck of the bladder to the bosom at rest, and with a Valsalva test.

Characteristic signs of sphincter insufficiency in three-dimensional reconstruction: the diameter of the urethral section is more than 1 cm in the proximal part, the width of the muscular sphincter decreases to 0.49 cm or less, the urethral sphincter deformity, the ratio of the numerical values of the urethral section area and the sphincter width is more than 0.74 cm A pattern of funnel-like deformation of the urethrovesical segment with a minimal sphincter is also characteristic, with a maximum ratio of the urethral sectional area and the sphincter width (up to 13 at a rate of 0.4-0.7).

III stage - urodynamic study

Indications for complex urodynamic examination (KUDD): presence of symptoms of urgent urinary incontinence, suspicion of the combined nature of the disorder, absence of effect from the therapy, mismatch of clinical symptoms and results of studies, obstructive symptoms, neurological pathology, urinary dysfunction women after operations on pelvic organs, "relapse" of urinary incontinence after the previous anti-stress surgery, my surgical treatment of urinary incontinence.

KUDDI is considered to be a non-alternative method for diagnosing urethral instability and detrusor hyperactivity, which allows us to work out the right therapeutic tactics and avoid unjustified surgical interventions in patients with a hyperactive bladder.

Urodynamic examination includes uroflowmetry, cystometry, profilometry.

Uroflowmetry is a measurement of the volume of urine isolated per unit of time, usually determined in ml / s, an inexpensive and non-invasive method of investigation, which is a valuable screening test for the diagnosis of urinary dysfunction. Uroflowmetry should be carried out as a primary research. 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 volume of the bubble and the pressure in it during its filling. The method provides information on the adaptation of the bladder with an increase in its volume, as well as control by the CNS for the reflex of urination.

The profile of urethral pressure makes it possible 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 time exceeds the pressure in the bladder. The profile of urethral pressure is a graphic expression of the pressure inside the urethra at consecutive points of its length.

Additional research methods

Cystoscopy is indicated for the exclusion of inflammatory and neoplastic lesions of the bladder.

Prior to the initial stage of the examination, all patients underwent a general urine and blood test and a standard biochemical study of blood serum. If there is evidence of urinary infection or erythrocyturia, the examination is complemented by bacteriological urine and nystourethroscopy to exclude new bladder tumors. In the case of detection of signs of urinary infection, the first stage of its treatment. It is of great importance for revealing the various forms of urinary incontinence that the patient is properly interviewed.

Vaginal examination in patients with incontinence allows to determine:

• the size of the vagina, the state of the mucosa and the nature of the discharge (macroscopic signs of colpitis or atrophic changes in the mucosa);
• presence of cicatricial deformities of the vagina and urethra (due to surgical benefits transferred or radiotherapy);
• the size of the anterior vaginal arch;
• position of the urethra and neck of the bladder;
• the presence and shape of cystocele and urethrocele;
• position of the cervix and uterus;
• the presence of hypermobility of the neck of the bladder and the proximal urethra under tension (indirect signs of sphincter failure even in the absence of involuntary discharge of urine when coughing or straining);
• involuntary discharge of urine when coughing or straining.

[28], [29], [30], [31],

Treatment of the urinary incontinence in women

To treat stress urinary incontinence, there are numerous methods that can now be combined into two large groups: conservative and surgical.

The preferred method of treatment is determined by the cause of the disease, the resulting anatomical disorders, the degree of urinary incontinence.

Conservative methods:

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

Surgical methods:

• suprapubic access:
• Operation Marshull-Marchetti-Krantz;
• Operation Вurch;
• vaginal access:
• Figurnov's operation;
• a suspension of the neck of the bladder by Raz;
• needle suspension according to Stamey;
• needle suspension by Gunes;
• needle suspension according to Peerie;
• sling of the anterior vaginal wall;
• TVT (tension-free vaginal tape) operation;
• laparoscopic suspension.

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

Patients with urinary incontinence of the third type need additional support for the urethra and the neck of the bladder, as well as the creation of passive retention of urine by compression of the urethra, as the function of the sphincter in these patients is completely lost.

In the absence of a sphincter apparatus of the bladder, the following types of surgical interventions are currently used:

• slinging operations with rags from the anterior wall of the vagina;
• fascial slings (auto- or artificial);
• injection of a substance (collagen, auto-fat, Teflon);
• artificial sphincters.

The essence of all sling interventions is to create a reliable "closing mechanism", which does not provide for the restoration of a damaged sphincter apparatus, but leads to the so-called passive retention of urine by compression of the urethra. Forming a sling (loop) around the neck of the bladder and the proximal urethra also restores their normal anatomical location. When these operations are performed, the urethra is elongated, the posterior vesicoureteral angle is corrected, the angle of the urethra is reduced to the pubic symphysis while the neck of the bladder is simultaneously raised.

Treatment of a hyperactive bladder

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

The main method of treatment of a hyperactive bladder is treatment with anticholinergic drugs, mixed-action drugs, α-adrenoreceptor antagonists, antidepressants (tricyclics or serotonin and noradrenaline reuptake inhibitors). The most famous drugs are: oxybutynin, tolterodine, trospium chloride.

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

Tolterodin is a competitive antagonist of muscarinic receptors, which has a high selectivity for receptors of the bladder in comparison with the receptors of the salivary glands. A good tolerance of the drug makes it possible to apply it for a long time in women of all age groups. Detruzitol is prescribed 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 direct antispastic effect by reducing the tone of the smooth muscles of the bladder. The mechanism of action of this drug consists in the competitive inhibition of acetylcholine on the receptors of postsynaptic membranes of smooth muscles. The drug has ganglioblokiruyuschey 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 for 5-15 mg 2-3 times a day.

Oxibutinin is a drug with a combined mechanism of action, since along with anticholinergic activity it possesses spasmolytic and local anesthetic action. The drug has a pronounced efficacy against all symptoms of a hyperactive bladder and is prescribed 2.5-5 mg 2-3 times a day. Like other anticholinergics, oxybutynin can cause side effects associated with blockade of M-cholinergic receptors in various organs; the most frequent of them are dry mouth, constipation, tachycardia. Elimination or reduction of the severity of the latter can be achieved by individual selection of a dose.

α-adrenoblockers are indicated for infravesical obstruction and urethral instability:

• tamsulosin 0.4 mg once a day in the morning;
• terazosin in a dose of 1-10 mg 1-2 times a day (maximum dose of 10 mg / day);
• prazozin 0.5-1 mg 1-2 times a day;
• Alfuzosin 5 mg 1 time a day after meals.

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

Inhibitors of serotonin reuptake:

• citalopram in a dose of 20 mg once a night;
• Fluoxetine 20 mg in the morning or in two divided: morning and night. The duration of therapy GMP and urgent urinary incontinence determines the intensity of symptoms and, as a rule, its duration is not less than 3-6 months. After the withdrawal of the drugs, the symptoms are resumed in 70% of patients, which requires repeated courses or continuous treatment.

The effectiveness of treatment is assessed by the data of the diary of urination, a subjective assessment of its condition by the patient herself. Urodynamic studies are carried out according to indications: in patients with negative dynamics against the background of therapy, in women with neurologic pathology. All patients in postmenopausal women are undergoing hormone replacement therapy in the form of suppositories "Estriol" in the absence of contraindications.

Treatment of stress urinary incontinence

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

When combined with stress incontinence of urine with cystocele, incomplete or complete loss of the uterus and vaginal walls, the main principle of surgical treatment is the restoration of the normal anatomical position of the pelvic organs and the pelvic diaphragm by abdominal, vaginal or combined access (colpopexy using own tissues or synthetic material). The second stage is performed by colpoperineolevatoroplasty and, if necessary, urethropexy by a free synthetic loop (TVT, TVT-O).

Treatment of mixed urinary incontinence

The complex form of urinary incontinence includes stress incontinence in combination with genital prolapse and detrusor hyperactivity, as well as recurrent forms of the disease. A single-valued approach to the treatment of patients with mixed incontinence and prolapse of the genitalia, constituting the heaviest contingent of patients, is still not available.

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

Etiologically, the inferiority of the urethral closure apparatus has much in common with the omission of the female genitalia, they practically always combine with each other. According to domestic obstetrician-gynecologists, genital prolapse is diagnosed in 80% of patients with stress urinary incontinence and in 100% of patients with mixed incontinence. Therefore, the principles of treatment should provide for the restoration of sphincter mechanisms of the urethra, impaired pelvic anatomy and reconstruction of the pelvic floor.

Decision on the need for surgical treatment of patients with a mixed form of urinary incontinence occurs after 2-3 months of conservative treatment. This period is sufficient to assess the changes occurring against the background of therapy.

The amount of surgery depends on the accompanying gynecological disease, the degree of prolapse of the genitals, the age and social activity of the woman. The most preferred method for correcting stressful incontinence is urethropexy by 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 a gynecological operation that corrects the genital prolapse itself. According to a number of researchers, the probability of the disappearance of clinical manifestations of mandatory 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 symptoms of urgency, restoration of normal urination and restoration of disturbed anatomical relationships of pelvic and pelvic organs. Criteria for a positive evaluation of the operation include the patient's satisfaction with the results of the treatment.

In the absence of pronounced prolapse of the genitals, treatment of patients with a mixed type of urinary incontinence begins with the administration of antimuscarinic drugs. All patients in postmenopausal women are recommended hormone therapy in the form of topical suppository or cream containing natural estrogen-estriol (Estriol).

After conservative therapy, about 20% of patients notice a significant improvement in their condition. Karram MM, stronghatia A. (2003) concluded that the combination of urinary incontinence with tension and instability detrusor should first try to treat medication, which can reduce the need for surgical intervention.

Pre-treatment with M-cholinolytics and nootropic agents (piracetam, nicotinoyl-gamma-aminobutyric acid) creates the prerequisites for restoring the normal mechanism of urination by improving the detrusor's contractile capacity, restoring the circulation of the bladder and the urethra.

With the expressed omission and prolapse of the internal genital organs (OVVPO), obstructive urination and unrealized sphincter insufficiency, it is expedient to initially correct the genital prolapse and antistress operation, and then decide on the need for drug treatment. The optimal choice of therapeutic tactics, and consequently, the obtaining of the highest results depends on the quality of preoperative diagnosis and clarification of the primary-consequence relationship of the combined pathology.

Analysis of the factors provoking incontinence showed that none of the patients with complicated and mixed incontinence were nulliparous, all patients had from 1 to 5 births in the anamnesis. The frequency of crotch ruptures during childbirth is 33.4%. From the peculiarities of the birth course, attention is drawn to the fact that every fourth patient has a child weighing more than 4000 g.

The course of the underlying disease aggravates the presence of various gynecological extragenital diseases in patients. Most patients with complicated and mixed incontinence have diseases of the cardiovascular system (58.1%), chronic diseases of the gastrointestinal tract (51.3%) and respiratory organs (17.1%), endocrine pathology (41.9% ). The frequency of osteochondrosis of various parts of the spine is 27.4%, in addition, neurological diseases (acute cerebrovascular accident in the anamnesis, atherosclerosis of the cerebral vessels, Alzheimer's disease) reveal in 11.9%. A sufficiently high incidence of varicose veins (20.5%), hernias of different locations (11.1%) indicate a systemic inconsistency of connective tissue in patients with mixed incontinence.

The combined pathology of the genitals is revealed in 70.9% of patients. The most commonly diagnosed with uterine myoma (35.9%), adenomyosis (16.2%), OVVPO (100%).

The combination of organic pathology with the disposition of the pelvic organs determines the variety of clinical manifestations. The most frequent complaints are the sensation of a foreign body in the vagina, incomplete emptying of the bladder, imperative urges to urinate, urinary incontinence in an imperative urge, urinary incontinence with exercise, nocturia.

Ultrasonographic examination (two-dimensional scanning and 3D) allows to reveal signs of incompetence of the urethral sphincter (wide and short urethra, minimal bladder capacity, funnel-shaped deformation of the urethra), which is regarded as an "unrealized" sphincter insufficiency restored after correction of genital prolapse in 15.4% of patients with complete / incomplete prolapse of the uterus. It is ultrasound with a three-dimensional reconstruction of the image allows you to avoid erroneous operational tactics. In cases where there is a combination of prolapse of the genitals with pronounced cystocele and sphincter insufficiency, with vaginal examination only OVVPO is determined, according to the data of KUDI - obstructive type of urination. If you do not take into account the data of ultrasound and three-dimensional reconstruction of the image, then, as a rule, the amount of surgical intervention is limited to the operation that corrects the prolapse of the genitals, and in the postoperative period, when the normal anatomy of the organs is restored, the mechanism of urethral obstruction disappears and there is an opportunity for clinical implementation of the symptoms of urinary incontinence at a stress caused by sphincter insufficiency. The manifestation of symptoms of incontinence 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 a significant prolapse of the genitals, the presence of a gynecological disease requiring surgical treatment, insufficient effectiveness of drug treatment and the predominance of symptoms of stress incontinence.

Correction of prolapse of the genitals is carried out by both abdominal and vaginal access. If necessary, perform hysterectomy as a "basic" operation. When dentition is performed fixation of the dome of the vagina with an aponeurotic, synthetic flap or due to the ligamentous apparatus of the uterus. Vaginopexy does not complicate the operation, is physiologically substantiated, allows simultaneous reposition of the bladder and rectum, restore or improve impaired functions of pelvic organs. The operation does not lead to severe intra- and postoperative complications and significantly reduces the frequency of relapses.

Colpoperineolevatoroplasty is an obligatory 2-nd stage of correction of genital prolapse, and simultaneously perform an anti-stress operation (urethropexy by a free synthetic loop: TVT or TVT-O).

Vaginal access allows simultaneous elimination of prolapse of the genitals and symptoms of urinary incontinence with tension.

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 a hyperactive bladder after surgery are preserved in approximately 34% of patients.

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

Indications for consultation of other specialists

In the presence of diseases of the central and / or peripheral nervous system, a consultation of a neuropathologist, an endocrinologist, and also in some cases a consultation of a psychologist is shown.

Forecast

The prognosis for life is favorable.

[32], [33]