Urinary incontinence
Urinary continence is the ability to postpone urination to carry out this act in conditions of hygienic-social convenience [1]Urology. Francesco Porpiglia. Minerva Medica Editions. 2015. Any involuntary loss of urine, beyond quantity (even if it's just one drop), However, it has recently been foundhyena defined “urinary incontinence”[2]Abrams, Paul, et al. – The standardization of terminology of lower urinary tract function. Report from the standardization sub-committee of International Continence Society. – Textbook… Continue reading.
CLASSIFICATION OF DIFFERENT TYPES OF INCONTINENCE:
L’incontinenza viene classificata in tre tipologie:
- Urinary incontinence from effort: involuntary loss of urine in response to physical exertion or a sudden increase in intra-abdominal pressure that occurs during activities such as sneezing or coughing[3]Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32., jump, lift weights, LAUGH, make efforts, do physical exercise[4]Harris, Shauna, Stephen W. Leslie, and John Riggs. -Mixed urinary incontinence.- StatPearls -Internet-. StatPearls Publishing, 2024..
- Urinary incontinence from urgency: involuntary loss of urine associated with urgency[5]Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32..
- Urinary incontinence Mr: is given by the combination of the first two. Si tratta di una incontinenza urinaria che viene elicitata sotto sforzo e che si presenta con la caratteristica dell’urgenza.
INCONTINENZA URINARIA DA SFORZO (IUS)
La continenza urinaria in situazioni di sforzo è garantita principalmente dall’integrità delle strutture anatomiche di supporto del collo vescicale e dell’uretra (la fascia endopelvica, con i suoi attacchi laterali all’arco tendineo, il muscolo elevatore dell’ano e la parete vaginale anteriore) e dall’efficienza dello sfintere uretrale[6]https://www.aiugstudies.it/lineeguida/commissione1/2/. FISIOPATOLOGIA DELL’INCONTINENZA URINARIA DA SFORZO – M.Meschia, P. Pifarotti, U. Gattei, F. Baruffi, P. Cavoretto Servizio… Continue reading. Gli interventi chirurgici per la IUS generalmente mirano infatti proprio a ripristinare un supporto al collo vescicale e all’uretra.
Allo stato attuale, si ritiene quindi che la patogenesi della IUS sia dovuta principalmente a fattori che inducono cambiamenti anatomici in quelle strutture che contribuiscono sia direttamente che indirettamente alla funzione minzionale. I più influenti tra questi fattori sono età, gravidanze, obesità e stitichezza ([7]Yang, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicina 59.1 – 2022 – 5..
Sono stati ideati diversi modelli teorici per spiegare i meccanismi anatomo-funzionali della continenza urinaria, che sono stati fondamentali anche per affinare gli approcci riabilitativi. Tra questi modelli i più interessanti sono the “teoria dell’amaca” e the “teoria della trasmissione delle pressioni intra-addominali” e[8]Yang, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicina 59.1 – 2022 – 5..
La “teoria dell’amaca” fa riferimento diretto proprio a quelle strutture anatomiche di supporto al collo vescicale e all’uretra a cui abbiamo già fatto riferimento. Questa teoria ha infatti individuato nel muscolo elevatore dell’ano, nella parete vaginale anteriore, nella fascia pelvica ma anche nel legamento pubo-uretrale, gli elementi portanti di una struttura di sostegno ad amaca la cui validità è fondamentale al controllo urinario.
In base alla “teoria dell’amaca”, nelle pazienti con incontinenza urinaria da sforzo, un improvviso aumento della pressione addominale superando la pressione esistente nell’ uretra causerebbe una involontaria fuga di urina per via di una carenza di supporto anatomico dell’uretra e del collo vescicale. In presenza di un supporto anatomico valido, l’aumento di pressione comporterebbe una fisiologica compressione dell’uretra e del collo vescicale contro un sostegno solido, determinandone la chiusura.
Secondo questo modello teorico, l’IUV non sarebbe tanto dovuta ad una inadeguata trasmissione delle forze pressorie addominali all’uretra, quanto invece alla perdita del supporto anatomico dell’uretra e del collo vescicale.
Secondo la “teoria della trasmissione delle pressioni intra-addominali“, l’IUS sarebbe invece correlata ad una riduzione della trasmissione della pressione addominale alla vescica e all’uretra prossimale. Questa riduzione di trasmissione ha uno stretto legame con la postura. Per questo motivo la rieducazione della postura è spesso parte integrante della riabilitazione della IUS.
non si è ancora giunti ad una completa comprensione dei meccanismi coinvolti nella genesi di questo fenomeno. E’ stato dimostrato che durante lo sforzo si verifica un aumento della pressione intrauretrale simultaneo all’aumento della pressione addominale e tutto ciò al fine di garantire la chiusura dell’uretra e mantenere un gradiente pressorio uretrovescicale positivo. Sebbene il concetto della trasmissione pressoria rappresenti una osservazione importante, le basi anatomo-fisiologiche su cui esso si fonda sono difficili da comprendere. Infatti Enhorning, agli inizi degli anni sessanta, ipotizzò che la trasmissione della pressione addominale all’uretra si verifica ogniqualvolta quest’ultima giace nel campo delle pressioni addominali, al di sopra di un teoretico pavimento pelvico, tuttavia è dimostrato come vi sia scarsa correlazione tra la posizione anatomica dell’uretra ed incontinenza urinaria da sforzo[9]https://www.aiugstudies.it/lineeguida/commissione1/2/. FISIOPATOLOGIA DELL’INCONTINENZA URINARIA DA SFORZO – M.Meschia, P. Pifarotti, U. Gattei, F. Baruffi, P. Cavoretto Servizio… Continue reading.
CAUSE PRINCIPALI/FATTORI DI RISCHIO DELL’INCONTINENZA URINARIA DA SFORZO
Proproblems following childbirth (episiotomy).
The episiotomy (o perineotomy) it is a surgical incision of the perineum that can be made during vaginal birth to facilitate the exit of the fetus from the vaginal orifice.
The surgical incision can be midline (longitudinal), lateral and medio-lateral depending on the direction of the cut which is decided by the surgeon from time to time based on how the birth appears. The midline incision is the least invasive and causes fewer short-term complications, medium and long term.
Episiotomy in some places is done routine, to reduce the risk of perineal lacerations in women and the complications that these may cause (urinary incontinence, feces, sexual dysfunctions) and to facilitate childbirth, thus reducing risks to the fetus. From a systematic review of the literature published in 2005 [10]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. But, it emerged that there is currently no evidence to support the benefits traditionally attributed to routine episiotomy for women's health. From this review it appears that in fact the outcomes of the’routine episiotomy they can be considered worse when compared to outcomes from birth without episiotomy.
The scientific evidence[11]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. derived from clinical studies suggest that the immediate results of routine episiotomy on women's health, including the severity of the perineal tear, pain and the use of painkillers, are no better than those relating to the restrictive use of this practice (it means applying it only in cases where the need to carry out surgery is evident because childbirth is difficult and not regardless of the situation). Clinical studies to date[12]Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. highlight the lack of benefits of routine episiotomy for the prevention of fecal and urinary incontinence or pelvic floor relaxation. It has also been found that pain during intercourse is more common among women who have undergone episiotomy.
Menopause or hormonal dysfunction
The decrease in estrogen and collagen that occurs with menopause, it reduces the elasticity of the detrusor muscle and induces atrophic changes in the pelvic floor muscles[13]trash, Abdulmaged M., et al. – Role of androgens in female genitourinary tissue structure and function. Implications in the genitourinary syndrome of menopause.- Sexual Medicine Reviews 6.4… Continue reading, thus creating a predisposition to urinary incontinence (IU).
Results of a systematic review[14]God, Ahmad Hasan, et al. – The Link Between Menopause and Urinary Incontinence: A Systematic Review.- Cureus 16.10 2024 – e71260. of the scientific literature that has investigated the link between menopause and UI, published in 2024, have highlighted the complexity and variability of UI in postmenopausal women:
in fact, the prevalence of UI in this population group varies, depending on the different studies selected by this review, from the 13,6% [15]Singh S, Baranwal K, Wound I, Khan IA, Bajpai S – Sociodemographic determinants of urogenital morbidities among menopausal women in rural areas of Eastern Uttar Pradesh. Cureus. 2023, 15 … Continue reading all’84,4%[16]Morals and, Delgado JL, Carmona F, et al. – Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study. Climacteric. 2018, 21 – … Continue reading. According to some of these authors [17]Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51. the most frequent problem during menopause would be UI e, specifically, l'Exercise UI would seem to constitute the typology more widespread [18]Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51..
Severe obesity and/or excessive weight changes.
The prevalence of obesity is increasing worldwide, with significant negative implications on health. Obesity is associated with low-grade systemic inflammation and the release of proinflammatory cytokines. This context alters collagen metabolism and, in combination with increased intra-abdominal pressure, contributes to the development of UI. Weight loss can reduce UI and, Non-motor symptomsn those patients who present a clear overweight condition, should be included among the objectives of a therapeutic project aimed at the rehabilitation of UI[19]Doumouchtsis, S. K., J. Loganathan, and V. Pergialiotis. – The role of obesity on urinary incontinence and anal incontinence in women. A review. – BJOG: An International Journal of… Continue reading.
Diabetes.
Diabetes can cause UI through several mechanisms[20]Feeney, Catherine, et al. – Lower urinary tract dysfunction in adult patients with mitochondrial disease.- Neurourology and urodynamics 39.8 – 2020 – 2253-2263., among which:
- l’hyperglycemia. This causes an increase in urine volume and an increase in the activity of the detrusor muscle, with time, undergoes alterations that determine a dysfunctional condition.
- The diabetic cytopathy and the damage to the detrusor nerve
Chronic bronchitis and asthma.
UI is more common among patients with COPD (Chronic Obstructive Pulmonary Bronchopathy) that among people who are not affected and lThe prevalence of UI increases with increasing severity of the disease.Chronic cough in fact, which is a very common symptom in COPD, involves greater stress on the pelvic floor due to continuous sudden increases in intra-abdominal pressure, thus undermining its stability.
The specific scientific literature on this topic states that “Urinary incontinence screening should be considered in patients with COPD and generally with impaired lung function[21]Burge, Angela T., et al. – Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease. A questionnaire survey.- Physiotherapy 103.1 – 2017 – … Continue reading”.
Pelvic or abdominal surgeries.
All those interventions that risk compromising the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system can be a potential cause of UI. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
Very intense sporting activity.
Exertional UI is considered the most commonpelvic floor dysfunction in female athletes[22]Dieter, Alexis A., Maggie F. Wilkins, and Jennifer M. Wu. – Epidemiological trends and future care needs for pelvic floor disorders. – Current Opinion in Obstetrics and Gynecology 27.5… Continue reading[23]Goldstick, Orly, and Naama Constantini. – Urinary incontinence in physically active women and female athletes. – British journal of sports medicine 48.4 – 2014 – 296-298.[24]Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – … Continue reading.
A systematic literature review with meta-analysis carried out in 2020[25]Pires, Thelma, et al. – Prevalence of urinary incontinence in high-impact sport athletes. A systematic review and meta-analysis. – Journal of Human Kinetics 73 – 2020 – 279. he highlightedthat the prevalence of exertional UI among female athletes is equal to 20,7% is thatin high impact sports on average it reaches 25,6%. Thehigher prevalence was observed in volleyball: 75,6%.
The most plausible explanation for thesehigher rates is that intense physical activity involves repeatedsudden and/or prolonged increases in intra-abdominal pressure and in the long termthey can weaken the pelvic floor, compromising its tightness[26]Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – … Continue reading[27]Santos, Keyla Mara, et al. – Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes.- International urogynecology journal 30 – 2019 – … Continue reading[28]Dosde Mattos Lourenco, Thais Regina, et al. – Urinary incontinence in female athletes. A systematic review. – International urogynecology journal 29 – 2018 – 1757-1763..
Heavy work activities.
The same considerations made for very intense sporting activities apply.
Trauma to the coccyx or pelvis.
In some cases, UI can be the consequence of trauma to the coccyx[29]Stude, David E., Thomas F. Bergmann, and Bradley A. Finer. -A conservative approach for a patient with traumatically induced urinary incontinence. – Journal of Manipulative and physiological… Continue reading or the pelvis[30]Pachcinski, Olaf, et al. – Treatment of female stress urinary incontinence after pelvic trauma.- GYNECOLOGY 95.5 – 2024 – 416-417.[31]with earrings, Bora, Yakup Kordan, and Turgut Alkibay. – Urinary incontinence after pelvic trauma: a case report. – International Urology and Nephrology 32 – 2001 – 363-365. that has compromised the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
MAIN CAUSES OF EMERGENCY URINARY INCONTINENCE:
Neurological disorders.
…
Chronic inflammatory forms of the bladder
When the bladder is inflamed, “reacts before its actual filling, giving a stimulus that cannot be controlled by the voluntary muscles which can lead to urine loss in women of all ages, but especially in postmenopausal women[32]https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza“.
Menopause or hormonal dysfunction.
Estrogen hormones help regulate the functioning of the neurotransmitters responsible for the stimulation/inhibition mechanisms that underlie urination[33]https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza.
Spinal pathologies:
Radicolopathy[34]Captain, Hulagu, et al. – The association between urinary incontinence and low back pain and radiculopathy in women. – Open access Macedonian journal of medical sciences 4.4 – 2016 … Continue reading. E’ A statistically significant correlation was found between both radiculopathies and unspecified UI and emergency UI.
Low back pain[35]Eisenstein, S. M., D. J. Engelbrecht, and W. S. El Masry. – Low back pain and urinary incontinence. A hypothetical relationship. – Spine 19.10 – 1994 – 1148-1152.. E’ A rare association between severe low back pain and urge incontinence was found, not explainable on the basis of any conventional neurological or genitourinary pathology.
Stenosis of the lumbar spinal canal[36]Gandhi, Jason, et al. – Neuro-urological sequelae of lumbar spinal stenosis. – International Journal of Neuroscience 128.6 – 2018 – 554-562.. Narrowing of the spinal canal at this level can damage the nerve structures contained within it. In this case, symptoms affecting the genitourinary system may occur, including emergency UI.
Spina bifida
Spina bifida is a congenital pathology due to an incomplete closure of one or more vertebrae of the spine and the membranes surrounding the spinal cord. Depending on the structures involved, it is called occult bifid, meningocele and myelomeningocele.
Trauma to the coccyx or pelvis.
Traumas that compromise the integrity of those anatomical nervous structures, muscular, ligamentous, tendons, bones necessary for the proper functioning of the urinary system can lead to dysfunction. Depending on the type of compromised structures, UI may therefore occur which may be due to strain, urgent or mixed.
REHABILITATION OF URINARY INCONTINENCE
The rehabilitation of urinary incontinence falls within the field of pelvic floor rehabilitation and makes use of the synergy between different types of interventions:
- Behavioral education
- Manual therapy
- Therapeutic exercises
- Aids for: muscle strengthening; perineal massage; treatment of deep trigger points; containment of prolapses
- Instrumental therapy
Note
| ↑1 | Urology. Francesco Porpiglia. Minerva Medica Editions. 2015 |
|---|---|
| ↑2 | Abrams, Paul, et al. – The standardization of terminology of lower urinary tract function. Report from the standardization sub-committee of International Continence Society. – Textbook of Female Urology and Urogynecology. CRC Press, 2010. 1098-1108 |
| ↑3, ↑5 | Denisenko, Andrew A., et al. – Evaluation and management of female urinary incontinence. – Can J Urol 28.S2 – 2021 – 27-32. |
| ↑4 | Harris, Shauna, Stephen W. Leslie, and John Riggs. -Mixed urinary incontinence.- StatPearls -Internet-. StatPearls Publishing, 2024. |
| ↑6 | https://www.aiugstudies.it/lineeguida/commissione1/2/. FISIOPATOLOGIA DELL’INCONTINENZA URINARIA DA SFORZO – M.Meschia, P. Pifarotti, U. Gattei, F. Baruffi, P. Cavoretto Servizio specialistico di Uroginecologia Dipartimento di Ostetricia e Ginecologia, Università di Milano Istituto L. Mangiagalli, Via Della Commenda 12, Milano |
| ↑7, ↑8 | Yang, Xunguo, et al. – The anatomical pathogenesis of stress urinary incontinence in women. – Medicina 59.1 – 2022 – 5. |
| ↑9 | https://www.aiugstudies.it/lineeguida/commissione1/2/. FISIOPATOLOGIA DELL’INCONTINENZA URINARIA DA SFORZO – M.Meschia, P. Pifarotti, U. Gattei, F. Baruffi, P. Cavoretto Servizio specialistico di Uroginecologia Dipartimento di Ostetricia e Ginecologia, Università di Milano Istituto L. Mangiagalli, Via Della Commenda 12, Milano |
| ↑10, ↑11, ↑12 | Hartmann, Katherine, et al.- Outcomes of routine episiotomy. A systematic review. – Jama 293.17 2005 – 2141-2148. |
| ↑13 | trash, Abdulmaged M., et al. – Role of androgens in female genitourinary tissue structure and function. Implications in the genitourinary syndrome of menopause.- Sexual Medicine Reviews 6.4 – 2018 – 558-571. |
| ↑14 | God, Ahmad Hasan, et al. – The Link Between Menopause and Urinary Incontinence: A Systematic Review.- Cureus 16.10 2024 – e71260. |
| ↑15 | Singh S, Baranwal K, Wound I, Khan IA, Bajpai S – Sociodemographic determinants of urogenital morbidities among menopausal women in rural areas of Eastern Uttar Pradesh. Cureus. 2023, 15 – e46677. 10.7759/cureus.46677 |
| ↑16 | Morals and, Delgado JL, Carmona F, et al. – Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study. Climacteric. 2018, 21 – 167-73. 10.1080/13697137.2017.1421921 |
| ↑17, ↑18 | Robinson, Dudley, and Linda D. Cardozo. – The role of estrogens in female lower urinary tract dysfunction.- Urology 62.4 – 2003 – 45-51. |
| ↑19 | Doumouchtsis, S. K., J. Loganathan, and V. Pergialiotis. – The role of obesity on urinary incontinence and anal incontinence in women. A review. – BJOG: An International Journal of Obstetrics & Gynaecology 129.1 -2022 – 162-170. |
| ↑20 | Feeney, Catherine, et al. – Lower urinary tract dysfunction in adult patients with mitochondrial disease.- Neurourology and urodynamics 39.8 – 2020 – 2253-2263. |
| ↑21 | Burge, Angela T., et al. – Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease. A questionnaire survey.- Physiotherapy 103.1 – 2017 – 53-58. |
| ↑22 | Dieter, Alexis A., Maggie F. Wilkins, and Jennifer M. Wu. – Epidemiological trends and future care needs for pelvic floor disorders. – Current Opinion in Obstetrics and Gynecology 27.5 – 2015 – 380-384. |
| ↑23 | Goldstick, Orly, and Naama Constantini. – Urinary incontinence in physically active women and female athletes. – British journal of sports medicine 48.4 – 2014 – 296-298. |
| ↑24, ↑26 | Maia, Mariana, Thuane Da Roza, and Teresa Mascarenhas. – Female athlete pelvic floor–urogynecological overview. – Acta Obstet Gynecol Port 9.1 – 2015 – 56-64. |
| ↑25 | Pires, Thelma, et al. – Prevalence of urinary incontinence in high-impact sport athletes. A systematic review and meta-analysis. – Journal of Human Kinetics 73 – 2020 – 279. |
| ↑27 | Santos, Keyla Mara, et al. – Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes.- International urogynecology journal 30 – 2019 – 693-699. |
| ↑28 | Dosde Mattos Lourenco, Thais Regina, et al. – Urinary incontinence in female athletes. A systematic review. – International urogynecology journal 29 – 2018 – 1757-1763. |
| ↑29 | Stude, David E., Thomas F. Bergmann, and Bradley A. Finer. -A conservative approach for a patient with traumatically induced urinary incontinence. – Journal of Manipulative and physiological therapeutics 21.5 – 1998 – 363-367. |
| ↑30 | Pachcinski, Olaf, et al. – Treatment of female stress urinary incontinence after pelvic trauma.- GYNECOLOGY 95.5 – 2024 – 416-417. |
| ↑31 | with earrings, Bora, Yakup Kordan, and Turgut Alkibay. – Urinary incontinence after pelvic trauma: a case report. – International Urology and Nephrology 32 – 2001 – 363-365. |
| ↑32, ↑33 | https://www.fondazioneveronesi.it/magazine/articoli/lesperto-risponde/quali-sono-le-principali-cause-di-incontinenza-da-urgenza |
| ↑34 | Captain, Hulagu, et al. – The association between urinary incontinence and low back pain and radiculopathy in women. – Open access Macedonian journal of medical sciences 4.4 – 2016 – 665. |
| ↑35 | Eisenstein, S. M., D. J. Engelbrecht, and W. S. El Masry. – Low back pain and urinary incontinence. A hypothetical relationship. – Spine 19.10 – 1994 – 1148-1152. |
| ↑36 | Gandhi, Jason, et al. – Neuro-urological sequelae of lumbar spinal stenosis. – International Journal of Neuroscience 128.6 – 2018 – 554-562. |