Management of Stress Incontinence - Essay Example

Managing Stress Incontinence Number Department Introduction Stress incontinence is a type of urinary incontinence which is also known as effort incontinence or the stress urinary incontinence (SUI). Thus, simply put, stress incontinence is the involuntary or unintentional loss or discharge of urine. Stress incontinence is essentially underpinned by an insufficient vigour of the pelvic floor muscles, and is always provoked by physical activities or movement such as coughing, exercising, sneezing, or any other sudden voluntary movement, due to the pressure that these movements or activities apply on the bladder. Stress incontinence can therefore be seen to be unrelated with psychological stress, though it remains the commonest form of urinary incontinence. Thus, the definition of stress incontinence as leakage of urine as a result of straining, coughing, sneezing, or sudden voluntary movement due to incompetence of the sphyncteric mechanisms can be lent credence. According to Chapple and Cardozo (2006, 16), women have been found to be more prone to stress incontinence, compared to men. Statistical provisions from reputable researchers point out that the preponderance of stress incontinence among women increases with age, so that 1 in 5 women who are over 40 suffer from some degree of stress incontinence. Becker (2005, 11) is poignant that those who experience stress incontinence are always subject to embarrassment, isolation, underperformance at the workplace, and a receding social life, especially when leisure activities and exercise form part of this social life. This makes management of stress incontinence a crucial undertaking which has been much celebrated. Management of Stress Incontinence There are several approaches to managing stress incontinence. Many medical practitioners heavily rely on physiotherapy. This involves, subjecting the patient to (prescribed) exercises, as a way of strengthening pelvic floor muscles. Since the target is mainly strengthening pelvic floor muscles, pelvic floor exercises form the main part of this prescription. The applicability of using exercises to strengthen pelvic floor muscles is based on the fact that kidneys constantly make urine. Because of this, trickles of urine constantly pass to the bladder, before going down to the ureters. The urters are tubes that connect the kidney to the bladder. The amount of urine a person makes depends on how much an individual drinks, eats and sweats (Collier and Longmore, 2003, 61). The crux of the matter herein is that the bladder comprises muscles, and also stores urine. That the bladder is elastic is underscored by it expanding like a balloon as it gets filled with urine. The urethra as the outlet for urine remains closed. It is the pelvic floor muscles that regulate the opening and closing of the urethra. As a certain amount of urine fills the bladder, one becomes aware of having a full bladder. On going to the lavatory to pass urine, the muscles of the bladder contract and squeeze the urethra. The pelvic floor muscles then get to relax. Complex nerve messages are relayed to the brain as the central nervous system, the bladder and then the pelvic floor muscles. It is these messages that prompt a person, informing him that his bladder is full and also prompt the right muscles to either relax or contract at the right time. Thus, the foregoing clearly shows that prescribing pelvic floor exercises for the stress incontinent will help tighten the muscles of the urethra and the bladder, and thereby helping stop unintended flow of urine. According to Bo, (2007, 34 a) and Gartley (2012, 75), kegel exercises have also been recommended as the best way of retraining and strengthening sphincter and pelvic floor muscles, as a way of reducing stress leakage. Kegel exercises have mostly proven most beneficial to those below 60 years. To this effect, it is a standard observation that the patient should do at least do 24 contractions daily, for at least 42 days (6 weeks). The physiotherapist should monitor the progress (the gradual strengthening of the pelvic floor muscle) by using the kegel perineometer. The feasibility of using the pelvic floor muscle exercises (PFME) to treat or manage stress incontinence, or to improve bladder control is exemplified and evidenced by successful treatment of birth-related urinary incontinence, through the use of PFME. In a closely related wavelength, there are numerous cases of successful of brief doses of electric stimulation being used to strengthen muscles located in the lower pelvis. This involves, temporarily placing electrodes in the rectum or vagina, in order to stimulate neighbouring muscles. This measure stimulates urethral muscles and helps stabilise over-reactive muscles. In a randomised trial, the British Medical Journal compared vaginal weights, pelvic floor exercises and electro-stimulation. The British Medical Journal, because of the research findings made recommendations that PFME should be the first resort when treating stress incontinence. The reason that the British Medical Journal advances for this standpoint is that simple exercises prove to be far more effective, compared to vaginal cones or electro-stimulation (Waterfield, 2011, 55). Waterfield (2011, 56,7) divulges that in 2010, the British Journal of Urology International confirmed the standpoint above by noting that the United Kingdom National Institute for Clinical Excellence (NICE) has neither recommended the use of weighted vaginal cones and electric stimulation devices, nor has the same methods been advocated for by clinicians. NICE divulges in its report that evidence of the efficiency of weighted vaginal cones and electric stimulation devices are yet to be adduced. Conversely, there are cases where behavioral changes are used to manage stress incontinence. The use of behavioral change involves decreasing the amount of liquid that the patient consumes and avoiding the use of caffeinated drinks, carbonated beverages, spicy foods, alcohol and citrus, since caffeinated drinks irritate the bladder. Quitting smoking is also encouraged as a factor that helps in alleviating stress incontinence, since smoking makes one cough (and thereby putting stress on the patient's bladder) and also irritates the bladder. There are respected scholars and specialists such as Semple and Smyth (2009, 67) who advance also weight loss as a way of managing stress incontinence. This follows the establishment of the discovery that weight loss in overweight women with a Body Mass Index (BMI) which exceeds 25, significantly reduces stress. The same case applies to women who experience close to 10 episodes of urinary incontinence, at least per week. In this light, exercises and restricted diet comes in handy, as they enabled women realize 70% reduction in episodes of overall stress incontinence. Pessaries have also helped in managing stress incontinence. A Pessary is a medical device which is inserted into the birth canal. The commonest kind of pessary takes a ring-shaped form and is recommended by doctors as one of the most appropriate ways of correcting vaginal prolapse. This device works by elevating the bladder neck and compressing the urethra up against the symphysis pubis. This reduces stress leakage for many women. Nevertheless, Slager (2005, 44) is poignant that there are drawbacks which accompany the use of pessary. First, Slager (2005, 44, 5) explains that the use of pessaries leaves the vagina and the urinary tract susceptible to infections. In a closely related wavelength, the use of pessaries remains relatively expensive since the physician will have to monitor the vagina and the urinary tract to ward off the danger of contracting infections. Again, pessaries can only be used on women, yet stress incontinence is distributed among both sexes. In a separate vein, Setchell (2001, 40) posits that there are medical centres which use biofeedback. Biofeedback involves the use of devices that help the patient become more aware of her or his bodily functions. When electronic diaries and devices are used to track the intervals and time in which the urethral muscles and the bladder contract, the patient is able to have more control over muscles which regulate the flow of urine. There are also cases when surgical interventions are administered to treat stress incontinence. This is always used as recourse to physiotherapy, after physiotherapy exercises prove unsuccessful. Urethropexy is arguably the commonest form of surgery which is done to manage stress incontinence. This surgical intervention is made to tighten and to support the outlet of the bladder (Bo, 2007, 56 b). According to Parsons and College (2002, 84), the Cochrane Review of studies also produced results that show that less-invasive variants of sling operations are just as effective as invasive counterparts, in treating stress incontinence. Ouslander (1985, 77) points out that an apt example of a surgical intervention which has been used to manage stress incontinence is the mini-sling. The mini-sling is also known as the Mini-Arc Precise. Mini-Arc Precise has been established to have relatively short term cure rates of minislings which range between 67% and 90%. Slings are the commonest forms of surgery used to manage stress incontinence. A sling normally comprises synthetic mesh materials which take the shape of a narrow ribbon. Sometimes, a porcine, bovine or the patient's tissue can be used, after being placed under her urethra. First, an incision is made on the vagina, followed by two minute abdominal incisions. The rationale herein is to replace the deficient urethral and pelvic floor muscles, and to provide a stronger backboard of support under the patient's urethra. There is also the re-adjustable sling which comprises standard synthetic mesh sling which has been combined with sutures. The sutures in turn are attached to a tensioning device which resides permanently beneath the skin in abdominal walls. Upon being implanted, the REMEEX (Re-adjustable Mechanical External) device becomes re-accessible. This is done under the local anesthesia so as to fine tine the sling, in the event that stress incontinence reappears years or months after the initial surgery. Haslam and Laycock (2008) also explain that there is also the transobturator tape (TO) which is used to manage stress incontinence. Also known as the Monarc, the TO sling procedure is geared towards the elimination of stress incontinence by giving support for the muscles beneath the urethra. This minimally-invasive form of surgical intervention lessens chance for the use of retropubic needle passage. This form of intervention involves making three small incisions in the groin area, to make way for the insertion of a mesh tape. Recent research developments confirm that Monarc has increased the success of cure rate to 90%. However, there is an acknowledgement of the fact that Monarc carries with it, some risks, during its initial stages of installation. In almost the same wavelength, there is also the tension-free transvaginal tape (TVT) which is used to manage stress incontinence. This approach involves the use of the TVT sling by placing a polypropylene mesh tape under the urethra. This procedure involves, making two miniature incisions in the vagina. According to Robinson and Mackler (1995, 84), one of the merits that accompany the use of the TVT method is its high cure rate which falls between 86% and 95%. This means that TVT is usually successful. Again, TVT is very convenient since it can be administered as outpatient care. This quality makes the TVT approach a very common form of managing stress incontinence. The only setback that comes with the use of the TVT is its concomitance with complications such as bladder perforation. Precisely, bladder perforation occurs in the retropubic space, in the event that the procedure is not done properly. For some such as Faulkner and Bridge (2011, 121), the use of bladder repositioning has gone along way in the management of stress incontinence. The usefulness of bladder repositioning is underscored by the fact that in most cases, stress incontinence among women emanates from the urethra sagging down, toward the vagina. Because of this, common surgery for stress incontinence has demanded for the pulling the urethra upwards, to a normal or its previous position. The surgeon has to raise the urethra and secure it with a string which has been attached to the muscle, bone or ligament, when working through an incision that has been made in the abdomen or vagina. Alternatively, the surgeon may have to secure the urethra with a wide sling, in case he is dealing with a severe case of stress incontinence. The crux of the matter herein is that this form of surgical intervention props the bladder up, while compressing the top of the urethra and bottom of the bladder and thereby staving off further leakage. Dmochowski (2004, 90) points out that other forms of interventions such as the Trans/Peri-Urethral Injections must be brought to mind when discussing methods of managing stress incontinence. Cardozo, Robinson and Miles (2006, 23) divulge that in this procedure, an array of materials has been used in times past to give more weight to the urethra, as a way of increasing outlet resistance. The GAX collagen, also known as the Gluteraldehyde cross-linked collagen has been the most widely used material in this form of intervention, and thereby proving to be of the greatest value to patients, as far as the Trans/Peri-Urethral Injections model is concerned. Some of the materials that have been used in the same exercise include blood and fat, albeit with limited success. Collier and Longmore (2003, 75) observe that one of the drawbacks of using the Trans/Peri-Urethral Injections model as a form of intervention against stress incontinence is the need to carry out the procedure over time. There are also rare cases where a surgeon may implant an artificial sac known as the urinary sphincter in the urethra. The artificial urinary sphincter is doughnut-shaped, so that it is able to encircle the urethra. A fluid is then made to fill and expand this artificial sac, and thereby squeezing the urethra, and making the urethra to close itself. A valve is implanted under the patient's skin, so that upon pressing this valve, the artificial urinary sphincter becomes deflated. Resultantly pressure is removed from the urethra, and thereby allowing urine to pass from the bladder. There are also healthcare practitioners such as Chapple and Cardozo (2006, 45) who prefer to use the Marshall-Marchett-Krantz (MMK) approach, as a way of managing stress incontinence. Also known as the bladder neck suspension or the retropubic suspension surgery, the MMK procedure must be performed within the confines of a hospital by a surgeon. This approach was developed by doctors by a surgeon in a hospital setting. Developed by doctors Andrew A. Marchetti (OB/GYN), Victor F. Marshall (urologist) and Kermit Krantz (OB/GYN) in 1949, this surgical procedure became the yardstick by which other urological surgical procedures are measured. More modifications were nevertheless added to the MMK model by Dr. Burch, in 1961, so that the changes that were made to the MMK model became known as the Burch modification. The Burch modifications mainly entailed, placing surgical stitches at the neck of the bladder, and then tying them with a Cooper ligament. Ndegwa and Cunningham (2009, 41) are clear that when carrying out the MMK procedure, the patient is placed under anaesthesia. After this, an incision is made across the abdomen, so that the bladder is exposed. After this, a long, thin and flexible catheter is placed into the bladder through the urethra, or the narrow tube which drains the urine. The separation between the bladder and is surrounding tissues is strengthened by making sutures or stitches in the tissues neighbouring near the urethra and the neck of the bladder. This causes the urethra, the pubic bone and fascia (the tissues situated behind the pubic bone) to be lifted. Since the stitches support the neck of the bladder, the patient gains control over the flow of urine. At the moment, MMK procedure remains one of the most effective forms of managing stress incontinence. This is because about 85% of women who have undergone the MMK procedure have been cured (Doughty, 2006, 34). Cespedes (2000, 50) argues that one of the pitfalls that accompanies the use of slings as a form of surgical intervention is its possible connection to long-term harm. Particularly, transvaginal mesh is under sharp scrutiny due to preponderance of long-term harm and suffering as a result of the implanted mesh. Collier, Longmore and Brinsden (2006) contend that management of stress incontinence can also be done through the use of a needleless sling, as a form of a single incision, known as the TOT. The needleless sling is implanted through the use of a unique incision. This needleless sling is different from the mini sling, since it (the needleless sling) has 136% more surface area. This quality helps the needleless sling more effective in supporting the urethra and the pelvic floor. Additionally, no sharp instruments are needed to implant the sling, alongside the scalpel which is to be used to make the incision. This means that not only is the needleless sling more effective in managing stress incontinence (when compared to other models such as the mini-sling), but the same is also more amenable to the enhancement of the patient's comfort. Conclusion In respect to the foregoing, the ravages of stress incontinence have been made clear, as a phenomenon strong enough to undercut an individual's socio-economic interests and advancement. Thus, great relief is found in knowing that successfully managing and treating stress incontinence is a reality. Because of this, when managing stress incontinence, it is important that proper diagnoses are made and that the best mode of managing stress incontinence is identified by working in close consultation with the patient, her health status as is revealed by her medical records, her relatives and the team of physicians also involved in the same project. The need to have the government further subsidise the cost of treating or managing stress incontinence can also not be sidestepped. If the case of patients opting for less effective modes of intervention because she is unable to afford the most effective methods of treating stress incontinence is to be extirpated, then the need for the government to step in to further subsidise the prices of stress incontinence management cannot and must not be sidestepped. References Becker, H. D. (2005). Urinary and Fecal Incontinence an Interdisciplinary Approach. Berlin: Springer. Bo, K. (2007). Evidence-Based Physical Therapy for the Pelvic Floor Bridging Science and Clinical Practice. Edinburgh: Churchill Livingstone. Bo, K. (2007). Evidence-Based Physical Therapy for the Pelvic Floor. Edinburgh: Churchill Livingstone. Cardozo, L., Robinson, D., & Miles, A. (2006). The Effective Management of Stress Urinary Incontinence. London: Aesculapius Medical Press. Cespedes, R. D. (2000). Advances in the Treatment of Urinary Incontinence and Pelvic Prolapse. New York/ London: Cengage Learning. Chapple, C. R., & Cardozo, L. (2006). 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