menopausal incontinence
Introduction
Introduction to menopausal urinary incontinence Urinary incontinence in menopausal women is a common problem among the elderly. It is one of the most common problems affecting elderly women, affecting the quality of life and the most expensive. Women from the perimenopause to the menopause, gradually into the old age, their organs All are changing, and the changes in the genitourinary system are also becoming more prominent. Estrogen deficiency, which relaxes the pubis, fascia, ligaments, etc., supports the decline of tissue function, can not maintain normal urethral position and bladder tension, when cough, breath holding, constipation and other increased pressure, and stress urinary incontinence (SUI) proposed The definition is: a sudden increase in abdominal pressure leads to involuntary discharge of urine, not caused by detrusor systolic pressure or tension pressure of the bladder wall against urine. It is characterized by no enuresis in the normal state, and the urine automatically flows out when the abdominal pressure suddenly increases. basic knowledge The proportion of diseases: the incidence rate of women over 50 years old is about 0.2%--0.3% Susceptible people: elderly women Mode of infection: non-infectious Complications: hematuria stress urinary incontinence
Cause
Causes of menopausal urinary incontinence
(1) Causes of the disease
Urinary incontinence (UI) is caused by involuntary changes in the urethra and bladder pressure gradient, and the intravesical pressure is higher than the intraurethral pressure. It can be caused by one or more of the following factors:
1 Temporary or persistent urethral pressure drop.
2 detrusor contraction.
3 The intra-abdominal pressure transmitted to the bladder is greater than that transmitted to the urethra.
4 excessive expansion exceeds the bladder elastic limit and the bladder internal pressure is passively increased.
5 Urine shunt due to fistula or ectopic urethra (although there is a normal pressure gradient).
The characteristics of bladder and urethra in elderly women are that bladder function changes with age. The bladder capacity of the elderly decreases, the residual urine volume increases, and there is an irreducible contraction. Alroms and Torrens have performed urination tests on women before and after 50 years old. , <50 years old, urinary rate > 75ml / s, > 50 years old, urination speed > 18ml / s, urination less than 15ml per second, that is, there is urethral obstruction, Parviren performed 59 cases of urinary bladder angiography Many patients were found to have trabecular diverticulum and funnel-like bulging, and were not associated with urinary tract infection. After menopause, due to decreased estrogen levels, vaginal and urethral mucosal epithelium became thinner, dense elastic fiber tissue around the bladder neck and surrounding urethra The glands and ducts of the bladder neck are thinned. Studies have confirmed that estrogen receptors are present on the cell membrane or nucleus of the bladder triangle, bladder mucosa, and urethral mucosa, and the concentration of urinary receptors is significantly higher than the intravesical receptor concentration. Therefore, postmenopausal women are prone to urinary incontinence, and studies have found that administering estrogen replacement therapy to postmenopausal women can reduce the occurrence of nocturia. Thus, it has been indirectly confirmed that estrogen deficiency can reduce bladder stability. Animal studies have shown that hormone withdrawal can affect the density of receptors in the bladder and urethra and sensitivity to hormones, and restoring its normal estrogen levels can reverse these effects. It increases the number of receptors and their response to muscarinic and epinephrine, and the reduction in estrogen levels triggers a decrease in the responsiveness of smooth muscle to nerve stimulation.
At the histological level, anatomical and ultrastructural studies have found that the urinary tract smooth muscle and striated muscle of elderly women have significant degenerative changes, and elderly women who do not have significant genitourinary lesions may also show abnormal changes. This is the elderly women. Susceptible to the cause of dysfunction of the genitourinary system.
Bladder muscle fibrosis in elderly women is one of the earliest reasons for dysuria. Collagen fibers and elastin are increased in the bladder of elderly women. Levy and Wight focus on the submucosa, which accounts for 25% of the thickness of the bladder wall. Biopsy tissue was studied under light microscopy and electron microscopy. It was found that urinary dysfunction was mostly due to the separation and arrangement of collagen. Collagen tissue was rarely found in urgency patients. Elbadawi examined bladder tissue and combined with urine power. Studies have shown that the ultrastructure obtained confirms that its histological changes are consistent with clinical manifestations, the degeneration of muscle cells and axons, leading to a decrease in contractile force, and the urinary dysfunction characterized by dysfunction of the dysfunction of the bladder. Instability and changes in ultra-muscle structure.
In recent years, changes in the senile bladder transverse sphincter have accelerated apoptosis and programmed cell death, which are associated with decreased muscle cells, which is a possible cause of urinary incontinence in older women.
Females maintain urination not only rely on urethral muscle tissue, but also rely on pelvic floor support. Female urethra-related pelvic floor muscles are generally the same as men. Urinary genital warts are much weaker than men. Except for urethra, vaginal vaginal vaginal wear After the urinary genital wart, there is a perineal superficial transverse muscle, which starts from the ischial tuberosity and ends in the center. The ischial corpus cavernosum muscle starts from the ischial tuberosity and ends in the clitoris. The corpus cavernosum muscle starts from the center and muscles. Separated on both sides of the vagina, passing through the vaginal opening and the urethra, ending in the clitoris, the pubis caudal muscles are in the urethra and the vaginal side walls. These muscles have a supporting effect on the pelvic floor and also act as a hanging urethra. These muscles are damaged. It can shorten the length of the urethra and reduce the resistance of the urethra, which is one of the causes of stress urinary incontinence in elderly women.
Causes of stress urinary incontinence:
1. Pregnancy and vaginal delivery
For the main cause of stress urinary incontinence, during pregnancy and childbirth, the fetal first exposed to the pelvic floor muscles excessive compression, the use of fetal head suction and breech traction and other vaginal surgery delivery, postpartum abdominal pressure increased, etc. can cause pelvic floor tissue Relaxation, a multiple regression analysis of Van's case-control study found that tension urinary incontinence was not associated with prolongation of the first stage of labor, but was significantly associated with forceps delivery (Van, 2001), Persson found that stress urinary incontinence It was significantly associated with primiparity, parity, fetal birth weight, and perineal anesthesia.
2. Urethral, vaginal surgery
Anterior and posterior vaginal wall repair, radical resection of cervical cancer, and urethral diverticulectomy can destroy the normal anatomical support of the urethra.
3. Dysfunction
Insufficient support or congenital insufficiency of congenital bladder and urethra is a cause of young women and unmarried women. Postmenopausal women have reduced estrogen, and the submucosal veins in the urethra and bladder triangle are thinned, blood supply is reduced and mucous membranes Epithelial degeneration, decreased tension in the superficial epithelium of the urethra and bladder, atrophy of the urethra and surrounding pelvic floor muscles, and urinary incontinence. Salinas also found that although menopausal status is associated with stress urinary incontinence, the risk does not increase with age. The risk of stress urinary incontinence disappears after the age of 52. Premenopausal symptoms are often due to malnutrition, weak constitution, urethral bladder neck muscles and fascia atrophy and urinary incontinence.
4. pelvic mass
When there is a huge mass in the pelvic cavity, such as uterine fibroids, ovarian cysts increase abdominal pressure, bladder urethra junction position is reduced and urinary incontinence.
5. Weight
Many reports have reported that the occurrence of stress urinary incontinence is associated with an increase in the patient's body mass index (BWI).
6. Periodic stress urinary incontinence
The symptoms of stress urinary incontinence in the second half of menstruation are more pronounced and may be related to progesterone relaxation.
(two) pathogenesis
1. General pathogenesis
(1) Characteristics of female pelvis: The front part of the female pelvis is wide, the pelvic floor muscle is relatively flat, and it is not inclined like a male. Therefore, the organ and the supporting force of the anterior pelvic cavity are weaker than that of the male, and the external urinary sphincter is not as strong as the male. When these supporting tissues are damaged, the bottom of the bladder can be drooped and the upper urethra can be lowered to the outside of the abdominal cavity. Therefore, stress urinary incontinence occurs in elderly women.
(2) decreased urethral resistance: the urethra can prevent the outflow of urine, which is related to the length and tension of the urethra. If the urethra is shorter than 3cm, it can not prevent the outflow of urine. The higher the tension of the urethral wall, the greater the resistance of the urethra, the length of the urethra and the wall of the urethra. The tension is proportional to the diameter of the urethral lumen, and La=law can express P=T/r (P-urethral wall tension, T-urethral length, r-urethral diameter).
Under normal circumstances, due to the contraction of the levator ani muscle, the external urinary sphincter and the pelvic floor muscles, the urethra is elongated, the lumen is thinned, and the tension is significantly increased, so that the urine accumulated in the bladder does not flow out due to the increase in pressure because the urethra has A certain length and tension, urine up to 1/3 of the proximal end of the urethra under the influence of abdominal pressure, and then return to the bladder, urinary incontinence due to sphincter system dysfunction, the above muscles are damaged or smooth muscle tone is reduced, muscle contraction is not enough The urethra is elongated, and when the abdominal pressure is increased, the urethral resistance is insufficient, that is, the urethral pressure is less than the bladder pressure, and as a result, the urine does not return to the bladder after entering the urethra as normal, and thus does not flow freely.
(3) Insufficient collateral tissue around the urethra: Under normal circumstances, the bladder urethral junction in the storage phase is more than 1/3 of the pubic symphysis, the posterior horn of the bladder urethra is 90° to 100°, and the urethral anteversion angle is 30° to 45. °, the position and angle change little when the position change and abdominal pressure increase, so that the bladder neck and the proximal urethra become intra-abdominal organs. When the abdominal pressure increases and the bladder pressure increases, this part of the urethra is also subjected to the same pressure. The so-called pressure transfer effect, and the bladder neck and urethra are platform-like, rather than funnel-shaped, the support tissue around the female urethra plays an important role in urine control. The sagging pelvic floor and urogenital sputum are not conducive to the urethra. External sphincter function, in the case of stress urinary incontinence, the posterior horn of the bladder urethra disappears, the urethral tilt angle increases, the congenital pelvic floor is weak, prolific, estrogen deficiency, hysterectomy, pelvic surgery and trauma can make the urethra The surrounding support organization is weak and replaced by fat and other connective tissues. The result is:
1 The bladder neck and urethra move down, and the proximal urethra shortens.
2 bladder neck and proximal urethra relaxation.
3 When the abdominal pressure is increased, the bladder neck and the proximal urethra are insufficiently closed, and the bladder and the proximal urethra are opened due to the sudden increase in bladder pressure.
4 The ability of the external urinary sphincter to close is reduced. If the bladder pressure is sufficient to overcome the pressure of the external sphincter urethra with insufficient closing force, stress urinary incontinence will occur.
(4) urethral mucosa atrophy: soft, wrinkled urethral mucosa can seal the urethral cavity left after sphincter contraction to prevent urinary incontinence, urethral mucosal pad has a more important role in female urine control, women before 45 years old The urethral mucosa and its submucosal tissues and blood vessels are abundant. As the estrogen level decreases, the above tissues shrink, and the sealing effect of the urethral mucosal pad decreases, which is prone to urinary incontinence.
2. The pathogenesis of stress urinary incontinence
Stress urinary incontinence is classified into bladder neck hyperkinesis and urethral sphincter disorder. The former accounts for more than 90%, and the latter is less than 10%. The pathogenesis of stress urinary incontinence is still unclear. The hypothesis is widely accepted, but the possible mechanisms include the following:
(1) Lower urethral resistance: Maintaining an effective urinary control mechanism requires two factors: the internal structure of the urethra and sufficient anatomical support. The integrity of the internal structure of the urethra depends on the resistance of both the urethral mucosa and the urethral closure pressure. The urethral mucosa is formed by mucosal folds, surface tension of the secretions and submucosal venous plexus. The closed seal can prevent leakage of urine. The urethral closure pressure comes from the tension of the submucosal blood vessels and muscles. The urethral closure pressure is increased and the resistance is high. It can control urination, relaxation of pelvic floor tissue and reduce urethral resistance. Some studies have found that neuromuscular conduction disorder can not reflect the increase of urethral pressure in the increase of abdominal pressure. This type of stress urinary incontinence is urethra. Internal sphincter disorder type.
(2) Pressure relationship of the urethral bladder: those with good urinary control have a proximal urethral pressure equal to or higher than the intravesical pressure. When the abdominal pressure increases, the abdominal pressure is transmitted to the bladder and 2/3 proximal urethra (in the abdominal cavity). Internal), the urethral pressure is still equal to or higher than the intravesical pressure, so no urinary incontinence occurs. On the contrary, in patients with stress urinary incontinence, 2/3 of the proximal urethra moves outside the abdominal cavity due to pelvic floor relaxation. At rest, the urethral pressure is reduced (still higher than the intravesical pressure), but when the intra-abdominal pressure is increased, the pressure can only be transmitted to the bladder and cannot be transmitted to the urethra, so that the urethral resistance is insufficient to resist the bladder pressure, and the urine overflows, explaining The mechanism of the occurrence of stress urinary incontinence in the bladder neck with high mobility.
(3) Anatomical relationship of the urethra bladder: the posterior horn of the normal urethra and the bottom of the bladder should be 90°100°, the vertical line of the upper urethra axis and the standing position, and the urethral inclination angle of the urethra is about 30°, in patients with stress urinary incontinence. Because the pelvic floor tissue is loose, the bottom of the bladder shifts downward and backward, gradually disappearing the posterior horn of the urethra, and the urethra is shortened. This change is like the initial stage of urination. Once the intra-abdominal pressure increases, it can induce involuntary urination. In addition to the disappearance of the posterior horn of the urethra, the urethral axis also rotates, increasing it from a normal 30° to more than 90°, as shown in Figure 1, which also explains the bladder neck hyperkinetic stress urinary incontinence from one side. The mechanism of occurrence.
Petros elaborated on the mechanism of stress urinary incontinence from the hypothesis of normal urethra and bladder neck closure mechanism: the closure of the urethra is caused by the contraction of the anterior portion of the pubic muscle to form a so-called "hammock", which is formed by the pubic urethra. The part of the vagina after the ligament is the transmission medium, and the closure of the bladder neck is called knuckle knot. It is based on the part of the vagina behind the pubic urethra and is completed by the common contraction of the lifting support structure. "Support structure" refers to the lateral muscle of the rectum and the longitudinal muscle around the anus. The measurement of the posterior vaginal myoelectric EMG confirms this hypothesis. In women without urinary incontinence, the "lifting support structure" contract causes the vagina to reach X point. The pubis muscle contracted and pulled the vagina forward to form a "hammock" and closed the urethral cavity. If the vaginal wall was loose, the pubic muscle contracted more than a fixed distance and could not reach the transition point XI, the urethra could not be closed and urinary incontinence occurred.
Prevention
Menopausal urinary incontinence prevention
Strengthen exercise, enhance physical fitness, try to avoid birth injury, surgical injury, pelvic mass should be detected and actively treated as soon as possible.
Complication
Menopausal complications of urinary incontinence Complications, hematuria, stress, urinary incontinence
Urinary and vulvar skin can also be complicated by infectious diseases, dysuria and hematuria are rare, and stress urinary incontinence is more complicated with bladder bulging.
Symptom
Menopausal symptoms of urinary incontinence Common symptoms Swelling urinary frequency enuresis Urinary diabetes Diabetes Paralysis Detrusor reflex hyperactivity Incontinence Urinary urgency
Involuntary enuresis with increased abdominal pressure is the most typical symptom, and urgency, frequent urination, urgent urinary incontinence and sensation of fullness after urination are common symptoms. Over the years, in order to standardize the diagnosis and guide the development of treatment plans, more A clinical classification system for urinary incontinence, clinically classified according to the mechanism of urinary incontinence:
1. Bladder-related urinary incontinence
These include reduced bladder capacity, unstable bladder, detrusor hyperreflexia, low compliance bladder, bladder urinary insufficiency, and different combinations of the above.
2. Urinary incontinence associated with the urethral sphincter
Due to the inability of the urethral sphincter and/or the external urinary sphincter to function properly, it may be caused by impaired sphincter contraction, dysfunction of the urethra support tissue, frozen urethra and different combinations of the above abnormalities.
3. Urinary incontinence associated with the bladder and urethra
It is the aforementioned combination of bladder and urethral lesions. According to the definition of standardized nouns established by the International Association of Urinary Associations, classification of urinary incontinence:
(1) Stress urinary incontinence (tension urinary incontinence) (SUI): leakage of urine in the case of increased abdominal pressure such as cough, sneezing, laughing or weight-bearing, often without urine, but a few seconds later Even 10~20s involuntarily spray 10~20ml urine, realize urinary incontinence in the back of wet clothes, female patients have more onset, and have a history of production, pelvic and gynecological surgery history, with increasing age, urine The degree of incontinence is aggravated. It is caused by excessive urethral peristalsis, pelvic floor prolapse, internal sphincter defect or urethral support tissue insufficiency, urethral mucosal atrophy and other anatomical abnormalities. 80% of patients with stress urinary incontinence have bladder About half of the patients who swelled but had bladder bulging had stress urinary incontinence.
(2) Urgency urinary incontinence: first, there is strong urinary urgency, that is, urgency can not control urination, and then urinary incontinence can be divided into sensory and exercise urinary incontinence. The former is due to central nervous system inhibition of dysfunction of the spinal cord. Caused by the latter is common in various causes of bladder inflammation, bladder capacity reduction and hyperesthesia.
(3) Impulsive urinary incontinence: commonly referred to as "excessive bladder" or functional urinary incontinence, spontaneous urine leakage associated with sudden urination desire is due to irreducible bladder detrusor contraction, including bladder urinary bladder Muscle instability and detrusor hyperreflexia, the former refers to innervation disorders, inflammation, tumor formation, loss of normal anatomical relationship between the bladder and urethra, urethral obstruction or urinary incontinence surgery, the latter refers to dysfunction caused by defects in innervation regulation Older women often show functional urinary incontinence and decreased bladder contractility. Therefore, in addition to urinary incontinence, combined with incomplete urination, the urinary process is prolonged and residual urine is increased.
(4) overflow urinary incontinence: also known as filling urinary incontinence or pseudo-urinary incontinence, when the bladder exceeds the capacity of spontaneous urine overflow, this situation is not common in postmenopausal women, usually due to lower urinary tract obstruction Or detrusor weakness and paralysis cause urinary retention to excessive bladder filling, neurological dysfunction, mainly due to the regulation of the lower motor nerve of the bladder without damage, can be seen in the sacral reflex lesions such as congenital malformations (recessive spina bifida); Lesions (sacral or pelvic nerve injury); tumors and inflammatory lesions (diabetic peripheral neuropathy), urinary incontinence in the elderly is an unexplained bladder sensation or bladder contraction caused by "active" urinary incontinence, may be the brain The result of the weakening of the suppression function.
(5) complete urinary incontinence (urethral sphincter deficiency true urinary incontinence): often due to congenital urethral sphincter hypoplasia or loss, such as upper urethral fissure, bladder valgus, trauma, birth injury, iatrogenic urethral sphincter injury, serious Occasionally, sphincter dysfunction can also manifest as complete urinary incontinence.
(6) Reflex urinary incontinence (neurological urinary incontinence, also known as active urinary incontinence): urinary incontinence due to detrusor hyperreflexia caused by neuropathy, except for varying degrees of detrusor hyperreflexia, and low The compliant bladder and the bladder leak pressure were all measured with a pressure of >40 cm H2O, and the bladder capacity was relatively small.
Examine
Menopausal examination of urinary incontinence
1. The size of the posterior horn of the urethra and the degree of urethral sag can be measured by a simple cotton swab method.
METHODS: The urethral mouth of the patient was placed 4 cm deep with a sputum-promoting docaine cotton swab.
(1) There is no anatomical defect in the urethra: the cotton swab is maintained at the original level of -5° to +10°.
(2) If the posterior horn of the urethra has disappeared, but the posterior urethra has not been displaced downward, the free end of the cotton swab can still maintain the original level or slightly upward, but not more than 10°.
(3) If the urethral support tissue has been severely weakened and the posterior urethra sag is significant, indicating that the urethra has been separated from the pubic symphysis, the cotton swab detachment will increase significantly and may form an angle of 45° or more with the horizontal line.
2. Determination of urethral pressure
The urethral pressure map can often prove that the urinary sphincter function of the patient with stress urinary incontinence is weakened at rest, and the urethral pressure map can determine whether it is internal sphincter disorder type stress urinary incontinence.
3. Urodynamic testing
Basic basic urodynamic tests include urine flow measurement and intravesical pressure measurement.
(1) Urine flow measurement: It is a non-invasive, easy and inexpensive method of examination. The patient urinates on the urine flow meter under the maximum bladder volume to understand the maximum urinary flow rate, average urination speed, urination time and urine output. The maximum urination rate <15ml/s and the urine output <150ml were abnormal.
The clinical significance of this test is:
1 If the bladder capacity is <300ml or >800ml, it is forbidden to perform stress urinary incontinence surgery.
2 urinary flow rate is reduced, long urination, which means that there is the possibility of postoperative urinary retention.
(2) Determination of intravesical pressure: After the urine flow measurement, the patient first performed residual urine measurement, and inserted the intravesical intubation from the urethral opening into the bladder neck level under aseptic conditions to measure the intravesical pressure and insert the intestine from the anus. Catheter, used to measure intra-abdominal pressure, injecting normal saline from room temperature into the bladder at a flow rate of 10 ~ 100ml / s, recording the bladder volume of the first urinary sensation; while the patient coughs and let the patient listen to the water, observe No leakage of urine; maximum urinary sensation, record the bladder volume at this time, and observe the leakage of urine when coughing and listening to water.
The normal result of intravesical pressure is: residual urine <150ml; the first urinary sensation is 150-200ml in saline; the maximum urinary capacity is >400ml; the intravesical systolic pressure rises with water injection, and the water injection stop pressure is not returned to the baseline. There is no stable contraction of the detrusor, and the diagnosis of stress urinary incontinence is stable contraction without detrusor, and leakage of urine when abdominal pressure is increased.
Urinary urethroscopic examination
Can directly observe the bladder, urethra, diverticulum, urinary fistula, tumor, stones, inflammation, determine residual urine, observe the position and variation of the urethra, bladder neck morphology, understand the length of the urethra, tension and exclude bladder mucosal lesions.
2. Bladder urethrography
Can check its shape and help understand its function:
(1) Change of urethral angle: on the lateral position, measure the posterior horn of the urethra and the inclination angle of the urethra. The normal urethral angle is between 90° and 100°, the urethral inclination angle is between 15° and 30°, and the maximum is not more than 45°. Incontinence patients often show changes in urinary tract anatomy on the X-ray.
Type I: The posterior horn of the urethra disappears completely or incompletely, but the urethral tilt angle is normal (10° to 30°) or smaller than 45°.
Type II: the posterior horn of the urethra disappears, the urethral tilt angle is >45°, the supporting tissue of the bladder neck is weak, the symptoms are severe, and the treatment is more difficult.
(2) Changes in the position of the bladder and urethra: the pubic symphysis is used as a marker to measure the distance between the bladder neck and the mark when the abdominal muscles are relaxed and the abdominal pressure is increased. In normal cases, the bladder neck is located at the junction of the lower third of the pubic symphysis at the time of relaxation, abdominal pressure When the increase is 0.5-1.5cm downward, the bladder neck is not at the lower edge of the bladder. In patients with stress urinary incontinence, when the abdominal muscles are relaxed, the bladder neck is lower than normal, and the abdominal pressure is further decreased when the abdominal pressure is increased. Normal, and the bladder position is lower than any part of the bladder.
(3) bladder neck changes: normal bladder is closed, even if the abdominal pressure is increased, the pressure urinary incontinence, that is, when the force is applied, the bladder neck is open, showing a vertebra.
Dynamic Bladder Development Video (VCD) can dynamically and continuously observe changes in the bladder and bladder neck. It is the most accurate method for diagnosing high motility of the bladder, but the equipment is expensive and not widely used in clinical practice.
3. Magnetic resonance imaging (MRI)
Clear images can be produced on the difference of soft tissue, and the image can be improved by placing the intraluminal volume in the vagina and the external volume in the rectum. Some scholars have studied the pelvic floor tissue of patients with stress urinary incontinence by MRI. It is found that urinary incontinence is related to the number of urethral genitour sphincters, and the anterior bladder space can also be measured.
4. Ultrasound examination
It can be examined through the vagina and the rectum to understand the resting state and the position of the bladder during Valsalva's movement to understand the bladder neck activity. Recently, it has been reported in the literature that computer technology can assist in more accurate diagnosis.
Diagnosis
Diagnostic diagnosis of menopausal urinary incontinence
According to clinical manifestations, laboratory and auxiliary examinations can be diagnosed.
The most confusing of symptoms and signs is the unstable bladder, which can be identified by urodynamic testing to identify a clear diagnosis. Urinary incontinence is very close to the unstable bladder, but such patients can be prevented with sufficient encouragement. Overflowing urine.
