Most women who have given birth will be familiar with the problem of urinary incontinence (UI), which is most commonly caused when vaginal muscles are stressed. Stress urinary incontinence (SUI) may be the most common form, but there are many risk factors for UI – pregnancy, childbirth, menopause, cognitive impairment, obesity and advanced age.
"It is a very common condition and studies say that 40% of women suffer from some form of UI, though most of them only address it during the menopause or after," says Ivan Fistonic, director of the Ob/Gyn & Menopause Health Center in Zagreb, Croatia. "It is often in the form of SUI from delivering children. The pelvic muscles are very strong between 20 and 25 years, then they start to get weaker and can be particularly weak in the months after giving birth."
Given the diverse risk factors, it is not surprising that most forms of UI are underdiagnosed. Despite the prevalence of SUI and the diminished quality of life it brings, many women who experience symptoms do not seek medical treatment. This may be due to embarrassment, lack of knowledge about possible therapies or even fear that treatment will require surgery.
"In a routine medical check-up, many women will not mention it, but if you ask specifically about UI, then they will report symptoms and how it affects their quality of life," explains Fistonic. "The main cause of SUI is vaginal delivery, especially if forceps are used. Women usually only address UI if it is caused by trauma like this or if the symptoms are serious − if they are leaking during sexual intercourse or if they have a prolapse. Then they will see a surgeon, who will tend to recommend invasive procedures because the problem has been hidden until it is too serious to ignore."
For Fistonic, the most important step in addressing any form of UI is early diagnosis.
"Concern about invasive procedures means women don’t mention the problem until it is too late and they then need a curative process," he says. "The medical profession needs to take a preventative approach and should raise awareness so that women seek consultations earlier. If they do, they will find a range of therapies that do not involve surgery."
Prevention or cure
Many women who have given birth will have been encouraged to perform Kegel exercises, which are recognised as the most effective way to resolve SUI. They can be used as a preventative measure or as a treatment for mild symptoms of UI.
These exercises, which train the pelvic floor muscles, involve repeatedly contracting and relaxing the pubococcygeus muscles. They can include the use of tools such as weighted vaginal cones to treat SUI. Though Kegel exercises are often recommended in the later stages of pregnancy and in the post-natal period, they are effective for UI that results from any of the most common risk factors. Nevertheless, there is a simple reason why Kegel exercises are not the only treatment for UI.
"They certainly work, but the problem is compliance, which is low," explains Fistonic. "These exercises are the best treatment. But people tend to do them for the first few weeks, then they stop."
The wide variety of treatments for UI encompasses many surgical and non-surgical procedures; for example, the implantation of an artificial urinary sphincter may be recommended in cases of intrinsic urethral sphincter deficiency (IUSD) or for women with intractable UI who have not responded to behavioural, pharmacological or other surgical treatments.
There are also a range of therapies such as the periurethral injection of bulking agents for IUSD and sacral nerve stimulation for urge UI. Electrical stimulation involves sending a mild electric current to nerves in the lower back or the pelvic muscles up to twice a day over a course of weeks, and has been successful in cases of urge UI and SUI. Transurethral radiofrequency therapy – the Renessa procedure – is also used to treat SUI in non-pregnant women who want to avoid surgical procedures and has proven in clinical trials to achieve significant improvement in 74% of patients with moderate-to-severe symptoms.
Another non-surgical option for SUI is the use of the antidepressant drug Duloxetine – a combined serotonin and noradrenaline reuptake inhibitor – that is thought to increase the tone of the urethral sphincter.
"The doctor must find out what type of UI is dominant to recommend the appropriate treatment, though there are not many randomised controlled studies to prove the efficacy of different therapies," says Fistonic. "We need to have those studies done."
Laser therapy
Fistonic has been working on a new application for a widely used therapy that may provide a new option for the treatment of UI. Laser treatment has many common applications in which it has proven successful, most notably in healing minor ligament damage and curing snoring.
"Laser treatment could be very effective," he explains. "It involves retracting and stretching the collagen with a photothermic effect. In milliseconds, the laser can reach a high temperature and target the collagen without harming the tissue on the surface. The technique has been used in dermatology for years, and it can shrink collagen by as much as two thirds."
"It has successfully healed damage to cruciate ligaments in the knee, and has been used on the tissue of the uvula and soft palate where excessive tissue can result in snoring. It has also helped many couples who have to sleep in separate beds because one of them snores. Now we are exploring its use in treating UI and improving sexual gratification by using it on the vaginal muscles."
Until now, laser treatment of the reproductive organs has focused on vaginal rejuvenation, which targets the lower part of the vagina. The treatment Fistonic has been developing targets the upper parts of the vagina wall. This application of laser treatment was first investigated by Dr Mario Rivera of the GynDermoLaser Clinic in Santa Cruz, Bolivia (see figure, above), and he reported impressive results. On hearing this, Fistonic visited Rivera with a view to bringing the technique to Europe and developing it further.
"Rivera quickly saw an 80% improvement, according to verbal reports from patients, so three years ago I started a project in Europe, seeking ethical approval to treat SUI and vaginal relaxation after childbirth in order to improve sexual gratification," says Fistonic. "The control group consisted of women using Kegel exercises. We are about to publish the results, which are very encouraging.
"Compared with the Kegel group, our results are better, though I must stress that laser treatment is not a magic solution. Patients must still change their habits. If they cough a lot, perhaps because they are heavy smokers or have bronchitis, they will undo the laser’s work. The same thing happens if they are overweight. So, they need to do exercises like squeezing vaginal cones and if they are post-menopausal, then oestrogen creams will add to the effect of the lasers."
Help and awareness
The fact that there are treatments available and many do not involve invasive surgery is good news for women suffering from UI, particularly in the form of SUI. Furthermore, treatments such as the laser process developed by Rivera and Fistonic mean the range of options continues to grow. Nevertheless, these treatments only achieve maximum benefits for patients if those suffering from symptoms of UI consult their doctors and have the condition diagnosed.
There is further work to do in developing technologies and processes to treat UI in its many forms, but there is perhaps a bigger job to do in raising awareness of the condition and overcoming the fears women may have about seeking advice. Help is at hand, and the earlier patients can consult medical experts about their symptoms, the less invasive the treatment and the better the outcome.
