TVT-O-STRESS INCONTINENCE TREATMENT

Urinary Incontinence

A woman is incontinence for urine as her urinary tract is intact and the pressure closing the urethra remains greater than the intravesical pressure. If the normal route is bypassed or if the pressure gradient is reversed, she becomes incontinence.

1. If the woman has incontinence with stress, the nature and volume of uninary loss are evaluated. In case of URINARY STRESS INCONTINENCE (USI), there is a loss of a few drops of urine COINCIDENT WITH THE STRESS. It I totally preventable by voluntary contraction of externalurinary sphincter. The diagnosis is confirmed by BONNEY’S test, in which she becomes continent on stress when the urethrovesical junction is elevated above the urogenital diaphragm with a finger on either side of it. Marchetti’s test is similar, expect that two Allis forceps are used under local anesthesia in place of the fingers to avoid continence by direct pressure of the fingers over the urethra.
   
   If the woman losses a stream of urine instead of a few drops, and the incontinence begins a few seconds after the stress, she has MOTOR URGE INCONTINENCE (MUI).
2. Motor incontinence can be the result of uninhibited, involuntary detrusor contractions. It may be with stress, or with stimuli which may be cold, running water (sight or sound), or psychogenic.
3. Motor may be manifest as spontaneous and intermittent loss of large volumes of urine, with symptoms like frequency and urgency. Urodynamic studies are done to confirm the diagnosis. The findings are involuntary detrusor contractions at rest, during bladder filling, or after provocative maneuvers like coughing, hand washing, and bounching on heels. Cystourethroscopy often shows bladder trabeculation due to hypertrophy of the detrusor.
   
   If the spontaneous and intermittent loss of a large volume of urine is associated WITH DYSURIA, it is likely to be SENSORY URGE INCONTINENCE (SUI). If it is associated with large residual volume of urine, it is overflow incontinence. Urodynamic studies in the former show of a small cystometric capacity, urethral relaxation or a marked variation in the urethral pressure profile, and an absence of detrrusor activity. CYSTOURETHROSCOPY may show the etiological condition like cystitis, diverticulum, foreign body, or neoplasia. In case of overflow incontinence, the bladder capacity is large. The bladder sensation is decreased. Detrusor contractility is poor or absent.

Causes of Overflow Incontinence

1. Diabetic neuropathy
2. Lower motor neuropathy
3. Postoperative obstruction
4. Pelvic mass
5. Massive prolapse with urethral kinking
6. Drugs: ganglionic blocking agents, alpha-adrenergic agonists, anticholinergic drugs.

Causes of Overflow Incontinence

1. Though a diagnosis of psychogenic incontinence is most often easy in woman with psychiatric disorders, psychogenic factors of more subtle nature are responsible in a number of cases. Behaviour therapy is useful in such cases.

Appropriate Surgery For Stress Incontinence

Urinary incontinence is a non life-threatening condition, and consideration should always be given to conservative measures (physiotherapy) before surgical treatment. Women should be adequately counseled about possible outcomes in terms of cure, complications and change in quality of life before they decide to proceed with surgery.

Key point for Patients / Treating of Doctor:

1. Physiotherapy should be offered as first-line treatment for all women presenting with stress or mixed urinary incontinence.
2. Urodynamic investigation is recommended prior to surgical treatment of stress incontinence particularly in women with mixed urinary symptoms and with a history of neurological disease, voiding difficulties, or previous surgery.
3. Patients should be carefully counseled on outcomes of surgery. The patient’s expectations from surgery are too much. They should be prepared to make in balancing success rate, recovery period, morbidity, and longevity of cure, etc. thus doctor should take a vital part of the decision-making process with patients.
4. Open colposuspension and Retropublic mid-urethral tape (TVT-O) procedures appear to have comparable success rates up to 5 years in patients with primary stress incontinence.Most patients favour the minimally invasive nature of the latter i.e. TVT-O. Until more robust long-term data become available, patients should be given the option of both procedures and let them decide.

TVT-O

MID-URETHRAL TAPE PROCEDURES (TVT-O)

In a survey of members of the International Urogynaecology Association, the minimally invasive mid-urethral tape procedures such as the – Tension –free Vaginal Tape (TVT-O) are the preferred choice of operation in primary stress incontinence.

To date, the largest published follow-up of patients undergoing TVT-O is 7 years, with objective and subjective cure rates of over 80%. The longest comparative follow-up showed no difference in re-operation rates for stress incontinence between TVT-O and colposuspension. Until more long-term evidence is available on both procedures, women with primary stress incontinence can be offered an informed choice between the two i.e. TVT-O and Open colposuspension.

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