Assessment and treatment of female urinary incontinence

Urinary incontinence, corresponding to the definition of involuntary urine leaks, due to alteration of the physiological mechanisms of continence, experienced as discomfort in everyday life affects approximately 10% of the female population. The main predisposing factors are age, childbirth (particularly the first), recurrent urinary tract infections, and obesity. Pathophysiologically, urine leak occurs when the forces of expulsion resulting from abdominal straining or detrusor contraction, exceed the physiological (urethral sphincter device) and pathological (obstruction) continence forces. These two mechanisms correspond to two types of incontinence, stress and urge incontinence, which are primarily diagnosed on the basis of the clinical interview, which must also strive to evaluate the volume of urine leaks, the circumstances inducing incontinence, and associated urinary symptoms such as dysuria and frequency. Clinical examination, in women in the gynaecological position, demonstrates incontinence on coughing and control of incontinence by supporting the bladder neck (Bonney's manoeuvre); it also evaluates vulval trophicity and the quality of perineal musculature; it analyses the components of possible vaginal prolapse. The objective of complementary investigations is not to confirm the data of the clinical interview and clinical examination, but to complete them by providing additional elements. Radiological examinations have largely been replaced by urodynamic examinations, able to detect detrusor instability and evaluate the duality of sphincter tone, which largely determines the success of surgery. Surgery remains the reference treatment for stress incontinence with a success rate of almost 90%; the main mechanism consists of supporting the bladder neck, allowing it to close during efforts increasing the abdominal pressure. Perineo-sphincter rehabilitation must be tried first, although its results are less lasting. Currently, the only effective medical treatment is anticholinergic drugs in urge incontinence.