Quarterly Health and Culture Publication - GYNAECOLOGY
Dr Carlo GASTALDI
HEAD OF THE OBSTETRICS AND GYNAECOLOGY UNIT
ISTITUTO CLINICO CITTÀ DI BRESCIA (BS)
Dr Claudio PAGANOTTI
ISTITUTO CLINICO CITTÀ DI BRESCIA (BS)
Dr Gianfranco MININI
ISTITUTO CLINICO CITTÀ DI BRESCIA (BS)
Urogynaecology offers particularly appropriate responses to the demand for a better quality of life, especially if we consider the main disorders of interest, such as urinary incontinence, uterine prolapse, chronic pelvic pain, dyspareunia (pain during sexual intercourse, ed.) and also bowel incontinence. Let’s find out more about urogynaecology with experts from the San Donato Hospital Group – Dr Carlo Gastaldi, head of the Obstetrics and Gynaecology Unit at the Istituto Clinico Città di Brescia, and Dr Claudio Paganotti and Dr Gianfranco Minini, gynaecology specialists.
While these disorders might not be life-threatening for women, they certainly have a significant effect on quality of life, with urinary incontinence seemingly the least acceptable. To all intents and purposes, an urogynaecologist is something of a “super-specialist” with complex skills centred around the pelvic floor (or perineum). This intimate and segregated part of the female body is the area that closes off the bottom of the pelvis, primarily consisting of layers of muscles around the end section of the urethra, vagina and rectum, before these organs reach the outside through the corresponding orifices. In simple terms, the perineum corresponds to the part of the body that makes contact with the surface of a bicycle seat. This organ, which has been overlooked for millennia, in western culture at least, is now attracting growing attention from doctors, from women themselves, from obstetricians and from healthcare facilities, leading to more and more awareness about the important role it plays. In fact, it is responsible for a number of key functions within a woman’s body, such as bladder and bowel continence, supporting the pelvic viscera, the expulsion of the infant during childbirth, and sexual activity. The perineum is continuously “put to the test” throughout a woman’s life in relation to the exertion sustained as part of daily living and work. However, there are two key moments that can cause significant perineal damage: menopause, that is to say the process of aging due to a hormonal shortfall, and giving birth. As regards to delivery, in particular, it should be remembered that when the baby’s head emerges, the perineal muscles that surround the vagina and have the task of supporting the bladder and rectum, are often torn, leading to the onset of two serious female disorders over time: uterine prolapse and urinary incontinence. Worn perineal muscles are certainly the main (but not the only) cause of this incapacitating disorder that affects women’s quality of life, having a negative influence on family and social relations. The true significance of obstetric damage to the pelvic floor emerges when surveying the large quantity of women who become incontinent after giving birth. Indeed, 30% of women experience temporary incontinence, which becomes permanent in 10% of cases. It is estimated that one in two women over the age of 50 experiences urinary incontinence to some degree and that 50% of women who have given birth suffer some form of prolapse: during their lifetime, 11 out of 100 American women undergo at least one operation for problems associated with perineal dysfunction (urinary incontinence and/or uterine prolapse). These disorders have become more significant than in the past in terms of the demand placed on the healthcare service, both as regards the increased average life span of women and their rightful aspirations for wellbeing even at an advanced age. It is easy to understand how wearing it must be for women, particularly if they are elderly, to experience urinary or bowel incontinence combined with the ongoing discomfort of a prolapse that protrudes (sticks out more than normal, ed.) from the genitals.
What is urinary incontinence?
“The ICS (International Continence Society) defines it as all urine loss that is objectively demonstrable and of sufficient quantity to cause hygiene and social issues,” replies Dr Gastaldi.
What are the causes?
“The main causes of urinary incontinence,” states Dr Paganotti, “are pregnancy and childbirth, the menopause and genetic predisposition.”
The urogynaecologist is a professional figure trained in gynaecology and urology, covering a very broad field. He or she is considered a real “super-specialist” with very complex skills incorporating women’s genital, urinary, sexual and anorectal areas.
What types of urinary incontinence are there?
“The classification of urinary incontinence,” explains Dr Minini, “includes stress incontinence, which is the most common and occurs after a coughing fit, a sneeze, exertion or a sudden movement; urge incontinence, where the leak occurs after the onset of a pressing and sudden urge to urinate (overactive bladder); mixed incontinence, which occurs when the symptoms of the two previous types are both present at the same time; overflow incontinence, when the bladder cannot be emptied sufficiently and remains too full, causing the urine to “overflow”; continuous incontinence, which causes persistent urine loss, drop by drop; post-micturition dribble incontinence, which appears after urinating; and, lastly, nocturnal incontinence (enuresis), which is involuntary urine loss during night-time sleep, typical of children, but also sometimes present in adults.”
Why isn’t it easy to diagnose?
“There are often delays in diagnosing urinary incontinence,” adds Dr Gastaldi, “due to the large number of prejudices still strongly associated with it: patients are often reluctant to talk about this disorder, partly due to embarrassment, partly because of a believe that it is a ‘paraphysiological’ condition linked to age, and lastly because of a lack of knowledge about the available treatments.”
What data do we have on this disorder?
“Some epidemiological data,” specifies Dr Paganotti, “demonstrates just how widespread this ‘disease’ is: 7.1% of the Italian population suffers from urinary incontinence, that is to say 4,200,000 people, of whom three million are women. It is estimated that 70% of cases are in women, 30% in men. The predominance of urinary incontinence in the European population varies from 14.1 to 68.8% and increases in proportion to age. In Italy, scientific literature highlights that this disorder affects 20‒30% of the young population, 30‒40% of the middle-aged and 30‒50% of the elderly. Stress incontinence is the most widespread type of incontinence. However, the form of urinary incontinence that leads to the most issues, both in mental and physical terms and as regards management, is mixed incontinence, which affects 2% of Italians. In 48% of cases, urinary incontinence can be definitively resolved through minimally invasive surgery. In Italy, 28,800 operations are carried out every year to treat stress incontinence. A study conducted in the USA found that 24% of patients consult their doctor, 14% undergo tests and only 7% receive therapy/treatment. Only a quarter of people with urinary incontinence state that they are in possession of information about the consequences of the disorder and the treatments available for it.”
How is it diagnosed?
“The diagnostic phase is fundamental for identifying the types of incontinence, the causes and the possible treatments, so that the patient, GP and specialist can plan the most suitable course of treatment,” replies Dr Minini. “A comprehensive clinical assessment includes a physical urogynaecological examination, and ultrasound and/or X-ray of the lower urinary tract (cystomanometry, urethral profilometry, uroflowmetry) and the PAD test (assessment of the quantity of urine lost, ed.). The tests have to be preceded by a targeted medical history using incontinence symptom self-assessment questionnaires. As regards the physical examination, it requires a precise assessment of perineal muscle function (contractile force, tone, fatigability, etc.). A diagnostic process such as this makes it possible to identify the type and degree of urinary incontinence (detrusorial, stress or mixed) and to identify the muscular characteristics of the pelvic floor, pinpointing any functional deficits and establishing the grounds for the correct rehabilitation programme.”
How is it treated?
“Each type of incontinence can be treated with one or more specific methods. In selected cases, multidisciplinary treatments (gynaecologists, urologists, physiotherapists) can be advantageous and effective. Fundamentally speaking, therapy can use three tools that can be combined in different ways: pelvic-perineal rehabilitation; conservative minimally invasive surgery, which allows for rapid operations with minimal recovery times, resolving the problem in the majority of cases; and drug treatment, which includes new and effective molecules,” explains Dr Gastaldi.
What does perineal rehabilitation involve?
“This is a therapeutic and preventive treatment,” says Dr Paganotti. “It consists of exercises for the perineal muscles using specific techniques (biofeedback, pelvic-perineal kinesiotherapy, functional electrical stimulation, bladder retraining) and sophisticated electronic tools. These exercises are designed to restore muscle tone and contractile strength, thereby effectively combatting incontinence and prolapse. These techniques were developed by an American gynaecologist, Arnold Kegel, in the mid-1950s. As well as being used for preventive purposes, they can also be used to treat moderate-mild cases of stress incontinence, often making it possible to avoid corrective surgery. It is easy to understand how restoring good perineal/vaginal muscle tone helps women to rapidly recover a suitable body image and resume a satisfying sex life, with obvious benefits for couples.”
When is surgery more appropriate?
“In more serious cases of stress incontinence, surgery is certainly the treatment of choice,” replies Dr Minini. “Innovative, minimally invasive surgical techniques, which are now routine in Italy too, have replaced the old invasive operations that were performed under general anaesthetic, with an abdominal incision and long recovery period. The new techniques (transobturator tape [TOT], single incision tape) involve implanting biocompatible synthetic sub-urethral tapes under the urethra that act in the event of stress, using periurethral bulking agents or devices and, lastly, fitting artificial sphincters. I should emphasize the great efficacy of the techniques involving the application of suburethral tapes (98% success rate), but also the simplicity of the operation and the rapid recovery times for patients. If the urinary incontinence patient has a prolapse too, both problems can be corrected at the same time.”
What are the most suitable drugs for treating urinary incontinence?
“As regards stress incontinence,” clarifies Dr Gastaldi, “there are no truly effective drugs with the exception of some that exploit “accessory” effects with respect to their principal indications (e.g. Paroxetine, α-adrenergics, oestrogens). More effective medical therapy is available for urge incontinence. It includes antimuscarinics or β-agonists, which ‘release’ the bladder.”
One of the most recent tools used in urogynaecology is sacral neuromodulation: what does it involve?
“It involves the use of a stimulator (similar to a pacemaker) for the sacral nerve roots that are attached to the bladder and other pelvic viscera. The electrical stimulation of the nerve fibres produces positive results both in overactive bladder syndrome and in cases of chronic urinary retention. Sacral neuromodulation is also used today to treat chronic intestinal and pelvic floor disorders. With the increase in indications for application, it is becoming an increasingly important tool for urogynaecological therapy,” concludes Dr Paganotti.
By: Tommaso Revera
Translation: TDR Translation Company
Editing: Violetta Valeeva