Introduction
Stress urinary incontinence is defined as the involuntary loss of urine through the intact urethra caused by a sudden increase in intraabdominal pressure on coughing, walking and in some cases during turning in bed.1 It is the most common type of urinary incontinence in woman and when it is of sufficient quantity causes a great embarrassment which was frequently underreported.
UI is a multifactorial syndrome produced by a combination of genitourinary pathology, age-related changes, and co morbid conditions that impair normal micturation or the functional ability to toilet oneself, or both.
Stress incontinence was first introduced by sir Eardlye Holland in 1928. However, the condition was first recognized in the 19th century, when special procedure for its cure first come to force.
Until more than 2 to 3decades ago, the diagnosis of urinary incontinence in the female was for the most part made casually, primarily on the basis of history given by the patient. The underlying anatomic abnormality was not precisely understood. Jeffcoate & Roberts [1952]1 were the first to call attention to the importance of the anatomic configuration of the urethrovesical junction and proximal urethra to the continence mechanism on the basis of their extensive studies using urethrocystography.1
UI is not associated with increased mortality. UI impairs quality of life, affecting the older person's emotional well-being, social function, and general health. Incontinent persons often manage to maintain their activities, but with an increased burden of coping, embarrassment, and poor self-perception. Caregiver burden is higher with incontinent older persons.
Surgical procedures to remedy stress incontinence generally aims to lift and support the urethra-vesical junction, although there is disagreement about the precise mechanism by which continence is achieved.
More than 100 surgical procedures2 have been described for correction of stress incontinence - vaginal, abdominal, combined, Endoscopic, laproscopic3 and prosthetic;3 just to name a few approaches and this abundance of approaches. Signifies the fact that no single approach can claim to benefit all cases of SUI and an accurate selection of cases combined with a meticulous surgical technique and attention to the lower tract female pubic anatomy is a must to ensure success both technical and symptomatic.4
Materials and Methods
This was a hospital Based retrospective study conducted in In the gynecology department k. e. m. hospital Mumbai with complaint of urinary incontinence were studied. A total 50 patient were included in following study.
Study setting & duration
Study was conducted in the department of gynecolog, KEM Hospital Mumbai India.
Total duration of study from enrollment to completion was 2 yeas Each patient was followed for 6 month
Working Definitions
Case: Women with complaint of involuntary loss of urine on coughing or on increase in abdominal pressure.
Failure: was defined as presence of urinary incontinence after a period of 6 months following SUI surgery.
Post operative urinary retention: It was defined as a persistence of high more than 100 ml post –void residual urine or 20% of voided volume.5
Complications
Intra operative complication: Bladder perforation, urethral injury, bowel injury
Post operative complication: Urinary retention, erosion, infection, hematoma .
History
Age, occupation, severity, duration and frequency of SUI, other menstrual history, urinary symptoms, detail obstetric history, parity, gynecological procedure, pelvic floor trauma, previous urinary tract infection, previous surgeries. trauma in childhood, any spinal surgery, or drugs
Examination
A focused physical examination should be performed. The examination is tailored somewhat in each case, based on the specifics of the patient's incontinence complaint and pertinent medical and surgical history, local and per vaginal examination Each patient should have height, weight, blood pressure, and pulse recorded. Obesity is an important contributor to stress incontinence, and the presence of obesity may influence management decisions. Lastly stress incontinence was clinically confirmed by “ Bonneys test “
Also there are certain urinary symptoms that can mimic stress incontinence and there are certain neurological causes of stress incontinence which need to be distinguished from the true anatomical stress incontinence. The clinical evaluation is therefore aimed at.
Establishing the diagnosis of stress incontinence.
Establishing the etiology of stress incontinence and once the diagnosis of anatomical stress incontinence is established
The degree of anatomical change producing stress incontinence
Bonneys test6 : Patient is examined in lithotomy position with full bladder, stress incontinence is demonstrated by asking the patient to cough. The severity of the problem is assessed, if patient doesn’t lose urine in lithotomy position she is than tilted to 45 degree upright position and asked to cough. This raised the resting bladder pressure by adding the weight of some of the abdominal content. About 80% of patient with surgically curable incontinence lose urine in lithotomy position with coughing. Another 10% required tilting to 45 degree position. The rest 10% demonstrated loss of urine related to coughing only when examined in the standing position
After stress urinary incontinence is demonstrated bonneys test is carried out by elevating the paraurethral tissue near the bladder neck with two finger and asking the patient to cough. The ability to control the stress incontinence is studied which usually indicate that bladder neck elevation is going to cure the patient. Care is taken not to compress the urethra directly. Next, voided volume and residual urine are checked this may give a clue to neurogenic bladder. Presence of cystocele or rectocele is determined.
Anal sphincter tone ad sensation at s2,3,4 dermatomes are checked to rule out any neurological lesion.
Investigation
Following investigation are helpful in evaluating patient of SUI
Urinary microscopy and culture sensitivity: Although urinary tract infection is mentioned in literature as a cause of urinary incontinence, a and patient with acute cystitis often have urge incontinence. A patient of urinary incontinence was not helped by clearing the bacteria
All routine hematological and other investigation required for anaesthesia fitness were done.
Treatment of stress urinary incontinnce
Before discussing different option in the treatment of SUI an important question should be addressed –who should be treated and why?
After underlying causes are ruled out or treated, most women with incontinence will have symptoms suggesting the stress or the mixed type. Management falls into these general categories:
Pharmacologic
Table 1
Results
The result of the current study with respect to various criteria are presented as far as possible in a table form for easy and simplicity.the total number of patient with SUI in this study is 50
Table 2
| S. No | Age grouping year | No. of patient | Percentage |
| 1 | Less than 30 | 0 | 00 |
| 2 | 30-39 | 15 | 30 |
| 3 | 40-49 | 16 | 32 |
| 4 | 50-59 | 10 | 20 |
| 5 | 60-69 | 09 | 18 |
Agewisw classifcation
Thus majority of the patients fall in the range of 30-50 yrs.
The following table depict the duration of symptomatology of these patients
Table 3
| S. No | Duration of symptoms | No. of patient | Percentage |
| 1 | Less than 6 mths | 22 | 44 |
| 2 | 6-12mths | 10 | 20 |
| 3 | 1-2 yrs | 15 | 30 |
| 4 | 3-5yrs | 02 | 04 |
| 5 | More than 5 yrs | 01 | 02 |
Duration of symptoms
Among various associated factors responsible for SUI, the following were evaluated in details
Table 4
| S. No | Parity | No. of patient | Percentage |
| 1 | Nulliparous | 0 | 00 |
| 2 | P1 | 02 | 04 |
| 3 | P2 | 15 | 30 |
| 4 | P3 | 07 | 14 |
| 5 | P4 | 12 | 24 |
| 6 | P5 or more | 14 | 28 |
Parity of the patient
The above table depict the parity of the patient majority of patient have more than two parity.
Table 5
| S. No | Menstrual history | No. of patient | Percentage |
| 1 | Normal mences | 20 | 40 |
| 2 | Menorrhagia | 10 | 20 |
| 3 | Menopausal | 20 | 40 |
Depict menstrual history
Table 6
Depict accidental associated disease
Table 7
| S. No | Previous surgery | No. of patient | Percentage |
| 1 | Tubal ligation | 12 | 24 |
| 2 | LSCS | 03 | 06 |
| 3 | Vaginal hysterectomy | 05 | 10 |
| 4 | Abdominal hysterectomy | 00 | 00 |
| 5 | No previous surgery | 30 | 60 |
Depict history of previous surgery
Bonneys test was performed in all cases and positive bonneys test was considered to be a prime requisite for patient under go sui surgery
Table 8
| S. No | Associated disease | No. of patient | Percentage |
| 1 | No growth | 40 | 80 |
| 2 | Growth of organisms | 10 | 20 |
Depict report of urine culture
The above table depict 20% of the patient has growth of E coli and Klebsiella. they have been treated with nitrofurontoin and norfloxacine and some with cephalosporin.
Table 9
| S. No | Associated disease | No. of patient | Percentage |
| 1 | Fibroid | 03 | 06 |
| 2 | Prolapse | 02 | 04 |
| 3 | Adenomyosis | 04 | 08 |
| 4 | DUB | 03 | 06 |
| 5 | Cystorectocele | 04 | 08 |
| 6 | SUI | 03 | 06 |
| 7 | Prolapse with CR | 31 | 62 |
Depict sui associated disease
Table 10
| S. No | Surgery | No. of patient | Percentage |
| 1 | Vaginal hyst with AP with SUI repair | 31 | 62 |
| 2 | Vaginal hyst with SUI repair | 12 | 24 |
| 3 | AP repair with SUI repair | 04 | 08 |
| 4 | SUI repair | 03 | 06 |
Depict siu repair along with other procedure
Table 11
| S. No | Complication | No. of patient | Percentage |
| 1 | Bladder perforation | 01 | 02 |
| 2 | Bowel injury | 00 | 00 |
| 3 | Urethral injury | 00 | 00 |
| 4 | Hematoma | 00 | 00 |
| 5 | No complication | 49 | 98 |
Depict the intraoperative coplication
Table 12
| S. No | Complication | No. of patient | Percentage |
| 1 | Urinary retention | 09 | 18 |
| 2 | Infection | 00 | 00 |
| 3 | Erosion | 00 | 00 |
| 4 | No complication | 41 | 82 |
Depict the post operative comlication
Table 13
| S. No | Procedure | Bladder perforation | No of patient |
| 1 | Kellys placation | 00 | 20 |
| 2 | Stameys repair | 00 | 05 |
| 3 | TVT | 01 | 10 |
| 4 | TOT | 00 | 15 |
Intra operative comlication of individual procedure
The above table depict the intra operative complication of individual procedure only TVT has single bladder perforation
Table 14
| S. No | Procedure | Urinary retation | No of patient | Percentage |
| 1 | Kellys placation | 06 | 20 | 30 |
| 2 | Stameys repair | 01 | 05 | 20 |
| 3 | TVT | 02 | 10 | 20 |
| 4 | TOT | 00 | 15 | 00 |
Post operative comlication of individual procedure
The above table depict the post operative Urinary retention majority of patient belong to kellys AP repair and no retention in TOT
Table 15
| S. No | Procedure | No of patient n=40 | Percentage |
| 1 | Kellys placation | 18 | |
| 2 | Stameys repair | 02 | |
| 3 | TVT | 08 | |
| 4 | TOT | 12 |
No of patient who come for follow up at 6 month
The following table depict total number of patient who come for follow up out of 50 patient only 40 came for follow up
Table 16
| S. No | Procedure | No of patient n=40 | Recurrence of SUI | Percentage |
| 1 | Kellys placation | 18 | 06 | 33 |
| 2 | Stameys repair | 02 | 00 | 00 |
| 3 | TVT | 08 | 01 | 12.5 |
| 4 | TOT | 12 | 01 | 8.3 |
Recurrence of sui in followup cases
The above table depict recurrence of SUI in follow up patient. However only kellys plication has more recurrence of sui in about 33 % of patient. As in stameys the number of follow up patient was only two and none of them had recurrence of sui.
Discussion
Stress urinary incontinence is a major problem among women unfortunately it is frequently ignored in spite of it being a treatable condition
SUI is classified in two group3, 27
The age group commonly affected by this disorder is usually between 40-60 yrs of age. In our study too, 62% of cases of SUI fall in age group of 30-50with 20 % of cases between the age of 50-59yrs of age also affected
Table 17
| S. No | No of patient | Mean age | |
| 1 | Ulmsten et al8 | 131 | 53(35-88) |
| 2 | Levin et al9 | 70 | 57(32-65) |
| 3 | Current studies | 66 | 58(40-80) |
The incidence of stress urinary incontinence is believed to increase directly with parity7, 10, 3 in our study not a single patient was nulliparous 100% of the patient were multiparous who delivers one or more time
According to various studies parity varies from 0-5 and average is two.
In this study, 40% patient had normal mences, 20% had menorrhagia and 40% had menopause
Out of fifty patient, three patient had only SUI complaints and forty seven patient were along with fibroid,adenomyosis,prolapse with cystorectocele, DUB, prolapse, cystorectocele. In our study 62% of patient had SUI along with prolapse cystorectocele,3% with fibroid, 3% with DUB,2% prolapse,4% with adenomyosis,4% with cystorectocele. The majority of patient had SUI along with prolapse cystorectocele.
In this study not only SUI repair but also SUI repair along with other surgeries included. Out of fifty SUI surgeries thirty one patient had vaginal hysterectomy with anterior colporrhaphy and posterior colpo perineorrhaphy with SUI repair, twelve with vaginal hysterectomy with SUI repair, four with AP with SUI repair, only three patient had SUI surgeries.
Out of fifty, eighty percent patients urine culture was suggestive of no growth and twenty percent had growth of organisms, were treated with sensitive antibiotics.
Intra operative complication like bladder perforation, bowel and urethral injury, hemorrhage has been included in this study. only single case had complication of bladder perforation, that was in TVT. In this study bladder perforation was seen in 10 % with TVT procedure as compared to 5%, and 9.7% in Barber et al and de Tayarac et al 2004 studies respectively in TVT procedure. No bladder perforation seen in TOT in both above mentioned studies.
Table 19
| S. No | TOT | TVT | |
| 1 | Barber et al11 2006 | 0% | 5% |
| 2 | de Tayarac et al12 2004 | 0% | 9.7% |
| 3 | Current studies | 0% | 6% |
Bladder perforation
Post operative complication like urinary retention, infection, vaginal erosion, and hematoma has been included in this study. Out of fifty, nine patients had urinary retention, of that six patients were of Kellys plication and two patient of TVT and one patient of stameys. No urinary retention seen in TOT and other complication like infection and erosion was not found in any cases.
In this study urinary retention of 30%was seen in Kellys plication, 20% with stameys, 10% with TVT, 0% with TOT.
de Tayarac et al 2004 reported risk of urinary retention in 13.3% patient with TOT and 25.8% patient with TVT surgery
Hilton et al 1991 reported risk of urinary retention in 17.3% patient with stameys repair,
Harris et al 1995 reported risk of urinary retention in 38% patient with Kellys plication.
Table 20
| S. No | TOT | TVT | |
| 1 | Laurence M D et al 200413 | 10 % | 22.8% |
| 2 | de Tayarac et al12 2004 | 13.3% | 25.8% |
| 3 | Current studies | 8 % | 18 % |
Urinary retention
Table 21
| S. No | Kellys plication | |
| 1 | Beck et al 199114 | 40% |
| 2 | Harris et al 14 1995 | 38% |
| 3 | Current studies | 38% |
Urinary retention
According to this study failure rate of 33.3% was seen with Kellys plication, 12.5% with TVT, 8.3% with TOT and failure rate was not reported in stameys operation. According to various studies done failure rate varies from 5.7-10.6 % in case of TVT operation and 4.8-6.6% with TOT operation.
Failure rate with Kelly’s plication varies from 31 – 48 % in various studies
Failure rate with stameys operation varies from 18-26 % in various studies
Table 22
| S. No | TOT | TVT | |
| 1 | Tomsaz et al 25 2002 | 6.6 % | 8.2 % |
| 2 | de Tayarac et 22 al 2004 | 6.5% | 8.8% |
| 3 | Porena M et al 2004 | 4.8 % | 10.6 % |
| 4 | Current studies | 5.4% | 5.7% |
Failure rate
Table 23
| S. No | Kellys plication | |
| 1 | Beck et al 199114 | 35% |
| 2 | Harris et al14 1995 | 46% |
| 3 | de Tayarac et al12 2004 | 47% |
| 4 | Current studies | 31% |
Failure rate
Table 24
| S. No | Stameys operation | |
| 1 | Hilton et al15 1991 | 26% |
| 2 | Ashken et al16 1993 | 18% |
| 3 | Current studies | 22% |
A comprehensive analysis of all studies done. Comparing various SUI surgeries suggest that there is less chances of complication like bladder perforation, urinary retention and failure rate with TOT operation as compared to other SUI surgeries.
Conclusion
In the general hospital major bulk of patient come with other complaint in gynaecology OPD. From detail history of every patient, it is concluded since the symptoms of SUI are not life threatening and most of the female are less health conscious the medical help is not sought for longer duration.
In the study TOT procedure was found superior with respect long term failure rate and also intra and post operative complication
