Urinary incontinence refers to an involuntary loss of urine that the patient complains of, which can cause significant social embarrassment. The different types of urinary incontinence are mainly defined by the circumstances associated with leaks. Thus, we differentiate urine leaks occurring during exercise (coughing, laughing, and sneezing) from those occurring following an emergency (sudden and irrepressible need to urinate). Incontinence can also be said to be imperceptible (when the patient is not aware of the mode of occurrence), permanent, postural (occurring during a change of position), per coital (during sexual intercourse), or even nocturnal (we then speak of enuresis). Several types of urinary incontinence can be associated in the same patient.

Identifying these different types of incontinence is crucial because the treatment proposed can be very different.

IS THIS A COMMON SYMPTOM?

The frequency and severity of urinary incontinence increases with age. Between 25 and 40% of women report having urinary incontinence according to studies. The frequency is less than 20% before the age of 25, reaching more than 45% after the age of 75. There are two peaks, a first at 45-50 years old at the time of menopause, a second after 75 years old. After the age of 75, almost 20% of women report having severe incontinence compared to 5% before the age of 45. 5 to 15% of women describe this incontinence as daily.

Multiple risk factors for incontinence: age, pregnancy, natural childbirth, menopause, obesity, tobacco intoxication, cough, chronic lung diseases, repeated efforts.

Urinary incontinence is a bothersome and disabling pathology with a potential impact on quality of life, sleep and sexual life. However, despite the significant increase in the number of women who consult, many women remain untreated for this symptom.

WHAT ARE THE MECHANISMS?

PHYSIOLOGY OF URINARY CONTINENCE

Urinary continence is the result of a balance between intravesical and urethral pressure.

The bladder is a distensible muscular reservoir, its muscle (the detrusor) allows itself to be stretched without resistance and therefore without an increase in pressure.

The urethra is located below the bladder. It corresponds to the channel through which urine is externalized. It contains a sphincter apparatus (muscle) essential for continence. It rests on the perineal floor and the vagina below and behind. It is attached to the pubis using suspensory ligaments at the top and in front. These tissues form urethral support, which participates in the mechanism of continence.

Maintaining continence depends on the proper functioning of all of these elements.

Furthermore, the vesico-sphincteric system is controlled by the nervous system, which must also be able to fulfill its role, otherwise it will disrupt the functioning of the bladder and the filling/emptying cycle of the bladder. This explains that certain neurological diseases can be responsible for urinary incontinence.

In a continent person, the bladder fills at low pressure while urethral pressures remain high.

At the time of urination, the mechanism reverses, the urethral pressures collapse, the urinary sphincter relaxes, the bladder contracts leading to normal urination allowing complete evacuation of urine.

Two main types of incontinence must be differentiated: stress urinary incontinence (occurring during abdominal pressure) and urgency urinary incontinence (occurring immediately following a sudden, sudden and irrepressible urge to urinate). ). These two types of incontinence have different origins and different treatment. They can, however, co-exist in the same patient: we then speak of mixed urinary incontinence.

It occurs either due to weakness of the perineal support system (responsible for hyper mobility of the urethra during exercise), or due to sphincter weakness. The two mechanisms can be associated. During an effort causing abdominal hyperpressure, the bladder being located in the abdominal cavity, the hyperpressure is reflected on it. This is the case for coughing, laughing, sneezing, running, etc. If the support mechanism of the urethra or the urethral sphincter are altered, the intraurethral pressure is no longer sufficient in relation to the intravesical pressure, leaks appear.

The causes favoring the weakness of urethral support are multiple deliveries, obstetric trauma, history of pelvic surgery. The pathologies responsible for repeated abdominal hyperpressure are also numerous, including chronic cough, constipation, obesity, etc.

This incontinence is linked to a urine storage disorder in the bladder, which can be linked to untimely contractions of the bladder, a limitation of its compliance or even hypersensitivity of the bladder. These phenomena trigger “urgencies”, that is to say sudden, brutal and irrepressible urges to urinate. When the bladder pressure becomes greater than that of the sphincter, the latter, even if it is perfectly functional, is no longer able to retain urine and the leak appears, immediately following the emergency.

These phenomena are sometimes due to bladder irritation (linked to the presence of a bladder tumor, a stone, or in the case of inflammation of the bladder or bacterial cystitis, for example). Certain neurological diseases such as multiple sclerosis, diabetic neuropathy or stroke can also cause bladder hyperexcitability. Finally, the causes are not always known and we then speak of idiopathic overactive bladder.