Stress Urinary Incontinence What is it?

Cough

Increased Abdominal Pressure

Increases Bladder Pressure

Urine Leakage

The complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.

Abrams, et al. Neurourol. & Urodyn. 21:167-178, 2002.

The effective management of stress urinary incontinence (SUI) requires knowledge of the pathophysiologic mechanisms behind the disorder. Key to identifying these mechanisms and providing proper treatment to women with SUI is an understanding of the anatomy and function of the female pelvic floor and its supporting structures.

THE URETHRAL SUPPORT SYSTEM

The urethral support system consists of all the structures extrinsic to the urethra that provide a supportive layer upon which the urethra rests . The major components of this supportive structure include the anterior vagina, the endopelvic fascia, the arcus tendineus fasciae pelvis, and the levator ani muscles

The endopelvic fascia is a dense fibrous connective tissue layer, which surrounds the vagina and attaches it to the arcus tendineus fasciae pelvis laterally. The arcus tendineus fasciae pelvis in turn is attached to the pubic bone ventrally and to the ischial spine dorsally. The arcus tendineus fasciae pelvis is a tensile structure located bilaterally on either side of the urethra and vagina. It acts like the catenary-shaped cable of a suspension bridge and provides the support needed to suspend the urethra on the anterior vaginal wall. Although well-defined near its origin as a fibrous band at the pubic bone, the arcus tendineus fasciae pelvis becomes a broad aponeurotic structure as it passes dorsally to the ischial spine. It therefore appears as a sheet of fascia as it fuses with the endopelvic fascia, where it merges with the levator ani muscles

The levator ani muscle consists of three parts: the pubococcygeus, the puborectalis, and the iliococcygeus muscles. The pubococcygeus and the puborectalis muscles form a U-shape as they originate from the pubic bone on either side of the midline and pass behind the rectum to form a sling. This sling of muscle is composed of predominantly Type I striated muscle fibers and therefore is suited to maintaining constant tone .

It is this constant tone that normally keeps the urogenital hiatus (9) closed. The iliococcygeus muscle arises laterally from the arcus tendineus levator ani and forms a horizontal sheet that spans the opening in the posterior region of the pelvis, thereby providing a shelf upon which the pelvic organs rest

Functionally, the levator ani muscle and the endopelvic fascia serve an interactive role in maintaining continence and pelvic support. In a hard cough intraabdominal pressure can increase suddenly by about 150 cm H2O and ultrasound studies have shown that this causes the proximal urethra to undergo a midsagittal plane caudodorsal displacement of about 10 mm

This displacement is evidence that the inferior abdominal This downward momentum must contents are forced to move then be arrested by stretch caudodorsally ( downwards ) resistance of the pelvic floor during a cough, presumably due structures. As the downward to a simultaneous contraction of momentum of the abdominal the diaphragm and abdominal contents is slowed by the stretch wall muscles. If the diaphragm of the pelvic floor structures, this contracts and shortens then, fluid movement compresses the because the abdominal contents proximal intraabdominal portion are essentially incompressible, of the urethra against the either the pelvic floor and/or the underlying supportive layer, abdominal wall must stretch. The which is composed of the downward motion of the bladder endopelvic fasciae, the vagina, neck visible in the ultrasound and the levator ani muscles. picture means that its surrounding tissues acquire downward momentum (recall from high school physics that momentum is defined as the product of a mass times its velocity).

We can estimate the stretch-resistance of the supportive layer to the dorsocaudal displacement, a resistance that is known to bioengineers as stiffness . If we divide the 150 cm H2O cough-related increase in intraabdominal pressure by the displacement of the bladder neck, the resulting ratio is 150 cm H2O divided by 10 mm, or 15 cm H2O/mm. This stiffness of the pelvic floor means that for about every 15 cm H2O increase in intraabdominal pressure we would expect the healthy pelvic floor to stretch downward 1 mm. The abdominal pressure acts transversely across the urethra, altering the stresses in the wall of the urethra so that its anterior wall is deformed toward its posterior wall, thereby helping to close the urethral lumen and prevent leakage caused by the increase in intravesical pressure.

If there are breaks in the continuity of the endopelvic fascia , or if the levator ani muscle were to be damaged (see below), the supportive layer under the urethra would likely be less stiff. In fact, it is shown that the stiffness of the bladder neck support is significantly less than in women with stress incontinence than in matched controls. The supportive layer would then provide less resistance to deformation during increases in abdominal pressure and thus closure of the urethral lumen is not ensured, raising the possibility of stress incontinence. An analogy that we have used previously is attempting to halt the flow of water through a garden hose by stepping on it

Attempting to halt the flow of water through a garden hose by stepping on it Let us take the same analogy, but refine it slightly. If the hose were lying on a very stiff trampoline, stepping on it would change the stress in the wall of hose wall, leading to a deformation and flattening of the hose cross-sectional area, resulting in closure of the lumen and cessation of water flow, with little indentation or deflection of the trampoline. If, instead, the hose were resting on low-stiffness (or compliant) trampoline, stepping on the hose would tend to cause it to indent the trampoline under it, then the hose and the trampoline would move downward together as the trampoline stretches. While the hose and trampoline move downward together, water could flow almost unabated in the hose. After a delay, the stretch of the trampoline will finally slow and halt the downward movement of the foot and hose, and flow may or may not be stopped. So, a loss in stiffness of the supporting tissues could well alter, and delay, the effect of abdominal pressure on the transverse closure of the urethral lumen.

The constant tone maintained by the pelvic muscles relieves the tension placed upon the endopelvic fascia. If the nerves to the levator ani muscle are damaged (such as can occur during childbirth), the denervated muscles would undergo atrophy thereby leaving the responsibility of pelvic organ support upon the endopelvic fascia alone. Over time, these ligaments would exhibit viscoelastic behavior, gradually stretching under the constant load, leading to the development of prolapse.

An example is the paravaginal defect that causes separation in the endopelvic fascia connecting the vagina to the pelvic sidewall. This separation reduces the stiffness of the fascial layer supporting the urethra. When this occurs, increases in abdominal pressure can no longer effectively compress the urethra against the supporting endopelvic fascia in order to close it during increases in abdominal pressure. This paravaginal defect, when present, can be repaired surgically, restoring normal anatomy.

During a cough, there is a simultaneous contraction of the levator ani muscle with the diaphragm and abdominal wall muscles to build abdominal pressure. This levator ani contraction helps to tense the suburethral fascial layer and thereby enhance urethral compression. It also protects the connective tissue from undue stresses. The strength of the levator ani muscle has recently been quantified under isometric conditions , and racial differences have also been found in their contractile properties

THE SPHINCTERIC SYSTEM

The sphincteric closure of the urethra is normally provided by the urethral striated muscles, the urethral smooth muscle, and the vascular elements within the submucosa. Each is thought to contribute equally to the resting urethral closure pressure .

Anatomically the urethra can be divided into percentiles with the internal urethral meatus representing point 0 and the external meatus representing the 100th percentile mark . The urethra passes through the wall of the bladder at the level of the vesical neck where the detrusor muscle fibers extend below the internal urethra meatus to as far as the 15th percentile. The striated urethral sphincter muscle begins at the termination of the detrusor fibers and extends to the 64th percentile. It is circularly oriented and completely surrounds the smooth muscle of the urethral wall. Starting at the 54th percentile the striated muscles of the urogenital diaphragm, the compressor urethrae and the urethrovaginal sphincter can be seen. They are continuous with the striated urethral sphincter and extend to the 76th percentile. Their fiber direction is no longer circular. The compressor urethrae passes over the urethra to insert into the urogenital diaphragm near the pubic ramus. The urethrovaginal sphincter surrounds both the urethra and the vagina . The distal terminus of the urethra runs adjacent to, but does not connect with, the bulbocavernosus muscles

The U-shaped loop of the detrusor smooth muscle surrounds the proximal urethra favoring its closure by constricting the lumen. The striated urethra sphincter is composed mainly of Type 1 (slow twitch) fibers, which are well-suited to maintain constant tone as well as allow voluntary increases in tone to provide additional continence protection .

Distally the recruitment of the striated muscle of the urethrovaginal sphincter and the compressor urethrae compress the lumen.

The smooth muscle of the urethra may also play a role in determining stress continence. The lumen is surrounded by a prominent vascular plexus that is thought to contribute to continence by forming a watertight seal via coaptation of the mucosal surfaces. Surrounding this plexus is the inner longitudinal smooth muscle layer, which is in turn surrounded by a circular layer that itself lies inside the outer layer of striated muscle. The smooth muscle layers are present throughout the upper four-fifths of the urethra. The circular configuration of the circular smooth muscle layer and outer striated muscle layer suggests a role in constricting the lumen when these layers contract. The mechanical role of the inner longitudinal smooth muscle layer is presently unresolved. It is possible that contraction of this longitudinal layer may help to open the lumen to initiate micturition, rather than constrict the lumen.

The levator ani muscles, endopelvic fascia, and muscular structures of the urethra comprise a system. These muscles are recruited during a cough to help prevent urine loss during stress. The coordinated action of these elements depends upon the central nervous system. Recent evidence has shown that nerve dysfunction accompanies stress incontinence. This is supported by the observation that many women, simply by learning to time a pelvic muscle contraction to occur during a cough, are able to eliminate stress incontinence during that cough .Women need to be told when best to contract their pelvic muscles to prevent leakage, as well as learning to strengthen them. A stronger muscle that is not activated during the time of a cough cannot prevent stress incontinence. Therefore, teaching proper pelvic muscle timing is critical.

BONE SCAFFOLDING
The maintenance of continence and prevention of pelvic organ prolapse rely on the support mechanisms of the pelvic floor. The bony pelvis consists of the 2 innominate bones, or hip bones, which are fused to the sacrum posteriorly and to each other anteriorly at the pubic symphysis. Each innominate bone is composed of the ilium, ischium, and pubis, which are connected by cartilage in youth but fused in the adult.The pelvis has 2 basins: the major (or greater) pelvis and the minor (or lesser) pelvis. The abdominal viscera occupy the major pelvis; the minor pelvis is the narrower continuation of the major pelvis inferiorly. The inferior pelvic outlet is closed by the pelvic floor. The female pelvis has a wider diameter and a more circular shape than that of the male. The wider inlet facilitates head engagement and parturition. The wider outlet predisposes to subsequent pelvic floor weakness. Numerous projections and contours provide attachment sites for ligaments, muscles, and fascial layers. Of note is the thin and triangular sacrospinous ligament , which extends from the ischial spines to the lateral margins of the sacrum and coccyx anteriorly to the sacrotuberous ligament. Its anterior surface is muscular and constitutes the coccygeus; the ligament is often regarded as the degenerate part of the muscle.The greater and lesser sciatic foramina are above and below the ligament.

Pelvic Diaphragm
The levator ani and coccygeus muscles that are attached to the inner surface of the minor pelvis form the muscular floor of the pelvis. With their corresponding muscles from the opposite side, they form the pelvic diaphragm. The levator ani is composed of 2 major muscles from medial to lateral: the pubococcygeus and iliococcygeus muscles.

The bulkier medial portion of the levator ani is the pubococcygeus muscle that arises from the back of the body of the pubis and anterior portion of the arcus tendineus. The arcus tendineus of the levator ani is a dense connective tissue structure that runs from the pubic ramus to the ischial spine and courses along the surface of the obturator internus muscle. The muscle passes back almost horizontally to behind the rectum. The inner border forms the margin of the levator (urogenital) hiatus, through which passes the urethra, vagina, and anorectum.

Various muscle subdivisions have been assigned to the medial portions of the pubococcygeus to reflect the attachments of the muscle to the urethra, vagina, anus, and rectum.These portions are referred to by some investigators as the pubourethralis, pubovaginalis, puboanalis, and puborectalis or collectively as the pubovisceralis, because of their association and attachment to the midline viscera.3 The urethral portion forms part of the periurethral musculature, and the vaginal and anorectal portions insert into the vaginal walls, perineal body, and external anal sphincter muscle.4 The puborectalis portion passes behind the rectum and fuses with its counterpart from the opposite side to form a sling behind the anorectum. Other more posterior parts of the pubococcygeus attach to the coccyx.

The thin lateral part of the levator ani is the iliococcygeus muscle, which arises from the arcus tendineus of the levator ani to the ischial spine. Posteriorly it attaches to the last 2 segments of the coccyx. The fibers from both sides also fuse to form a raphe and contribute to the anococcygeal ligament. This median raphe between the anus and the coccyx is called the levator plate and is the shelf on which the pelvic organs rest. It is formed by the fusion of the iliococcygeus and the posterior fibers of the pubococcygeus muscles. When the body is in a standing position, the levator plate is horizontal and supports the rectum and upper two thirds of vagina above it. Weakness of the levator ani may loosen the sling behind the anorectum and cause the levator plate to sag.5 This opens the urogenital hiatus and predisposes to pelvic organ prolapse . Women with prolapse have been shown to have an enlarged urogenital hiatus on clinical examination.6

 The coccygeus muscle that extends from the ischial spine to the coccyx and lower sacrum forms the posterior part of the pelvic diaphragm. It sits on the anterior surface of the sacrospinous ligament. Three-dimensional magnetic resonance imaging (MRI) of the pelvic diaphragm (Figure 4) shows its peripheral attachments and demonstrates the urogenital hiatus.7

Direct innervation of the levator ani muscle on its cranial surface is primarily from the third and fourth sacral nerve roots via the pudendal nerve.8 The puborectalis may derive some if its innervation from a pudendal branch on the caudal side.2 Regarding the type of the striated muscle, it has been reported that the majority of the muscle fibers in the levator ani are slowtwitch fibers that maintain constant tone (type I),9 with an increased density of fast-twitch (type II) fibers distributed in the periurethral and perianal areas.10,11 This suggests that the normal levator ani maintains tone in the upright position to support the pelvic viscera. Furthermore, voluntary squeezing of the puborectalis may increase the tone to counter increased intra-abdominal pressure.

Urogenital Diaphragm (Perineal Membrane)

Another musculofascial structure, the urogenital diaphragm, is present over the anterior pelvic outlet below the pelvic diaphragm. However, there is controversy over whether this structure contains a transverse sheet of muscle extending across the pubic arch (deep transverse perinei muscle) sandwiched between superior and inferior fascia12 or 3 contiguous striated muscles (compressor urethrae, sphincter urethrae, and urethra-vaginalis) and an inferior fascial layer called the perineal membrane .Despite the controversy, MRI scans clearly depict the structure.2,

Perineal Body The perineal body is a pyramidal fibromuscular structure in the midline between the anus and vagina with the rectovaginal septum at its cephalad apex.4 Below this, muscles and their fascia converge and interlace through the structure. Attached to the perineal body are the rectum, vaginal slips from the pubococcygeus, perineal muscles, and the anal sphincter; it also contains smooth muscle, elastic fibers, and nerve endings. During childbirth, the perineal body distends and then recoils.It is an important part of the pelvic floor; just above it are the vagina and the uterus. Acquired weakness of the perineal body gives rise to elongation and predisposes to defects such as rectocele and enterocele.demonstrates the pelvic organs with the 2 major levels of muscular support: the upper muscular structure, with the pelvic diaphragm, and the lower muscular structure, with the perineal membrane anteriorly and anal sphincter posteriorly

Mechanism of incontinence
The hammock hypothesis is a readily understood way to explain the continence mechanism. The requirements for continence include a quiescent bladder, functioning musculofascial supports, and a functional urethral sphincter mechanism. The fascial attachments connect the periurethral tissue and anterior vaginal wall to the arcus tendineus at the pelvic sidewall, whereas the muscular attachments connect the periurethral tissue to the medial border of the levator ani.Urethral support is provided by a coordinated action of fascia and muscles acting as an integrated unit under neural control.This musculofascial support provides a hammock onto which the urethra is compressed during increases in intraabdominal pressure. One can surmise that the urethral sphincter mechanism is operative and adds to the process. Furthermore, failure of one of the support components will not invariably produce stress incontinence, because of the compensatory effect of the other component. This may explain why some women with hypermobility have no incontinence. It may also explain why injectable agents can be used in women with hypermobility: the bulking agent may improve urethral sphincter function.