Urinary leaks: causes, treatments - Top Santé

Never normal, whatever the frequency and quantity, involuntary leakage of urine would nevertheless affect 8% of the French population, the vast majority of women. If the annoyance and discomfort caused by these leaks are constant, the mechanism is not always the same. Urologists thus distinguish between stress incontinence, the most frequent, and urgency incontinence (overactive bladder).

In reality, half of women suffer from mixed incontinence according to the High Authority for Health, combining the two forms, successively or simultaneously. However, no woman or man should suffer from incontinence today, says Professor Xavier Gamé, urologist surgeon at the Toulouse University Hospital. So don't hesitate to talk to your doctor about it.

Urinary leakage triggered by exertion

Just cough, burst out laughing, carry your water pack or run to cause more or less abundant leaks. In fact, it is the effort that causes the relaxation of the bladder sphincter (muscular structure capable of opening or closing the urethra), the origin of these leaks.

What are the causes ? Two mechanisms are involved, explains Professor Game. In the first case, the urethra (channel through which the bladder empties) is no longer properly supported by the perineum, a set of muscles and ligaments that forms a kind of "support hammock". We talk about hypermobility of the urethra. "Imagine a garden hose, water inlet open, compares the surgeon. If the hose is in the sand (defective perineum) and you press on it, the water will continue to flow. If this same hose is on tar (tonic perineum), the pressure you are going to exert will be enough to retain the water".

This lack of support is favored by the intensive practice of sports which have overworked the perineum (in particular with jerks and jumps), obesity, chronic cough (smoking), constipation (by dint of "pushing", the perineum is distended).

Sabine Courtand, physiotherapist specializing in perineal rehabilitation, also receives many women with static disorders (scoliosis, hyperlordosis) which could contribute to this incontinence. In the second case, stress incontinence is the cause of sphincter insufficiency: the sphincter no longer contracts enough to properly close the urethra and therefore retain urine. This disorder is favored by age, menopause (less hormonal impregnation which leads to a loss of tone), a history of pelvic surgery (hysterectomy, excision of tumours), poorer vascularization (smoking, atherosclerosis) and obstetric trauma ( difficult births).

What treatments? In all cases, the first treatment is perineal-sphincteric rehabilitation, which will cure at least 1 woman out of 2, if she is well accompanied by a specialized physiotherapist, a rehabilitation doctor or a midwife.

If the disorders persist, the urologist may suggest to the patient the placement of sub-urethral strips, which will reinforce the defective pelvic floor. Whatever the technique (retropubic or transobturator strips), this procedure is performed on an outpatient basis, in about twenty minutes under epidural or general anesthesia (more rarely local). "It gives at least 70 to 80% good results, assures Professor Gamé, and the strips are still effective twenty years after their introduction."

For sphincter deficiencies, an operation under general anesthesia will place periurethral balloons on each side of the urinary sphincter. "We slip them under the neck of the bladder, then we inflate them so that they support and compress the urethra at the same time. It's effective in about 65% of cases." An alternative: the artificial urinary sphincter. This device consists of a cuff (an "inflatable ring") placed around the urethra and connected to a balloon or reservoir (in the stomach) which will retain urine. The assembly is connected to an activation pump implanted under the skin of the labia majora. "In 8 out of 10 cases, this device corrects incontinence, but still few centers offer it in France", deplores Professor Gamé. As for the injection of filling agents (hyaluronic acid) into the wall of the urethra, it is only effective in half of the cases and the injection must be repeated every two years on average. It is therefore rather reserved for elderly women who cannot be operated on.

Urinary leakage caused by an irrepressible urge

This is so-called "urgent" incontinence. We feel an irresistible urge to pee when we slip the key in the lock or when we arrive at a restaurant. Impossible to hold back, the first drops escape before reaching the toilet...

What are the causes ? It is favored by age, menopause and obesity which make the bladder more sensitive to distention, irritants such as coffee and tea, but also neurological diseases (multiple sclerosis, Parkinson's). And, of course, by situations that generate automatic behaviors (kinds of Pavlovian reflexes) such as "I'm going home, I'll be able to relieve myself", or even stress, cold, running water...

What treatments? It all depends on the cause, but again, we usually start with rehabilitation, which has proven its interest. If these leaks are rather of psychological origin (reflex, stress, etc.), cognitive and behavioral therapies (CBT) give rather good results. We learn to relax, to use different tools to de-dramatize the situation, repel the urge... If this urgency is essentially linked to menopause, it will be local hormone replacement therapy (gel or cream, vaginal egg).

All other treatments are aimed at reducing the "overflow" message that the bladder sends to the brain. First, anticholinergics and beta-3 agonists (1 tablet per day), specific drugs to treat overactive bladder. “Both are effective, but the former are preferred (except in the case of angle-closure glaucoma), because they are covered by health insurance, admits Professor Gamé. Six months after the disappearance of the leaks, the treatment is interrupted. treatment to take stock. If leaks reappear, it is taken again. These drugs are however accompanied by side effects (sensation of dry mouth, constipation), which sometimes lead patients to abandon their treatment. They can then be offered a stimulation of the tibial nerve by two external electrodes, 20 minutes a day every 24 hours for two months, or more if necessary.

Surgery also relieves some patients. In the hospital, under general anesthesia, the surgeon places a stimulation electrode in the sacrum and a trigger box (a kind of bladder pacemaker) subcutaneously in the back. This electrode delivers an electric current continuously or cyclically. This neuromodulation treatment, whose mechanism of action is not well known, is reversible and only requires changing the batteries every 5 years, and soon every 15 years. As a last resort, it may be preferable to inject botulinum toxin into the wall of the bladder in order to partially paralyze it, but the intervention must be repeated every six months and, in 3 to 7% of cases, it causes a retention of 'urine.

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