Skip to main content
SpringerLink
Log in

Harninkontinenz bei Frauen und Männern aus beckenbodenchirurgischer Sicht

Male and female urinary incontinence from the viewpoint of the pelvic floor surgeon

  • CME Weiterbildung · Zertifizierte Fortbildung
  • Published:
Der Urologe Aims and scope Submit manuscript

Zusammenfassung

Aus beckenbodenchirurgischer Sicht werden Belastungsharninkontinenz und Harndrangsymptome überwiegend durch bindegewebige Lockerungen von viszeralen Ligamenten und Faszien verursacht. Ein neues Verständnis der Pathophysiologie dieser Dysfunktionen führte seit 1986 zu neuen operativen Techniken. Während die Belastungsharninkontinenz durch mitturethrale Beseitigung der Lockerung meist behoben werden kann, bedarf es zur Behandlung von Drangsymptomen einer eingehenden Diagnostik, bevor eine anatomiegerechte Beckenbodenrekonstruktion zur Errichtung einer stabilen Vaginalwand unter der Blase indiziert wird. Simulierte Operationen sind angesichts der Komplexität von Defekten und defektbedinger Symptome wichtig. Als Sonderfall verdient das „tethered vagina syndrome“ Beachtung. Es führt zur Harninkontinenz und hat als Ursache eine vernarbte und kontrakte vordere Vaginalwand. Bei männlicher Belastungsharninkontinenz wird eine bindegewebige Lockerung am Sphinkterapparat als ein Pathomechanismus postuliert, der chirurgisch behebbar ist.

Abstract

From the perspective of pelvic floor surgery, stress urinary incontinence and urge incontinence are caused primarily by pelvic floor defects, which can be described as loosening of visceral ligaments and fascias. While stress urinary incontinence is mainly associated with defects in the anterior zone, urge incontinence can be caused by loosening in any zone of the pelvic floor. New insight into the pathophysiology of these dysfunctions, which are described here in detail, enabled the development of new surgical procedures from 1986 onwards. The midurethral tape procedure removes looseness in the anterior zone and can usually cure stress urinary incontinence. In patients with urge incontinence, extensive diagnostics are required before an anatomy-orientated reconstruction of the pelvic floor, aimed at establishing a stable vaginal wall beneath the bladder, is indicated. Simulated surgery is important given the complexity of defects and symptoms. Particular attention should be paid to one special case, the “tethered vagina syndrome”. This is caused by the scarred and contracted ventral vaginal wall and leads to urinary incontinence. In male stress urinary incontinence, loosening of connective tissue in the sphincter area is postulated as one pathomechanism which can be surgically cured.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9
Abb. 10

Literatur

  1. Brown JS, Sawaya G, Thorn DH et al (2000) Hysterectomy and urinary incontinence: a systematic review. Lancet 356:535–539

    Article  CAS  PubMed  Google Scholar 

  2. Burch JC (1961) Urethrovaginal fixation to Cooper’s ligament for correction of stress urinary incontinence, cystocele and prolapse. Am J Obstet Gynecol 81:281–290

    CAS  PubMed  Google Scholar 

  3. Constantinou CE, Govan DE (1982) Spatial distribution and timing of transmitted and reflexly generated urethral pressures in healthy women. J Urol 127:964–969

    CAS  PubMed  Google Scholar 

  4. Courtney H (1950) Anatomy of the pelvic diaphragm and ano-rectal musculature as related to sphincter preservation in ano-rectal surgery. Am J Surg 79:155–173

    Article  CAS  PubMed  Google Scholar 

  5. Davies TO, Bepple JL, McCammon KA (2009) Urodynamic changes and initial results of the advance male sling. Urology 74:354–357

    Article  PubMed  Google Scholar 

  6. Delorme E (2005) Surgery for female stress urinary incontinence with transobturator tape. Ann Urol (Paris) 39:10–15

    Google Scholar 

  7. Dulkin BL, Wessels H, Cui H (2003) A national survey of urinary and health related quality of live outcome in men with artificial urinary sphincter for prost-radical prostatectomy incontinence. J Urol 169:237–239

    Article  Google Scholar 

  8. Enhörning G (1961) Simultaneous recording of intravesical and intraurethral pressure. Acta Chir Scand 276:1–67

    Google Scholar 

  9. Everaerts W, Gevaert T, Nilius B et al (2008) On the origin of bladder sensing: Tr(i)ps in urology. Neurourol Urodyn 27:264–273

    Article  CAS  PubMed  Google Scholar 

  10. Galloway NT, Davies N, Stephenson TP (1987) The complications of colposuspension. Br J Urol 60:122–124

    Article  CAS  PubMed  Google Scholar 

  11. Gill EJ, Hurt WG (1998) Pathophysiology of pelvic organ prolapse. Obstet Gynecol Clin North Am 25:757–769

    Article  CAS  PubMed  Google Scholar 

  12. Glazener CMA, Lapidan MC (2006) Urodynamic investigations for the management of urinary incontinence in children and adults (Cochraine Review). In: The Cochrane Library, Issue I

  13. Göschen K, Petros P (2009) Der weibliche Beckenboden. Funktionelle Anatomie, Diagnostik und Therapie nach der Integraltheorie. Springer, Heidelberg

  14. Gomha MA, Boone TB (2002) Artificial urinary sphincter for post-prostatectomy incontinence in men who had prior radiotherapy: a risk and outcome analysis. J Urol 167:591–596

    Article  PubMed  Google Scholar 

  15. Gordon AM, Huxley AF, Julian FJ (1966) The variation in isometric tension with sarcomere length in vertebrate muscle fibres. J Physiol 184:170–192

    CAS  PubMed  Google Scholar 

  16. Gozzi C, Bauer RM, Becker AJ et al (2008) Functional retrourethral sling. A change of paradigm in the treatment of stress incontinence after radical prostatectomy. Urologe A 47:1224–1228

    Article  CAS  PubMed  Google Scholar 

  17. Hocking IW (2008) Experimental Study No. 9: Double incontinence, urinary and faecal, cured by surgical reinforcement of the puburethral ligament. Pelviperineology 27:110

    Google Scholar 

  18. Hunt M, Konsky B von, Venkatesh S et al (2000) Bayesian networks and decision trees in the diagnosis of female urinary incontinence. Engineering in Medicine and Biology Society 2000. Proceedings of the 22nd Annual International Conference of the IEEE. Volume 1 Issue, pp 551–554

  19. Kegel AH (1948) Progressive resistant exercises in the functional restoration of the perineal muscles. Am J Obstet Gynecol 56:238–248

    CAS  PubMed  Google Scholar 

  20. Krantz KE (1951) The anatomy of the urethra and anterior vaginal wall. Am J Obstet Gynecol 62:374–386

    CAS  PubMed  Google Scholar 

  21. Lemack GE (2004) Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection adn predicting outcome? Curr Opin Urol 14:307–311

    Article  PubMed  Google Scholar 

  22. Liedl B, Schorsch I, Stief C (2005) Fortentwickelte Konzepte zur weiblichen (In-)Kontinenz. Pathophysiologie, Diagnostik und operative Therapie. Urologe A 44:803–820

    Article  Google Scholar 

  23. Liedl B, Wagenlehner F, Petros P (2008) Prolapse repair and stress urinary incontinence. Eur Urol Rev 3(2):62–65

    Google Scholar 

  24. McLennan MT, Melick C, Bent AE (2001) Urethral instability: clinical and urodynamic characteristics. Neurourol Urodyn 20:653–660

    Article  CAS  PubMed  Google Scholar 

  25. Palma P, Herrmann V (2007) Urodynamics and stress urinary incontinence: the dark side of a gold standard. Int Urogynecol J Pelvic Floor Dysfunct 18:1385–1386

    Article  PubMed  Google Scholar 

  26. Petros P, Ulmsten U (1990) An integral theory of female urinary incontinence. Acta Obstet Gynecol Scand 69(Suppl 153):1–79

    Article  Google Scholar 

  27. Petros P, Ulmsten U (1993) An integral theory and its method for the diagnosis and management of female urinary incontinence. Scand J Urol Nephrol Suppl 153:1–93

    CAS  PubMed  Google Scholar 

  28. Petros P, Ulmsten U (1993) Bladder instability in women: A premature activation of the micturition reflex. Neurourol Urodyn 12:235–239

    Article  CAS  PubMed  Google Scholar 

  29. Petros P, Ulmsten U (1998) An antomical classification – a new paradigm for management of lower female urinary dysfunction. Eur J Obstet Gynecol Reprod Biol 80:87–94

    Article  CAS  PubMed  Google Scholar 

  30. Petros P (2000) The Influence of hysterectomy on pelvic floor dysfunction. Lancet 356:1275

    Article  CAS  PubMed  Google Scholar 

  31. Petros P (2007) The female pelvic floor. Function, dysfunction and management according to the integral theory. Springer, Heidelberg

  32. Petros P, Swash M (2008) The musculo-elastic theory of anrectal function and dysfunction. Pelviperineology 27:89–93

    Google Scholar 

  33. Petros (2009) Persönliche Mitteilung

  34. Rehder P, Gozzi C (2007) Transobturatoric sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol 52:860–866

    Article  PubMed  Google Scholar 

  35. Reynolds WS, Patel R, Msezane L et al (2007) Current use of artificial urinary sphincters in the United States. J Urol 178:578–583

    Article  PubMed  Google Scholar 

  36. Rodriguez LV, Almeida F de, Dorey F et al (2004) Does Valsava leak point pressure predict outcome after the distal urethral polypropylene sling? Role of urodynamics in the sling era. J Urol 172:210–214

    Article  PubMed  Google Scholar 

  37. Roovers JP, Oelke M (2007) Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: a literature review. Int Urogynecol J Pelvic Floor Dysfunct 18:455–460

    Article  PubMed  Google Scholar 

  38. Shafik A, Doss S, Asaad S (2003) Etiology of the resting myoelectric activity of the levator ani muscle: physioanatomic study with a new theory. World J Surg 27:309–314

    Article  PubMed  Google Scholar 

  39. Yamada H (1970) Aging rate fort the strength of human organs and tissues. In: Evans FG (ed) Strength of biological materials. Williams and Wilkins, Baltimore, pp 272–280

  40. Zacharin RF (1963) A suspensory mechanism of the female urethra. J Anat 97:423–427

    CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Beratungs- und Referententätigkeit für AMS, Serag-Wiessner, Dahlhausen.

Author information

Authors and Affiliations

  1. Abteilung für Urogenitale Chirurgie, Beckenbodenzentrum München, Denningerstr. 44, 81679, München, Deutschland

    B. Liedl

Authors
  1. B. Liedl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B. Liedl.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Liedl, B. Harninkontinenz bei Frauen und Männern aus beckenbodenchirurgischer Sicht. Urologe 49, 289–302 (2010). https://doi.org/10.1007/s00120-009-2033-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00120-009-2033-1

Schlüsselwörter

Keywords

Search

Navigation