Urethral hypermobility is a condition characterized by excessive movement of the urethra, the tube that carries urine from the bladder out of the body. This instability often leads to involuntary urine leakage, particularly when pressure inside the abdomen increases. It is a common factor associated with stress urinary incontinence (SUI), a type of incontinence where physical activities cause urine to escape.
What is Urethral Hypermobility?
The urethra’s normal function relies on its stability, allowing it to remain closed, especially during moments of increased abdominal pressure like coughing or sneezing. It is supported by a network of pelvic floor muscles, ligaments, and fascia, collectively known as the urogenital diaphragm.
In urethral hypermobility, these supportive structures weaken, allowing the urethra and bladder neck to move downwards and outwards from their normal resting position. This excessive movement compromises the urethra’s ability to remain tightly closed, leading to urine leakage. The lack of adequate support means the urethra cannot withstand sudden increases in pressure, resulting in involuntary urine loss.
Causes and Contributing Factors
Urethral hypermobility often develops when the pelvic floor’s supportive tissues are weakened or damaged. Contributing factors include:
Childbirth, especially vaginal, multiple, or difficult deliveries, due to stretching and trauma to pelvic floor muscles and ligaments.
Aging, which can lead to a loss of collagen and muscle tone in the pelvic floor.
Chronic straining from conditions like severe constipation or persistent coughing, which exerts continuous downward pressure.
Obesity, which increases intra-abdominal pressure and strains the pelvic floor.
Certain pelvic surgeries, such as a hysterectomy, which can alter the urethra’s anatomical support.
Genetic predispositions, including connective tissue disorders like Ehlers-Danlos syndrome, leading to weaker supportive tissues.
Identifying Symptoms and Diagnosis
The primary symptom associated with urethral hypermobility is stress urinary incontinence (SUI), which involves involuntary urine leakage during activities that increase abdominal pressure. This leakage can occur when a person coughs, sneezes, laughs, lifts heavy objects, or engages in physical exercise. The amount of leakage can vary from a few drops to a significant gush, depending on the severity of the condition.
Diagnosis typically begins with a thorough review of the patient’s medical history, focusing on urinary symptoms and past events like childbirth or surgeries. A physical examination, including a pelvic exam, assesses for pelvic organ prolapse and observes the movement of the urethra and bladder neck. A bladder diary, where the patient records fluid intake and urinary episodes, provides valuable information about bladder function.
Specialized tests are often used to confirm urethral hypermobility. The Q-tip test involves inserting a lubricated cotton swab into the urethra to the bladder neck. The swab’s angle is measured at rest and when the patient strains or coughs. An upward deflection of 30 degrees or more indicates urethral hypermobility. Urodynamic studies are comprehensive tests that assess bladder and urethral function by measuring bladder pressure, urine flow rates, and urethral closure pressure, providing detailed insights into urine storage and release.
Management and Treatment Options
Treatment for urethral hypermobility aims to restore proper support to the urethra and bladder neck, thereby reducing or eliminating urine leakage. Both conservative and surgical approaches are available, tailored to the individual’s condition and preferences.
Conservative management often begins with pelvic floor muscle training, commonly known as Kegel exercises. These exercises strengthen the muscles that support the bladder and urethra, improving their ability to resist downward pressure. A physiotherapist provides guidance on proper technique and develops a personalized exercise program, which can include both short, quick contractions and longer holds to improve endurance and strength.
Lifestyle modifications also play a role in conservative management. Weight management reduces intra-abdominal pressure on the pelvic floor. Timed voiding, where individuals urinate at scheduled intervals, helps manage bladder capacity. Avoiding bladder irritants like caffeine and alcohol alleviates symptoms.
Supportive devices such as pessaries, which are inserted into the vagina, can provide mechanical support to the urethra and bladder neck, lifting them to a more anatomically correct position and reducing leakage. Pessaries come in various shapes and sizes and are managed by the patient or a healthcare provider, often needing replacement every three months.
When conservative methods do not provide sufficient relief, surgical options are considered. These procedures aim to create a more stable support system for the urethra.
Mid-Urethral Slings
Mid-urethral slings are a widely used surgical approach, involving the placement of a thin, hammock-like mesh (often made of polypropylene) underneath the middle part of the urethra. This mesh provides support and prevents excessive downward movement during increased abdominal pressure. Two types are the retropubic sling (e.g., tension-free vaginal tape or TVT), which passes the mesh just above the pubic bone, and the transobturator sling (e.g., transobturator tape or TOT), which exits through incisions on each side of the groin, avoiding the pelvic cavity.
Colposuspension
Colposuspension, such as the Burch procedure, involves stitching the paravaginal fascia (connective tissue alongside the vagina) to ligaments near the pubic bone, elevating and stabilizing the urethra and bladder neck. While effective, colposuspension is generally more invasive than mid-urethral slings and may have a longer recovery time.
Urethral Bulking Agents
Urethral bulking agents offer a less invasive surgical option, where a paste-like substance is injected into the urethral wall. This injection narrows the urethral opening, improving its closure mechanism. While less invasive, bulking agents have lower long-term success rates compared to slings and may require repeat injections.