**5. Discussion**

If we accept the criteria for the classification of dysfunctions of the lower urinary tract in the three groups of patients under discussion here, i.e. low urethral pressure/normal detrusor, abnormal urethral pressure/normal detrusor, and normal urethral pressure/underactive detrusor with increased capacity, the dysfunction was sufficiently mild and the defense mechanisms used sufficiently effective that the patients had not sought specialist medical care until additional factors had appeared, such as childbirth, reducing their ability to retain or pass urine. Ordinary medical care had been more oriented to symptomatic diagnosis and treatment. The complicated mechanisms underlying the appearance and development of UI and the broad background of psychosomatic conditions require adequate diagnostics and a thorough investigation of the etiopathology of pelvic floor muscle dysfunction, the absence of which retards properly targeted treatment and the choice of appropriate prevention methods.

A Multi-Disciplinary Perspective on the Diagnosis

and young women may be much higher.

muscles.

and Treatment of Urinary Incontinence in Young Women 49

they are mostly treated symptomatically. Years later, they are often diagnosed as the generally familiar risk factors in later phases of the life cycle: age, childbirth, overweight, genetic predispositions (Minassian et al., 2003; Nygaard et al., 2003; Rechberger & Skorupski, 2005). It would appear that the actual frequency of these dysfunctions in girls

Among the essential factors producing the low rate of early diagnosis of dysfunctions in the lower urinary tract in girls are the lack of access to specialists who comprehend the complicated mechanisms for retaining and passing urine, the inadequacy of knowledge among pediatricians in respect to the diversity of urinary dysfunctions, and the lack of education for parents in respect to observing behaviors or abnormalities associated with bladder emptying in children. In our opinion, reliable scientific research on a representative sample would allow us to identify the needs and the principles for education and screening, in order to achieve earlier diagnosis and treatment of urinary dysfunctions in girls and young women. Like most authors, we believe that this results from the broad spectrum of personal variability and the functional norms generally accepted for the functional parameters, which do not entail specifying the normal resting tone of the pelvic floor

The constant maintenance of the pelvic floor muscles in increased resting tone is generally speaking one of the basic ways of coping with the problem of UI and severe static disorders. It is natural that, if only the muscles of the bladder and pelvis are not partially denervated or significantly weakened, a woman feels the degree of bladder fullness and the changes in intraabdominal pressure. Normal innervation of the lower urinary tract and normal muscle strength enable the autonomically controlled reactions of flexing the pelvis in response to a full bladder or increased intraabdominal pressure. In the case of the dysfunctions under discussion here, the conscious contraction of the pelvic floor muscles can facilitate the retention of urine in the collection phase and during exertion in all the basic types of UI seen in adult women (stress incontinence, urge urinary incontinence, and mixed). When this way of coping is maintained for many years (though often unconsciously, or consciously concealed by the patient), it is at least in part, along with neurogenic causes and disturbances of statics (postnatal, post-traumatic, spinal diseases, etc.) the cause of urinary dysfunctions, urine retention and recurrent infections. It can also lead to chronic constipation, difficulties with bowel movements, and fecal incontinence (Namysł & Garstka-Namysł, 2011). If squeezing the pelvic muscles has been the main reason for urinary dysfunction or discomfort in the urogenital region, once the patient has been made aware of the causes of her symptoms and taught to relax these muscles, spectacular treatment effects can be achieved: resolution of UI symptoms, and improved quality of sexual life, partner relations, and HRQOL in a very short time after the patient becomes aware of the reasons

If functional testing of the pelvic floor muscles using surface electromyography confirms a neurogenic component, there are indications for implementing functional electrostimulation procedures with a neuroregenerative effect (Namysł & Garstka-Namysł, 2011). Expanding diagnostics with non-invasive surface electromyography, performed, depending on the subject's age, with rectal electrode in children, or (in women who have undergone sexual initiation) with a vaginal electrode, would facilitate early detection of increased muscle resting tone in the pelvic floor. Also, appropriately constructed psychological instruments at

for the symptoms and rehabilitation has been implemented.

Fig. 2. a,bEMG recordings of perineal muscle resting tone made in supine position with Veriprobe ® vaginal probe and MyoPlus® EMG unit (Verity Medical Ltd) from different patients. A previously increased muscle resting tone tends to normalize after 8 weeks of rehabilitation using EMG biofeedback and functional electrostimulation. Source: authors' own examinations.

It is generally known that UI and urinary dysfunctions in childhood and adolescence are difficult medical problems in young women, though relatively rare, occurring less often than in adult women (Bø, 2004). The statistical data cover children and adolescents registered in medical facilities, with symptoms of the most severe urinary dysfunctions, primarily as a result of congenital defects of the spine and lower urinary tract. Milder (subclinical) and probably much more common disturbances remain undiagnosed, and thus

Fig. 2. a,bEMG recordings of perineal muscle resting tone made in supine position with Veriprobe ® vaginal probe and MyoPlus® EMG unit (Verity Medical Ltd) from different patients. A previously increased muscle resting tone tends to normalize after 8 weeks of rehabilitation using EMG biofeedback and functional electrostimulation. Source: authors'

It is generally known that UI and urinary dysfunctions in childhood and adolescence are difficult medical problems in young women, though relatively rare, occurring less often than in adult women (Bø, 2004). The statistical data cover children and adolescents registered in medical facilities, with symptoms of the most severe urinary dysfunctions, primarily as a result of congenital defects of the spine and lower urinary tract. Milder (subclinical) and probably much more common disturbances remain undiagnosed, and thus

own examinations.

they are mostly treated symptomatically. Years later, they are often diagnosed as the generally familiar risk factors in later phases of the life cycle: age, childbirth, overweight, genetic predispositions (Minassian et al., 2003; Nygaard et al., 2003; Rechberger & Skorupski, 2005). It would appear that the actual frequency of these dysfunctions in girls and young women may be much higher.

Among the essential factors producing the low rate of early diagnosis of dysfunctions in the lower urinary tract in girls are the lack of access to specialists who comprehend the complicated mechanisms for retaining and passing urine, the inadequacy of knowledge among pediatricians in respect to the diversity of urinary dysfunctions, and the lack of education for parents in respect to observing behaviors or abnormalities associated with bladder emptying in children. In our opinion, reliable scientific research on a representative sample would allow us to identify the needs and the principles for education and screening, in order to achieve earlier diagnosis and treatment of urinary dysfunctions in girls and young women. Like most authors, we believe that this results from the broad spectrum of personal variability and the functional norms generally accepted for the functional parameters, which do not entail specifying the normal resting tone of the pelvic floor muscles.

The constant maintenance of the pelvic floor muscles in increased resting tone is generally speaking one of the basic ways of coping with the problem of UI and severe static disorders. It is natural that, if only the muscles of the bladder and pelvis are not partially denervated or significantly weakened, a woman feels the degree of bladder fullness and the changes in intraabdominal pressure. Normal innervation of the lower urinary tract and normal muscle strength enable the autonomically controlled reactions of flexing the pelvis in response to a full bladder or increased intraabdominal pressure. In the case of the dysfunctions under discussion here, the conscious contraction of the pelvic floor muscles can facilitate the retention of urine in the collection phase and during exertion in all the basic types of UI seen in adult women (stress incontinence, urge urinary incontinence, and mixed). When this way of coping is maintained for many years (though often unconsciously, or consciously concealed by the patient), it is at least in part, along with neurogenic causes and disturbances of statics (postnatal, post-traumatic, spinal diseases, etc.) the cause of urinary dysfunctions, urine retention and recurrent infections. It can also lead to chronic constipation, difficulties with bowel movements, and fecal incontinence (Namysł & Garstka-Namysł, 2011). If squeezing the pelvic muscles has been the main reason for urinary dysfunction or discomfort in the urogenital region, once the patient has been made aware of the causes of her symptoms and taught to relax these muscles, spectacular treatment effects can be achieved: resolution of UI symptoms, and improved quality of sexual life, partner relations, and HRQOL in a very short time after the patient becomes aware of the reasons for the symptoms and rehabilitation has been implemented.

If functional testing of the pelvic floor muscles using surface electromyography confirms a neurogenic component, there are indications for implementing functional electrostimulation procedures with a neuroregenerative effect (Namysł & Garstka-Namysł, 2011). Expanding diagnostics with non-invasive surface electromyography, performed, depending on the subject's age, with rectal electrode in children, or (in women who have undergone sexual initiation) with a vaginal electrode, would facilitate early detection of increased muscle resting tone in the pelvic floor. Also, appropriately constructed psychological instruments at

A Multi-Disciplinary Perspective on the Diagnosis

of successfully treated women.

pp. S114-123

**7. References** 

and Treatment of Urinary Incontinence in Young Women 51

In our opinion, a multi-disciplinary approach to the therapy of urine retention dysfunctions and additional basic tests can contribute to a better understanding of the specific nature of different types of urinary incontinence in young women, reduce the number of diagnostic errors, hasten the implementation of correct treatment, reduce the recurrence of symptoms, provide a better understanding of the reasons for treatment failure, and increase the number

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the preliminary interview stage (including a brief psychosexual biography, focused on the problems associated with UI), would help us change the treatment plan to obtain good outcomes in the large group of female patients previously diagnosed with, and unsuccessfully treated for, high urethral pressure. Thus the application in the diagnostic algorithm of the evaluation of the occurrence and intensity of the interaction (rather typical, as it seems at the present state of our knowledge) between the development of UI and urinary dysfunctions with mental functioning, facilitates the differentiation of risk groups among young female patients in the case of even a routine visit for recurrent lower urinary tract infections or sporadic episodes of UI (Bidzan, Smutek & Bidzan, 2010).

The awareness of these facts will help us avoid diagnostic errors, choose an appropriate therapy, and make use of multi-disciplinary interventions, including psychological help, or psychiatric help and rehabilitation in cases where it is needed.
