Further
focus

Patients unfortunately suffer from urinary bladder and sexual dysfunction, e.g. in Parkinson's disease, multiple sclerosis, paraplegia or congenital malformations. Acquired diseases such as stroke, dementia, diabetes mellitus and others also lead to urinary bladder dysfunction sooner or later in the majority of cases. In multiple sclerosis, paraplegia and dementia, for example, up to 90% of patients are affected by urinary bladder dysfunction in the course of the disease. Likewise, patients with chronic bladder inflammation (interstitial cystitis) or painful bladder syndrome (CPPS) are also cared for in neuro-urology.

Modern equipment for ultrasound, endoscopy and urodynamic measurements are available for the diagnosis of these functional disorders in the urological field. As the clinical pictures are often multi-layered and the problems complex, 2 or even 3 appointments are often necessary for a good diagnosis. Here, good coordination with the treating neurologists is also of great importance. Only the exchange of all important aspects of treatment can ensure optimal care for these chronically ill patients. We ensure that your patient data, e.g. X-ray findings, are only transmitted via secure channels that comply with the legal requirements of data protection and the latest state of the art.

Neuro-urological treatment is always based on the individual situation, the course of the disease and the patients' wishes. Treatment ranges from conservative measures, e.g. urotherapy, physiotherapy, medication, etc., to minimally invasive methods, e.g. nerve stimulation therapy or Botox injections, to surgical therapy, e.g. neuromodulation (bladder pacemaker) and bladder dilation plastic surgery. In any case, close interdisciplinary coordination is also of great importance in therapy, for the benefit of the patient.

In many cases, chronic neurological diseases require lifelong neuro-urological care. The physician becomes the patient's companion and recognizes changes, problems and needs. Many practical obstacles have to be removed over time, e.g. aids have to be prescribed, cost claims have to be made, therapy goals have to be adjusted.

alta uro's neuro-urology is oriented towards the current state of science and is actively represented nationally and internationally in numerous professional societies. New findings are implemented promptly if they mean an improvement in patient care.

The treatment of female incontinence also falls into this area, and often a mixture of these symptoms is present. Overall, over half of all menopausal women experience symptoms of incontinence and pelvic floor weakness. So the need for treatment in this area is very great. No woman today should be afraid to openly address these problems with her health care provider. At alta uro, we have a great deal of experience in the field of urogynecology, so that all patients, regardless of age, can be offered a wide range of advice and personalized treatment.

Diagnostics are performed in a comfortable and relaxed environment. The initial clinical examination, together with the medical history, is the most important guide for further therapy. Special examinations may still be required to develop a personalized treatment plan. Additional problems such as recurrent urinary tract infections, dryness of the vagina or surrounding skin changes require special attention, as they are often very unpleasant and cause a high level of suffering.

For the treatment of pelvic floor weakness and incontinence problems, conservative methods are initially available, e.g. physiotherapy, biofeedback, assistive devices, medications, local treatment agents (creams, ointments, suppositories) or pessaries. Here, good control and accompaniment of the female patients is very important. For the treatment of female incontinence, a cure can often be achieved with minimally invasive methods under local anesthesia, e.g. urethral injection or implantation of small artificial tapes. Even simple forms of pelvic floor prolapse can be corrected with minimally invasive methods. The treatment must always be adapted to the personal requirements and wishes of the patient. The extended offer of surgical therapy ranges from vaginal interventions to larger reconstructive interventions on the pelvic floor and bladder, which can usually be performed with a small abdominal incision (bikini incision).

Every 3rd woman is affected by stress incontinence in her lifetime and about 55% if urinary urgency symptoms are added (mixed incontinence). There are a number of risk factors that promote incontinence (e.g. certain medications, pelvic surgery, childbirth, menopause, smoking, obesity, and everyday physical stress. Female stress incontinence, as it is therefore called, is first of all a clinical diagnosis; a specific anamnesis and the clinical examination are pathbreaking. First, the exact cause of the urine leakage must be determined, typically a sudden increase in pressure in the abdomen, e.g., when coughing, sneezing, laughing, jumping, bending, lifting. The symptoms can also be recorded more precisely with questionnaires and a drinking and toileting log. The actual loss of urine is only inadequately reflected by the number of inserts used, since very different sizes are used. The everyday situation is better represented by weighing the inserts, so that the actual fluid loss can be objectively recorded.

Basic diagnostics includes a urine and ultrasound examination as well as a vaginal examination in lithotomy position (gynecologist's chair) with various functional tests that are in no way painful or uncomfortable. In special cases, a urodynamic

examination is also performed, e.g. if the basic examination reveals an unclear finding or a neurological disease with bladder dysfunction is present.

In principle, conservative therapy of incontinence always comes first. Here, specially trained pelvic floor therapists create awareness of the patient's own pelvic floor, with targeted mobilization of muscular reserves. Pessaries are usually a temporary therapy and are tolerated by 70-90% of women. Special ring pessaries in particular can significantly improve stress incontinence. Good adjustment and control of pessary therapy can prevent damage to the vaginal skin. Minimally invasive urethral injections under local anesthesia can also achieve a significant improvement in incontinence over long periods of time.
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Artificial ligaments are available to replace the patient's own defective tissue for a permanent cure of female incontinence. These operations are generally associated with very little stress for the patients and can be performed on an outpatient basis. The success rates of the various techniques are well above 90%. Alternative classical surgical procedures are also characterized by short operating times and short hospital stays. The results, e.g. colposuspension, have withstood the test of time, with an overall continence rate of 69-88% over the long term to over 10 years. Likewise, our patients can be offered techniques using the body's own material (fascia tissue), which have proven particularly effective in the case of recurrent incontinence.

Incidence can be 1-25% depending on the type of incontinence and treatment. Incontinence typically occurs immediately after surgery for prostate cancer and is delayed after radiation therapy. Incontinence rates after radical prostate surgery are similar for all methods. After radiotherapy, urethral elasticity and muscular function may be decreased, affecting the function of the closure mechanism.

Taking a medical history is the basis of a successful treatment strategy. Concomitant diseases and medications have a great influence on continence function.

Personal perception of involuntary urine loss varies widely. Template tests are used for objectification, preferably over a 24 h period. In further diagnostics, urine flow measurement with residual urine determination is obligatory. If further symptoms or a neurological concomitant disease are present, a urodynamic examination should also be performed. Urethroscopy of the urethra and bladder is also important to assess the function of the sphincter and to exclude other pathologies.

Since different patients have very different prerequisites, the course of treatment can also be very different. The recognized treatment methods are therefore not fundamentally equally suitable for all patients. The therapy of incontinence is initially influenced by the severity and duration of the incontinence as well as the general condition and expectations of the patient.

Initially, conservative measures, above all training of the pelvic floor muscles by specially trained therapists, are in first place and can be supplemented by auxiliary devices and medication. Minimally invasive methods under local anesthesia, e.g. urethral injection, are also available. This is particularly useful for older patients who are at increased risk of surgery or who do not wish to undergo surgery.

Artificial ligaments can compensate for sphincter dysfunction after radical prostatectomy; when well indicated, the success rate is about 80%. Tapes with the possibility of subsequent regulation are also available. This can be done, for example, by simple sterile water injection, which increases the closing pressure of the urethra. The artificial sphincter represents the gold standard in the treatment of severe stress incontinence of the. man. In addition to the most commonly used AMS 800 model, several other systems are now available so that treatment can be tailored to the individual patient.

Aids such as condom urinals, penile clamps or anatomically correct pads can also enable elderly patients to participate in social life without a catheter.

The replacement of diseased or damaged tissue usually has better long-term results than "repair". In urology, too, prosthetics has a long tradition. The first pressure-controlled artificial urethral sphincter was developed as early as 1947. The most commonly used artificial urethral sphincter today is a three-part hydraulic system and dates back to the development of F. Brantley Scott; the prototype was implanted in a 45-year-old woman in 1972. After numerous modifications, the AMS 800 still represents the so-called gold standard in the treatment of severe stress incontinence in men.

Implantation is performed through a small incision in the scrotum or perineal area and rarely takes longer than 60 minutes. Although the operation is in principle very simple, older patients in particular may be overwhelmed by it, which must be tested before any operation. When used correctly, the success rate is about 90%. After 10 years, it can be assumed that 2 out of 3 implants are still working. In principle, the artificial sphincter can also be used in women, but this is rarely done because other methods are less costly.

Several other artificial sphincter systems are in use in men today. An easier to implant system is the Zephyr sphincter, which has only 2 instead of 3 components, but the pump to operate it is larger. The cuff around the urethra is adjustable like a belt and therefore exists in only one size. This and other systems are also subsequently adjustable by sterile water injection.

Another field of prosthetics is the treatment of male potency disorders. When the usual treatments with medications or aids are no longer satisfactory or are no longer tolerated, the use of implants comes into question. The inner erectile tissue in the penis, which normally produces an erection, can be replaced by artificial erectile tissue, which is also filled by a small pump under the skin, as in the case of the artificial sphincter. Implantation is also done through a small incision on the scrotum and also rarely takes more than 60 minutes. An erectile tissue implant is not externally visible and can be filled as often and as long as desired. Patient satisfaction is over 90% in the long term, in contrast to satisfaction with medication (51%) or erectile tissue injection (40%).

In the vast majority of cases, men are affected. Short stenoses (strictures) are usually first treated endoscopically. The narrowed tissue can be incised with a tiny knife or a laser beam. Since scar tissue often develops over time and forms new strictures again, short sections of the urethra can also be surgically removed and the connection subsequently restored. The male urethra is a sufficiently long (average 21 cm), elastic tube that makes this possible. If there are repeated, long-distance or multiple strictures of the urethra, it is better to replace the scar tissue with autologous tissue; this provides better results in the long-term (success >80%). In this case, tissue replacement with a thin piece from the oral mucosa has proven particularly effective. This is similar to the inner urethral tissue and usually heals well and quickly. In the case of long-standing strictures, open tissue replacement can also be performed immediately, without prior slitting.

In very elderly patients or those at high risk of surgery, urethral strictures can also be stretched from the inside without surgery. The effect of the treatment is limited in time, but the therapy is without risk and can be repeated often. Some patients also perform such internal dilatations (bougienage) on their own after appropriate training.

In children, congenital malformations of the urethra may require surgical correction, but this still occurs in adulthood if such malformations remain untreated for a long time. Furthermore, injuries of the urethra, fistulas or ulcers caused by catheters occur. Through experience in urethral surgery, the appropriate surgical procedure for restoration can be selected for this.

Changes in the urethra in women also occur not infrequently and often at a young age. Small glands next to the urethra can form cysts, which often reach a considerable size and cause discomfort. The urethra can form bulges (diverticula), which can hinder the emptying of the bladder and cause infections. Likewise, urethral strictures are also found in women, mostly at the entrance to the urethra. All of these changes are very treatable and can be permanently eliminated with minor surgical procedures. In most cases, urethral surgery in women is easier and faster to perform than in men. Damage to the female urethra also occurs in the course of incontinence surgery, especially during or as a result of the insertion of artificial tapes. With the same care and experience, these problems can also be corrected with minor surgical procedures.