Long-Term Improvement in Urinary Incontinence in an Elite Female Athlete Through the Laser Treatment: A Case Report

Abstract

Stress urinary incontinence (SUI) is increasing in elite female athletes (EFAs), affecting competition results and quality of life. Pelvic floor muscle training (PFMT) is the first-line treatment for SUI, and surgery is generally performed when PFMT is insufficient. However, in EFA, there are few cases in which surgery is performed and fewer reports. Therefore, there is no known general treatment strategy for EFA with SUI. In our study, a 23-year-old track-and-field medalist with severe SUI was successfully treated with a vaginal and urethral erbium-doped yttrium aluminum garnet laser (VEL + UEL). After 12 treatments over one year, urinary incontinence decreased from 300 mL or more in the 400 m track run before treatment to 0 mL. She did not experience any more problems during running or competition. There was no recurrence of SUI for three years, and the urethral pressure profile examination confirmed improvement. MRIs showed that the left puborectalis muscle was absent from the first visit. The urethra was oval with an anteroposterior outer diameter of 10 mm and a transverse outer diameter of 13 mm before treatment. However, after three years of treatment, both anteroposterior and transverse diameters became circular, measuring 11 mm. Vaginal wall thickness increased from 8 to 12 mm at the center of the height of the urethra, making it possible to support the urethra, and pretreated adipose tissue space between the urethra and vagina disappeared. It was noted that the uneven and fragile urethra/vagina, the presence of adipose tissue space, and the absence of the left puborectalis muscle may have been the cause of the SUI. One year of VEL + UEL treatment resulted in long-term improvement of SUI; MRI showed changes in the urethra and vagina.

Keywords: anteroposterior and transverse urethral diameters; elite female athletes; erbium yag laser; pelvic floor muscle training; pelvic floor muscles; puborectalis muscle; stress urinary incontinence; therapeutic targets.

Figure 1. The 400 m pad test and the degree of interference with the competition

Bar graph: 400 m pad: Weight of urinary leakage (g) of the pad during a 400 m track running with urine collected to the maximum capacity of the bladder Line graph with black circles: VAS: Degree of hindrance to competition (0: no hindrance to 10: maximum hindrance) Y: Youth Player Period, VAS: Visual analog scale, VEL: Vaginal erbium SMOOTH laser, UEL: Intraurethral SMOOTH Er: YAG Laser, VEL+UEL: Vaginal and urethral erbium-doped yttrium aluminum garnet laser, T0: Before treatment, L1 to L12: Laser treatment (performed monthly), T1 to T3: one to three years after completion of laser treatment Track and field race: Track and field competition held between T2 and T3

Figure 2. Morphology and size of the urethra at the level of the striated sphincter muscle in the axial view

(a) Before treatment (T0), (b) After treatment (T3) T0: The transverse diameter 13 mm, anteroposterior diameter 10 mm T3: The transverse diameter 11 mm, anteroposterior diameter 11 mm Pu, pubic bone; V, vagina; R, rectum; Ad, adductor muscle; OE, obturator externus muscle; OI, obturator internus muscle; IT, sciatic tubercle; LA, Levator ani muscle; F, femur

Figure 3. Median sagittal view showing the longitudinal urethral diameter and adipose tissue space

a: Before treatment (T0) b: After treatment (T3) T0: Vertical urethral diameter 21 mm, T3: 21 mm U, uterus; B, bladder; Pu, pubic bone Red arrow: fat layer space

Figure 4. Vaginal wall thickness

(a) Before treatment (T0), (b) after treatment (T3) U1: Upper end of the urethra (vesicourethral boundary), U0: Lower end of the urethra (urethral opening), U0.5: Midway between U0 and U1, Va: Thickness of the anterior vaginal wall at U0.5, Vp: Thickness of the posterior vaginal wall at U0.5

Figure 5. Axial view of the left anterior puborectalis muscle defect

Blue arrow: Right anterior puborectalis muscle Blue dotted circle: Anterior defect of the left puborectalis muscle Pu, pubic bone; V, vagina; R, rectum

Figure 6. The anteroposterior urethral and transverse urethral diameters in the three age groups

X line means the anteroposterior urethral diameter (mm), Y line means the transverse urethral diameter (mm), The blue dots and blue line show the 20s women group data, The red dots and red line show the 30s women group data, The green dots and green line show the 20s women group data, The black dot included in the blue X-Y lines is the EFA of this case report (T0)

Figure 7. Regression line of the shape of the urethra in premenopausal women without SUI

X line means the anteroposterior diameter (mm), Y line means the transverse diameter (mm), Open circle: premenopausal women without SUI, Closed circle: EFAs in this case report (T0), Closed square: EFAs in this case report (T3), Red dotted line: regression line, Black dotted line: Limits of 95% confidence interval