Immediate and undesired urinating during the daily routine is called “urinary incontinence”. It has different names such as ''urinary incontinence”, ''enuresis”,''loss of bladder control”. It’s a very common health problem especially among female individuals..
If urinary incontinence is affecting your social life and life quality, it should definitely be treated. This is not a condition to be ashamed of and a part of your life. In many patients, good results are possible after basic lifestyle changes and basic medical treatment..

TYPES OF URINARY INCONTINENCE
There are 4 types of urinary incontinence when the reasons are considered.

Stress Related Urinary Incontinence :
It’s the most common reason among female patients. It’s the urinary incontinence seen when the intra-abdominal pressure increases during the actions such as coughing, sneezing, straining and laughing. It’s caused as a result of deficiency or weakness of bladder and urethra valves and pelvic floor muscles. The most significant reasons of it are pregnancy, labor and menopause.

Urge incontinence (urge type):
It’s defined as the urinary incontinence after an immediate urge to urinate. Urinary incontinence occurs before the person can go to the bathroom on time. Unlike stress related urinary incontinence, it’s not caused by the weakness of the weakness of pelvic floor muscles, but because of hyperactivity of bladder muscles..

Mix type urinary incontinence:
It’s observed in the cases where stress related and urge type urinary incontinences are combined..

Overflow type urinary incontinence:
No urge to urinate is felt due to loss of sensation even though the bladder is full and when urine exceeding the capacity of the bladder is stored, overflow type urinary incontinence occurs. This type of incontinence is seen in nervous system diseases such as bladder traumatization, urethra blockage, advanced diabetes diabetes (with nerve damage), spinal cord damage or multiple sclerosis.

REASONS OF URINARY INCONTINENCE
• Advancing age
• Menopause (due to decreasing amount of oestrogen)
• Labor (difficult labor, giving birth to a hefty baby, giving birth multiple times...)
• Diabetes
• Obesity
• Genetic (loose connective tissue in some female patients)
• Systemic diseases (chronic kidney diseases, asthma, bronchitis, multiple sclerosis, Parkinson’s etc)

Reasons causing temporary incontinence:
Alcohol, excessive fluid intake, bladder stimulants, various medications (cardiacs, hypertension medication), urinary tract infections, constipation may increase the symptoms of urinary incontinence or may cause temporary urinary incontinence in even healthy individuals..

How Is the Urinary Incontinence Diagnosed?
In diagnosing urinary incontinence, a thorough medical history (anamnesis) obtained is very significant in order to determine the type and severity of urinary incontinence. After the detailed anamnesis is obtained, physical examination starts. Physical examination is very vital in the diagnosis of the person’s urinary incontinence problem. .

Examination: The urinary incontinence should be examined through a detailed pelvic exam. Also, the patient should be examined for uterine prolapse (descensus), urine bag prolapse (cystocele) and intestine prolapse (rectocele) for their severity as well. Various tests are conducted on the patient during the physical examination. The most common ones are “Marshall Test” where the bladder neck is lifted vaginally and the “Q Type Test” where the activity of bladder neck is measured with a cotton-tipped swab.

24-hour urination history: It’s a form containing answers regarding fluids taken daily and frequency and amount of urination. This history helps the physician for diagnosis and treatment.

Urine Analysis: Findings regarding urinary tract infections, blood in urine or stone may be diagnosed.

Postvoiding residue measurement (PVR): Urine remaining in the bladder after urinating can be measured easily through ultrasonography. Presence of excessive amount of urine remaining in the bladder after urination shows the possibility for a urinary tract blockage or problems regarding nerve and muscle layer of the bladder

Urodynamic tests: These are the tests that are based on the measurement of pressure in the bladder during inactivity and activity. Although they are not always needed for the diagnosis of incontinence, it might be helpful in determining the type of incontinence.

URINARY INCONTINENCE TREATMENT
Incontinence treatment is planned in accordance with the type and severity. Conservative treatments, various medical or surgical treatments should be individualized in line with the patient.

CONSERVATIVE TREATMENTS (NON-OPERATIVE TREATMENTS)
The purpose here is to strengthen pelvic floor muscles lifting the bladder and bladder muscles..

Bladder Exercises: Bladder training and strengthening is aimed through delaying urination and holding it for a while when the urge is felt..

Training Pelvic Floor Muscles: Exercises for pelvic floor muscles, or ''KEGEL EXERCISES'' in other words is the first step of the treatment since it strengthens the support for the vesicourethral junction (urinary tract angle in bladder and urethra) and levator immediate and pelvic floor diaphragm of especially patients with stress related urinary incontinence..

Electrical Stimulation: Anal and vaginal electrodes are used. This is a treatment method which is based on the contraction of pelvic floor muscles through electrical stimulation by stimulating the pelvic nerves. Increasing the urethral closing pressure is aimed through causing reflex contraction on the muscles surrounding the urethra. It required plenty of sessions and the treatment should continue for months. It’s not a commonly preferred treatment method today..

MEDICATION
Oestrogen hormone: It can be used to increasing the blood flow by stimulating bladder mucosa and the tissue below the mucosa and to increase the smooth muscle response and urethra closing pressure this way. Local oestrogen is applied intravaginally before going to bed with the dosage of 1-2 gr for 6 weeks and 2-3 times a week.
Urge and overflow type incontinences can be treated using anticholinergic and/or tricyclic antidepressants. It increases the widening of urine bag and urine capacity and suppresses the involuntary contractions of urine bag.

SURGICAL TREATMENT
Surgical treatment is preferred especially for stress type incontinence. Surgery can be conducted on the abdominal with open section, laparascopically or vaginally. The most common one is “SLING” operations after the advancement of surgical techniques and synthetic mesh technology in our day..
Operation types
• Abdominal operations: MMK-Burch-Marchall Marchetti Kranz or Burch operation. These can be open of laparascopically..
• SLING OPERATIONS: TVT, TOT and mini-sling techniques.
• Artificial urethral sphincter
• Periurethral injections: (Teflon, collagen, autologous fat …)


 


  • TOT ameliyatının şematik gösterimi

     

    SLING OPERATIONS:
    Sling operations are mostly conducted for stress and mix type incontinences. The common point of sling operations is that they are the operations based on forming a pelvic sling by going under urethra or bladder neck and supporting bladder neck and urethra (TVT, TOT and Mini sling). The patient can be released one day after the operation and return his/her daily routine right away. I generally prefer conducting the TOT (TRANSOBTURATOR TAPE) operation. It’s conducted through a 1-2 cm long section under the urethra vaginally. It’s a simple operation that takes around half an hour. The success rate is over 90%. Long-term results are quite well and the possibility of relapse is minimal.


 

Recommendations to reduce the risk of urinary incontinence;
• Losing weight in case of being overweight
• Avoiding constipation and consuming fibrous food products
• Avoiding activities causing incontinence
• Quitting smoking (reduces the risk of incontinence)
• Avoiding bladder stimulants (reducing the consumption of caffeinated drinks such as tea, coffee, cola)
• Getting treated for the diseases causing chronic caugh
KEGEL EXERCISES (doing kegel exercises reduces the risk of incontinence especially during and after pregnancy)
• Doing sports or exercises regularly

 

© 2016 - Op. Dr. Cem ÖZLÜK