What mechanisms maintain urinary control and continence in a healthy woman?
Gynaecology and urogynaecology – the mechanisms that maintain the normal processes of urine storage in the bladder, the ability to wait until the bladder is full without passing urine, and the induction of urination when the bladder is full, include a bladder that is strong enough to store adequate amounts of urine, sphincter muscles in the urinary canal that hold urine, and sufficient support from the pelvic floor to prevent urine leakage.
Signals from the brain hold the urine in the bladder until it is full. During this time, sphincter muscles in the urinary canal prevent urine leakage. In addition, the collection of muscles we call the pelvic floor provides extra help in preventing leakage when we cough, sneeze, or laugh.
What is urinary incontinence? How often does it occur? What types exist?
Urinary incontinence means involuntary discharge of urine. Urine from the external urinary tract causes the pushing force of the bladder to overpower its holding force. Urinary incontinence is a common condition in women and negatively affects the lives of 35 out of every 100 women. It is more prevalent than chronic diseases such as high blood pressure, depression, diabetes, asthma and bronchitis.
In general, there are 3 types of urinary incontinence that affect women:
- The first type is one that occurs when the bladder fails to hold all the urine that enters it and leaks the excess amount. 22 out of every 100 cases of urinary incontinence fall into this category, called urge urinary incontinence.
- The second type of urinary incontinence is that which is stress-related. It occurs when coughing, sneezing, during physical activity, and is called stress type urinary incontinence. Stress, in this case, refers to physical activity. 50% of urinary incontinence cases fall into this category.
- Finally, there is urinary incontinence that combines both elements. About 30% of urinary incontinence cases fall into this category.
Which types of urinary incontinence are more common and at which age?
Stress type urinary incontinence is more common in young and middle-aged women, and urge and combined urinary incontinence – in older women.
What are the social effects of urinary incontinence?
Women consider urinary incontinence at any age to be a problem that impairs their quality of life. To some extent, the sufferer has to tailor her life to the condition. They prefer not to leave home, avoid social environments and worry about having to be near a toilet wherever they go. They try to avoid public transport. Their worry about the problem sometimes causes them not to consume enough fluids, which can lead to other health problems. The condition can cause problems in relationships with people.
What causes urinary incontinence?
- It could be a hereditary predisposition. If your mother or sister suffers from urinary incontinence, your chance is 3 times greater.
- Age is an important factor.
- Pregnancy can lead to incontinence or make an existing situation worse.
- One in five cases of urinary incontinence that occur later in pregnancy remain permanent.
- Childbirth is a significant factor in itself.
- Difficult births or those with intervention, or normal births of large babies, are factors that increase the risk.
- Because the pelvic area is subject to less tension during Caesarean (C-section) births, it is less common in Caesarean than in normal births.
- The prevalence of urinary incontinence is more prevalent in women who have undergone certain childbirth surgeries and radiation treatment for cancer.
- Frequent urinary infections, cystitis, and specific medications can lead to urinary incontinence.
- Excessive alcohol consumption.
- Herniations of nerves involved in bladder function, dementia and diseases such as multiple sclerosis.
- Entering menopause can cause urinary incontinence. Menopause damages the urinary retention mechanism.
- Chronic constipation is a significant factor. Constant straining can damage the urinary retention mechanism.
- Susceptibility can be increased by diseases such as diabetes, high blood pressure, heart disease and chronic lung disease.
- And again, overweight and obesity.
- When a person is overweight, it puts extra strain on the pelvic floor, which can lead to urinary incontinence or worsen an existing problem.
- Urinary incontinence is seen more often in people who do not get enough exercise or lead a sedentary lifestyle.
What are the signs of urinary incontinence?
The most obvious sign is true urine leakage or such a sensation. Sometimes, women may not realize that they have leaked urine. If the sufferer uses a sanitary napkin, urine leakage is visible when the pad is wet. Sufferers of urge urinary incontinence may feel a sudden urge to urinate or involuntarily drop a few drops of urine. In most cases, this will be obvious. In addition, indications may be frequent going to the toilet or getting up at night to urinate.
How is this condition diagnosed?
The most important diagnostic method is discussing the problem with the patient. This consultation establishes when accidents occur, in what situations, to what extent they can be avoided, whether she uses a sanitary pad, the impact on social life, the degree of urinary incontinence, previous surgery or childbirth and any underlying chronic diseases. In addition, the patient was asked to fill in a questionnaire and do some tests herself. This gives us valuable information about the type of urinary incontinence, how serious it is, in what situations it occurs and its effect on social life. The patient is also asked to complete what we call a 'bladder diary', recording in it the frequency, volume and timing of urination, the volume of fluid she consumes and other indicators. Along with a detailed physical examination, these are our most important diagnostic tools. Sometimes additional urine tests, ultrasonography and urine flow studies are required for a definitive diagnosis.
How is urinary incontinence treated?
After diagnosis, 3 types of urinary incontinence treatment can follow. The first is called ‘conservative treatment’, which focuses on creating specific lifestyle changes in the patient, such as losing weight in overweight patients, motivating patients to exercise regularly, quitting smoking, changing medications that can lead to urinary incontinence, regulating fluid intake, limiting soft drinks, consuming tea and coffee, and overcoming constipation.
In some patients, the problem is completely or partially overcome after being taught specific urinary retention postures and after being instructed regarding urination.
In recent years, treatments using pelvic floor strengthening exercises and muscle stimulation devices have been introduced as methods of dealing with the problem.
Can female urinary incontinence be controlled using medications?
Female patients may benefit from medication treatment depending on the type of urinary incontinence. Medication can be used to treat specifically urge type urinary incontinence. Medication increases the collecting capacity of the bladder, reduces the frequency of urination, significantly lowers the perceived need to urinate, and reduces leakage incidents in about 50% of cases. This type of medication could have side effects and interfere with taking medication for other conditions; it should only be considered in consultation with a urologist. The effectiveness of the medication can be monitored, and if necessary, it or its dose can be changed. Stress-type urinary incontinence, in some cases, can also be treated with medication, although usually not effective.
When is surgical treatment appropriate?
Surgery could be a reasonable choice in cases where the patient is unable to make lifestyle changes, in severe cases and in cases where the patient does not respond to medical treatment. Typically, surgery is recommended in cases where examinations have revealed physical abnormalities. It may also be recommended when the patient's quality of life and social life are affected to an extreme degree.
What type of surgery is performed to treat female urinary incontinence?
We usually treat female urinary incontinence patients by closed surgery through the vagina. The aim is to help prevent urinary incontinence. In patients who do not have a distinct relaxed bladder the problem is permanently resolved after a 15-20-minute procedure. In appropriate cases, this can be performed with local anaesthesia without hospitalization. The patient is usually discharged the same day and the effect of the operation will be felt the following day. 90% of mild or moderate cases are completely cured without any side effects.
In cases where there is significant bladder and pelvic organ drooping, closed surgery through the vagina is also preferred. The duration of the operation is extended to about 1 hour, as the problems of sagging are also addressed during the operation; it is performed under full anaesthesia and usually requires an overnight stay in hospital. Prior to recent advances in medical science, these cases required open surgery, but today it is only performed in very rare cases.
Can urinary incontinence occur again after surgery? And does childbirth after surgery lead to reoccurrence?
The chances of recurrence after surgery are 10-20%. In these cases, reoperation is possible. We generally recommend that patients who become pregnant at a later stage deliver by caesarean section. However, some patients give birth normally and lose the benefits of surgery for urinary incontinence, and in these cases repeat surgery is possible.