General Information
Urinary incontinence can basically be described as involuntary urinary incontinence.
While bladder filling is controlled by the sympathetic nervous system, voiding function is controlled by the parasympathetic nervous system.
A) Sympathetic Nervous System (T11-L3: norepinephrine) = Bladder filling
- adrenergic system: increases closing tone in the urethra and bladder neck
- Beta adrenergic system: reduces the tone of the bladder body.
B) Parasympathetic nervous system (S2-54-acetylcholine) Bladder emptying
- Controls bladder contraction and bladder emptying
C) Somatic innervation (S2-4): External urethral sphincter
etiology
Age (risk increases with older age)
Pregnancy
Birth (giving birth at a young age); Parity stress is a risk factor for urinary incontinence, but not for urge incontinence.
Interventional delivery with forceps
Obesity
functional impairment
cognitive impairment
Medical diseases; stroke, diabetes, spinal cord injuries, parkinson
Menopause
History of hysterectomy
Cigarette
Presence of urinary symptoms
Chronic increased intra-abdominal pressure; chronic cough, constipation, occupational causes
Race: Stress urinary incontinence is more common in Caucasians, and urge incontinence is more common in blacks.
Medications
Benzodiazepines: May cause secondary incontinence due to confusion.
Alcohol: Has a similar effect to benzodiazepines and causes diuresis. Anticholinergics (antihistamines, antipsychotics, tricyclic antidepressants, antispasmodics, drugs used in Parkinson's treatment): They cause urinary retention and overflow incontinence.
α-agonists: They cause difficulty in micturition.
a-blockers (prozosin, terazosin): They reduce the urethral closure pressure and cause stress incontinence.
Calcium channel blockers: They reduce the smooth muscle contractility of the bladder. There may be incontinence and nocturia.
ACE inhibitors: They cause urine leakage due to coughing.
diuretics
COX-2 inhibitors and thiazolidinediones: It causes nocturnal diuresis.
Narcotic analgesics: They cause urinary retention.
After vaginal delivery, a number of changes occur that lead to stress urinary continence (SUI). One of them is the loss of power in the m.levator ani muscle. Urinary continence may occur due to laceration in the pubococcygeus part.
Another change is the lowering of the bladder neck and another is partial denervation of the pelvic muscles caused by pudendal neuropathy. Because of all these changes, the risk of developing SUI increases as the number of vaginal deliveries increases in young women.
Diagnosis
► Urination diary: It is used to evaluate the daily urine frequency and volume.
► Urinalysis: Used to rule out urinary infection, hematuria and metabolic abnormalities. Often, a simple UTI can cause exacerbation of incontinence.
► Post micturition residual volume: Incomplete emptying of the bladder may lead to incontinence. While residual volume below 50 ml is considered normal, it is pathological if it is above 200 ml.
► Urinary stress test: It is done when the bladder is full. The patient is asked to strain or cough forcefully to evaluate whether there is urinary incontinence. If there is urine leakage, a diagnosis of SUI is made. If there is no escape with this maneuver, the patient is stood up and asked to cough again.
► Q-tip test: The mobility of the bladder neck is evaluated using a sterile cotton swab. The change in the angle of the bladder neck with Valsalva maneuver or coughing is evaluated, above 30 degrees is considered abnormal. Not recommended today.
► Urodynamics: It gives objective and dynamic information about lower urinary system function.
It is the gold standard in the diagnosis of urinary continence. Indications for moving to advanced examinations such as urodynamics after simple examinations; the diagnosis is uncertain, surgical treatment is planned, hematuria without infection, high post-void residual volume, a neurological disease that may complicate the treatment (multiple sclerosis), significant pelvic organ prolapse, and many previous corrective operations.
► Display methods: They should never be used as first choice. MRI is the best method for urethral diverticulum. Cystoscopy is not included in the routine evaluation of incontinence.
True Stress Urinary Incontinence (G-SUI)
General Information
► It is defined as urine leakage that occurs as a result of intravesical pressure exceeding the maximal urethral closure pressure without detrusor contraction.
► It occurs due to the change in the normal anatomical position of the proximal urethra (urethral hypermobility) or intrinsic sphincter insufficiency. Thus, urine leakage occurs as a result of increased intra-abdominal pressure.
G-SUI is the most common type of urinary incontinence in women and is often seen in younger women.
Treatment
Conservative
0 In mild cases, alcohol and caffeine restriction, restriction of fluid intake and Kegel exercises should be tried first. The first option in the conservative approach is Kegel exercises.
Medical (a agonists)
0 Has a minor role.
0 Since the tone of the urethra and bladder neck is largely dependent on the α-adrenergic activity of the sympathetic nervous system, many pharmacological agents are used in the medical treatment of G SUI. These drugs are imipramine, ephedrine, pseudoephedrine, phenylpropanolamine, and norepinephrine.
0 Duloxetine is a serotonin and norepinephrine reuptake inhibitor. It provides urine storage by relaxing the bladder and increasing outflow resistance. It is a drug that should be considered in the treatment of women with disturbing stress incontinence and being treated for depression.
Surgical
0 The common goal in many surgical techniques is to support the bladder neck by elevation of the uretrovesical junction. Surgical techniques used in the treatment of G-SUI are:
► Colposuspension (Retropubic urethropexy):
0 Marshall-Marchetti-Krantz (MMK)
0 BURCH (Colposuspension)
► Pubovaginal Sling (uretropexy): The periurethral tissue is suspended in the rectus fascia.
► Midurethral sling procedures: It is the gold standard in stress incontinence surgery.
0 Trans-obturator tape (TOT)
0 Tension-free vaginal tape (TVT)
► Periurethral and transurethral injections: The angle of the bladder neck is tried to be corrected by injecting silicone and Teflon-like agents into the submucosal area of the bladder neck.
► Artificial sphincter: It is an alternative in cases with inadequate urethral sphincter function. By inflating the balloon-shaped sphincter, the escape is prevented, and the balloon is deflated when the patient wants to urinate.
► TVT, pubovaginal sling and urethral injections are used in intrinsic urethral sphincter insufficiency.
Retropubic Uretropexy (Colposuspension) Operations
· In the Marshall-Marchetti-Krantz (MMK) operation; The periurethral fascia is attached to the posterior aspect of the symphysis pubis.
· In Burch colposuspension; at the level of the bladder neck, the periurethral fascia hangs over the Cooper ligament
· Kelly plication; It is not used in the treatment of stress incontinence.
Urge incontinence
General information
• Urge incontinence is defined as urinary incontinence following a strong sense of urination and develops due to involuntary detrusor contraction (detrusor instability = overactive bladder). However, urodynamic study (cystometry) is absolutely necessary for this diagnosis.
• Involuntary detrusor contractions are called detrusor hyperreflexia if they are of neurological origin (eg Parkinson's and multiple sclerosis).
• Having an operation for stress incontinence is a risk factor for urge incontinence.
Urge incontinence is the most common type of urinary incontinence among older women.
Treatment
► In the first stage, Kegel exercises and behavioral treatments should be tried.
► The main treatment of urge incontinence is medical. Detrusor contraction occurs with cholinergic activity as a result of parasympathetic stimulation. Therefore, anticholinergics are used in the treatment. Drugs used for this purpose; oxybutynin, hyoscyamine, dicyclomine, probantelin, tolterodine, imipramine, fesoterodine, trospiumchloride, solifenacin succinate and darifenacin.
► However, all these anticholinergics have significant side effects. Among them; dry mouth (most common), increased heart rate, hyperthermia, urinary retention, constipation and blurred vision.
Mirabegron is a beta3 adrenergic receptor agonist that increases bladder capacity by relaxing detrusor smooth muscle and is used in the treatment of overactive bladder.
► Alternative treatments are used in patients who do not respond to conservative and medical treatment. The most important is sacral neuromodulation. In this method; There is an implanted device that continuously stimulates the sacral nerves and reduces symptoms. It is a good option supported by studies in refractory urge incontinence.
► Intradetrusor Onabotulinum toxin A injection; It is injected into the bladder wall via cystoscopy and paralyzes the detrusor smooth muscle. There are 60-70% recovery rates. It provides benefits for 3-12 months and repeat injections are also effective.
|
Comparison of stress and
urge incontinence symptoms |
||
|
urinary
symptoms |
urge |
stress |
|
Urgency |
there
is |
none |
|
Frequent urination with a feeling of urgency |
there
is |
none |
|
Urinary incontinence with increased intra-abdominal pressure |
none |
there
is |
|
The amount of urinary incontinence during each incontinence |
lots |
little |
|
nocturia |
there
is |
none |
The primary treatment of true stress incontinence is surgery.
Primary treatment of urge incontinence is medical, anticholinergics are used.
PELVIC RELAXATION AND PELVIC ORGAN PROLAPSU
etiology
• Pregnancy (parity)
• Vaginal birth
• Age
• Menopause; linked to aging and hypoestrogenism
• Chronic increased intra-abdominal pressure; COPD, constipation, obesity, irritable bowel syndrome, chronic cough
• Pelvic floor trauma; prior repairs, episiotomy, and hysterectomy
• Genetics; race (white) and connective tissue diseases (Ehters-Danlos Syndrome)
• Spina bifida
• Low education level
Pelvic relaxation is the most common indication for hysterectomy in women over 55 years of age.
PELVIC RELAXATION TYPES
cystocele
• It often occurs secondary to defects in the pubo-cervical fascia due to birth trauma. However, it develops as a result of congenital insufficiency of endopelvic fascia or pelvic floor muscles in non-delivery cases. It is usually associated with urethrocele. After menopause, its degree may increase with the decrease of pelvic support due to hypoestrogenism. It does not require treatment unless it is symptomatic.
• Urinary incontinence is the most common and most important symptom; however, most cases do not have incontinence, and repair of the cystocele (colporrhaphy anterior) does not improve incontinence.
• In the presence of cystocele, residual urine and related urinary complications (cystitis, dysuria, urgency and urinary frequency) may develop due to the inability to empty the bladder completely. As long as cystocele does not prevent coitus, it does not affect sexual functions.
• Levator and perineal muscles should be strengthened with antepartum and postpartum exercises (Kegel) to prevent cystocele. Movements that increase intra-abdominal pressure should be avoided. Estrogen therapy in the postmenopausal period is beneficial in supporting the pelvic musculofascial structures.
Treatment
► Medical: It should be considered in young cases, in women who have not yet completed their fertility, and in elderly patients where surgery is at risk. For this purpose, Pesser and Kegel exercises can be used.
► Surgery: Surgery is performed in cases where rectal evacuation is difficult or manual evacuation is required. Posterior colporrhaphy and perineal body reconstruction are the most common surgical techniques.
rectocele
• It usually develops secondary to birth traumas such as cystocele. The view that episiotomies reduce the traumatic effects of birth on the pelvic floor is not accepted today, on the contrary, it is reported that median episiotomies increase the risk. Other risk factors are menopause and chronic increase in intra-abdominal pressure. Vaginal pressure and rectal fullness are the most common symptoms. Constipation and, rarely, fecal incontinence may be observed.
Treatment
► Medical: Rarely, vaginal pessaries are useful. Biofeedback therapy can be considered as primary treatment for impaired defecation.
► Surgery: Surgery is performed in cases where rectal evacuation is difficult or manual evacuation is required. Posterior colporrhaphy and perineal body reconstruction are the most common surgical techniques.
enterocele
• It is herniation of the peritoneum and small intestine. The most common cause; previous hysterectomy. Most of them descend between the uterosacral ligaments and the rectovaginal space. It often accompanies total prolapse and procidentia. The most common symptoms are; urinary incontinence, defecation problems (tenesm, constipation, diarrhea, fecal incontinence), pelvic pain, low back pain and dyspareunia.
Enterocele is the only true hernia among the types of pelvic relaxation.
Treatment
Medical: It is applied in elderly patients for whom surgery is inconvenient. Vaginal pessary, vaginal tampons and estrogen-containing or bacteriostatic creams may be helpful. Weight loss is recommended in obese patients.
Surgery: Enterocele can be repaired by abdominal or vaginal route. With abdominal intervention, the enterocele sac is obliterated by the sacrouterine ligaments and endopelvic fascia (Moschowitz operation). Mc Call culdoplasty can be done vaginally.
UTERINE PROLAPSUS
• It is the sagging of the cervix and uterus towards the lower introitus as a result of weakening of the apical supports of the cardinal and uterosacral ligaments. The risk is higher in retroverted uteruses. It is very confused with cervical elongation in the differential diagnosis. procidentia is the protrusion of the uterus and vagina completely out of the introitus.
Treatment
Medical: It is the same as in enterocele.
Surgery: The decision for hysterectomy should be planned considering the patient's preference and age. Surgery can be planned in different ways in anterior, posterior and apical region prolapses accompanying uterine prolapse. Among the operations applied for this purpose;
- Abdominal surgeries; Sacrocolpopexy, uterosacral suspension
- Vaginal surgeries; Sacrospinous fixation, endopelvic fascia vaginal suspension, iliococcygeal vaginal suspension, sacrouterine ligament suspension, and Mc Cali culdoplasty
- Vaginal obliteration (colpocleisis) may be considered in elderly patients who have extensive medical problems and are not sexually active.
|
Pelvic
organ prolapse classification system (POP-Q) |
|
|
STAGE 0 |
no prolapse |
|
STAGE 1 |
Distance from the lowest point of the prolapse to the hymen >
1 cm (above the hymen) |
|
STAGE 2 |
Distance from the lowest point of the prolapse to the hymen <
1 cm (below or above the hymen) |
|
STAGE 3 |
Distance from the lowest point of the prolapse to the hymen >
1 cm (below the hymen) |
|
STAGE 4 |
Complete or nearly complete eversion of the vagina. |