In women; The branch of medicine that deals with health problems arising from pelvic floor insufficiency is called "urogynecology". A gynecologist and obstetrician who specializes in the treatment of problems related to pelvic floor disorders is defined as a "urogynecologist".
What are pelvic floor disorders?
The one that covers the abdominal cavity from the bottom, The structure consisting of muscle and connective tissue is called the pelvic floor. The muscle and connective tissue surrounding the lower part of this space like a frame attaches to the pelvic bone; It's like a hammock. The base not only closes the gap, it also provides support to the organs localized here, which we call the pelvic organs. These organs are the urinary bladder and urinary tract in the front, the uterus and chamber (vagina) in the middle, the last part of the intestine, the rectum, and the anus (anus) in the back.
Insufficiency of the pelvic floor, which it supports This results in the organs sagging downwards from where they are located. Palpation of a mass, feeling of pressure, perception that something is about to be born, as well as complaints arising from dysfunctions of prolapsed organs (urinary and fecal incontinence, difficulty in urination, pelvic pain and sexual problems) are within the scope of this specialty.
What is urinary incontinence?
Involuntary urinary leakage is a condition that should be investigated outside of early childhood. As a result of these investigations, the type of urinary incontinence is determined and medical or surgical treatment is planned for this.
Types of urinary incontinence
1.Stress urinary incontinence.
- If you are leaking urine, you may have a "stress urinary incontinence" problem.
The word “stress”does not describe your emotional state, but describes physical exertion that increases intra-abdominal pressure. p>
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Difficult birth, giving birth to a large baby, advanced age pregnancy; It can cause stress urinary incontinence even years after birth.
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In women, the aging process along with menopause can also cause this type of urinary incontinence.
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In addition, serious respiratory diseases such as emphysema and cystic fibrosis, which cause frequent coughing, can also cause stress urinary incontinence.
Stress urinary incontinence develops due to the weakening of your bladder muscles.
2.Overactive bladder – Urge urinary incontinence
It is the situation of feeling stuck in the toilet even though the bladder is not fully filled, and then leaking urine before being able to reach the toilet.
Although urgency does not always cause urinary incontinence, it is a situation where you feel like you are stuck in the toilet, even though your bladder is not full, and you leak urine due to the need to get to the toilet in a place where you gather or at a business meeting. It may cause interruption in your life:
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Urinary tract diseases caused by microbes such as cystitis (bladder infection) in women,
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Stones in the bladder, Having a tumor,
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The presence of diseases affecting the muscle and nervous system such as multiple sclerosis and Parkinson's may cause "urinary incontinence".
'Urge type urinary incontinence' is caused by overactive work of the bladder muscles, unlike stress-type urinary incontinence, which develops due to weakening of the bladder muscles.
3.Mixed type urinary incontinence.
It is a condition in which the symptoms of stress urinary incontinence, which develops due to the weakening of the bladder muscles, are experienced together with the symptoms of urge urinary incontinence, which arises from the overactive functioning of the bladder muscles.
It is more common in women and is also experienced by elderly people who are debilitated. They may also complain of mixed urinary incontinence.
4.Overflow type urinary incontinence
When the bladder outflow tract, which needs to relax for urine to come out while the bladder contracts, cannot relax enough, the bladder cannot be completely emptied every time you urinate, and the remaining in the bladder is not emptied completely. It is a situation where a small amount of urine creates constant pressure on the bladder, resulting in urine leakage.
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The uterus has fallen below where it should be (uterine prolapse)
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Destruction of the nerves that control the bladder due to diabetes,
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Damage to the nerve cells that control the bladder, such as spinal cord injuries, may cause overflow type urinary incontinence.
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Rheumatic disorders that limit movement and may prevent reaching the toilet,
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Dementia, Alzheimer's, Nervous system health problems such as stroke, which prevent you from thinking and taking action to go to the toilet, cause this type of urinary incontinence.
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Diseases that cause nervous system damage
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Accidents with spinal cord injuries
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Medical interventions that can cause side effects in the nervous system, such as radiotherapy, may cause this type of urinary incontinence.
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TVT (Tension free Vaginal Tape): The operation is performed vaginally. A needle is inserted through a small 1 cm incision under the urethra, and the patch is placed under the urethra, ensuring that the patch arms remain behind the pubic bone. Simultaneous cystoscopy (visualization of the inside of the bladder with the help of a camera) is performed.
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TOT (Trans Obturator Tape):The operation is performed vaginally. The patch is placed under the urethra by entering the obturator hole on both sides of the pelvis with a hook.
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Mini-sling:The operation is performed vaginally. Since a short patch is used in this surgery, long anatomical distances are not covered.
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Laparoscopic and laparotomic sling operations; Burch and MMK colposuspension operation.
5.Functional type urinary incontinence
Although the bladder muscles and bladder work well, movement may occur due to rheumatic diseases. It is a type of urinary incontinence due to difficulty in going to the toilet and not being able to reach the toilet.
6.Reflex type urinary incontinence
Any It is a condition of involuntary urinary leakage without warning.
Is the urinary incontinence problem temporary or permanent?
If urinary incontinence due to reasons such as urinary tract infections or the use of drugs such as diuretics that cause the bladder to overwork is relieved by the improvement of existing conditions (e.g. If the disease causing urinary incontinence has responded to treatment or if it is no longer necessary to use diuretic medications), it is called transient urinary incontinence. On the other hand, if complaints of urinary incontinence continue, it is called persistent type of urinary incontinence.
Urinary Incontinence Treatment
1.Urinary Incontinence. Changing Habits, Exercise and Medical (Medication) Treatment
Although there are various opinions about the place of medical treatment in stress urinary incontinence, drug treatment can be planned especially in overactive bladder, that is, urge urinary incontinence.
Urination. The first start of incontinence treatment is changing habits and pelvic floor exercises. Quitting smoking, losing weight, administering female hormones (estrogen), controlling diabetes, and special pelvic floor exercises found by Kegel can control simple urinary incontinence.
Drugs that tighten the sphincter and prevent involuntary contractions of the bladder are simple and moderate. It can be tried for severe urinary incontinence. Use drugs When urine is stopped, urinary incontinence continues. In the medical treatment of urinary incontinence, medications may have some side effects. These are dry mouth, constipation, blurred vision, headache, insomnia, nausea, tachycardia (increased heart rate), orthostatic hypotension (low blood pressure when standing up). Drugs in the medical treatment of urinary incontinence should not be used in patients with closed-angle glaucoma, a muscle disease called myasthenia gravis, heart diseases with conduction disorders, and GIS obstructions (stomach or intestinal obstructions).
Time to stop the drug if the patient's complaints disappear. There is no clear information about it. Because the symptoms may reoccur shortly after stopping taking the medication.
An endoscopic (closed method) injection can be made through the urinary canal and into the urethral sphincter area, under the mucosa, but it is temporary and the success rate is low. Botox injections into the cystoscopic bladder may also be tried. This process also needs to be repeated at 6-month intervals.
2. Surgical treatment
Another treatment for stress urinary incontinence is surgery. However, in long-lasting mixed-type incontinence, surgery should be performed even if stress-type incontinence is at the forefront. Which operation will be performed on which patient is decided after the evaluation of the patient.
The most common and most effective surgical treatment is the placement of a synthetic or natural patch (mesh) under the urinary tract. This patch, which resembles a fishing net, also prevents urinary incontinence by supporting the urethra. This patch can be placed in 4 ways:
What is the most common problem related to patch surgery for stress urinary incontinence?
Problems that may be related to surgery
Although it is rare, it is a situation where a part of the mesh becomes visible (mesh erosion) due to the placed mesh not being covered by the body. It is sufficient to cut the visible part under local anesthesia and simply stitch the tissue. If the apparent size of the mesh is less than 0.5 cm and the patient is in menopause, estrogen cream treatment may be sufficient without surgery.
Also very rarely, bleeding may occur if the hook damages a vital vessel during the operation. After the operation, inability to urinate, abdominal and groin pain, fistulas, numbness in the feet and difficulty in walking may occur.
Should urodynamics be performed in every patient?
This examination is appropriate. should be done in patients. For example, patients who have previously undergone surgery for urinary incontinence but whose complaints continue, those with urge urinary incontinence, those with advanced genital organ prolapse, those with unclear complaints about this issue; These tests may be performed if there is a history of urinary retention (inability to excrete urine even though the bladder is full), the patient is older than 65 years of age, urinary incontinence at night, and known or suspected neurological disease.
Pelvic Organ Prolapse
It is a condition of prolapse of the Urinary Bladder, Uterus and Rectum (cystocele, uterine prolapse, rectocele).
The organs located in the genital area, in the pelvic bone (pelvic bone), can only be fixed thanks to various ligaments that fix them. They can move in a limited way. As age progresses and especially as the number of births increases, these ligaments may lose their properties and thus cause the genital organs to prolapse into the vagina.
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