Incontinence is the involuntary leakage of urine. It occurs when the intra-bladder pressure exceeds the urethra closing pressure.
The basic structures that are effective in holding urine:
1- The natural structure of the urethra (urinary tract) and the muscle layers surrounding the urethra, which we call sphincters. The sphincter, consisting of striated muscles, is voluntary, while the sphincter, composed of unstriated muscles, plays a role in urine retention by contracting and relaxing involuntarily.
2- The muscles that form the pelvic floor (levator ani muscle) and the support formed by the fascia surrounding them. This support provided to the pelvic organs is especially effective in preventing urinary incontinence (stress urinary incontinence) that may occur in cases where intra-abdominal pressure increases.
The control of urine storage and periodic discharge is primarily controlled by the spinal reflex urination center (parasympathetic) located sacral in the medulla spinalis. Urination occurs reflexively after the stimuli reaching this center as the bladder fills, but such events in infants can be delayed by the suppressive stimuli of the urination center in the brainstem and the brain in adults, and urination occurs by removing these suppressive stimuli at the appropriate place and time. This may lead to different types of urinary incontinence due to problems in neurological control.
The main mechanisms that ensure continence (urinary retention) in women can be summarized as follows:
1-Bladder compliance: Normal bladder compliance means that the bladder Despite the significant increase in bladder volume during filling, there is a slight increase in intravesical pressure. Thus, the feeling and need to urinate is felt after the bladder reaches a certain fullness.
2- Effective urethral sphincter: Active contraction of the smooth and striped sphincters around the urethra is in continence. It is important. Basal contraction profit at rest It increases milliseconds before the intra-abdominal pressure increases (coughing, sneezing), creating a force against the intra-abdominal pressure.
3- Effective pelvic floor support: The pelvic floor muscles and fascia are anatomical and passive, like a hammock from below, against the increasing intra-abdominal pressure. They provide support.
4- The flexibility of the urethra mucosa and the vascular-rich structure of the tissue under the mucosa contribute to the closure of the urethra.
The types of urinary incontinence (IC) in women are, in order of frequency:
1-Stress urinary incontinence (STUI): 49%
2- Urge urinary incontinence (RITI): 22%
3--Urgency + Stress = mixed type urinary incontinence (CUI): 29%
4-Other types of incontinence (overflow type, fistula and those due to ectopic ureter...) 2%
Some of these types of incontinence They may coexist in patients and create a confusing situation. Another type of urinary incontinence is temporary urinary incontinence, which is mostly seen in the elderly and occurs due to reasons other than the urinary system. The main reasons for this are urinary infections, atrophic vaginitis, psychological problems, some medications, excessive urine production, movement restriction and Constipation can be considered.
The incidence of urinary incontinence in society increases with age, with a slight increase to 30% until the age of 50, stable between 50-70 years, and increasing again after 70 years to 35-40%. The rates of urinary incontinence types also vary with age. While mixed and urge incontinence are more common in the elderly, stress incontinence is more common in young and middle ages.
Risk factors of urinary incontinence:
1-Predisposing factors.
2-Gynecological and obstetric factors
3-Incentive factors
PREPOSITORY FACTORS:
-Race: STIC is more common in Caucasians than in black and yellow races
-Familial predisposition: The risk of STI and CTI is higher in those whose mother and sister have IC
-Anatomical anomalies: Ureter and congenital defects of the urethra or urinary fistulas.
- Neurological disorders: Congenital (s.bifida), traumatic, degenerative lesions.
GYNECOLOGICAL AND BIRTH-RELATED FACTORS:
-Pregnancy: IC is common (8-85%), STI is seen in 28% and disappears in 16% of cases. Those with IC during pregnancy are prone to the development of IC in later life. However, it is controversial whether pregnancy itself or birth contributes to late-term IC.
-Birth: Vaginal birth, episiotomy, instrumental birth increase the risk compared to cesarean section, and high birth weight increases the susceptibility.
- Number of births: IC is very common in those who have 4 or more children.
-Pelvic surgery and radiotherapy: Its effect is controversial. Hysterectomy may cause bladder insensitivity, but its effect on increasing the risk of IC is controversial. Radical pelvic surgeries may contribute by causing pelvic floor dysfunction. Radiotherapy may also contribute to nerve and muscle damage, but a direct relationship with IC has not been shown.
- Pelvic organ prolapse:
This situation sometimes occurs. It can mask IC and HR may occur after correction.
PROMOTING FACTORS:
- Age: changes in the bladder (reduced capacity) and pelvic floor, as well as cognitive disorders, dementia or It also plays a role in diabetes.
- Other co-existing diseases: Diabetes, vascular insufficiency, heart failure, movement and ability limitations
- Obesity: the prevalence of IC, especially STI, is significantly high. , STİK is 4.2 times more, SITK is 2.2 times more. Weight loss in extremely obese people It was observed that the CSO decreased from 61% to 12%.
- Conditions that increase intra-abdominal pressure:
-Constipation: Stool mass in the rectum blocks the bladder outflow, causing urinary retention and urine leakage, stretching the pelvic floor. It may cause CSO by inhibiting pelvic floor contractions.
-Lung diseases and smoking: Cr. In bronchitis and emphysema, intra-abdominal pressure increases and the risk of IR increases; IR was found to be 2-3 times higher in smokers. Smoking increases cough and therefore intra-abdominal pressure, causes lung diseases, and has an antiestrogenic effect.
- Urinary infections: Although they are considered to be a temporary factor of IH, the effects of frequent urinary infections on late-term CSO are controversial.
- Dementia has a negative effect on the conscious control of urination. , prevents reaching the toilet on time in case of physical problems.
-Menopause: Although the lower urinary system is sensitive to estrogen, the role of estrogen in the continence mechanism is not clear. There is no definitive evidence showing that menopause is an independent risk factor in IC, and estrogen treatment in IC is controversial.
-Some drugs directly or indirectly affect continence with their side effects.
EVALUATION:
-History
-Assessment of the intensity of symptoms
-Physical examination (FM)
-Lab. Tests
-Urodynamic tests
-Imaging methods
STORY:
1- Urological history: How often, in what amount and in what quantity? It happens in situations. Other urological symptoms; Weak flow, straining, inability to pass urine, feeling of not being able to void. perineal discomfort, during urination or contact Is there any pain?
2-Obstetric and gynecological history: Pregnancies, births, menstruation, pelvic surgeries and radiotherapy.
3- Medical history: Chronic cough, constipation, heart or kidney failure. , endocrine disease, neurological problems.
4-Drugs and habits: Sedative, diuretic, anticholinergic, anxiolytic, alcohol, caffeine, cigarette use
ASSESSMENT OF THE INTENSITY OF SYMPTOMS:
For this, voiding diary and frequency-volume cards must be filled in by the patient. In this way, the frequency of day and night, polyuria (excessive amount of urine) during the day and night, average voiding volumes, frequency of urinary incontinence, urgency, and pad use are revealed.
PHYSICAL EXAMINATION:
General FM : Height-weight (body mass index), abdominal examination (scarring, enlarged bladder), neurological FM, especially for the sacral segments.
Perineal and genital examination: redness and irritation due to urine contact, stress test (by straining or by coughing), evaluation of extra urethral leaks and pelvic organ prolapse, evaluation of pelvic floor muscles by vaginal and rectal examination.
LABORATORY TESTS:
Standard laboratory. tests:
-urinalysis: urinary infection, diabetes
-standard biochemical tests
URODYNAMIC STUDIES: If we take a look at the conditions that can be detected with the three studies listed below:
1-Flow rate study:
-Lower urinary tract symptoms (strain, straining, weak flow)
-Op. Post-voiding problem
2-Cystometry (filling and voiding phase):
-Detrusor (bladder muscle) overactivity
-Detrusor overactivity incontinence
-Urodynamic stress incontinence
-Det rusor underactivity
-M bladder outlet obstruction
3- Evaluation of urethral pressure:
-Leak Point Pressure.
Although these conditions can be detected by urodynamics, they are generally treated conservatively and medically. If treatment is being considered, history and FM findings can often provide sufficient information, and urodynamics is unnecessary.
However, urodynamic examinations are necessary in the following cases:
-Possibility of neuropathic bladder
- Difficulty urinating (possibility of bladder outlet obstruction)
-History and symptom incompatibility
-Before surgical treatment (detrusor over- or insufficient activity, outflow obstruction and painful bladder exclusion)
-In case of conservative, pharmacological and surgical treatment failures.
IMAGING TECHNIQUES:
Upper urinary tract imaging is not necessary except for neurogenic urinary incontinence.
Imaging indications:
-Neurogenic IC. ,Risk of renal damage
-CHRONIC RETENTION RIC. (Overflow type urinary incontinence)
-Extra urethral IC due to upper urinary tract anomalies. Suspicion.
URINARY INCONOCE TREATMENTS:
For urge urinary incontinence:
1- Bladder training and exercises
2-Oral bladder relaxant drugs.
3-Drugs administered intra-bladder (botox, etc.)
In Stress Type urinary incontinence:
1-Pelvic floor exercises in mild types
2- In moderate and advanced cases, sling surgeries applied to the urethra.
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