Female Urology

Female urology deals with the diagnosis and treatment of urinary incontinence in women, vaginal organ prolapses (such as cystocele, rectocele..), pelvic and bladder pain syndromes, sexual dysfunction and other voiding problems. In addition to urodynamic and pathophysiological evaluation of these conditions, treatment is carried out with physical, medical and surgical methods. Stress urinary incontinence and overactive bladder syndrome, which are very common in women, are among the conditions that are treated particularly intensively.

Urinary Incontinence

The lower urinary tract has two important functions. These are the storage of urine and its release at the appropriate time. Urine coming from the kidneys collects in the bladder (urinary bladder), and when it reaches a certain volume, the urge to urinate arises; during urination, the sphincter that holds urine in relaxes and the bladder contracts, emptying the urine. Urinary retention (continence) continues both at rest and during exertion as long as the pressure in the external urinary passage (urethra) is higher than the pressure inside the bladder. This balance is related to the functional state between the bladder and the urethra. Involuntary urine leakage by a patient is called incontinence (urinary incontinence). Urinary incontinence is not a life-threatening event, but rather a social problem. Urinary incontinence can occur at any age. It is most commonly seen in children, elderly patients or some women, but it can be seen at any age and in both sexes. Many classifications of urinary incontinence have been made. The most widely used classification is that of the International Continence Society:

• Stress incontinence; Urine leakage during physical activity due to increased intra-abdominal pressure. This is defined as true urinary incontinence, where the event is an inability to retain urine due to a pressure increase without bladder contraction. It is stress-type urinary incontinence caused by weakening of the anatomical support of the pelvic floor and bladder. In stress incontinence, the patient involuntarily leaks urine when coughing, sneezing or straining. This condition is usually associated with having many births, delivering a large baby, home births, difficult births, interventional deliveries, or deliveries performed by untrained persons. It is also frequently seen due to age, menopause, long-standing constipation, obesity, and lung diseases such as asthma and bronchitis.
• Urge incontinence: Leakage caused by involuntary bladder contractions. It is accompanied by frequent urination and a sudden urge to urinate. Urge incontinence may occur together with any neurological disease, or it may occur without any cause; this condition is called bladder muscle instability. Some neurological diseases may cause involuntary bladder contractions, such as Parkinson's disease, multiple sclerosis, spinal cord injuries, etc.
• Total incontinence: The patient does not feel that they are leaking urine and constantly reports that their underwear is wet.
• Overflow incontinence: It can also be defined as overflow incontinence. Here there is weak contraction of the bladder muscle and excessive contraction of the sphincter. It is a condition that may be seen in spinal cord injuries, diabetes, brain tumors and lumbar disc herniations.
• Mixed incontinence: The presence of both true incontinence and urge incontinence together.
• Nocturnal Enuresis: A complaint of urine leakage during sleep.

What are the causes and risk factors of urinary incontinence?

• Age: Due to advancing age and entering menopause, the decrease in estrogen hormone and, consequently, the loosening of the ligaments supporting the bladder and uterus and the weakening of supporting tissues cause urinary incontinence.
• Genetics: Some studies have shown a genetic predisposition to stress and urge incontinence.
• Childbirth: Those who have had many births, large babies, or difficult deliveries have a higher risk of urinary incontinence.
• Chronic diseases: Asthma, chronic bronchitis, diabetes, trauma, previous spinal cord surgeries and brain diseases increase urinary incontinence. Chronic constipation, obesity, recurrent urinary tract infections, uterine and vaginal surgeries, and smoking are factors that predispose to urinary incontinence.

How is urinary incontinence diagnosed?

In diagnosing patients, it is necessary to perform a differential diagnosis of more serious diseases and to identify the probable underlying functional abnormality. The best aid in making the diagnosis is taking a good medical history. If there are additional complaints, these should also be examined; the presence of pain and bleeding should be questioned. The patient's age, the onset of the complaint, medications used, previous illnesses and surgeries, and deliveries performed should be inquired about.

Examination

A detailed pelvic and general examination is performed by a urologist. During the examination, the patient needs to have a full bladder and be examined in the lithotomy position. The patient is observed for urine leakage while coughing and bearing down; if there is no leakage in the lying position, the patient should be stood up and asked to cough and bear down. The Boney test, Pad test and Q-tip test should be performed together with these. The neurological examination begins with observing the patient's gait and behavior as they enter the room. A rectal examination must definitely be performed, anal tone should be checked, and genital sensation and reflexes should be evaluated.

What tests should be performed?

• Urinalysis and urine culture must definitely be performed. If there is a urinary tract infection, it should be treated; the presence of bleeding in the urine test should be investigated.
• Urinary tract ultrasound should be performed and residual urine should be checked.
• Pad Test: A semi-objective measurement of the amount of urine leaked within a specified time period.
• Uroflowmetry: Measurement of urine flow.
• Urodynamic evaluation and, if necessary, videourodynamics.
• If necessary, cystoscopy should be performed.

Treatment

Medical treatment
In urinary incontinence due to overactivity of the bladder muscle, it is necessary to find the underlying cause. Urinary infections are the conditions that most often cause overactivity of the bladder muscle, and treatment resolves them after medications are used. Anticholinergic, antimuscarinic and tricyclic antidepressants may be used.

Estrogen Hormone Application: Local estrogen may be given to some patients in order to stimulate the bladder mucosa and submucosal tissue, increase circulation and thereby enhance the smooth muscle response, and achieve improvement at the urethral outlet. Especially in patients in the menopausal period, local estrogen applications in the form of suppositories, cream or gel may be beneficial.

Pelvic floor exercises, electrical stimulation and biofeedback methods may be used.

Surgery: In the last century, more than 100 different techniques have been proposed for the surgical treatment of SUI. The short-term success rates of these operations vary between 65-95% depending on the technique applied. Generally, the first surgical intervention has the highest chance of success. Operations performed in subsequent sessions have a lower chance of success. If there are accompanying pathologies such as bladder prolapse (cystocele) or bowel prolapse (rectocele, enterocele), the surgical intervention is decided accordingly; prolapses are corrected by the vaginal approach (from below) and the incontinence is resolved. In choosing the type of operation, the patient's general condition, urethral mobility on tests, preoperative urodynamic parameters, surgical experience and the possible complications of the technique to be applied are taken into account.

Surgeries Applied in Stress Incontinence

Anterior Colporrhaphy and Kelly Plication: It is one of the oldest operations performed for bladder prolapse and urinary incontinence complaints. The success rate varies between 30-70%.

1-Abdominal incision bladder neck suspension operations: Surgical operations performed through an abdominal incision may be applied to young, non-obese individuals with a mobile urethra.

These are:

• Marshall-Marchetti-Krantz (MMK) Operation: Sutures passing through the bladder neck and urethral neck are attached to the pubic bone. Thus the bladder neck and urethra are placed in a high position.
• Burch Operation: Sutures passing through the bladder neck and urethral neck, made using an autologous fascial graft, are attached by passing through the iliopectineal ligament (Cooper's ligament).
• Laparoscopic Colposuspension: Performing the MMK or Burch operation under laparoscopic guidance (closed).

2. Needle fixation operations through the vagina: In these operations, the suture threads placed on the anterior vaginal wall are brought to the suprapubic area with a needle and tied, thereby aiming to lift the bladder neck and urethral outlet. These operations are preferred mainly in elderly patients with prolapse, in cases where the operation time should be short, and in patients whose urethra is also hypermobile. The most frequently applied ones are:

• Modified Pereyra Operation
• Stamey needle bladder neck operation
• Raz Vaginal Wall Sling
• Gittes Operation.

3. Sling Procedures: The common feature of sling operations is the use of a strip-shaped material that passes entirely beneath the urethra or bladder neck and is suspended from the abdominal wall. Sling procedures are most frequently applied in true stress incontinence and mixed urinary incontinence.

• TVT Operation: These operations, performed since 1995, are called "tension-free vaginal tape" (TVT). TVT operations can be performed under local, regional or general anesthesia. The aim of the operation is to elevate the urethra with a sling material consisting of a "polypropylene tape" placed around the urethra. Over time, this tape forms scar tissue through tissue reaction and provides support to the urethra. It is a less traumatic operation compared to other surgeries.
• TOT Operation: It is a relatively new surgical method, first described in 2001. In this operation, through a small incision in the vagina, a band called "polypropylene mesh" is placed with a special needle to elevate the urethral canal. In the TOT operation, the patient's wound healing is very rapid, the hospital stay is very short (on average one day), and postoperative complaints are very few.

For up to 24 hours after surgery, the bladder is kept at rest by a catheter placed inside it. Afterwards the catheter is removed and urination is observed.

• Other Sling Techniques:

4- Periurethral Injection: This method, which is mainly for patients who cannot take the risk of general anesthesia, involves injecting various substances around the bladder neck and urethra under local anesthesia, under the control of a device called a cystoscope. Injected substances: collagen, autologous fat, silicone and Teflon. Repeated injections are usually necessary. The most frequently injected materials are Teflon, collagen, fat and blood cells. The aim is to increase resistance by exerting pressure on the urethra, thus preventing urine leakage, even if only for a certain period.

5- Artificial (Prosthetic) Urinary Sphincter: Applied to patients who have undergone multiple incontinence operations (including sling and periurethral injection) with unsuccessful results, or who have complete sphincter (bladder neck muscle) insufficiency.