Discharging System in Women

Kadınlarda Boşaltım Sistemi         Bladder is an organ that stores and discharges urine. Urethra in women (the urinary channel) is a 4-5 cm long channel that discharges urine. The vagina is a 5-6 cm cylinder structure and the urinary channel is placed longitudinally alongside the entire upper side of it. From inside out, the urinary channel (urethra) consists of a mouth-like mucosa, tissue-rich tissue and two separate muscle layers, one being voluntary and the other involuntary.

Kadında İdrar Kaçırma         The urinary channel includes two pcs urinary retaining bolt mechanisms called sphincters, one located at the bladder outlet and operating voluntary, meaning that it provides automatic control; and the other one located at the middle of the bladder and operating voluntarily, meaning that it allows us to retain and discharge our urine whenever we want (Image 2: Internal and External Sphincter). This urine retaining bolt mechanism is quite sophisticated. It operates with a very sophisticated system that is related to the brain, the nervous system and estrogen.

Causes of Urinary Incontinence

        Genetic factors as well as decrease in estrogen hormone with age, loss of elasticity in tissues, previous surgeries, multiple and difficult childbirths etcetera cause both the urinary channel and the urine retaining mechanisms to more or less lose their functions.

        There are 3 outlet holes from the perineum to the front, sequentially being the anus, the vagina and the urethra (urinary channel outlet). As human is a walking living being and therefore exposed to gravity, they lose their strength over time due to pressure by internal organs. Internal organs may prolapse outwards from said outlets owing to gravity and other factors. Perineum (anus, vagina and urethra outlet) can be likened to a suspension bridge. These three outlets on the perineum are supported by the peripheral bone structures (pubis, pelvis) just like steel ropes in suspension bridges. But they can loosen due to age or miscellaneous causes.

        The urethra and the bladder are connected to the peripheral tissue and the pubis bone with three bonds in the perineum (pubo cervical ligament of pubo urethral, urethro pelvic and endopelvic fascia). These bonds partially loosen while the urinary channel performs urination, allow the urinary channel to move and permit urination. They revert to their original status after urination is complete and don’t leak urine. This elastic spring system may malfunction over time. The urinary channel loosens more than normal if these bonds are damaged. This is called hypermobile urethra.

        For a normal urination function, the urinary channel should neither be very mobile (hypermobile) nor lose its mobility (fixed urethra). Entire loss of mobility occurs when unnecessary interventions are made to the urinary channel. Multiple and difficult childbirths, genetic factors as well as tears in bonds and loss of elasticity due to ageing are the most important factors behind urinary incontinence. As the urinary channel is more mobile than required in this case (hypermobility), urinary incontinence occurs.

        In patients that have undergone unnecessary vaginal surgeries, the urinary channel entirely loses its mobility due to surgical complications. The urethra (urinary channel) entirely loses its mobility in such case. This disorder we call fixed urethra causes complaints such as urination disorder, stricture and urinary incontinence. The surgical procedure for repairing fixed urethra is very sophisticated and requires experience.

        Until 20 years ago, the storage and discharge functions weren’t as known as they are today. One tried to treat patients with exhausting surgeries that required long hospitalization periods. As urination physiology and physiopathology were understood with PETROS and ULMSTEN, surgeries about urinary incontinence have become quite simple with least traumatic impact on patients. The majority of patients can be discharged within the same day.

Types of Urinary Incontinence?

Causes of urinary incontinence in women are different.

Stress type urinary incontinence

The primary cause in stress type urinary incontinence is the urethra (urinary channel) and the urine retaining bolts in the urethra. Stress type urinary incontinences are divided into 3 depending on their intensity.

  • Type 1: The most basic type of urinary incontinence occurs in cases like coughing, sneezing and hiccups where intraabdominal pressure increases. The majority of these problems can be controlled by drugs. The urethra becomes hypermobile, meaning more mobile than normal, when the bond in the perineum loosen or are ruptured. This may be caused by the removal of the womb (hysterectomy), difficult childbirth, menopause, damaging of nerves in the perineum, smoking and genetic factors.

  • Type 2: Even if sudden increase in intraabdominal pressure isn’t in question during minimal activities such as walking, bending over, standing up, running and sports, urine leakage occurs at intervals. The cause of urinary incontinence is further damage in the bonds and the urine-retaining sphincter (bolt). Causes in Type 1 are identically valid. Many consecutive vaginal surgeries, diabetes and lack or estrogen are the primary causes.

  • Type 3: The urine continuously leaks in this type. The urine retaining internal sphincter (intrinsic sphincter), which is located on the bladder neck, is controlled by the autonomous nervous system in the body. It allows involuntary urine retention. This mechanism completely malfunctions in this type. This rather owes to neurologic causes. It doesn’t respond to drug treatment.

Urge urinary incontinence (urgency incontinence)

        The bladder muscle is the primary reason for urge urinary incontinence. Urinary incontinence is accompanied by a sudden and forcible urge to urinate that is difficult to postpone. It owes to miscellaneous causes. It occurs when the bladder muscle (detrusor) involuntarily flexes, during which flexion of the bladder cannot be controlled.

Mixed type urinary incontinence (owing to both stress and urgency)

        This group includes both stress type and urgency type urinary incontinence. There are disorders in the functions of both the bladder and the urinary channel. It occurs due to reasons such as distortions in the function of the pelvic base (perineum), constipation, advanced age, obesity etcetera.

Continuous urinary incontinence associate with fistula

        Fistula means an undesired pseudo channel in the body. As a complication of womb removal (hysterectomy), caesarean section, general surgical procedures that involve gynecology and rectum cancer, and undesired new path (fistula) occurs between the bladder and vagina. In such case, urine continually flows through this newly formed channel (fistula) instead of urethra (urinary channel) and exits through the vagina. In addition, an undesired channel may form between the urinary channel and the female organ as a complication of urologic loose sling surgeries that are performed through the vagina due to urinary incontinence. In such case, urine again flows through the vagina. Meaning that the fistula (undesired channel) emerges as a complication of previous operations. Such fistula type urinary incontinence, which leads to physical, psychological and hygienic problems), is the most difficult one amongst urinary incontinence surgeries. For this reason, this subject is handled on a separate page of our website. Please click here for detailed information on the causes and treatments of fistula.

Urinary incontinence during sexual intercourse

        Patients of this type only leak urine during sexual intercourse. 40 percent of patients have stress type urinary incontinence. Full diagnosis may not be made if the patient isn’t queried thoroughly. The patients may consider this as pre-ejaculate due to satisfaction during sexual intercourse. But the main reason is the rupture or loosening of bonds.

Diagnosis in Urinary Incontinence?

        Diagnosis can easily be made by a good query (anamnesis) of patients that haven’t undergone a previous surgery. Incontinence type is identified. One should research into whether symptoms of over active bladder are present. After a good query, many patients may heal with drug treatment without the need for surgery. A research should be made into smoking, number and type of childbirths (vaginal childbirth - cesarean section), obesity, diabetes, genetic predisposition, drugs used and other associated diseases. Supplemental examinations such as cystoscopy and urodynamics aren’t needed.

        In addition to making a better query for patients, who have previously undergone surgical procedures for urinary incontinence or other gynecological or miscellaneous causes, one may need cystoscopy, tomography and when require, also MR imaging and urodynamics. Patients that have previously undergone unsuccessful loose sling (TOT-TVT) surgeries can be diagnosed by labial ultrasonography.

Treatment of Urinary Incontinence

Changing Habits and Drug Treatment for Urinary Incontinence

        Quitting smoking, losing weight, female hormone (estrogen) supplement, bringing diabetes under control as well as special pelvic exercises, which are discovered by Kegel and which strengthen the voluntary bolt in the urinary channel, can bring basic urinary incontinence under control.

        Drugs (such as alpha-blockers, alpha adrenalgic blockers, alpha adrenalgic agonists) can be tried for urinary incontinence at basic and interim level. Urinary incontinence will continue when these drugs are stopped.

        By entering the urinary channel with an endoscope (closed method) squeezing injection may be applied below the mucosa in the region where the bold is located. But this is temporary and has a low rate of success.

Urinary Incontinence Surgery

Surgery for Urinary Incontinence at Basic and Interim Level

        Firstly, a good query is required. In complex cases, we decide the type of operation after applying the necessary examinations and imaging procedures. The cause in patients that were previously operated for the same complication is that the bonds are damaged or ruptured. These bonds are replaced with synthetic ones during urinary incontinence surgery. We thus prevent the over mobility of the urinary channel to ensure that the patient can hold her urine. All this procedure is performed by a 1-1.5 cm incision on the female organ and inflicts no aesthetical damage on it. The patient can be discharged within the same day. Especially in women that are sexually active, bladder prolapse may accompany urinary incontinence. Apart from advanced ones, bladder prolapses shouldn’t be operated unnecessarily. All unnecessary procedures performed on the female organ may lead to problems in the patient’s sexual functions.

        The patient is taken in to birth (gynecologic) position. The urinary bladder is observed by a camera. We enter the bladder by a catheter through the urinary channel. A 1.5 cm incision is made 2 cm above the urinary channel outlet hole (urethra mea) on the middle line. The artificial loose sling, which is in form of a sterile set, is placed below the urinary channel. In this procedure, we replace the pubo urethral bond, which connects the urinary channel to the pubis bone and which causes urinary incontinence due to its rupture, with an artificial bond at the same location and therefore allow the patient to retain her urine. (Vaginal middle urethra loose sling surgery)

        The first method passes the artificial bond from the rear of the pubis bone (retro public loose sling operation TVT). In the second method developed by DOLORME, the synthetic slinger bond obturator is passed through the channel (Trans obturator loose sling surgery). First method is more difficult to apply. The second method (TOT) is applied more easily. Both methods have the same rate of success in the mid-term. But studies have shown that the long-term results of the first method (retro public sling) are far better than the second method (TOT). The third method that commenced implementation during the recent years is the Mini Sling surgical method. It has high costs and a low rate of success in the short-term.

Complex Urinary Incontinence Surgery;

        We call patients with associated diseases such as obesity, COPD and diabetes and those previously underwent unsuccessful urinary incontinence surgery as complex cases. As in addition to the voluntary urine retainer bold, such patients may also suffer from malfunctioning involuntary internal bolt that is located in the bladder neck, we prefer he TVT Method, where we pass the artificial bond that strengthens the perineum (sling) from the rear of the pubis bone. That is because when a deficiency of the internal urine retainer mechanism (sphincter) occurs, one should compress and support the sphincter circularly (coadaptation, support compression). Only the TVT method can ensure this.

        In more complex patients, we apply the spiral sling procedure that circles all around the urinary channel. Our study on this subject has been published in the international Urogyneacology Journal. We recommended that all patients that require surgery due to urinary incontinence, undergo loose sling procedure (TVT) (method performed from rear of the pubis bone). That is because researches show that when applied according to its technique, its success in the long-term is much better. Also many experienced international centers only prefer the retropubic loose sling operation (TVT) and rarely implement the second method (TOT).

        In women that have undergone several unsuccessful vaginal surgeries in the past, the urinary loses its elasticity due to the scar tissue created by these surgeries (fixed urethra). Patients may leak urine. Surgeries for these are more difficult. The urinary channel should first be freed and the adherences around it should be cleaned. This re-allows elasticity. And in the presence of urinary incontinence, we can provide urinary control not with synthetic slings but by grafts (rectus sheath or fascia lata) that we take from the patient’s body.

        Synthetic bond (sling) may be rejected by some bodies. In such cases, the patient’s own body tissue taken from the rectus fascia or her leg muscle fascia is used instead of synthetic bond. If the body rejects it, we can prevent urinary incontinence in the patient by using her own body tissue as a bond.

Complications of Urinary Incontinence Surgery

        Complication rate is low if surgery is performed by experienced surgeons. As an unimportant complication in the post-operative period, the patients may frequently suffer difficulties while urinating although they can control their urine. This can be treated easily by simple drugs.

        Severe complications owe to technical implementation errors. Artificial bond hasn’t been placed correctly on its location or placed too tightly. The urinary channel was injured during urination. Urinary bladder may have been punctured. Serious complaints such as difficulty while urination or the impossibility to urinate may occur when the sling (artificial bond) is placed too tightly. The bladder cannot fully discharge in such case. A catheter is placed for some time. We wait for 2-4 weeks. If the complaint persists, we relieve the patient by either freeing the artificial bond with incision or by removing it completely.

        Late complications include the slipping of synthetic slings towards the interior of the urinary channel or the bladder (erosion). This may lead to serious problems. Another complication is the extrusion of synthetic slings (mesh) within the female organ. It causes gleet and inflammation. It may cause pain for the man and woman during sexual intercourse. Correcting serious complications and re-enabling urinary retention requires more experience.

Visuals of Urinary Incontinence Surgery in Women