Everything about Urinary Incontinence in Forty Questions

Everything about urinary incontinence in forty questions 

1. What is urinary incontinence? 
 Urinary incontinence is the condition of uncontrolled leakage of urine which causes a social and/or hygienic problem 
.
2. When is urinary incontinence considered to be normal? 
 Urinary incontinence is considered normal and not treated in children under three years of age, in dementia arising at advanced ages, and in psychiatric patients.
3. What are the causes of urinary incontinence? 
 Multiple deliveries, giving birth to a big baby, giving birth with intervention, difficult delivery, delivery on her own, genetic causes, pregnancy, overweight, menopause, constipation, chronic obstructive pulmonary disease (bronchitis, asthma, etc.), having surgeries related to pelvic floor and smoking are the causes of urinary incontinence. 


4. How many types of urinary incontinence are there? 
 There are three most common types.

• Stress incontinence: It is urinary incontinence seen in cases of increased intra-abdominal pressure such as coughing, sneezing, straining, and forcing. The cause is the weakened anatomical support of the bladder base and the urethra.
• Urge incontinence: It is a type of urinary incontinence with a strong urge to urinate while doing water-related works and incontinence while going to the toilet. The cause is the sudden contraction of the bladder while filling with urine. The cause is unknown in the majority of patients. Some of them have chronic diseases such as diabetes, Parkinson’s disease, dementia and multiple sclerosis. These findings are symptoms of overactive bladder syndrome.
• Mixed incontinence is the coexistence of both.

5. What is the incidence of urinary incontinence in the community? 
 According to the studies conducted in our country, it is 57% in postmenopausal period and 24-46% in premenopausal period (Demirci et al). Of this rate, 70-80% is in the form of stress incontinence, 20-30% is in the form of not being able to get to the toilet. The rate of stress incontinence is low in developed countries because of the low fertility rate and high average age of women, while incontinence is high and seen in younger women because of the high fertility rate in our country.
6. What is the importance of urinary incontinence type? 
 The type of urinary incontinence should absolutely be determined. Depending on the type and severity of incontinence, the decision of conservative treatment or surgical treatment is made.
7. How is the type of urinary incontinence determined?
 First, the patient is asked to keep bladder diary for 3-4 days in which bladder habits are noted, and then a questionnaire including comprehensive questions is filled in. A thorough examination of the pelvic floor, vagina and anal functions is carried out by a competent urogynecologist. Urinalysis and urine culture are studied to investigate the presence of infection. Afterwards, tests showing the incontinence objectively, called stress test and pad test, are carried out. Based on the results of these tests, the occurrence conditions and type of urinary incontinence are determined with the tests, called urodynamic, evaluating the bladder functions. 


8. What is urodynamics? 
 Urodynamics is the computer-assisted measurement of pressure and flow changes showing the presence and type of urinary incontinence and functions of the bladder and urethra.
9. How is urodynamics performed? 
 It is a very simple and painless method. Pressure changes are recorded while giving fluid into the bladder through a very fine (2-3 mm) catheter. Intraabdominal pressure is measured using a probe placed in the vagina. The pressures are measured together when the bladder is filled and emptied. The changes are recorded automatically. The presence of urine leak is tested with a number of maneuvers. Meanwhile, the questions are asked to form an opinion about the bladder. The functions of the urethra are measured. Finally, voiding cystourethrography is performed to form an opinion about the urinary tract and muscles. Whether the urinary incontinence treatment is effective and how effective it is are compared objectively by performing urodynamics before and after the treatment.
10. What is done after urodynamics? 
 Recorded and calculated computer data are combined with the patient’s examination findings and complaints to decide on the type of treatment.
11. What is found as a result of urodynamics? 
 The function of the bladder and urethra, the type and severity of urinary incontinence, if any, are determined.
12. Should urodynamics be performed on every patient? 
No, it is not necessary for every patient. It is not necessary, especially if the patient has pure stress incontinence. If the patient has mixed urinary incontinence and had previously undergone surgery, and has prolapse and urinary disorder, urodynamics is performed.
13. What kind of treatment should be administered in which type of urinary incontinence? 
 If the complaints are mild in all types of urinary incontinence, conservative treatment is performed first. If these treatments are inadequate, surgery is performed.
14. What are the conservative treatment methods?

Conservative treatment methods:
•

• Medication
• Behavioral therapy (bladder training)
• Pelvic floor exercises (Kegel)
• Exercise with vaginal cones
• Biofeedback
• Functional Electrical Stimulation (FES)
• TENS
• Pessaries
• Extracorporeal magnetic innervation (ExMI)/magnetic therapy/electromagnetic stimulation (Magnetic chair)

15. Which type of urinary incontinence is treated with medication or abovementioned conservative methods? 
 If mild urinary incontinence or overactive bladder is present, medication or conservative methods are used.
16. Is surgery performed in overactive bladder?

The classical information is the use of non-surgical treatment methods in overactive bladder. However, a group of urogynecologists in Germany developed a new surgical method with a success rate of 75% (see CESA/VASA operation)

17. How is the type of conservative treatment determined?
 The type and duration of the treatment is determined by a qualified physician according to the urodynamics, bladder diary, stress test, pad test and examination findings.
18. What is medication and for how long is it given? It is used to prevent involuntary contractions of the bladder and to increase the capacity of the bladder in urge incontinence. The drug has no definitive theurapeutic effect. The goal of use is to improve the quality of life.
19. What are the important side effects of drugs? The most important side effects of drugs are constipation, increased intraocular pressure, and dry mouth.
20. Is drug used in stress incontinence? The classical information is that drug is not used in stress incontinence. A drug developed in recent years (Duloxetin) has been used for the treatment of stress incontinence.
21. What is exercise therapy? 
 It is therapies to strengthen the genital are and pelvic floor muscles. Besides methods such as cone exercise, FES and biofeedback carried out urogynecology centers, there are also exercises that the patient can do on his/her own, called Kegel exercises.
22. How and for how long Kegel exercises are done? 
 It is important to do Kegel exercises correctly. If done incorrectly, the picture may worsen, and even prolapse may develop in the genital organs. It is done by the patient after the contraction of right muscles is shown to the patient by the physician in the urogynecology center. It should be done for life.
23. Is Kegel exercise only useful for urinary incontinence?
 These exercises increase the strength of the muscles surrounding the vagina, prevent genital organ prolapse, and improve the quality of orgasm and sexual intercourse (both for men and women).
24. What is FES treatment? 
 It is carried out using a probe that gives very low dose of electrical current and is placed inside the vagina. Electric current strengthens the uterus and bladder muscles by intermittently contacting them and prevents involuntary contractions. Success is achieved in all types of urinary incontinence. The dose and duration are adjusted according to the patient.
25. What does FES do and for how long is it performed? 
 These low dose electrical currents strengthen the pelvic floor muscles and regulate the stimulation of the nerves. It is usually performed twice a week for a period of 6-8 weeks, each session taking for 20-30 minutes.
26. On whom and how do you perform FES treatment? 
 It is performed on eligible patients who are considered suitable as a result of urodynamics. In recent years, portable FES devices that patients can use at home are also used.
27. Who are not eligible for FES treatment?
 Those with pelvic organ prolapse, pregnant women, those with vaginal atrophy, vaginal infection, cardiac arrhythmia and cardiac pacemaker are not eligible for FES treatment.
28. What is magnetic chair treatment?
 It is a chair that creates a magnetic field which stimulates the pelvis muscles at certain intervals. No probe is used on the patient. The patient sits on the chair with clothes on for 20 minutes. It is a new treatment method. The success rates are quite high in the literature (60-80%).
29. In which type of urinary incontinence is it effective? How long is it performed?
 It is effective in all types of urinary incontinence. It is performed 2-3 times a week for 8-10 weeks.
30. Is there a group of patients on whom magnetic chair treatment is not used?
 It is not used on patients with pacemaker, those with intrauterine device and those with severe arrhythmia.
31. Is magnetic chair used only for urinary incontinence?
 It is also used for orgasm problems, vaginal relaxation, gas-fecal incontinence, vaginal tightening after normal delivery, urinary problems after radiotherapy, nighttime incontinence, chronic pelvic pain, erectile dysfunction in men, and urinary incontinence after prostate surgeries.
32. What is the difference between FES and Magnetic chair?
 The success rates of both methods are similar. In FES, a probe is placed into the vagina and the pelvic floor is stimulated by this probe. Whereas, magnetic chair is a non-invasive method in which no probe is used.
33. What factors determine the success of conservative treatments?
 In conservative treatments, dysfunction should be explained very well to the patient with visual materials. Lifestyle, fluid intake and nutrition should be reorganized with the recommendations of the physician. The pelvic floor exercises should be learnt under the supervision of a physician and be made a part of the life.
34. What is the goal of surgical treatment and how is it performed? 
 The goal of surgery is to restore prolapsed bladder and urinary tract, to correct prolapsed uterus, if any, and to reform genital region muscles.
35. How is surgery performed? 
 Surgery is performed either to correct only urinary incontinence or to correct additional pelvic abnormalities, if any (bladder, large intestine and uterine prolapse, gas incontinence). Surgeries for only urinary incontinence are now performed under local anesthesia and the patient is discharged on the same day.
36. Can you give some information about the form of the most commonly performed surgeries? 
 The surgeries performed in the past have been abandoned due to low success rates and high complication rates. Today, only midurethral slings (TVT, TOT) and minislings (Ophira, Needless etc.) are used.
37. What are the success rates of these surgeries?
38. The average results of the last 17 years are given in the literature, and the success rates are above 90%.
39. 
 What is the most important factor affecting the success rates?
 The most important factor affecting the success rates is the previous surgery. Unfortunately, these ineffective operations are still performed and some of our patients are those who had undergone these surgeries. Therefore, the patient should be evaluated well and the most appropriate operation should be selected.
40. What are the other factors affecting the success? Overweight patient with an overactive bladder at the same time (mixed incontinence). The presence of genital prolapse.