Female Urology

Female urology is the branch of medicine that examines urinary tract, bladder, and pelvic floor health in women and offers solutions to problems such as urinary incontinence and organ prolapse through reconstructive surgical methods. This discipline aims to improve women’s quality of life by treating pelvic floor dysfunctions with current clinical approaches while preserving the anatomical integrity of the lower urinary system. Covering a wide range from urogynecological operations to functional bladder treatments, this specialty restores the body’s natural mechanism by repairing weaknesses in supporting tissues and neurological control disorders on a scientific basis.

What Is Female Urology and How Does It Affect Our Lives?

The anatomical structure of the female body contains many unique wonders as well as sensitivities. One of these sensitive areas is the lower urinary tract and the support system surrounding these organs. In previous years, urinary incontinence or prolapse in the pelvic region was regarded as a natural and inevitable consequence of aging, and many women could not speak about these problems because they felt embarrassed. However, today, the specialized field called female urology proves that these problems are not destiny and can be treated very successfully. This field aims to ensure that neighboring organs such as the bladder, urethra, vagina, and rectum both remain in the correct position and function healthily. It not only provides anatomical correction but also repairs the nerve networks and muscle dynamics that control these organs, allowing the individual to participate confidently in social life, laugh comfortably, and exercise. This discipline, which directly improves women’s quality of life, plays a highly critical role in enabling women of all ages to lead healthy and comfortable lives.

What Is the Pelvic Floor and What Are Its Main Functions in Our Body?

In the lower part of our body, there is a very special structure that covers the inside of the pelvis like a tightly woven hammock. This structure is called the pelvic floor. This hammock consists not only of fixed ligaments but also of living muscle fibers that can continuously contract and relax. Its task is quite demanding. It supports the bladder, uterus, vagina, and the final part of the large intestine against gravity and prevents them from prolapsing downward. In addition to providing anatomical support, functions such as controlling urine and stool, postponing the need to use the toilet, and maintaining a healthy sexual life largely depend on these muscles working with correct timing.

Pelvic floor muscles can weaken or become damaged over time, just like the muscles in our arms or legs. This weakening does not happen suddenly; it usually emerges as a result of the accumulation of certain challenging processes experienced over the years. As the tissues lose their elasticity, the organs gradually begin to shift downward.

The main risk factors leading to weakening of the pelvic floor muscles are:

• Pregnancy
• Difficult vaginal delivery
• Obesity (Excess weight)
• Chronic cough (For example, due to asthma or smoking)
• Chronic constipation
• Hormonal changes during menopause

Each of these factors increases the load placed on the pelvic floor. For example, excessive straining caused by chronic coughing or persistent constipation increases intra-abdominal pressure and causes this hammock to be continuously pushed downward. During menopause, reduced estrogen weakens the collagen structure that provides elasticity to the tissues. The puborectalis muscle, one of the most important muscles in this region, surrounds the final part of the intestines like a sling and provides stool control. Dysfunction in this muscle can cause a constant feeling of needing to use the toilet or fecal incontinence. Therefore, in treatment, it is not enough merely to lift prolapsed tissues upward; it is also highly important to restore flexibility and strength to the muscles.

What Causes Urinary Incontinence and In Which Situations Does It Occur?

Urinary incontinence, in medical terminology, is the involuntary loss of bladder control. This problem is not merely a physical condition that creates a feeling of wetness. It is a profound psychological burden that can cause women to change their travel plans, hesitate to visit others, constantly search for a toilet whenever they go outside, and even become depressed. Concerned that their clothes may smell, individuals gradually begin to withdraw from their social environment.

Urinary incontinence has many different types and causes. Sometimes weakening of the valve system that holds urine, known as the sphincter, and sometimes independent contractions of the bladder muscles without control from the brain lead to this condition. Understanding which type of incontinence is present is one of the most important steps in effectively treating the problem. Treatments started without a correct diagnosis may result in wasted time and disappointment.

How Is Urinary Incontinence Diagnosed and Which Tests Are Applied?

The diagnostic process begins with an in-depth discussion of the patient’s complaints. The patient’s history is the greatest guide in finding the true source of the problem. The moments when urinary incontinence occurs are highly important. Does it happen while coughing, or does it occur with a sudden urge and an inability to reach the toilet? The number of glasses of tea or coffee the person drinks each day, how much water she consumes, and any blood pressure or heart medications she uses are examined carefully. This is because certain foods and medications may cause the kidneys to work too quickly or stimulate the bladder, thereby increasing the amount of leakage.

After the medical history is taken, a detailed physical evaluation is performed. During this examination, whether there is any organ prolapse and how mobile the urethra is are observed. The patient is asked to cough or strain on the examination table so that the degree of urine leakage from the urethra when intra-abdominal pressure increases can be directly observed.

The clinical tests most frequently used during the diagnostic stage are:

• Voiding diary (Monitoring fluid intake and urine output)
• Urodynamic test (Measurement of bladder pressure and function)
• Ultrasonography (Imaging of the kidneys and bladder)
• Urine culture (Infection control)
• Cystoscopy (Examination of the inside of the bladder with a camera)

A voiding diary is a very simple yet extremely valuable form in which the patient records what she eats and drinks and how much urine she passes at what times for three days. Through this diary, it becomes clear how much fluid the patient is actually consuming or how small an amount of urine her bladder can hold. Urodynamic testing is a much more advanced computer-assisted measurement. Thanks to very thin sensors placed in the urethra, pressure changes inside the bladder are recorded with millimetric precision while the bladder is gradually filled. This test largely reveals whether urinary incontinence is caused by overactivity of the bladder muscle or weakness of the urinary sphincter.

What Is Stress Urinary Incontinence and Which Methods Are Used to Treat It?

The word “stress” here does not refer to psychological anxiety, sadness, or depression. In medical terms, it describes physical pressure in the abdominal cavity, namely mechanical stress. During moments requiring effort, such as laughing, sneezing, severe coughing, lifting a heavy object, or jumping, intra-abdominal pressure suddenly rises. This pressure strongly compresses the bladder. If the pelvic floor muscles and the ligaments holding the urethra in place have weakened, the urethra cannot resist this pressure and opens, causing urine leakage. This condition is called stress urinary incontinence.

The treatment process always begins with the mildest and least harmful methods. If complaints are still at an early stage, special exercises aimed at strengthening the pelvic floor muscles, known as Kegel exercises, are recommended. Just as lifting weights in a gym builds muscle, these exercises strengthen the hammock-like muscles in the pelvic region and enable the urethra to close more tightly. However, in cases where muscle weakness is very advanced or the patient’s social life is seriously affected, surgical treatments called sling operations are a highly effective and long-term option. In these operations, a synthetic tape that takes over the function of the weakened connective tissue is placed beneath the urethra. When intra-abdominal pressure increases, the urethra rests against this tape, closes, and leakage is prevented.

What Are the Differences Between TVT and TOT Operations?

There are two main and highly successful methods used in surgery for stress urinary incontinence. In both methods, a thin mesh is placed beneath the urethra to create hammock-like support. However, the pathways and techniques used to pass this mesh through the body differ from one another.

In the method called TVT (Tension-Free Vaginal Tape), the mesh placed beneath the urethra through the vagina is passed behind the pelvic bone and advanced toward the lower abdominal region. Because this method provides anatomically strong upward traction and support, it can produce highly successful and long-lasting results, especially in patients whose urinary sphincter has become severely weakened. However, since the procedure passes very close to the bladder, it is routinely necessary to look inside the bladder with a camera, known as cystoscopy, to check whether the needles have punctured the bladder.

In the other method called TOT (Transobturator Tape), the mesh is passed laterally through the natural bony openings in the groin, known as the obturator foramina, rather than toward the abdominal region. Since this route is anatomically quite distant from the bladder, the risk of bladder injury is significantly lower. The operation usually lasts less than twenty minutes, and the patient may be discharged on the same day or the following day. Although both methods achieve success rates above 90%, the surgeon determines specifically which technique should be applied to which patient according to the results of the physical examination and urodynamic tests.

What Should Be Considered During the Postoperative Recovery Process?

The quality of recovery is determined not only by how successfully the surgery was performed but also by how closely the patient follows the rules after discharge. It takes time for the mesh placed during surgery to integrate with the tissues and for the body to produce new cells in that area, creating a firm structure. During this period, it is critical that the tissues are not stretched and the mesh does not shift from its position.

The basic rules to be followed after surgery are:

• Not lifting heavy objects (Especially during the first 3 months)
• Avoiding constipation (Preventing excessive straining)
• Avoiding strenuous sports and activities that require jumping
• Observing sexual abstinence for a certain period (Usually 4-6 weeks as recommended by the doctor)

Patients are especially advised not to lift objects heavier than four kilograms, including grocery bags, during the first three months. Since straining directs intra-abdominal pressure toward the operated area, fiber-rich foods and plenty of water should be consumed to prevent constipation, and bowel-stimulating syrups may be used if necessary. Likewise, to avoid jeopardizing the process of mesh integration with the tissue, sexual intercourse should be avoided for the period specified by the doctor. If these rules are not followed, the implanted mesh may tear through the tissue and protrude into the vagina, creating a predisposition to infections.

What Is Overactive Bladder Syndrome and Which Symptoms Does It Cause?

Sometimes urinary incontinence occurs not because of physical strain but due to a sudden and uncontrollable intense urge to use the toilet. Patients usually describe this condition as a severe cramp in the groin and a feeling of urinary release when they insert the key into the door upon arriving home, hear the sound of water, or suddenly enter a cold environment. This condition is called Overactive Bladder Syndrome. Under normal circumstances, the bladder is an organ that expands and relaxes as it fills with urine. It is not expected to contract until the brain gives the command, “It is now time to use the toilet.” However, in overactive bladder, the muscles inside the bladder begin to contract uncontrollably and involuntarily even when there is only a very small amount of urine.

The most disturbing symptoms of this syndrome are not limited to being unable to reach the toilet and leaking urine, known as urge incontinence. Waking up repeatedly at night to use the toilet, known as nocturia, disrupts quality sleep and causes the patient to feel extremely tired, irritable, and exhausted the next day. During the daytime, constantly having to calculate where the nearest toilet is can make life unbearable.

How Is Overactive Bladder Treated With Medication and Which Medications Are Used?

The aim of treating this condition is to stop these inappropriate and uncontrolled contractions of the bladder and restore the bladder’s capacity to its former comfortable volume. Certain oral medications are used for this purpose. On the muscle fibers in the bladder wall, there are receptors that detect signals coming from the brain. When these receptors become overly sensitive, medications come into play.

Some of the medications used, known as antimuscarinics, attach directly to these receptors and block the faulty signals that cause the bladder to contract from reaching the muscle. The bladder muscle, unable to receive the signal, relaxes and becomes capable of storing more urine. Another group of modern medications, known as Beta-3 agonists, works by directly relaxing the smooth muscles in the bladder wall instead of interrupting the signals. In this way, the bladder becomes a much more flexible balloon. These medications generally provide highly successful results and rapidly improve the patient’s quality of life. However, while using antimuscarinic medications, completely manageable and temporary side effects such as mild dry mouth or constipation due to slowed bowel movements may occur. In elderly patients, treatment is continued safely by choosing special medication groups with more selective mechanisms of action that do not cause mental confusion. In patients who wake from sleep very frequently at night, hormone-like tablets called Desmopressin derivatives, which slow the rate of nighttime urine production by the kidneys, are used with the aim of providing uninterrupted sleep.

Which Advanced Treatments Are Applied in Resistant Overactive Bladder?

Although many patients benefit from medications, in some cases the bladder may not respond to medication, or patients may be unable to tolerate the side effects. Patients whose complaints continue despite medication and dietary changes are called “resistant cases.” However, being resistant certainly does not mean being without options. Modern technology offers highly advanced third-line treatments that can provide positive results for these patients.

The advanced methods applied when medication is insufficient are:

• Intravesical botox (Botulinum toxin) application
• Sacral neuromodulation (Bladder pacemaker)
• Percutaneous tibial nerve stimulation (PTNS / Nerve stimulation from the ankle)

Intravesical botox injection uses the very same botulinum toxin that is used cosmetically to stop facial expressions. Without making a surgical incision, a thin camera is inserted through the urethra, and botox medication is injected into the bladder wall at twenty to thirty different points. This medication helps the bladder relax by temporarily reducing the activity of the nerve endings responsible for uncontrolled bladder contractions. Its effect generally lasts between six and ten months, after which the procedure may need to be repeated.

Sacral neuromodulation, commonly known as a bladder pacemaker, is a much more advanced technique. Just like pacemakers that regulate heart rhythm, a very thin wire is placed over the main nerve network extending from the tailbone to the bladder. Mild electrical signals emitted by a small generator concealed beneath the skin regulate the communication language between the brain and the bladder. Faulty signals are corrected, and the bladder returns to its normal operating rhythm.

What Is Pelvic Organ Prolapse and How Is It Corrected?

Pelvic organ prolapse is the herniation of organs that should normally remain inside toward the outside through the vaginal canal as a result of tearing or severe loosening of the pelvic floor muscles and fascia over the years. Most women notice this condition while cleaning themselves in the bathroom, when they feel a rounded mass at the vaginal opening or experience intense downward pressure and heaviness. If the prolapsed organ is the bladder, it is called cystocele; if it is the final part of the large intestine, it is called rectocele; and if it is the uterus, it is called uterine prolapse. Although this condition is not an immediately life-threatening or fatal disease, it severely restricts a woman’s movement, walking, and sexual life.

Treatment options are shaped according to how far the organs have prolapsed and the severity of the patient’s complaints. If the prolapse is still very mild, special silicone rings called pessaries, which are placed inside the vagina and hold the organs upward with mechanical support, may be used. However, a more permanent and long-term solution is generally provided through surgery. The primary goal of surgery is to preserve the natural length and function of the vagina while repairing the disrupted anatomy. Some operations are performed without an abdominal incision, solely through the vaginal route, by tightening the patient’s weakened tissues with sutures. In more advanced prolapse or when more permanent support is desired, the abdomen is entered through a minimally invasive approach, laparoscopic or robotic, and the prolapsed organs are suspended with synthetic meshes from the stronger final bone of the spine, the sacrum or tailbone, using an operation called sacrocolpopexy.

What Is Bladder Pain Syndrome (Interstitial Cystitis) and Can It Be Treated?

Interstitial cystitis is a highly debilitating chronic disease of unknown cause that the medical world makes great efforts to solve. Also known as Bladder Pain Syndrome, this condition causes the patient to experience persistent burning in the urinary tract, severe groin pain, and an unbearable feeling of urgency despite the absence of bacteria or infection in the urine. Some patients feel the need to use the toilet forty or fifty times a day to relieve the pain.

The basic mechanism of the disease is generally the perforation or deterioration of the protective shield, known as the GAG layer, that covers the inner surface of the bladder and prevents acidic substances in the urine from damaging the bladder wall. When this shield deteriorates, the acid in the urine directly contacts the nerve endings in the bladder wall and triggers a severe pain response as if salt had been poured onto an open wound. Treatment focuses on repairing this damaged surface and managing pain. In addition to various oral medications, the building blocks needed to repair this protective shield, such as hyaluronic acid and chondroitin sulfate, are injected into the bladder through a urinary catheter at regular intervals.

Foods that may trigger the disease and should be avoided are:

• Acidic beverages
• Coffee (Caffeinated or decaffeinated)
• Black tea
• Hot spices
• Tomatoes and tomato products (Tomato paste, etc.)
• Citrus fruits (Orange, lemon, mandarin, etc.)

Restricting these foods in the diet makes the urine less acidic and greatly relieves pain attacks. If medications administered into the bladder and dietary changes are insufficient, surgical interventions such as expanding the bladder with water under high pressure under general anesthesia, known as hydrodistension, and gently cauterizing bleeding cracks inside, known as Hunner lesions, are applied to provide relief for the patient.

Frequently Asked Questions