Voiding Dysfunction Treatment

Voiding disorders are functional and mechanical disruptions occurring during the processes of storing urine in the bladder at low pressure or emptying it at the appropriate time. Disruption of this vital cycle of the lower urinary system results from damage to the neural communication or muscle structure between the brain, spinal cord, and urinary tract due to anatomical, neurogenic, and habit-related causes. These problems, which develop due to developmental factors in children and generally due to the prostate or pelvic floor in adults, are considered precursors of serious renal complications that may progress to kidney failure if left untreated. Today, urology specialists successfully manage this process with personalized diagnostic algorithms and modern treatment methods.

What Are Voiding Disorders and How Does Our Lower Urinary System Work?

A healthy urination cycle occurs through the balanced harmony of two main phases that work opposite to each other. These phases are storage and emptying. The main center managing the process is located in the frontal lobe of our brain. This region continuously tells the bladder to wait and remain calm until an appropriate toilet environment is found. At the same time, another center in the lower parts of the brain organizes the coordinated operation of the bladder muscle and the retaining valves (sphincters) in the urinary tract.

During the storage phase, one branch of the autonomic nervous system becomes active and relaxes the bladder wall. You can imagine the bladder as a flexible water balloon; as it fills with water, it expands without increasing pressure. At the same time, the muscles at the outlet of the urinary tract contract tightly, locking the door and preventing urine leakage. When we sit on the toilet, the system changes direction completely. The brain has now given permission; while the retaining muscles relax completely, the muscles in the bladder wall contract strongly and pump all the fluid inside outward. Our external valve muscles also have a remarkable reflex that suddenly contracts during coughing, laughing, or heavy lifting and protects us against increases in pressure. A disruption at any point in this balance appears as voiding disorders.

How Do We Feel Bladder Fullness to Avoid Voiding Disorders?

We feel how full our bladder is thanks to special nerve endings in its walls that instantly detect stretching. As the amount of fluid inside increases, these sensors continuously send signals to the spinal cord and from there directly to the brain. In a healthy functioning system, the need to use the toilet is perceived gradually rather than suddenly. Any change in sensitivity at these stages may create a predisposition to sudden urinary leakage or the need to visit the toilet frequently.

The healthy stages of urinary sensation are as follows:

• First sensation of filling
• First desire to urinate
• Strong sensation of urgency

To explain these stages in detail, the first sensation of filling occurs when the bladder is approximately forty percent full. This is a very mild signal perceived by the brain in the background that does not greatly distract attention. When the bladder reaches sixty percent of its capacity, the first desire to urinate becomes apparent. The person is aware of the need to use the toilet but can continue daily activities without panic and can easily postpone the sensation. When capacity exceeds ninety percent, a strong sensation of urgency begins. At this point, a constant desire to empty the bladder arises that is very difficult to postpone. However, even at this final stage, a healthy person does not experience fear of urinary leakage and only feels the urgency to go to the toilet.

What Causes Voiding Disorders and Bedwetting in Children?

Voiding disorders seen in children constitute a very large proportion of outpatient clinic visits. This condition generally results from functional problems caused by incorrect use of the muscles in the urinary tract rather than a congenital anatomical defect. The issue that worries parents most is nighttime bedwetting (nocturnal enuresis), especially in children older than five years. Although it is widely believed in society that this condition results from psychological trauma, stress or lack of self-confidence is not the cause of the disease but a consequence of the social pressure it creates.

Problems frequently encountered in childhood are as follows:

• Daytime urinary incontinence
• Nighttime bedwetting (Enuresis)
• Sudden sensation of urgency
• Intermittent urination
• Constipation

The most common physical cause of nighttime bedwetting is that the amount of urine produced by the child during the night exceeds the capacity the bladder can hold. In normal physiology, when we fall asleep at night, the brain releases a special hormone (antidiuretic hormone) that slows urine production by the kidneys. If this mechanism has not yet fully matured, urine production far above bladder capacity occurs, and bedwetting becomes an inevitable physical result. The bladder capacity of these children may be small for their age, or the bladder muscles may contract unnecessarily throughout the night and push the urine outward.

How Are Voiding Disorders in Children Treated Without Surgery?

When it comes to voiding disorders in children who do not have any neurological or anatomical defect, the most basic step that should be taken before medications or interventions is reorganizing the lifestyle. This approach, called urotherapy, aims to explain to the child and family how the bladder works in the body and to establish correct toilet habits. This educational process, consisting of quite simple rules, can greatly help manage a significant proportion of urinary incontinence problems.

The main lifestyle changes applied are as follows:

• Regulation of fluid intake
• Timed urination habit
• Correct toilet position
• Regular bowel emptying (prevention of constipation)
• Restriction of foods that stimulate the bladder

The most critical point in regulating fluid intake is to encourage drinking plenty of water during the day while completely stopping all fluid consumption, including water, two hours before bedtime in the evening. The timed urination habit prevents children from becoming absorbed in play and postponing the toilet until the last moment; they are asked to go to the toilet regularly every two to three hours with a clock reminder. In the correct toilet position, the child’s feet should never hang in the air. Placing a stool under the feet and keeping the knees slightly higher than the hips allows the muscles that retain urine to relax completely. In addition, since a full bowel compresses the bladder, preventing constipation and establishing regular toilet habits with fiber-rich foods are vitally important. Foods that irritate the bladder from within, such as chocolate, caffeinated beverages, or acidic drinks, should especially not be given in the evening.

How Does Prostate Enlargement Cause Voiding Disorders in Men?

The number one cause of lower urinary tract complaints in older men is benign prostatic hyperplasia (BPH). The prostate gland is positioned immediately at the bladder outlet and surrounds the urinary tract like a ring. With advancing age and hormonal changes, this tissue begins to increase in volume. When the enlargement occurs inward, it compresses the urinary tract passing through its center. This resembles stepping on a running water hose. A physical obstruction develops in the pathway through which urine should flow freely.

Complaints caused by this obstruction can basically be examined in three groups:

• Storage symptoms
• Voiding symptoms
• Post-voiding symptoms

The bladder muscle has to exert much more force than normal to expel urine through this narrowed pathway. This muscle, which constantly works under high pressure, thickens over time, becomes fatigued, and becomes overly sensitive. Storage symptoms, including frequent visits to the toilet, waking from sleep at night, and a sudden severe urge to urinate, result from this tired and irritable bladder. Voiding symptoms, such as waiting before urination begins, weakening of the stream, intermittent urination, and the need to strain, are direct consequences of the narrowing caused by the prostate. Post-voiding symptoms are the feeling of incomplete emptying experienced immediately after getting up from the toilet. When the bladder muscle becomes fatigued and begins to lose function, some urine starts to remain inside.

How Are Prostate-Related Voiding Disorders Controlled With Medication?

Voiding disorders caused by prostate enlargement do not always require immediate surgery. If the patient’s quality of life has deteriorated but no permanent damage has occurred to the kidneys or bladder, medication treatment is the first preferred option. The purpose of treatment is to relieve complaints, restore the patient’s nighttime sleep, and facilitate urine flow.

The main medication groups used in treatment are as follows:

• Alpha blockers
• 5-alpha reductase inhibitors
• Phosphodiesterase type 5 (PDE5) inhibitors
• Antimuscarinics
• Beta 3 agonists

Alpha blockers relax the smooth muscles within the prostate and bladder neck, rapidly reducing pressure on the urinary tract within days and facilitating flow. 5-alpha reductase inhibitors interrupt the hormonal cycle that causes prostate growth and reduce the physical size of the prostate with long-term use. In this way, they reduce the risk of future obstruction. If the patient has erectile problems in addition to prostate enlargement, phosphodiesterase type 5 inhibitors may provide a solution to both problems by increasing blood flow in the pelvic region. If frequent urination and sudden urgency are more prominent than obstruction, antimuscarinics that calm the overactive bladder muscle and the much more innovative beta 3 agonists are introduced. When necessary, these medications may be combined to achieve a much stronger effect.

What Are the Surgical Methods for Prostate Diseases Causing Voiding Disorders?

In cases where medication treatment is insufficient, the urinary tract is completely obstructed, recurrent bleeding occurs, or kidney function deteriorates, surgical intervention on the prostate tissue is essential. Thanks to today’s technology, these procedures have become extremely safe and comfortable minimally invasive methods performed entirely through the urinary tract without the need for open surgery.

Modern surgical methods successfully applied today are as follows:

• Transurethral resection of the prostate (TUR-P)
• Laser prostate enucleation (HoLEP, ThuLEP, ThuFLEP)
• Water vapor therapy (Rezum)
• Pressurized water treatment (Aquablation)
• Urolift implant application

Transurethral resection of the prostate is a highly reliable method that has been applied for many years; prostate tissues obstructing the urinary tract are cut into small pieces using electrical energy and removed. Holmium laser prostate enucleation is a groundbreaking technology, especially for very large prostates; the prostate tissue is separated with laser energy as if a fruit were being removed from its peel, pushed into the bladder as a whole, and fragmented and cleared there. Since a large portion of the tissue is removed, the risk of the disease recurring years later is quite low. In patients seeking more minimal approaches, water vapor therapy aims to open the channel by injecting hot steam into the tissue, while the Urolift method physically widens the urinary tract by suspending the prostate lobes to the sides with tiny staples without cutting any tissue. The greatest advantage of these minimal methods is that they allow a high rate of preservation of men’s sexual functions and generally provide a rapid recovery process.

What Causes Urinary Incontinence and Voiding Disorders in Women?

Contrary to common belief, urinary incontinence in women is not merely a natural consequence of aging but a common health problem with clear underlying anatomical and functional causes. These voiding disorders, which deeply disrupt a person’s energy for life, social relationships, and psychology, mainly result from weakening of the hammock-like muscle tissue supporting the bladder and urinary tract within the pelvis or from uncontrolled functioning of the bladder muscle.

The most common types of urinary incontinence encountered in women are as follows:

• Stress urinary incontinence
• Urge urinary incontinence
• Mixed urinary incontinence

In stress urinary incontinence, involuntary urine leakage occurs during movements that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or heavy lifting. The word stress here refers not to psychological pressure but to physical force. Factors such as difficult childbirths, excess weight, or chronic coughing stretch and weaken the muscles supporting the urinary tract from below. In urge incontinence, however, the situation is different; the supporting muscles are intact, but the bladder muscle makes severe contractions on its own without permission from the brain. The person suddenly feels an overwhelming and non-deferrable need to use the toilet and usually leaks urine before reaching it. In the mixed type, the symptoms of these two conditions occur together in the same patient.

Which Surgical Solutions Are Applied for Voiding Disorders in Women?

In women, especially in cases of stress urinary incontinence developing with exertion, surgical interventions are the most successful solution when exercises strengthening the pelvic floor muscles are insufficient. Modern surgical approaches work on the principle of placing artificial support in place of the stretched natural supporting tissue that can no longer perform its function and aim to provide long-term dryness in a large proportion of patients.

The main sling methods used in surgery are as follows:

• Transobturator tape (TOT)
• Tension-free vaginal tape (TVT)

The common purpose of these operations is to place a special, biocompatible synthetic band immediately beneath the urinary tract. This band takes over the function of the weakened pelvic floor muscles and supports the urinary tract like a hammock. Thus, when the woman coughs or lifts weight, the urinary tract does not sag downward and open; instead, it bends over this band and prevents urine from leaking outward. These operations are minimally invasive procedures that take a very short time and generally allow the patient to return to normal life on the same day or the following day. The only difference between the two methods is the anatomical route through which the band is passed inside the body; the physician determines the most appropriate route according to the degree of tissue prolapse and the patient’s general condition.

How Do Neurogenic Voiding Disorders Caused by Neurological Diseases Affect the Kidneys?

Damage occurring in the brain, spinal cord, or peripheral nerves may cause the voiding function to collapse completely. This condition is called neurogenic bladder. While spinal cord injuries, Parkinson’s disease, or nerve damage associated with diabetes create this condition in adults, the most common cause in children is incomplete closure of the spinal cord in the womb. This disease is not merely a comfort problem such as urinary incontinence or inability to urinate but a critical condition that directly threatens the kidneys.

Depending on the level of neurological damage, the bladder may take on two different dangerous characteristics. Sometimes the bladder becomes completely paralyzed, expands like a balloon, and retains liters of urine but cannot expel it. In the even more dangerous second scenario, while the bladder makes excessively strong contractions on its own, the retaining valve muscles at the outlet stubbornly contract instead of relaxing. The system becomes completely locked. The pressure inside the bladder increases so much that the infected and contaminated urine inside begins to reflux toward the kidneys through the urinary ducts, which are the only open pathway. This high-pressure fluid reaching the kidneys crushes the kidney tissue from within and creates the basis for irreversible kidney failure. Therefore, the most urgent goal in the treatment plan is to rescue the kidneys from this relentless pressure rather than merely remaining dry.

Why Is Clean Intermittent Catheterization (CIC) Life-Saving in Voiding Disorders?

For patients whose bladders cannot empty safely on their own, the most vital and simplest solution offered by modern medicine is clean intermittent catheterization (CIC). This method involves emptying the bladder at regular intervals from outside with the help of a thin and sterile catheter. Contrary to common belief, it is not painful, and even young children learn to perform this procedure independently on their own within a very short time.

• The main goals of this procedure are as follows:
• Protecting the kidneys from high pressure
• Preventing urinary tract infections
• Improving quality of life

Emptying the bladder with a catheter at regular intervals prevents pressure from accumulating inside and largely prevents urine from refluxing toward the kidneys. This is the most important barrier closing the path to dialysis. In addition, urine that constantly remains in the bladder creates a highly suitable environment for bacterial growth. Since no residual urine is left inside with the help of the catheter, the risks of life-threatening febrile urinary tract infections decrease dramatically. Finally, this procedure prevents the person from continuously wetting themselves and eliminates diaper use. The patient or child has the opportunity to plan their hours and continue school, work, or social life with confidence.

How Is the Main Source of Voiding Disorders Detected With a Urodynamic Test?

Listening to a patient’s complaints or examining the kidneys with ultrasound gives us an idea about the anatomical structure of the system, but it does not show how the system works while in motion. In voiding disorders, we need a very special test that measures the source of the problem, the strength of the muscles, and the coordination of the nerves with millimetric precision. The name of this test, which can be considered the electrocardiogram of the lower urinary system, is urodynamics. This test plays a fundamental role in determining whether the problem is a physical obstruction or a neurological mismatch.

The main stages of the urodynamic test are as follows:

• Uroflowmetry
• Cystometry
• Pressure-flow study

The first stage of the test is very simple; the patient urinates into a special toilet connected to a computer, and the system charts the flow rate, amount, and pattern of the urine second by second. In the second stage, very thin sensor-equipped wires are placed into the bladder through the urinary tract. As the bladder is slowly filled with sterile fluid, the increase in pressure in its wall, its stretching capacity, and involuntary contractions occurring independently of the brain are measured. In the final stage, the patient is asked to urinate again while these measurement wires are still inside. In this way, it is seen how much pressure the bladder muscle produces inside and whether it can expel urine despite this force. If the bladder strains greatly and produces very high pressure but urine comes out drop by drop, the presence of a significant obstruction at the outlet is strongly supported medically.

How Do Modern Technologies Work in Resistant Cases of Voiding Disorders?

In very persistent voiding disorders where conventional medications, surgeries, or lifestyle changes do not provide benefit, medicine has highly advanced technological tools for patients whose complaints have virtually turned into a nightmare. Rather than cutting or reshaping organs, these advanced treatments aim to repair the faulty neural commands controlling the bladder and related organs with externally delivered energy and restart the system.

The advanced treatment methods used in resistant cases are as follows:

• Sacral neuromodulation (Bladder pacemaker)
• Percutaneous tibial nerve stimulation (PTNS)
• Biofeedback therapy

Sacral neuromodulation, commonly known as a bladder pacemaker, corrects impaired communication between the brain and bladder by delivering mild and regular electrical currents to the nerves in the tailbone region. It can generally provide highly positive results in patients who cannot use the toilet or who experience continuous leakage. If a surgical procedure is not desired, percutaneous tibial nerve stimulation, in which regular electrical current is delivered externally to a nerve at the ankle through an acupuncture needle, may be preferred. This current travels upward through the leg and stimulates and trains the bladder control center. Biofeedback therapy is a fully computer-assisted muscle training program. With the help of special sensors, the person learns how to contract and relax the pelvic muscles correctly by watching graphs or games on a computer screen.

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