Urinary incontinence is a very important health problem that removes the person from the social environment, damages self-confidence significantly and negatively affects the quality of life by limiting the independence of the person in daily life. Although it is more common in women, most women do not report this situation to health personnel because they are embarrassed and ignore an important problem.

The most common types of urinary incontinence are stress urinary incontinence, urgency urinary incontinence and mixed type urinary incontinence. Stress urinary incontinence is the most common type in women.
Stress urinary incontinence is the involuntary leakage of urine with effort, physical exertion, sneezing, coughing. Theoretically, it is thought to have two types. First, the urethra is healthy but hypermobile. The second is the intrinsic insufficiency of the sphincter.

URINARY CONTINENCE MECHANISM

The ability to hold urine in the bladder outside of voluntary voiding is called continence. It takes place with the control of the urinary system. In order for the urinary system to carry out this control, the central and peripheral nervous system, which works fully and in harmony, needs neuronal connections and other structures to perform their functions.

The continence mechanism takes place in two stages, the filling phase and the discharge phase;
In order to ensure urinary continence in the filling phase, the intraurethral pressure must always be higher than the intravesical pressure. Thus, the urethral closure pressure calculated by subtracting the intra-bladder pressure from the intra-urethral pressure is kept at positive values. While contraction of internal and external sphincteric structures is primarily responsible for the formation of intraurethral pressure at rest, urethral wall elasticity and vascularity also play an important role. Despite large increases in intravesical volume at rest, minimal changes in intravesical pressure occur. Also known as bladder accommodation, this condition develops as a result of the passive viscoelastic property of the bladder wall and the relaxation of the detrusor muscle with voluntary cortical control.

Coughing, which is one of the stress conditions resulting in increased intra-abdominal pressure, increases both the intra-bladder pressure and the intra-urethral pressure in direct proportion to the intra-abdominal pressure due to passive pressure reflection in addition to the resting pressures. During stress, contraction of the external urethral sphincter also contributes to an increase in intraurethral pressure. An increase in the intraurethral pressure at least as much as the intravesical pressure during stress ensures the continuation of the urethral closure pressure at positive values. However, the bladder neck and proximal urethra must be supported anatomically in the intrapelvic position in order to effectively reflect the increased intra-abdominal pressure to the intra-urethral pressure. For this, in addition to the anatomical stability of the urogenital region, the levator ani muscle, which contracts under stress and elevates the bladder neck and proximal urethra by stretching this diaphragm, must also be functional.

The level of urethral closure pressure at the time of stress is also closely related to the state of the intraurethral pressure at rest. The higher the intraurethral pressure, the more can be tolerated the pressure reflection and dysfunction of the external urethral sphincteric structures.

In order for urine flow to occur in the evacuation phase, the intra-bladder pressure must be higher than the intra-urethral pressure and the urethral closure pressure must fall to negative values. To achieve this, the detrusor muscle contracts while the sphincters relax voluntarily under cortical control. With a reverse mechanism, while the intraurethral pressure increases with the contraction of the sphincteric structures under cortical control, the intra-bladder pressure decreases with the simultaneous relaxation of the detrusor muscle. When the urethral closure pressure reaches positive values, urine flow is stopped and micturition is terminated.

The levator ani muscle acts in synergy with the striated muscles of the anterior abdominal wall and accompanies the formation of intra-abdominal pressure. In cases of increased intra-abdominal pressure, such as coughing or sneezing, this pressure is equally reflected in all areas of the pelvic and abdominal wall. When the levator ani muscle is weakened, an imbalance occurs in the pressure distribution over the pelvic organs. If this pushes the organ out of the pelvic cavity, as at the viscero-urethral junction, the increase in intra-abdominal pressure, which is normally evenly distributed over the intraperitoneal or intra-abdominal part of the urethra and bladder, will only affect the bladder, since the intra-bladder pressure will be greater than the intra-urethral pressure. urinary incontinence will occur.

URINARY INCONTINENCE

According to the International Continence Society (ICS), urinary incontinence is involuntary urinary incontinence. It is more common in women than men. Its incidence increases with increasing age. Along with the decrease in the social and physical activities of individuals, it also reduces the quality of life. There are 3 main types. These;

Stress urinary incontinence is the involuntary leakage of urine in cases of exertion and physical strain such as coughing, sneezing, laughing, which cause an increase in intra-abdominal pressure.

Urge urinary incontinence is expressed as the involuntary leakage of urine with a sudden and strong urge to urinate. Simultaneous involuntary leakage of urine from the urethra occurs as a result of the activation of the detrusor muscle.

Mixed urinary incontinence is the coexistence of both stress and urge types.

The most common type in women is stress urinary incontinence.

STRESS URINARY INCONTINENCE

Stress urinary incontinence is classified based on patient-reported symptoms, clinician-observed findings, and urodynamic assessments. If a woman reports involuntary urinary incontinence with any exertion that increases intra-abdominal pressure, physical activity, laughing or sneezing, symptom-based stress is defined as urinary incontinence. If the clinician observes urinary leakage simultaneously with these conditions, it refers to the diagnosis of stress urinary incontinence based on the findings. Urodynamic stress incontinence is defined as involuntary urine leakage with an increase in intra-abdominal pressure during urodynamic studies, but if the leakage is not caused by detrusor muscle contraction.

Pathophysiology
Two main mechanisms play a role.
1) Internal Urethral Closure Mechanism
2) Supporting External Mechanism

The internal closure mechanism depends on the integrity of the tunica mucosa, tunica spongiosa and tunica muscularis, and the control mechanism that provides contraction and tone of the urethral sphincters. The thickness of the mucous membrane, the swelling of the tunica mucosa and the tunica spongiosa determines the inner diameter of the urethra and is responsible for one-third of the pressure in the urethra. The tunica muscularis has smooth muscle fibers in its inner layers and striated muscle fibers in its outer layers. It actively contributes to the intrinsic urethral closure mechanism with muscle tone.

Increased intrabdominal pressure leads to an increase in urethral closure pressure in normal body posture and normal position of the pelvis, associated with increased activity of smooth muscles in the wall of the urethra by sympathetic stimulation. The pelvic floor muscles, which provide external support to the urethral closure mechanism by their contraction during physical exertion, also prevent the up and down movement of the bladder neck and urethra. In this way, intra-abdominal pressure on the pelvic floor results in compression of the urethra.

The proximal closure mechanism remains closed as a result of continuous contraction of smooth muscle fibers. It depends on the effective transfer of abdominal pressure to the bladder neck. The distal closure mechanism is dependent on the increased tone of the pelvic floor muscles and the striated urethral sphincter. Increased tone refers to involuntary contraction of the pelvic floor. This involuntary increase in tone occurs just before the increase in intra-abdominal pressure. Normally, increased intra-abdominal pressure is the result of simultaneous contractions of the back and abdominal muscles, diaphragm, and pelvic floor. Involuntarily activated pelvic floor muscles compress the urethra, urethral closure pressure increases and continence is achieved. If one or both of these mechanisms are dysfunctional, incontinence occurs.

Etiology

Gender and race: It is more common in women. Prevalence is higher in Caucasians than in other races. Socio-economic factors also contribute.
Age: The prevalence of urinary incontinence increases with advancing age. The reason for this is the changes that occur in the lower urinary system with age. These;

• Decreased urethral closure pressure
• Involuntary detrusor contractions or detrusor hyperactivity
• Decrease in urine flow rate due to decreased detrusor contraction during urination, increase in postvoid residual volume
• It is atrophy of the urethral mucosal epithelium due to estrogen loss after menopause and an increase in nocturia due to the diurnal change in the micturition pattern.

Decreased mobility: Conditions such as bedridden or wheelchair use, incompletely healed hip fractures, osteoporosis, and surgery limit movement and increase the risk of urinary incontinence.
Obesity: Increased pressure on the bladder and greater urethral mobility increase the risk. In addition, excess weight can impair the blood flow and nerve conduction of the bladder.
Pregnancy and childbirth: A woman is more likely to experience incontinence during pregnancy than before pregnancy. In addition, those who have this problem during pregnancy have an increased risk of postpartum life. Because pregnancy and vaginal delivery cause compression, stretching and tearing in nerve, muscle and connective tissue.
Menopause: With the acceleration of aging after menopause and the decrease in tissue repair capacity, degeneration occurs in the elastic connective tissue. Therefore, the incidence of postmenopausal incontinence is high. The decrease in estrogen level with menopause causes changes in the pelvic floor muscles and urethral structures by affecting the connective tissue. As a result, the urethral closure pressure decreases.
Smoking: It increases the risk of developing all types, especially stress urinary incontinence.
Pelvic floor muscle weakness: The most important causes of urinary incontinence and pelvic organ prolapse are pelvic floor muscle weakness.
Pelvic traumas and surgeries: The risk of incontinence increases in pelvic traumas affecting the urinary system and after surgeries such as hysterectomy. In men, urinary incontinence may develop after prostate cancer surgery.

PHYSIOTHERAPY AND REHABILITATION IN URINARY INCONTINENCE

Although surgery is recommended as the most effective treatment for women with severe stress urinary icontinence (stage 3-4), and physiotherapy, including pelvic floor muscle training, as the first treatment option for women with mild/moderate stress urinary incontinence (stage 1-2), the general recommendation is; It is the initiation of non-surgical treatment in all stages, including severe stages of stress urinary incontinence. (5)

Patient Information and Recommendations

The pelvic physiotherapist explains the patient’s disease, how it occurs, risk factors, pelvic floor anatomy, disease process, factors that will affect the prognosis, and the necessary concepts in accordance with the patient’s ideas, preferences and expectations.

Bladder Training

Before the training, the amount and frequency of urinary incontinence of the patient should be evaluated. The amount of fluid taken and the time of going to the toilet should be followed using a frequency/volume chart. In this way, the time when urinary incontinence occurs can be calculated approximately. In this case, despite the same amount of fluid given to the patient, the time to go to the toilet is tried to be delayed within an increasing time period from 2 hours to 4 hours. Thus, bladder-urine tolerance is increased over time. It should be applied especially in patients who make it a habit to go to the toilet at every opportunity in order not to leak urine.

Pelvic Floor Muscle Training

a) EXERCISE: Initially, sitting in a chair, a position with the arms supported on the knees and the thighs and feet slightly open to the side may be preferred. In this position, during contraction and relaxation, feedback is generated by perineal sensory stimuli, thanks to the placement of the perineum against the chair.

When the exercise can be done correctly and easily in the sitting position, different positions and different situations are taught to exercise. Two different pelvic floor muscle contractions are requested from the patient. In slow contractions, which are the first contractions, it is requested that this contraction be continued for a few seconds after the muscle is contracted and then the patient relaxes. In rapid contractions, which are the second contractions, the patient is asked to quickly contract and relax the pelvic floor muscles. Slow contractions are given for long-term urinary retention, and fast contractions are given to provide rapid contraction of the pelvic floor muscles in cases of sudden intra-abdominal pressure increase.

The physiotherapist should control the contraction of the hip and abdominal muscles of the patient at this time. During exercise, activities such as holding your breath or straining should be avoided. In addition, exercises should be given as a home program. For an effective treatment, a program consisting of 8-12 repetitions for at least 15-20 weeks, 3-4 days a week, and where each contraction lasts 6-8 seconds is recommended.

b) EDUCATION WITH BIOFEEDBACK: There are treatment purposes such as teaching how to contract the pelvic floor muscles, showing the patient information about the contraction force, training the muscles and improving physical fitness.
It is not a stand-alone therapy. It can be used to show the strength and activity of the pelvic floor muscles or the direction of contraction and contraction of the correct muscle groups in patients with SUI at rest, contraction and relaxation. Thanks to this visualization, the continuity of the exercise can be ensured.

c) TRAINING WITH FOLEY CATHETER or BUMP: It is an inflated catheter used to provide feedback to the patient during pelvic floor contractions. Pulling this catheter placed in the vagina slightly outward creates a stretching effect on the pelvic floor muscles and additionally, voluntary contraction is provided against resistance. Stretching is small and light at the beginning and is increased by this amount as muscle strength and tolerance increase. The catheter can be used by inflating with air or water, or it can be applied with a tampon that is discarded after each use instead of the catheter. (3)

d) TRAINING WITH THE VAGINAL CON: Pelvic floor muscles will need to contract to prevent the subject placed inside the vagina from falling. However, holding in place may not be the best choice for increasing strength, as it is not entirely composed of multiple contractions of the pelvic floor muscles. Their effectiveness is likely to depend on the patient’s motivation and initial pelvic floor muscle strength, as well as the individual acceptability of the method.
Application; women are asked to place the vaginal subject with the weight they can carry while standing, walking and coughing in an upright position above the level of the levator muscle plateau and carry it for 15 minutes. Being able to carry 2 times in a row is asked to try the next heaviest subject in a forward step. In general, the training is in the form of moving the subject for 15 minutes, 2 times a day, for a month or more.

Electrical Stimulation

It is used as an effective method in the treatment of incontinence through the reorganization of spinal reflexes and regulation of cortical activity. It can be administered transcranially or suprapubic route, as well as tibial or sacral nerves.

Extracorporeal Magnetic Innervation

It is the stimulation of pelvic floor muscles and nerves with magnetic waves intermittently. Thanks to this stimulation, urethral and anal sphincter functions increase, bladder contraction decreases and pelvic floor muscles get stronger. In the application, the patients are dressed and seated in a special chair with a magnetic field generator and connected to an external power unit. For an effective treatment, the primary axis of the emitted magnetic field must come over the pelvic floor muscles and sphincters. For this, patients should be seated so that their perineum coincides with the table in the middle of the chair. Stimulation is applied in the form of intermittent low stimulation at a frequency of 5 Hz (5 seconds of stimulation, 5 seconds of rest) for 10 minutes, and intermittent high stimulation at a frequency of 50 Hz for the following 10 minutes.

REFERENCES

SAHIN, U. K. (2020). The Effects of External Electrical Stimulation in Addition to Pelvic Floor Muscle Training in Women with Stress Incontinence.
Kaya, S. (2013). Investigation of the Efficacy of Pelvic Floor Muscle Training Together with Bladder Training in Women with Urinary Incontinence Symptom.
Prof.Dr.A.Ayşe KARADUMAN ,Prof.Dr.Öznur TUNCA YILMAZ (Ed).(2017). Physiotherapy and Rehabilitation 1 (General Physiotherapy). Ankara
Orhan, C. (2017). The Effects of Vaginal Pad Training in Addition to Pelvic Floor Muscle Training in Women with Stress Urinary Incontinence.
Akbayrak T. (Ed). (2016) Physiotherapy and Rehabilitation in Women’s Health. Ankara
Akbayrak T., Kaya S. (Ed). (2015) KNGF Guideline Physiotherapy for Patients with Stress Urinary Incontinence. Ankara