Female Urology

Definition: Urinary incontinence (UI) is defined as any involuntary loss of urine.

Impact: Its severity can range from occasional leakage of small amounts of urine to frequent and heavy leakage. Regardless of the amount, UI can affect confidence, social life, physical activity, intimacy, and emotional well-being.

Brief Anatomy of Urinary Control: To understand incontinence, it is helpful to know the structures involved:

• Bladder: A sac-shaped muscular organ that stores urine.
• Urethra: The tube through which urine exits the bladder.
• Urethral sphincter: A circular muscle at the base of the bladder/beginning of the urethra that remains contracted to prevent urine leakage and relaxes to allow urination.
• Pelvic Floor Muscles: A group of muscles that support the bladder, uterus, and rectum, and that play a crucial role in urinary and fecal continence, and in sexual function.

Stress Urinary Incontinence (SUI):

• What is it: Urinary incontinence that occurs when there is a sudden increase in pressure in the abdomen (and consequently on the bladder). This typically happens when coughing, sneezing, laughing, lifting heavy objects, jumping, running, or doing other types of physical exercise.
• Main Cause: Weakening of the pelvic floor muscles and/or the urethral sphincter, which are unable to keep the urethra effectively closed during these efforts.

Urinary Urgency Incontinence (UUI) or Overactive Bladder (OAB):

• What is it: Urinary incontinence preceded or accompanied by a sudden, intense, and unavoidable urge to urinate (urgency). Overactive bladder is a syndrome characterized by urinary urgency, usually with increased urinary frequency (urinating many times during the day) and nocturia (waking up one or more times at night to urinate), which may or may not be associated with urinary incontinence (UUI).
• Main Cause: Involuntary and inappropriate contractions of the bladder muscle (detrusor muscle) during the filling phase.

Mixed Urinary Incontinence (MUI):

• What is it: The presence of symptoms of both stress incontinence and urge incontinence/overactive bladder. It is a very common form of incontinence.

Overflow Urinary Incontinence:

• What is it: Urine leakage (often in small amounts, like constant or intermittent dripping) that occurs when the bladder does not empty completely and becomes chronically distended (overfull).
• Main Cause:It can be caused by a weak bladder muscle that does not contract effectively to empty the bladder (detrusor hypocontractility) or, more rarely in women, by an obstruction to the outflow of urine (e.g., severe prolapse, urethral stricture after surgery).

Functional Urinary Incontinence:

• What is it: Urinary incontinence due to physical or cognitive difficulties that prevent a person from reaching the bathroom in time, even though the urinary system may be functioning normally (e.g., severe arthritis, dementia, very reduced mobility, environmental barriers).

Transient Urinary Incontinence:

• What is it: A temporary form of incontinence that can be caused by factors such as urinary tract infections (UTIs), certain medications (e.g., diuretics, sedatives), severe constipation, or excessive consumption of bladder irritants (such as caffeine or alcohol).

Detailed Medical History: The doctor will ask about:
• Your symptoms: when do the leaks occur, how often, in what quantity, what are the triggering factors (coughing, sneezing, urgency).
• Your fluid intake and urination habits.
• Medication that you take regularly.
• General medical history, obstetrics (pregnancies, deliveries) and surgical history.
• The impact of incontinence on your quality of life.
• You may be asked to fill out a form — Voiding Diary — for 2 to 3 days (a record of the liquids you drink, how many times you urinate, the amount of urine in each urination – if possible – and episodes of urine leakage and the circumstances in which they occurred).

Physical examination: Includes an abdominal exam and a pelvic (gynecological) exam to:
• To assess the health of the vaginal and urethral tissues.
• To detect the presence of pelvic organ prolapse (descent of the bladder, uterus, or rectum).
• Assess the strength of the pelvic floor muscles.
• To carry out a Cough Stress Test: With her bladder comfortably full, the patient is asked to cough vigorously while the doctor observes whether there is any leakage of urine from the urethra.

Urine Analysis (Type II / Urine 2 and Urine Culture): To rule out a urinary tract infection (which can cause or worsen incontinence) or the presence of blood in the urine (which may require further investigation).

Post-void residual (PVR) measurement: It assesses the amount of urine that remains in the bladder immediately after urination. A high PVR may indicate that the bladder is not emptying completely, which can contribute to overflow incontinence or infections. It can be measured by ultrasound or through brief bladder catheterization.

Complete Urodynamic Study: It is a set of more specialized tests that assess bladder and urethral function during the filling and emptying phases. It measures bladder and abdominal pressures, the volume of urine the bladder can hold, the presence of involuntary bladder contractions, and urinary flow. It is often recommended in cases of uncertain diagnosis, before considering surgical treatment, or if previous treatments have been unsuccessful.

Cystoscopy: It is an endoscopic examination that allows visualization of the inside of the urethra and bladder with a small camera. It is rarely necessary for the initial diagnosis of most types of incontinence, but it may be performed if other bladder pathologies are suspected (e.g., hematuria, persistent bladder pain, suspected fistula).

Maintain a healthy body weight.

Practice Kegel exercises regularly, especially during pregnancy, after childbirth, and throughout life.

Avoid constipation through a diet rich in fiber and adequate hydration.

Don’t smoke (to avoid chronic cough).

Avoid lifting excessive weights incorrectly.

Manage fluid intake appropriately and avoid or moderate consumption of known bladder irritants.

Female Pelvic Organs: The female pelvis contains important organs such as the bladder (where urine is stored), the uterus (where the baby develops during pregnancy), the vagina (the canal that connects the uterus to the outside), and the rectum (the final part of the intestine where feces are stored).

The Pelvic Floor: These organs are held in their correct position by a complex network of muscles, ligaments, and connective tissue (fascia) called the pelvic floor. This system functions like a kind of supportive “trampoline.”

What is Pelvic Organ Prolapse (POP)? Pelvic organ prolapse (POP) occurs when the muscles and ligaments of the pelvic floor weaken or become injured, losing their ability to adequately support the pelvic organs. As a result, one or more of these organs may descend (prolapse) from their normal position, potentially herniating into the vagina or, in more advanced cases, protruding through the vaginal opening.

Impact: Although POP is generally not a life-threatening condition, it can cause significant physical discomfort, urinary, bowel, or sexual symptoms, and affect self-image and quality of life.

Cystocele (Bladder Prolapse or “Fallen Bladder”): This is the most common type. The bladder descends and pushes against the anterior (front) wall of the vagina.

Rectocele (Rectal Prolapse): The rectum descends and pushes against the posterior (back) wall of the vagina.

Uterine Prolapse: The uterus descends into the vagina. In severe cases, the cervix may become visible or even protrude through the vaginal opening

Vaginal vault prolapse: This occurs in women who have had a hysterectomy (removal of the uterus). The upper part of the vagina (the vaginal vault) loses its support and descends.

Enterocele: A portion of the small intestine (intestinal loops) herniates into the space between the rectum and the vagina, pushing against the upper part of the posterior vaginal wall.

Uretrocele (Urethra Prolapse): The urethra (the tube that carries urine from the bladder to the outside) descends, often associated with a cystocele.

Pregnancy and Vaginal Delivery: These are considered the main risk factors. The baby’s weight during pregnancy and the strain of childbirth can stretch and injure the muscles, nerves, and ligaments of the pelvic floor. Additional factors include multiple births, large babies (macrosomia), instrumental vaginal deliveries (use of forceps or vacuum extraction), and prolonged labor.

Aging and Menopause: As we age, tissues tend to lose strength and elasticity. The decrease in estrogen levels after menopause also contributes to the weakening of pelvic tissues.

Chronic Increase in Intra-abdominal Pressure: Conditions that repeatedly or for prolonged periods increase pressure within the abdomen can strain the pelvic floor. These include:

• Chronic cough (associated with bronchitis, Chronic Obstructive Pulmonary Disease – COPD, or smoking).
• Chronic constipation, with excessive straining to defecate.
• Obesity.
• Regular weightlifting (due to profession or intense physical exercise).

Previous Pelvic Surgery: Some surgeries, such as hysterectomy, can sometimes alter the anatomical supports of the pelvis and predispose to future prolapse, especially of the vaginal vault.

Genetic Factors: Some women may have a hereditary predisposition to having weaker connective tissues.

Connective Tissue Diseases: Rare conditions such as Marfan syndrome or Ehlers-Danlos syndrome can affect the integrity of supporting tissues.

Ethnicity: Some studies suggest that Caucasian and Hispanic women may have a higher incidence of POP

Feeling of pressure or heaviness in the pelvis or vagina: Many women describe it as a sensation of a “ball” or “something falling” inside the vagina.

Protrusion or Bulge in the Vagina: It is possible to feel or even see a mass coming out of the vaginal opening, especially when straining or at the end of the day.

Discomfort or pain in the lower back (pain in the “hips”).

Urinary Symptom:

• Involuntary loss of urine, especially when coughing, sneezing, or exercising (stress urinary incontinence).
• An urgent need to urinate and, sometimes, leakage before reaching the bathroom (urge urinary incontinence).
• Difficulty starting urination or completely emptying the bladder.
• Weak or interrupted urine stream.
• The need to change position or push the vagina in order to urinate.
• Recurrent urinary tract infections.

Intestinal symptoms (especially with rectocele):

• Difficulty in passing stool (constipation).
• The need to press on the posterior vaginal wall or perineum to help with defecation (“digital maneuvers”).
• A sensation of incomplete rectal emptying after defecation.
• Incontinence for gas or feces.

Sexual Symptoms:

• Discomfort or pain during sexual intercourse (dyspareunia).
• A sensation of a “loose” vagina or loss of vaginal sensitivity.
• Shame or embarrassment that affects intimacy.

Worsening of Symptoms: Symptoms tend to worsen at the end of the day, after long periods of standing, or with activities that increase abdominal pressure (such as coughing or lifting weights).

Detailed Medical History: The doctor will ask about your symptoms, their intensity, and how they affect your daily life. Information will also be gathered about your obstetric history (pregnancies, deliveries), previous pelvic surgeries, other medical conditions, and lifestyle habits. Specific quality of life questionnaires may be used.

Pelvic (Gynecological) Examination: This is the fundamental step in the diagnosis.

• The doctor will inspect the vulva and vagina.
• Using a speculum, you will observe the vaginal walls and the cervix (or the vaginal vault in hysterectomized wome
<liYou may be asked to strain (as if you were having a bowel movement – ​​Valsalva maneuver) or cough so that the doctor can observe the descent of the pelvic organs and assess their severity.
• The type and degree of prolapse are generally classified using standardized systems (such as the POP-Q system).

Assessment of Pelvic Floor Muscle Function: The doctor can test the strength and tone of your pelvic floor muscles.

Additional tests (requested in specific cases):

• Complete Urodynamic Study: A set of tests that assess the functioning of the bladder and urethra. It is particularly useful if there are significant urinary symptoms, such as incontinence or difficulty emptying the bladder, and before surgery for prolapse.
• Pelvic ultrasound (abdominal, transvaginal or transperineal): It can help visualize the pelvic organs, confirm the type of prolapse, and detect other abnormalities.
• Dynamic Magnetic Resonance Imaging (MRI) of the Pelvis: A more detailed imaging examination may be useful in cases of complex prolapse involving multiple compartments, or when the physical examination is inconclusive.
• Cystoscopy: Visualization of the bladder and urethra interior with a small camera-equipped instrument, if intravesical problems are suspected.

Conservative (Non-Surgical) Treatment:

• Lifestyle Modifications:
• Weight loss, if overweight or obese
• Treatment of chronic cough and constipation.
• Avoid lifting excessive weights or learn the correct techniques for doing so.
• Pelvic Floor Physiotherapy:
• It consists of specific exercises (such as Kegel exercises) to strengthen the pelvic floor muscles.
• It can help relieve the symptoms of mild to moderate prolapse and prevent its progression.
• Techniques such as biofeedback and electrostimulation can be used to optimize muscle training.
• Vaginal Pessaries:
• These are devices made of silicone or similar materials, available in various shapes and sizes, that are inserted into the vagina to provide mechanical support to prolapsed organs.
• They are a good option for women who do not want surgery, who have medical contraindications for surgery, who wish to become pregnant in the future, or as a temporary measure while awaiting surgery.
• They require regular checkups with a doctor or nurse for adjustments, cleaning, and monitoring of vaginal health.
• Local Hormone Therapy with Vaginal Estrogen:
• In postmenopausal women, the application of creams, tablets, or vaginal rings with low doses of estrogen can help improve the thickness, elasticity, and vascularization of vaginal tissues. This can alleviate symptoms such as dryness, irritation, and pain during sexual intercourse,

Surgical Treatment:

• Surgery is generally considered when the symptoms of prolapse are significant and do not improve with conservative treatment, or if the woman, after being properly informed, prefers a surgical solution.
• The goal of surgery is to restore the normal anatomy of the pelvic organs, alleviate symptoms, and improve quality of life, ideally by preserving or improving urinary, bowel, and sexual functio
• There are many different surgical techniques, and the choice depends on the type of prolapse, its severity, and the surgeon’s experience.
• Reconstructive Surgery (Prolapse Repair): It aims to rebuild and strengthen weakened pelvic supports.
• Use of Native Tissues (Repair with the patient’s own tissues): The surgeon uses the woman’s own ligaments and fascia to repair the defects.
• Use of Reinforcing Materials (Meshes/Nets): In some cases, especially in recurrent or severe prolapses, synthetic (such as polypropylene meshes) or biological materials may be used to reinforce the repair. The use of vaginal meshes for prolapse treatment is a topic that has generated controversy due to potential complications (such as mesh erosion, pain), and its indication is now very carefully considered and reserved for specific cases, generally by experienced surgeons. Meshes used abdominally (laparoscopically/robotically) for apical suspension (sacrocolpopexy) have a different safety and efficacy profile and are considered a gold standard treatment for apical prolapse.
• Surgical Access Routes:
• Vaginal route: The surgery is performed through incisions made inside the vagina. It is a common approach for correcting cystoceles, rectoceles, and, in some cases, uterine prolapse (with or without vaginal hysterectomy).
• Abdominal route:
• Laparoscopy: Small incisions are made in the abdomen, through which a camera and thin surgical instruments are inserted.
• Robotic Surgery (e.g., Sacrocolpopexy or Robot-Assisted Sacrocolpopexy): It is an advanced form of minimally invasive surgery. The surgeon operates while seated at a console, controlling robotic arms that manipulate the instruments with great precision.
• This approach is particularly advantageous for complex procedures such as sacrocolpopexy (suspension of the vaginal vault or cervix to the sacral bone using a mesh) or sacrohysteropexy (suspension of the preserved uterus).
• Advantages of Robotic Surgery: It offers an enlarged, high-definition, three-dimensional view of the surgical field, greater precision, dexterity, and range of instrument movement. This facilitates meticulous dissection and precise placement of the support mesh. It generally results in less blood loss, less postoperative pain, shorter hospital stay, and faster recovery compared to open surgery. Sacrocolpopexy (open, laparoscopic, or robotic) is considered the most durable treatment for apical prolapse.
• Obliterative Surgery (Colpocleisis):
• This procedure involves the partial or complete closure of the vaginal canal. It prevents future vaginal intercourse.
• It is an effective and low-risk option for older women with severe prolapse who are not sexually active and do not wish to be in the future, or who have medical conditions that make longer and more complex reconstructive surgeries too risky.
• Hysterectomy (Removal of the Uterus): It can be performed as part of prolapse correction surgery if the uterus is prolapsed. However, there are also uterine suspension techniques (hysteropexy) that allow the organ to be preserved, if that is the woman’s wish and clinically appropriate.

Practice Kegel Exercises Regularly: Strengthen the pelvic floor muscles, especially during pregnancy and after childbirth, and throughout life.

Maintaining a Healthy Body Weight: Reduce pressure on the pelvic floor.

Preventing Chronic Constipation: Adopt a diet rich in fiber, drink enough fluids, and exercise regularly.

Treating Chronic Cough: Seek treatment for respiratory conditions that cause a persistent cough.

Learn the Correct Techniques for Lifting Weights: Avoid holding your breath and straining your pelvic floor when lifting heavy objects.

No Smoking: Smoking is associated with chronic cough and weakening of tissues.

Definition: Endometriosis occurs when tissue similar to the endometrium (the inner lining of the uterus that is shed during menstruation) grows outside the uterine cavity.

Behavior of Ectopic Tissue: This “displaced” tissue behaves similarly to the uterine endometrium: it responds to the hormonal stimuli of the menstrual cycle, growing and bleeding monthly. Since this blood has nowhere to go, it can cause inflammation, intense pain, scar tissue formation (fibrosis), and adhesions between the pelvic organs.

Common Places: Endometriosis implants are most often found in the ovaries (forming cysts called endometriomas), fallopian tubes, ligaments that support the uterus, the outer surface of the uterus, the intestines, and the lining of the pelvic cavity (peritoneum).

Definition:UTE occurs when endometriotic tissue implants and grows in any organ of the urinary system, which is responsible for producing, storing, and eliminating urine

Most Common Locations in the Urinary Tract:

• Bladder: The bladder is the urinary organ most frequently affected by endometriosis (responsible for approximately 80-90% of cases of encephalopathy). The lesions can be superficial, in the inner layer of the bladder, or infiltrate deeply into its muscular wall.
• Ureters: These are the thin tubes that carry urine from each kidney to the bladder. Endometriosis involvement of the ureters can be extrinsic (when endometriotic tissue grows around the ureter, compressing it) or intrinsic (when the tissue invades the ureter wall). This condition is particularly concerning because it can lead to silent obstruction of urinary flow and dilation of the kidney (hydronephrosis or hydroureteronephrosis), with potential loss of kidney function if left untreated.
• Kidneys: Direct kidney involvement by endometriosis is very rare.
• Urethra: The tube that carries urine from the bladder out of the body. Urethral endometriosis is also rare.

Prevalence: Although endometriosis is common, urinary tract involvement is estimated to occur in a relatively small percentage of women with the disease (estimates range from 1% to 6%), but it may be underdiagnosed due to the varied and sometimes nonspecific nature of the symptoms.

Retrograde Menstruation (Sampson’s Theory): During menstruation, some of the menstrual blood containing endometrial cells can flow backward through the fallopian tubes into the pelvic cavity, instead of leaving the body. These cells can then implant and grow in pelvic organs, including the surface of the bladder or near the ureters.

Lymphatic or Vascular Dissemination: Endometrial cells can enter blood or lymphatic vessels and be transported to other parts of the body, including the urinary tract.

Iatrogenic Implantation (Accidental Dissemination): In rare cases, endometrial cells can be accidentally transferred to surgical sites during pelvic surgeries, such as cesarean sections or hysterectomies.

General Symptoms of Endometriosis:

• Chronic pelvic pain (often described as deep, cramping, or a feeling of heaviness).
• Dysmenorrhea (very painful menstrual periods, which can be debilitating).
• Deep dyspareunia (pain during or after sexual intercourse, felt deep in the pelvis).
• Dyschezia (painful bowel movements, especially during menstruation).
• Infertility or difficulty getting pregnant.
• Chronic fatigue, abdominal distension, changes in bowel movements.

Specific Symptoms of Urinary Tract Endometriosis:

• If it affects the bladder (bladder endometriosis):
• Pain or pressure in the bladder (suprapubic) area.
• Urinary urgency (sudden and compelling need to urinate).
• Pollakiuria (increased urinary frequency, urinating small amounts at a time).
• Dysuria (pain, burning, or discomfort when urinating).
• Catamenial hematuria (presence of blood in the urine that occurs specifically during menstruation) – this is a highly suggestive symptom of bladder endometriosis.
• Sensation of incomplete bladder emptying.
• Pain when filling the bladder.
• If it affects the ureters (ureteral endometriosis):
• Often, ureteral endometriosis is “silent” (asymptomatic) in its early stages, until it causes significant obstruction of urine flow.
• Recurrent urinary tract infections (if the obstruction leads to urinary stasis).
• Hematuria (less common than in bladder endometriosis).
• Nausea or vomiting (if there is severe pain or infection).
• Important: Prolonged and untreated ureteral obstruction can lead to dilation of the kidney (hydronephrosis) and progressive, sometimes irreversible, loss of function in the affected kidney, without the woman noticing serious symptoms.
• If it affects the kidneys or urethra: These are very rare locations. Symptoms may include flank pain (renal) or dysuria and hematuria (urethral), respectively.

Detailed Medical History and Physical Examination: The doctor will carefully explore your symptoms, their relationship to your menstrual cycle, and your medical and gynecological history. The pelvic exam may reveal lumps or tenderness.

Symptom Diary: Keeping a record of urinary symptoms and their occurrence in relation to the menstrual cycle can be very helpful.

Urine Analysis (Urinalysis, Urine Culture): To rule out urinary tract infection and detect the presence of blood (hematuria).

Imaging Tests:

• Transvaginal Ultrasound (with bowel preparation) and Pelvic/Renal Ultrasound: It can identify endometriotic nodules in the bladder wall and is essential for detecting hydronephrosis (dilation of the kidneys/ureters) caused by ureteral obstruction.
• Pelvic Magnetic Resonance Imaging (MRI) with Endometriosis Protocol: This imaging exam is very important for mapping deep pelvic endometriosis, including the assessment of lesions in the bladder and ureters (wall thickening, compression), and their relationship to neighboring organs. It aids in surgical planning.
• Uro-CT (Computed Tomography of the Urinary Tract) or CT Urography: It can be used to assess the anatomy of the urinary tract and the excretory function of the kidneys, especially if ureteral obstruction is suspected.

Cystoscopy:

• It is a procedure in which a thin tube with a camera at the end (cystoscope) is inserted through the urethra to visualize the inside of the bladder.
• It allows for the direct identification of endometriosis lesions in the bladder mucosa or wall (which may have a characteristic appearance, such as bluish or reddish nodules or areas of inflammation).
• During cystoscopy, biopsies of suspected lesions can be taken for histological confirmation (microscopic analysis). It is ideal to perform this examination during or shortly after menstruation, when the lesions may be more active and visible.

Diagnostic and Surgical Laparoscopy:

• It remains the “gold standard” for the definitive diagnosis of pelvic endometriosis
• It is a minimally invasive surgical procedure in which a camera is inserted into the abdominal/pelvic cavity to directly visualize the organs and identify endometriosis implants, including those affecting the surface of the bladder or ureters.
• It allows not only diagnosis but also surgical treatment (removal of lesions) in the same procedure.

Fertility: Endometriosis, in general, is a known cause of infertility or subfertility. Specific involvement of the urinary tract is not the direct cause of infertility, but the presence of extensive pelvic endometriosis (which often accompanies UAE) can affect the ovaries, fallopian tubes, or pelvic environment. Surgical treatment of endometriosis, including UAE, can, in some cases, improve spontaneous pregnancy rates or the outcomes of assisted reproductive treatments.

Kidney Function: This is one of the most critical aspects of UAE. Ureteral endometriosis, if not diagnosed and treated promptly, can lead to progressive and “silent” obstruction of the ureter. This obstruction causes an accumulation of urine in the kidney (hydronephrosis), which, if it persists, can irreversibly damage kidney tissue and lead to complete loss of function in the affected kidney. Early detection of hydronephrosis through imaging tests and treatment of the obstruction are fundamental to preserving kidney function.

Recurrence: After surgery, there is a risk of recurrence of lesions or symptoms. The recurrence rate varies depending on the initial severity of the disease, the extent of the surgery, and the use of suppressive medical treatment post-operatively.

Medical Monitoring: Regular, long-term follow-up with a gynecologist specializing in endometriosis is essential, and, if there has been significant urinary involvement, also with a urologist. This follow-up may include periodic imaging tests to monitor kidney function and detect any recurrences early.

Continuous Management: Long-term management may involve hormonal treatment to suppress disease activity, pain control strategies (including pelvic floor physiotherapy and sometimes follow-up in chronic pain units), and lifestyle adaptations (such as an anti-inflammatory diet and regular exercise), which can help improve quality of life.

Endometriosis with urinary tract involvement is a specific and challenging manifestation of this chronic disease. It requires in-depth understanding, accurate diagnosis, and a carefully crafted treatment plan from an experienced multidisciplinary team. Urinary symptoms, especially if cyclical, should not be ignored.

If you have been diagnosed with endometriosis and are experiencing urinary symptoms, or if you suspect that your urinary symptoms may be related to this condition, it is crucial to seek a specialized medical evaluation. We have the knowledge, experience, and advanced technologies, including robotic surgery, to offer the best possible treatment, aiming to alleviate your symptoms, preserve organ function, and improve your quality of life.

Schedule a consultation so we can discuss your case in detail and determine the most appropriate treatment strategy for you.