Urinary Incontinence

Description

Alternative Names

Surgery

There are nearly 200 procedures for incontinence. Most of these procedures are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence. A national, 3-year study is underway to evaluate the two most common surgical treatments for urinary incontinence in adult women, the Burch colposuspension and the pubovaginal sling. The goal will be to determine, for the first time, which provides the best result. Each procedure has an 80 to 90 percent success rate.

The American Urological Association suggests that surgery should actually be considered as initial therapy for women with severe stress incontinence. It is an effective and safe alternative when conservative treatments fail. Many of the procedures are safe even for women up to 80 years old who do not have serious medical conditions. Potential complications of all procedures include obstruction of the outlet from the bladder, causing difficulty in urination and irritation.

The choice of procedure is a difficult one and often depends on whether particular anatomical abnormalities are involved, or other factors causing the incontinence. It should be noted that although hysterectomy is associated with improvements in continence, it must not be performed only as a cure for incontinence.

In general, patients should weigh all options carefully in order to pick the best procedure possible. The patient should discuss the situation with their physician, and also inquire about their surgeons experience. As a general rule, the more times a procedure has been successfully performed by the surgeon, the better. Patients are also advised to research success rates on any procedure used for the condition in question.

Retropubic Colposuspension and Other Suspension Procedures

Retropubic Colposuspension Surgery. Retropubic colposuspension using standard "open" surgery is currently the most effective treatment for stress incontinence, especially over the long term. ("Open" surgery implies the use of a wide incision in order to "open" the area.) Long-term continence rates can range from 85% to 90%.

The goal of colposuspension is to correct the position of the bladder and urethra by sewing the bladder neck and urethra directly to the surrounding pelvic bone or nearby structures. There are many variants, but in general, they are effective only for women with urethral hypermobility. Most procedures require a general or spinal anesthetic and a two-day hospital stay.

Burch colposuspension (sometimes called colpocystourethropexy) is a standard approach. It requires a wide abdominal incision and is often performed during other abdominal surgeries, such as hysterectomy or hernia operations. The surgeon secures the urethra and bladder neck with lateral (sideways) sutures that pass through thick bands of muscle tissue running along the pubic bones. Unlike an older suspension procedure, this procedure poses a much lower risk for obstruction of the urethra. It is more effective in premenopausal than postmenopausal women and may not be appropriate for all women.

Marshall-Marchetti-Krantz (MMK). The MMK approach requires a wide abdominal incision. The surgeon then elevates the urethra and bladder neck using sutures. These structures are then secured and anchored in nearby cartilage. This approach is one of the most time-tested and reliable, but it is being used less often because of the risk for scarring and because the incision limits the ability of the surgeon to correct any hernias (cystoceles), if present.

Laparoscopy. Other less invasive procedures use laparoscopy, which require only one or two small incisions over the pubic bone. Evidence now suggests that laparoscopy, performed by experienced surgeon, is now comparable to the standard open (wide-incision) approach in immediate cure rates and failure rates. Laparoscopy has a higher complication rate, however, but faster recovery time and less postoperative pain. Still, well-conducted long-term studies are needed for an accurate comparison with standard colposuspension.

Needle Suspension. Needle suspensions include a number of approaches, including the Pereyra, Stamey, Raz, and Gittes procedures. The basic approach employs sutures that are anchored on either side of the bladder and are tied to muscle tissue or the pubic bone. Some of these procedures use transvaginal suspension, which requires only a small abdominal incision or the surgeon works through the vagina and places sutures through the vaginal walls. Transvaginal suspension is effective, however, only if the walls of the vagina are strong enough to withstand the procedure. Some studies report poor long term results, particularly compared to colposuspension. In one study, only 35% of patients who had transvaginal suspension were continent after about six years, and in another, failure rate was 83% after four to five years. In another study, 20% of women reported worse sexual function after the procedure.

Postoperative Considerations for Most Procedures. Following most standard procedures, patients usually leave the hospital on the second or third day, but will require a urinary catheter for about 10 days. Newer procedures may require shorter stays and less intensive postoperative care.

Complications after surgery include the following:

• Some risk of damage to the surrounding nerves or vessel. This can result in internal sphincter deficiency. (In some cases it may already have been present before the operation.)
• Difficulty in urinating from surgical overcorrection (which may require additional surgery).
• Poor wound healing.
• Adhesions (scar tissue) that obstruct the urethra. This complication is higher with older standard procedures.
• Vaginal abnormalities (prolapsed vagina).

Sling Procedure

A sling procedure may be a good option for severe stress incontinence in women with either intrinsic sphincter deficiency or urethral hypermobility. With increasing experience it is even proving to help women with less severe incontinence and even certain young girls with severe incontinence. Studies suggest that it may also be useful for managing urge incontinence in certain women. Sling procedures are also available for men who experience urge, stress, or mixed incontinence after prostatectomy. Nevertheless, not all studies on the benefits of sling procedures are positive, and comparison studies with standard surgeries and conservative treatments are needed.

The Percutaneous Sling Procedure for Women. The procedure generally works as follows:

• The surgeon makes an incision above the pubic bone and removes a strip of abdominal fasci (a layer of tissue that covers muscle fibers). This muscle strip serves as the sling. The use of fasci taken from a cadaver or synthetic slings are also being investigated. The muscle strip may have fewer complications than some of the common synthetic materials, however. Studies are also mixed on whether cadaver material lasts long enough to be useful.
• The surgeon makes an incision in the vaginal wall. The piece of muscle fiber or material is attached under the urethra and bladder neck, somewhat like a hammock, and secured to the abdominal wall and pelvic bone.
• This sling then compresses the urethra back to its original position. The sling must be supportive without being too tense, which can cause urinary obstruction.

Complications can include infection, bleeding, and the formation of fistulas (channels that form and are usually infected).

Vaginal Sling and Tape Procedures for Women. Newer outpatient procedures use no abdominal incisions and are performed through a small incision the vagina. Typically, two small tacks are placed in the pubic bone. A sling is inserted into the vagina and is attached to the tack.

One procedure called a tension-free vaginal tape procedure employs a special gauze tape covered by a polypropylene coating, which is attached on each side of the urethra. The patient is typically conscious and asked to cough during the procedure so that the surgeon can determine if the tape is being placed properly. Small early studies report cure rates of 84% to 100% and that is as effective as colposuspension, the standard suspension procedures. (Success rates are lower with mixed incontinence, however.) Evidence from a 2003 multicenter study suggested that compared with the standard procedure this approach has more injuries to the bladder and vagina during the operation, but a faster recovery rate and fewer postoperative complications. To date, studies have been limited, however, and long-term results of well-conducted studies are still needed to determine any advantages.

Sling Procedures in Men. For some men who have prostatectomy-induced incontinence, sling procedures may be a good option. Researchers at Northwestern Memorial Hospital, who helped pioneer the sling technique for use in men, have reported an 80% success rate, the same as with an artificial urinary sphincter, the standard surgical treatment for such patients. The sling procedure has been less effective in men who have had radiation therapy, although improved techniques are making this approach useful even for these patients. Minimally invasive procedures are also being tested. The sling procedure may even eventually prove to be beneficial for boys with intractable incontinence.

Treatments for Loss of Sphincter Function

Artificial Sphincter. In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This procedure is useful for appropriate male and female candidates of any age, including children. It is particularly helpful for men after radical prostatectomy. Studies have found poor results for patients with incontinence due to radiation therapies, although a 2001 study of men with prostatectomy indicated that it was useful regardless of previous radiation therapy.

Click the icon to see an illustrated series detailing artificial sphincter surgery.

This device uses a balloon reservoir and a cuff around the urethra that is controlled with pump. The patient opens the cuff manually by activating the pump. The urethra opens and the bladder empties. The cuff closes automatically several minutes later. The two major drawbacks of the internal sphincter implant are the following:

• Malfunction. If the implant malfunctions, the surgery must be performed again.
• Infection. Infection is more serious as it can cause erosion of the urethra or bladder neck underneath the implant. Such infections not only require removal of the device, but also may worsen the incontinence. Fortunately, techniques have improved so that infection is uncommon.

In a 2001 study, after an average of seven years, 70% of female patients with stress incontinence had either the original implant or a replacement, and 82% were continent. (Only 37% still had the original implant, however.) Studies on men have reported similar findings, although newer devices that use narrow cuffs may significantly improve re-implantation rates. Nearly all patients still need to use pads for leakage.

Bulking Material Injections

Injections of materials, such as collagen, that provide bulk to help support the urethra are proving to be beneficial for certain patients:

• Women (even the elderly) with severe stress incontinence who cannot or do not wish to have surgery that involves anesthesia.
• Men who have slight incontinence caused by prostate surgery. Men who have bulking injections after TURP (transurethral resection of the prostate) have a continence rate that is equal to the rate in women. After radical prostatectomy (removal of the prostate gland in prostate cancer), collagen injections can achieve some level of continence in up to nearly half of men. (Collagen injections are not beneficial after radiation therapy for prostate cancer.)

The Procedure.

• First, bladder instability or hyperactivity should be medically treated and managed to control muscle activity before having the procedure. Otherwise it is likely to fail.
• The basic procedure involves injecting bulking material into the tissue surrounding the urethra.
• The material used is usually animal or human collagen. (Collagen is the basic protein in bones, muscles, and all connective tissue.) Synthetic bulking agents, such as carbon-coated beads, are also being used.
• The physician passes the collagen-containing needle through a cystoscope, a tube that has been inserted into the urethra. The collagen can also be injected into the skin next to the sphincter.
• The injected collagen tightens the seal of the sphincter by adding bulk to the surrounding tissue.
• The procedure takes about 20 to 40 minutes and most people can go home immediately afterward.
• Two or three additional injections may be needed to achieve satisfactory results.

Postoperative Care. People may experience immediate improvement followed by a temporary relapse after a week or so. Patients must be taught to use a catheter tube for withdrawing urine for a few days following the procedure. In general, it takes about a month for the full benefits to be apparent.

Complications.

• There is a risk for infection and urinary retention, although these conditions are temporary.
• An increase in autoimmune disease has been reported in a small number of cases.
• The procedure may not be appropriate for patients with certain cardiac conditions.

Duration of Effectiveness. Collagen is absorbed over time, so injections generally need to be repeated every six to 18 months. According to one study, however, after a year 44% of women who had the implants still experienced the same level of improvement. (Synthetic materials may last longer than collagen from other sources, but they pose a risk for rejection as well as migration to the lymph nodes and to other parts of the body.)

Repair of Prolapsed Uterus or Vagina

Procedures that repair a prolapsed (fallen) uterus or vagina (called the anterior vaginal repair) can often correct incontinence in women who have these conditions. The anterior vaginal repair (also called bladder tuck) requires an incision to be made through the vagina to release a portion of the anterior (front) vaginal wall. This portion is attached to the base of the bladder. The pubocervical fascia (the supportive tissue between the vagina and bladder) is folded and stitched to bring the bladder and urethra in proper position. There are several variations on this procedure that may be necessary, based on the severity of the prolapse. It is not as effective as retropubic suspension procedures, however, and should not be used as the primary method for correcting incontinence.

Click the icon to see an illustrated series detailing bladder neck surgery.

Radiofrequency Energy

An interesting investigative approach uses radiofrequency energy to shrink tissue that supports the bladder neck and so reduce hypermobility. Early studies are promising. In one, for example, the cure rate was nearly 80% at the end of a year, and 83% of patients reported satisfaction with the procedure.