Surgery Options for Urinary Incontinence
The trend in surgery for incontinence is toward less invasive surgical procedures that can usually be performed on an outpatient basis and sometimes in the physician’s office. Because some surgical procedures for stress incontinence are now relatively quick and require less recovery time, your doctor may recommend surgery earlier if your incontinence is caused by a repairable structural problem or if it seems unlikely that nonsurgical approaches will be satisfactory. When choosing to have minimally invasive surgery, it is especially important that your surgeon be highly trained and experienced in the specific procedure you choose.
The most common condition treated surgically is stress incontinence; this is done by inserting a sling of material to support the urethra. Overactive bladder may also be treated with the surgical implantation of a neuromodulation device (see “Sacral neuromodulation”). If incontinence is caused by a prolapsed uterus in a woman or an enlarged prostate in a man, surgery to correct those conditions (not described in this report) may relieve the incontinence along with other symptoms.
Whether and when to have surgery is a personal decision that has no right or wrong answer. You may consider surgery if nonsurgical treatments are not providing the control you need or if an anatomical problem makes it unlikely that nonsurgical techniques will help. Even if surgery is ultimately your choice, the effort you spend in bladder training and strengthening your pelvic muscles is not wasted; these techniques increase the chance of a successful outcome following surgery for incontinence and can reduce postoperative incontinence after prostate surgery. After their operations, some people say they regret the time they spent coping with incontinence and wish they had taken the step sooner. Others hope to put off the decision as long as possible, because new and less invasive procedures are becoming available every year.
Surgery for stress incontinence
For women, surgeries for stress incontinence are designed to provide extra support for the urethra so it can remain closed under physical stress, such as during coughing or sneezing. This can be done by several methods. For years, the best method was the Burch procedure, a form of bladder neck suspension in which the surgeon places stitches on either side of the urethra and bladder neck and attaches the stitches to a ligament at the top of the pubic bone. Now, the most common procedure involves a simple-to-install sling of synthetic mesh that supports the urethra, hammock-style.
Before you and your doctor decide on surgery, you may need to have detailed diagnostic testing (see “Evaluating urinary incontinence”) to help determine which type of surgery would work best. The availability of minimally invasive procedures has led physicians to consider such treatments for stress incontinence in women who are younger and have less severe incontinence as well as older women who may benefit from a minimally invasive procedure. However, women who hope to have future pregnancies are often advised to postpone surgery if possible until childbearing is complete, because delivering a baby through the vaginal canal may undo the effects of the surgery. If you do choose surgery, choose your surgeon and procedure carefully, because additional attempts may be less successful.
Before your surgery, gain the best control possible over your bladder by strengthening your pelvic floor, using bladder training, and avoiding bladder irritants such as caffeine. This will minimize urinary urgency and frequency that sometimes develop following surgery.
Four distressing but uncommon problems may occur after any type of surgery for stress incontinence, although the risks vary with the different procedures:
- You might develop symptoms of overactive bladder, even if you were never troubled by them before (7% to 15% of patients experience this).
- Although it’s not common, you might undo the benefits of the surgery by lifting or other strenuous activity, even after the healing period is over.
- You might go from incontinence to having difficulty urinating temporarily, in rare cases requiring a catheter to empty your bladder.
- The mesh sling may erode or perforate vaginal or other tissues.
Sling and tape procedures. These procedures have become increasingly common because they are less invasive and equally effective compared with older surgical methods, such as the Burch procedure discussed below. For these procedures, a surgeon installs a supportive sling under and around the urethra to support it. The sling is made of either your own tissue or an artificial tape similar to nylon or polypropylene, common materials used for sutures. In women, the sling can support the urethra in the proper position, which helps the urethra hold in urine during a cough or sneeze. In 2011, the FDA issued a safety recommendation warning doctors and their female patients that installing a mesh sling to treat pelvic organ prolapse has resulted in complications such as erosion of the vaginal wall, pain, and bleeding. The FDA is reviewing the rate of complications for the sling for urinary incontinence. If you are considering one of these procedures, the key to a successful, complication-free outcome is choosing an experienced surgeon who performs the procedure frequently.
In men, the sling puts pressure on the urethra just below the bladder.
After less invasive surgery such as this, recovery is rapid. If you are over age 70 or have other medical problems, you may be hospitalized overnight. Otherwise, you will probably be discharged after you have recovered from any anesthesia and have been able to urinate. You may need pain relief medication for a few days. Initially your urine stream may be slower. When you sit to urinate, relax and wait for the reflex that starts urine flowing. Straining can make it more difficult to urinate and can loosen the sling.
For women. Two types of minimally invasive sling surgery are available. In one, known as a transvaginal tape (TVT) procedure, the surgeon places a hammock of narrow mesh underneath the urethra and extending up to two anchors in the abdominal wall above the pubic bone, forming a U-shape to support the urethra (see Figure 6). The mesh stays in place without sutures, as your body creates scar tissue around and through the mesh. This surgery (available in several systems with brand names such as Gynecare TVT and SPARC) is faster and easier than older, more invasive sling procedures and, in many cases, can be performed under local anesthesia. Some surgeons combine the placement of TVT with other pelvic reconstructive surgery, such as vaginal hysterectomy or repair of cystocele or rectocele (bladder or rectal tissues bulging into the vagina). Most women can return to work within three to seven days after a TVT sling procedure as long as no heavy lifting is required at work.
In a second minimally invasive sling procedure, transobturator tape (TOT, with brand names such as Monarc and Uratape) is inserted through a small vaginal incision, and the ends are brought out through tiny incisions between the labia and the creases of the thighs. The sling supports the urethra gently, forming a curve shaped more like a smile than the letter U. No sutures or anchors are used. Surgery takes about half an hour, and most women can return to work within a few days if they do not have to lift heavy objects. Performed without an abdominal incision, this procedure reduces the risk of bowel or bladder injury during surgery, and it can be used in women who have scar tissue from previous surgeries.
The field continues to evolve as ever less invasive procedures are developed. A newer, single-incision sling procedure, called the mini sling, involves inserting a supportive mesh hammock under the urethra using a slim needle. The procedure requires a small vaginal incision but no abdominal or groin incisions, and it can be performed in an outpatient surgery center or a physician’s office under local anesthesia. Since the mini sling was introduced in 2007, preliminary research results have shown it is as effective as the regular slings. No long-term data on its effectiveness are yet available.
In all sling and tape procedures, it is important that patients follow postoperative instructions to avoid excessive activity, such as lifting or exercise, after the sling is in place. After the surgery, there is a possibility that the sling will push too hard against the urethra, blocking the flow of urine. If this occurs, a second, minor surgery may be necessary to loosen up the sling. Some people develop symptoms of urinary urgency (even if this was never a problem previously) that can usually be controlled with medication, bladder training, or Kegel exercises.
For men. Minimally invasive sling surgery (also called bulbourethral sling surgery, or by brand names such as AdVance and InVance) is relatively simple and usually does not require an overnight hospital stay. During the half-hour procedure, which is performed under spinal or general anesthesia, the surgeon makes an incision between the scrotum and rectum and attaches the sling to anchors or screws inserted into each side of the pelvic bone.
Complications following male sling procedures can include infection, discomfort, and a shift from incontinence to the opposite problem — difficulty urinating and urinary retention. Men may need to use a catheter to empty their bladders for a short time after this surgery. The sling is usually for men who have mild to moderate stress incontinence due to prostate removal or treatment, other surgery, or trauma. Scarring from previous surgeries or injuries (such as a pelvic fracture) may decrease the likelihood of success.
Bladder neck suspension. This procedure, known as the Burch colposuspension, has been largely replaced by the sling and tape procedures discussed above. Bladder neck suspension is a surgical procedure for women with stress incontinence that elevates or increases support for the bladder neck area to protect against leakage when a woman coughs or exerts herself physically. This operation often involves cutting an incision of three to five inches in the lower abdomen and lifting the tissue next to the bladder neck up, using strong stitches (sutures) to anchor the tissue to a ligament (called Cooper’s ligament) near the pubic bone. The Burch procedure is performed under general anesthesia and usually requires a two-day hospital stay and six weeks of recovery before a woman can return to full activity. Sometimes the procedure can be performed laparoscopically, with a quicker recovery.
Figure 6: Sling surgery (for women)
For some women with stress incontinence (leaking when coughing or jumping), the surgical insertion of a urethral sling or tape can help support the urethra. In the version shown here, known as a transvaginal tape (TVT) procedure, the surgeon makes a small incision under the urethra through the vagina and two small incisions in the lower abdomen, to insert a strip of synthetic mesh under the urethra to support it. Gradually, your body’s own tissues grow through the mesh to hold it in place.
Surgery for overflow incontinence
If you have overflow incontinence because something is blocking your urethra (such as an enlarged prostate in a man) or bladder (such as a prolapsed uterus in a woman), surgery can be performed to remove the obstruction. The procedures and results will depend on the exact cause and location of the blockage.
For example, a man with an enlarged prostate may undergo transurethral resection of the prostate, or TURP, an incision-free surgical procedure that reduces prostate tissues with an electrical loop. It relieves urinary obstruction in at least 75% of cases, and the improvement is usually long-lasting. However, urinary problems can recur if the prostate tissue grows back. While TURP may aid overflow incontinence, other types of incontinence may occur as a side effect of the procedure.
Women with incontinence resulting from a prolapsed bladder, uterus, or rectum may undergo procedures to reposition the out-of-place organs and shore up their support.
Figure 7: Artificial urinary sphincter (for men)
For men who have had prostate surgery, initial incontinence usually improves over several months. But for those with intractable incontinence caused by sphincter weakness, the artificial sphincter is a possible solution. After it is surgically inserted, the fluid-filled cuff compresses the urethra to stop the flow of urine. To allow urination, a man squeezes a small pump to open the cuff and allow urine to pass. The cuff automatically refills.
Artificial urinary sphincter
An artificial sphincter is a fluid-filled cuff surgically placed around the urethra to prevent urine from leaking out (see Figure 7). A small pump is inserted into a woman’s labium or a man’s scrotum. To urinate, you squeeze the pump and the fluid drains from the cuff into a storage balloon implanted in the abdominal cavity. This releases pressure on the urethra and allows urine to flow out. Over the next few minutes, the fluid automatically returns to the cuff.
The operation to implant the cuff, balloon, and pump takes about two hours and three small incisions. It is usually performed under general anesthesia. During a healing period of four to six weeks, the pump will not be activated. Once the pump is activated, your urinary control will improve. The major complications with an artificial sphincter include the possibility of infection, erosion of the tissue around the implants, or malfunctioning or shifting of the device. Such complications may require surgery to repair or remove the device.
Artificial sphincters are used far less frequently in women than in men. However, if you are a woman with severe stress incontinence due to intrinsic sphincter deficiency, or if you are still having major leakage problems after other surgeries, the artificial sphincter is an option.
Selecting your procedure and surgeon
If you are planning surgery for urinary incontinence, you may have several choices of procedures. Among the factors in your decision will be the risks and benefits of each option and the specific problems your evaluation has revealed. In addition, you and your physician may favor one approach over another for individual reasons. Among things to consider: Is a rapid recovery and return to work a priority? Do you need another pelvic surgery — such as a hysterectomy, tubal ligation, or treatment for prolapse — that can be done at the same time? Are you more comfortable using your own tissue or a synthetic?
In the rapidly changing field of incontinence surgery, not all surgeons may be prepared to offer the least invasive option suitable to your medical situation. Look for a urologist or urogynecologist who has substantial experience in urinary procedures, is adept at cystoscopy (since the surgeon must use a lighted medical scope to inspect the inside of the bladder at the end of most procedures), and is up to date with the latest approaches.
Suprapubic tube insertion
For severe and intractable incontinence, a surgeon can insert a suprapubic (above the pubic bone) tube from outside your abdomen directly into your bladder. Urine is diverted through the tube and collected in a bag outside the body. Although this solution is a last resort, it is easier than other management techniques for people in some situations. Although for the average person this would mean a decrease in quality of life, for those with truly severe incontinence, it can be a big improvement.