There are nearly 200 surgical procedures for incontinence. Most are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence. Injections of bulking materials are another option for women and men.
The choice of surgical procedure depends on a number of factors, including the presence of bladder or uterine prolapse, the severity of incontinence, and the surgeon’s experience in performing specific types of surgery.
In general, patients should weigh all options carefully. They should discuss the situation with their doctor, and ask about their surgeon's experience. They should also be completely informed about the benefits and risks of the procedures. Patients will need to have a complete diagnostic evaluation before any surgical procedure, including assessment of post-void residual urine volume.
A sling procedure is usually the first-line surgical approach for stress incontinence in women who have either intrinsic sphincter deficiency or urethral hypermobility. It may also be useful for managing female urge incontinence. Sling procedures are also available for men who experience incontinence after prostatectomy.
The purpose of a sling procedure is to create a sling or hammock around the neck of the bladder to help keep the urethra closed. There are different types of sling procedures. They include:
- Suburethral, which is the traditional type
- Midurethral, which includes retropublic transvaginal tape (TVT) and transobturator tape (TOT)
Suburethral Sling Procedure. The suburethral, also called pubovaginal, sling is the traditional sling procedure. It uses a sling made from the patient’s own tissue (fascia), animal tissue, or a synthetic material. Suburethral means “beneath the urethra”. The procedure may be performed with laparoscopic or conventional “open” surgery. The procedure generally works as follows:
- The surgeon makes an incision above the pubic bone and removes a layer of abdominal fasci (tissue that covers muscle fibers). This muscle strip is set aside and later serves as the sling.
- 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 (holes that form and are usually infected).
Midurethral Sling Procedures. Midurethral sling procedures use slings made from synthetic mesh materials that are placed midway along the urethra. This newer type of sling procedure has become more commonly used than the conventional suburethral procedure because it can be performed on an outpatient basis using minimally invasive surgical techniques and no abdominal incisions.
There are two types of midurethral slings:
- In the retropublic procedure, the surgeon makes a small vaginal incision under the urethra and then two small incisions above the pubic bone.
- The transobturator procedure uses only a vaginal incision.
Sling Procedures in Men. For some men who have prostatectomy-induced incontinence, sling procedures may be a good option. Researchers have reported an 80% success rate, the same as an artificial urinary sphincter, which is 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.
Effectiveness and Complications. The sling procedure and the Burch colpsuspension seem to have similar success rates. Post-operative urinary problems, such as voiding problems, common urinary tract infections, and urge incontinence may occur. The FDA has reported complications associated with some synthetic mesh slings.
Retropubic Colposuspension (Burch Colposuspension)
Retropubic colposuspension aims 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 2-day hospital stay.
Burch colposuspension is the standard approach. (Marshall-Marchetti Krantz [MMK] is an alternative approach.) It is often performed during abdominal surgeries such as hysterectomy or hernia operations. It is also performed along with sacrocolpopexy, a surgical procedure used to repair pelvic organ prolapse. (Pelvic organ prolapse occurs when the uterus or bladder slips from the pelvic cavity into the vagina. It is often due to pelvic muscle weakness that develops after childbirth.) Prolapse can lead to stress incontinence. However, prolapse surgery itself sometimes causes incontinence.
The Burch colposuspension procedure may be performed using open surgery or laparoscopy. The surgeon makes an abdominal incision and secures the urethra and bladder neck with lateral (sideways) sutures that pass through thick bands of muscle tissue running along the pubic bones.Click the icon to see an illustrated series detailing bladder neck surgery.
Effectiveness and Complications. Patients usually need to use a urinary catheter for about 10 days after surgery. Because colposuspension surgery involves an abdominal incision, it can take up to six weeks for full recovery. (Laparoscopic procedures have a faster recovery time than open surgery.)
Complications can include problems with wound healing and postoperative voiding function. Convalescence time is longer with retropubic colposuspension than with sling procedures.
In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This procedure is generally used for men, such as those who have experienced incontinence following radical prostatectomy.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 a 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 malfunction of the implant and risk of infection.
Bulking Material Injections
Injections of materials, such as collagen, that provide bulk to help support the urethra may help the following patients:
- Women 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 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 materials, such as carbon-coated beads, are also being used.
- The doctor 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 - 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.
- There is a risk for infection and urinary retention, although these conditions are temporary.
- The procedure may not be appropriate for patients with certain heart conditions.
Duration of Effectiveness. Collagen is absorbed over time, so injections generally need to be repeated every 6 - 18 months.
The sacral nerves, located near the sacrum (“tail bone”), appear to play an important role in regulating bladder control. A sacral nerve stimulation system (InterStim) may help some patients with urge incontinence. The system uses an implanted device to send electrical pulses to the sacral nerves to help retrain them. InterStim is reserved for the treatment of urinary retention and the symptoms of overactive bladder in patients who have failed or cannot tolerate less invasive treatments.
Complications include infection, lower back pain, and pain at the implant site. The system, however, does not cause nerve damage and can be removed at any time.
Patients have reported improvement in the frequency and volume of urination, as well as the intensity of urgency and their quality of life.