Incontinence: Surgical Management
Bladder control is a common problem in America affecting over 15 million men and women. The prevalence is much greater in women than in men, and older women are more often afflicted than younger women. Regardless of gender or age, incontinence of urine has significant impact on both quality of life and cost of living. Many affected persons suffer from depression and social isolation. Fortunately, with continued advances in medical science, noninvasive procedures and effective drugs are available to many patients. Continue reading to learn more about available treatment options that you can discuss with your urologist.
What can be expected under normal conditions?
The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the two kidneys, the two ureters, the bladder and the urethra. The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable sugars, salts and minerals. Urine, the waste product of the filtration, is produced in the kidney and flows through two 10 to 12 inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one quarter of an inch in diameter and their muscular walls contract to make waves of movement that force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It has one-way flap valves that allow unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the ureters and kidneys. When the bladder contracts it passes urine into a tubular structure, called the urethra, which transports the waste out of the body.
What is urinary incontinence?
Urinary incontinence is the involuntary leakage of urine. It is not a disease but rather a symptom that can be caused by a wide range of conditions. Incontinence can be caused by diabetes, stroke, multiple sclerosis, Parkinson's disease, spinal cord injury, pelvic surgery or even childbirth. More than 15 million Americans, mostly women, suffer from incontinence. Although it is more common in women over 60, it can occur at any age. In the normal population, the incidence of incontinence in females over 65 is more than 25 percent and in males it is about 15 percent.
What are the various types of urinary incontinence?
Most health-care professionals classify incontinence by its symptoms or circumstances in which it occurs.
Stress Incontinence: Stress urinary incontinence is the most common type of leakage. It is defined as urine loss as a result of effort or exertion, or from sneezing or coughing. It tends to occur during activities such as walking, running, jumping or aerobics. The increased abdominal pressure associated with these activities causes urine to leak out through the urethra. The pelvic floor muscles, which support the bladder and urethra, are often weakened in this condition allowing mobility or movement of the urethra thus preventing it from working properly. Urine leakage also occurs as a result of a damaged urethral sphincter resulting in poor sphincter tone and function. Damage in these areas may be caused by many things, including prior surgery or previous childbirth. In men, the most common cause of stress incontinence is surgery on the prostate. This is more frequent after radical prostatectomy for prostate cancer than after transurethral surgery for benign prostatic hypertrophy, or BPH.
Urge Incontinence: Also referred to as overactive bladder, urge incontinence is another form of leakage. This can happen when a person has an uncontrollable urge to urinate but cannot reach the bathroom in time and has an accident. At other times, running water or cold weather may cause such an event. Some people have no warning and experience leakage just by changing body position (e.g., getting out of bed). Overactive bladder is associated with neurologic disease including stroke, multiple sclerosis and spinal cord injuries as well as aging, diabetes and back injury.
Mixed Incontinence: Mixed incontinence refers to a combination of stress and urge incontinence. Many patients experience symptoms of both types.
Overflow Incontinence: Overflow incontinence occurs as a result of poor bladder emptying and an always full bladder. In these patients, leakage occurs because the cup is already full and as more urine is produced it overflows and leaks out. Frequent small urinations and constant dribbling are symptoms. This is rare in women and more common in men with a history of surgery or prostate problems.
Functional Incontinence: This type of incontinence is the inability to access a proper facility or urinal container because of physical or mental disability.
What is the cause of incontinence?
Multiple factors have been found to be associated with urinary incontinence. Neurologic disease, prostatic disease, and obstetric factors have been the leading culprits. Studies have found that pregnancy, mode of delivery and parity are all factors that can increase the risk of incontinence. Women who delivered babies (via cesarean section or vaginal delivery) have much higher rates of stress incontinence than women who never delivered a baby. Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not. Increased parity (having more babies) also increases the risk. Age is also known to be a factor, as the human body ages muscle loss and weakness occur and the urinary tract is not spared. Menopausal women can also suffer from urine loss as a result of decreased estrogen levels interestingly, replacement estrogen has not been found to ameliorate the symptoms. Many medications have been associated with urinary incontinence. These include diuretics, estrogen, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives. Poor overall general health has been associated with incontinence. Specifically, diabetes, stroke, high blood pressure, smoking history, Parkinson's, back problems, obesity, Alzheimer's, and pulmonary disease have all been associated with incontinence.
How is the diagnosis made?
As with any medical problem, a good history and physical examination are critical. An urologist will first ask questions about the individual's habits and fluid intake as well as their family, medical and surgical history. A thorough physical examination looking for correctable reasons for leakage, including impacted stool, constipation, prostate disease and prolapse or hernias will be conducted. Usually a urinalysis and cough stress test will be performed at the first evaluation. If findings suggest further evaluation is necessary, tests such as cystoscopy or urodynamics may be recommended. Cystoscopy is performed by placing a small scope or camera through the urethra and into the bladder. Urodynamics is an outpatient test that is done with a tiny tube in the bladder inserted through the urethra and often with a second small tube in the rectum. The bladder is filled and the patient is asked to void while pressure measurements are recorded.
What are the treatment options for stress incontinence in women?
In most cases of incontinence, conservative or minimally invasive management is tried initially. This may include fluid management, bladder training, pelvic floor exercises and/or medication. However, when the symptoms are more severe or when conservative measures are not helping or are unsatisfactory the treatment is surgery.
Behavioral Modification: Mild to moderate stress incontinence in the female is treated initially with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.
Pelvic Floor Muscle Training: Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.
Periurethral Injections: One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to improve the coaptation of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Bulking material is injected into the urethral sub mucosal layer under direct vision. Unfortunately, the cure rate with this treatment is only 10 to 30 percent despite multiple formulations on the market for use. This treatment can be repeated and sometimes acceptable results are seen after multiple injections. The operation is minimally invasive but the cure rates are lower compared to the other surgical procedures.
Sub urethral Sling Procedures: The most common and most popular surgery for stress incontinence is the sling procedure. Today, most of these procedures are being called by the names TVT or TOT. In this operation a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better more sustainable outcomes. We have found however that synthetic meshes have both the ease of use with no need for harvest as well as superior long term results.
Retropubic Colposuspension: Another option is abdominal surgery in which the vaginal tissues or periurethral tissues are affixed to the pubic bone. The long-term results are good but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. This procedure can also be performed laparoscopically however long term results are not as good as with the open procedure.
Bladder Neck Needle Suspension: A long needle is used in these procedures to thread suture from the vagina to the abdominal wall. The suture incorporates paraurethral tissue at the level of the bladder neck. These procedures were found to be less effective than open retropubic suspensions and slings and as a result are rarely done today.
Anterior Vaginal Repair: Sutures are placed in the periurethral tissue and fascia in order to elevate and support the bladder neck. This procedure has also fallen out of favor for inferior long term outcomes compared to open retropubic suspensions and slings.
The potential adverse outcomes of surgical treatment include bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, pelvic organ prolapse, and failure of the surgery to fix the leakage. With the use of mesh materials there is a very small risk of erosion of the material into the bladder, urethra or vagina.
What additional treatment options are available for stress incontinence in men?
Men should also initially be managed with behavioral modifications and pelvic floor exercises. Periurethral injections can also be used in men. If these measures fail surgical options are available, these are different from those performed in women.
Male Sling: In male patients with stress incontinence, an alternative is to perform a urethral compression procedure, called a male sling. This is done with the use of a segment of cadaveric tissue or soft mesh to compress the urethra against the pubic bone. It is placed through an incision in the perineum (the area between the scrotum and the rectum). The results show decent success rates in patients with low volume incontinence, poor success is seen with severe incontinence. Long term data is not currently available.
Artificial Urinary Sphincter: The most effective treatment for male incontinence is implantation of an artificial urinary sphincter. This device is made from silicone and has three components that are implanted into the patient. The cuff is the portion that provides circular compression of the urethra and therefore prevents leakage of urine from occurring. This is placed around the urethra after an incision is made in the perineum. A small fluid-filled pressure-regulating balloon is placed in the abdomen and a small pump is placed in the scrotum to be controlled by the patient. The fluid in the abdominal balloon is transferred to the urethral cuff, closing the urethra and preventing leakage of urine. When the patient needs to urinate he presses the scrotal pump which releases the fluid back to the abdominal balloon opening the urethra and allowing the patient to void.
What are the treatment options for urge incontinence?
For urge incontinence there are also multiple treatment options available. The first step is behavior modifications including drinking less fluid, avoiding caffeine, alcohol and spicy foods, not drinking at bedtime, and timed voiding with urinating around the clock and not at the last moment. Exercising the pelvic muscle (Kegel exercises) can also help. It is important to keep a log on the frequency of urination, number of accidents, the amount lost, the fluid intake and the number of pads used. This helps the urologist tailor treatment to your specific needs.
Medications: The mainstay of treatment for overactive bladder and urge incontinence is medication. This consists of the use of bladder relaxants that prevent the bladder from contracting without the patient's permission. The most common side effect of the medication is dryness of the mouth, constipation or changes in vision. Sometimes, reduction of medication takes care of the side effects. Combinations of medications can also be used in some situations.
Neuromodulation: Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exciting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient's back close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses stimulate the bladder nerves and control bladder function. The exact mechanism of action remains unknown.
Botuliunum Toxin: Botox can also be used in refractory cases of urge incontinence. It is injected into the bladder muscle using a small needle and a cystoscope. It is however an off label use since it has not yet gained FDA approval for urgency incontinence. As a result the patient must pay out of pocket upwards of $1500 for the medication.
Bladder Augmentation: In more difficult cases, the bladder can be made bigger using a segment of small intestine. This operation, called augmentation cystoplasty, is very successful in curing incontinence but its main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization to empty their bladder. It is extremely effective in curing bladder urgency and urge incontinence.
What are the treatment options for overflow incontinence?
The treatment for overflow incontinence is complete emptying of the bladder. When the bladder is allowed to cycle properly with filling and emptying on a regular basis urine loss is usually prevented. Patients with neurologic conditions, diabetic bladder, or patients with obstruction secondary to prostate disease or organ prolapse can develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. This may include resection of prostatic tissue or urethral stricture or repair of pelvic organ prolapse. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly the incontinence often disappears.
What can be expected after treatment?
The goal of any treatment for incontinence is to improve quality of life for the patient. In most cases, great improvements and even cure of the symptoms are possible. Medical therapy is usually effective, but not if the patient sips fluids all day and does not time their urination. Similarly, large shifts in weight gain and activities that promote abdominal and pelvic straining put any repair to the test and cannot be expected to stand the test of time. Positive, long-term outcomes can almost be assured with common sense, proper body mechanics and care.
Surgery for stress incontinence in the female is in general very successful, but choosing the proper procedure is important. Many patients with stress incontinence also have other conditions like bladder prolapse, rectocele or uterine prolapse that must be treated at the same time. The combination of urgency incontinence symptoms requires medical treatment as well to try to improve these symptoms. The procedure of choice will depend on multiple factors, like the need for abdominal surgery for other conditions, the degree of incontinence, the degree of mobility of the urethra and bladder and the surgeon's personal experience. For simple stress incontinence with mild to moderate leakage, a sub urethral sling is most often the procedure of choice. Cure rates between 70-90% can be expected from this operation.
Surgery for urinary incontinence in the male like the artificial sphincter can cure or greatly improve more than 70 to 80 percent of the patients. Prior radiation, bladder malfunction and/or scar tissue in the urethra may result in a deterioration of the results. Being a mechanical device, it may require modification over time.
Medical treatment of urge incontinence can be very successful, but factors like prior surgery, lack of hormones, neurological conditions and age may make the treatment less effective. Surgery, like the insertion of a bladder pacemaker or enlargement of the bladder using a segment of intestine may cure the urgency incontinence in many of these refractory cases. It is sometimes the only choice when medication fails. Cure and improvement rates of 60 to 75 percent have been found with bladder pacemakers and 80-90% with bladder enlargement surgery.
Frequently asked questions:
What is a bulking agent?
It is a substance used to inject under the urethra to improve urinary continence.
What is an artificial sphincter?
An artificial sphincter is a patient-controlled device made of silicone rubber that has an inflatable cuff that fits around the tube through which urine leaves the body (urethra), a balloon that regulates the pressure off the cuff, and a bulb to control inflation and deflation of the cuff. The balloon is placed within the pelvic space, and the control bulb is placed in the scrotum of a male or the external vaginal lips of a female. The cuff is inflated to keep urine from leaking. When urination is desired, the cuff is deflated, allowing urine to drain out.
What are bladder relaxants?
They are medications used to improve the urgency and frequency of urination.
Where can I get more information?
AUA Guidelines Patient Guides: Female Stress Urinary Incontinence
Common misspellings: prostrate
Reviewed January 2011
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