Surgery - Treating Urinary Incontinence: Bladder Conditions

Content provided by the Faculty of the Harvard Medical School

Surgery

Surgery for urinary incontinence is generally recommended only after less invasive measures have failed to provide enough help. But because some surgical procedures for stress incontinence are relatively quick and low-risk, your doctor may recommend surgery earlier if your incontinence is due to a repairable structural problem or if it seems unlikely that nonsurgical approaches will be satisfactory.

Surgery is most often used to treat stress incontinence, but it is also possible to treat severe urge incontinence by implanting a stimulator. If incontinence is caused by a prolapsed uterus in a woman or an enlarged prostate in a man, surgery to correct those conditions (not detailed in this report) may relieve the incontinence along with other symptoms.

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 when you cough or sneeze. This can be done by several methods. The most successful method used to be bladder neck suspension of a type called the Burch procedure, 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 is to create a sling to support the urethra hammock-style. A third method involves injecting a bulking agent to firm up tissues surrounding the urethra.

For men, injected bulking agents are often helpful (see "Injection of bulking agents"). Men can also benefit from insertion of a sling designed for male anatomy, and they are also far more likely than women to benefit from an artificial urinary sphincter.

Before a decision to operate is made, you will need to undergo detailed diagnostic testing so the surgeon can decide which type of surgery would work best. 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 carefully, because additional attempts are less successful.

Three 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 urge incontinence, even if you were never troubled by them before (7%–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, in rare cases requiring a catheter to empty your bladder.

Bladder neck suspensions. Bladder neck suspensions are surgical procedures for women with stress incontinence that elevate or increase support for the bladder neck area during physical exertion. These procedures are performed less commonly now that tape and sling procedures (see below) are available.

Retropubic suspension. For this procedure, the surgeon cuts a 3- to 5-inch incision in your lower abdomen and lifts the tissue next to the bladder neck up, anchoring it near the pubic bone. The various procedures are usually named for the surgeons who developed them. In the Burch procedure (or Burch colposuspension), your surgeon uses strong stitches (sutures) to anchor the tissue to a ligament (called Cooper's ligament) near your pubic bone. If the stitches are placed into the pubic bone itself, the operation is called the Marshall-Marchetti-Krantz (MMK) procedure.

Needle suspension procedures. Often working through an incision in the vagina, the surgeon places long sutures through the supporting tissue near the urethra and hitches the tissue up slightly by attaching the sutures to a layer of strong connective tissue on top of the abdominal muscles near the pubic bone (reached through a tiny abdominal incision). Because the attachment is made to movable tissues, rather than bone or ligaments, the sutures can break or stretch out, reducing the benefits of the operation. Needle suspension procedures frequently fail and are far less effective than abdominal surgeries or sling procedures. If your doctor recommends a needle suspension, ask to have alternative procedures considered.

Sling and tape procedures. These procedures have become increasingly common because they are easy and effective. The basic procedure involves the surgeon installing a supportive sling — made either of your own tissue or an artificial tape similar to nylon — under and around the urethra to support it (see Figure 4). In women, the sling can support the bladder neck and urethra in the proper position, which helps the urethra hold in urine during a cough or sneeze. In men, the sling puts pressure on the urethra just below the bladder.

For women. Two types of minimally invasive sling operation are available. In one, your surgeon places a hammock of tension-free vaginal tape (TVT) underneath the urethra and extending up to the abdominal wall above the pubic bone (see Figure 4). The tape 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 a standard sling 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). In a randomized clinical trial, women had significantly greater improvement in continence following TVT placement than after the laparoscopic Burch procedure. Operating and recovery times are shorter, and most women return to normal activities within about 10 days.

Figure 4: Sling surgery For some women with stress incontinence (who leak urine when they jump, cough, or laugh), the surgical insertion of a urethral sling or tape can help support the urethra. In the version shown here, the surgeon makes two small incisions in the lower abdomen, to insert a strip of synthetic mesh (tension-free vaginal tape) around the urethra to support it. Gradually, your body's own tissues grow through the mesh to hold it in place.

A newer minimally invasive sling, the transobturator tape procedure (with brand names such as TVT-O and Monarc), 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 in a gentler fashion, 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 may reduce the risk of bowel or bladder injury during surgery, and it can be used in women who have scar tissue from previous surgeries. The most common complications are urinary infection, difficulty urinating, and erosion of the vaginal wall near the tape. Since this type of sling is newer, there are no long-term data available. The Urinary Incontinence Treatment Network, a consortium of centers that conduct incontinence research, is comparing outcomes following TVT versus transobturator sling procedures.

For either procedure, 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 surgery may be necessary to correct the problem. 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.

The availability of minimally invasive procedures has led physicians to consider surgical treatment for stress incontinence in women who are younger and have less severe incontinence.

For men. Sling surgery (also called bulbourethral sling surgery) is relatively simple and usually does not require an overnight hospital stay. During the half-hour procedure, an incision is made between the scrotum and rectum, and the sling is held in place by anchors inserted into each side of the pelvic bone.

Complications following male sling surgery can include infection, discomfort, and a shift from incontinence to the opposite problem — difficulty urinating and urinary retention. Men often need to use a catheter to empty their bladders for a short time after this surgery. The sling is usually for men who have lost their urethral sphincter function because of prostate treatment, other surgery, or trauma. Scarring from previous surgeries or injuries (such as a pelvic fracture) may decrease the likelihood of success.

Injection of bulking agents. Injection of a bulking agent can reinforce the tissue around the urethra. This procedure can help men who have had their prostates removed and women with the type of stress incontinence known as intrinsic sphincter deficiency, in which the urinary sphincter no longer closes completely and allows urine to leak out, particularly with exertion. After injection, the bulking agent pushes against the urethra to make it narrower, so that it closes off more readily.

The most common injectables are collagen (Contigen), the protein that gives skin its tone and that's often used in cosmetic surgery; carbon-coated beads (Durasphere); a synthetic polymer that is injected as a liquid but changes into a spongy material (Tegress); and a solution of round calcium particles suspended in a gel (Coaptite). Collagen tends to be reabsorbed after a year or two. The lifespan of synthetic bulking agents is unknown and may be far longer, but they have been demonstrated to remain for at least a year.

Injection of bulking agents takes less than half an hour and can be performed in the physician's office or as an outpatient procedure in the hospital. A needle is placed into the urethra using a cystoscope for viewing, and the bulking agent is injected into the tissue alongside the urethra. A few injections may be given during one session. Although the procedure is minimally invasive and can be considered nonsurgical, you will be given either local or a light general anesthesia or sedation. Only small amounts of bulking agents are injected at one time, so more than one treatment may be needed to achieve satisfactory results. Physicians must be cautious about injecting too much; if the urethra becomes blocked, the material may need to be removed surgically.

For the first day or two after an injection, you may feel irritation when you urinate. You might even need to use a catheter intermittently until swelling goes down in the area of the injection. After a few days, you should be able to return to normal activities.

Bulking agents work best in women with intrinsic sphincter deficiency; it is not likely to help if you have urge incontinence, an abnormally small bladder capacity, or if your bladder neck is hypermobile (not well supported). In general, women do better after injections of bulking agents than men do. About 80% of women show some level of improvement; 40% become dry and remain dry with only one or two treatments.

Men typically have this procedure after prostate removal; the bulking agent is injected into the area the prostate had occupied in order to provide support for the urethral muscles so urine isn't as easily lost. Although 70% of men experience some improvement in their symptoms, only 8% become dry with one or two treatments and require no further injections.

Approximately 3% of people are allergic to the cattle-derived medical collagen, leading to inflammation, tenderness, and a variety of urinary symptoms. To minimize the risk, you will be required to have a collagen skin test a month before the injection.

You should not be injected with bulking agents if you have a urinary tract infection or have had many in the past, or if the physician sees through the cystoscope that the lining of your urethra is fragile and might erode in the area of the injection.

Artificial sphincters

An artificial sphincter is a fluid-filled cuff surgically placed around the urethra to prevent urine from leaking out (see Figure 5). 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.

Figure 5: Artificial sphincter 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.

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. During that time your incontinence will not 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 to 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.

Surgery for urge incontinence

In both men and women, urge incontinence is generally treated with medication and behavioral approaches. Surgery is considered only when the problem is severe and has not responded to less invasive approaches.

Sacral neuromodulation. Without your awareness, there is a constant loop of communication between your bladder and one of your lower spinal nerves (the third sacral nerve). About six times per second, the sacral nerve sends an impulse to the bladder to remind it "don't go now." If that signal isn't sufficiently strong or frequent, you can develop problems with urgency, frequency, and urge incontinence.

In the late 1990s, the FDA approved a pacemaker-like implanted device, InterStim, for use in men and women with bladder frequency, urgency, and urge incontinence that has not responded to medication, bladder training, or biofeedback. If your doctor thinks the device might help you, you can be temporarily fitted with a test system. To do so, the physician places a wire near your sacral nerve and attaches it to an external device that sends electrical impulses through it. If your symptoms improve greatly while wearing the device, you are a good candidate for long-term stimulation.

The long-term device is inserted while you are under general or local anesthesia. The surgeon makes a small incision over the sacrum (the spinal bone above your tailbone) and inserts a lead wire there. From the sacrum, the wire runs just under your skin and fat layer until it connects to the small stimulator device (about the size of a stopwatch) implanted just under the skin and fat in a nonintrusive location in your upper buttock or abdomen. You use a hand-held control device to adjust the stimulator as necessary. Every three years or so, you will need another minor surgery to replace the battery. The manufacturer warns that it is unsafe to undergo medical treatments involving diathermy (heating parts of the body using electrical currents or ultrasound) while the device is in place; the energy can damage the system and cause serious or life-threatening damage to surrounding tissue.

In a multicenter trial without a control group, sacral nerve modulation significantly improved symptoms of urge incontinence and severe urgency and frequency. After a year, 45% of subjects with urge incontinence remained completely dry, and another 34% had less than half of their previous leakage. Almost two-thirds of patients with frequency problems reduced their number of voids by more than half.

On the other hand, this treatment is not without risks. About one-third of patients require repeat surgery because of pain, infection, or movement of the wire. InterStim is expensive, but Medicare and most insurers cover it.

Bladder augmentation. Men and women who have severe urge incontinence because their bladders have become incapable of expanding normally are sometimes treated with bladder-enlarging surgery. Bladder augmentation, also called a "clam" augmentation cystoplasty or cystoenteroplasty, enlarges your bladder by attaching a piece of your intestine. Both the surgery and recovery are difficult.

Bladder augmentation is unlikely to be recommended unless your bladder is very small or an injury (usually a spinal cord injury) or disease (such as multiple sclerosis, severe interstitial cystitis, or radiation treatment for cancer) has made it incapable of expanding to hold a reasonable amount. This major abdominal surgery is usually reserved for people who have tried and failed to get relief through other measures, including sacral neuromodulation. It does not always cure urge incontinence.

The surgery is performed under general anesthesia and takes up to seven hours. Afterward, you will use a catheter for many days until you are able to urinate. Following this procedure, most patients need to use intermittent catheterization in order to urinate. Other possible complications are infection and chronic diarrhea.

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 women), 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.

Surgery for reflex incontinence

The only surgery available for reflex incontinence is the artificial urinary sphincter.

Last updated:	September 05, 2008