Surgical Management
of Urinary Incontinence

Bladder control is a common yet complex problem  that can seriously affect a person's life. Fortunately, with today's high-tech procedures and powerful drugs, a diagnosis may simply mean the road to bladder control is challenging, rather than impossible. So read below to learn more about the available treatment options so you are better prepared when talking 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 kidneys, 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 glucose, 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-fourth 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 also is a one-way flap valve that allows unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the kidneys. It also closes passageways into the ureters so that urine cannot flow back into the kidneys. The tube through which the urine flows out of the body is called the urethra.

What is urinary incontinence?

Urinary incontinence is the involuntary loss 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, a stroke, multiple sclerosis, Parkinson's disease, some surgeries 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. Most health-care professionals classify incontinence by its symptoms or circumstances in which it occurs. In the normal population, the incidence of incontinence in the female over 65 is more than 25 percent and in the male it is about 15 percent.

What are the various types of urinary incontinence?

How is the diagnosis made?

As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual's habits and fluid intake as well as their family, medical and surgical history. A thorough pelvic examination looking for correctable reasons for leakage, including impacted stool, constipation and hernias will be conducted. Usually a urinalysis and cough stress test will be conducted at the first evaluation. If some findings suggest further evaluation, other tests may be recommended ? such as a cystoscopy or even urodynamic testing. This outpatient test is usually done with a tiny tube in the bladder inserted through the urethra and sometimes with a small rectal tube, as well.

What are some treatment options for each type of incontinence?

In most cases of incontinence, minimally invasive management (fluid management, bladder training, pelvic floor exercises and medication) is prescribed. However, if that fails, surgical treatment can be necessary.

Stress incontinence in the female is treated at the beginning with behavior modification and pelvic exercise. Sometimes techniques like electrical stimulation of the pelvic muscles can help. But when the symptoms are more severe and conservative measures are not helping the treatment is surgery. In selected cases bulking agents can be used to increase continence. The operation is done under local anesthesia and is minimally invasive but the cure rates are lower compared to open surgical procedures.

Anterior repair (Kelly plication) is a common option used by gynecologists but has not given good long-term results. Another option is abdominal surgery (Burch suspension) in which the vaginal 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. The most common and most popular surgery for stress incontinence is the sling procedure. In this operation a strip of tissue or polypropylene tape is applied under the urethra to provide compression and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. The tissue used to create the sling can be a segment of the patient's abdominal wall, specially treated fascia, skin from a cadaver or a synthetic material.

Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exiting 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 control bladder function. There is more than 60 to 75 percent cure or improvement with this technology. 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.

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.

Medical treatment of overactive bladder (urgency and urge incontinence) can be very successful, but factors like prior surgery, lack of hormones, neurological conditions and age may make the treatment less effective. There are mild complications from medications, including constipation and dryness of the mouth that some patients cannot tolerate. Surgery, like the insertion of a bladder pacemaker, can result in 50 to 70 percent cure or great improvement of the symptoms. Enlargement of the bladder using a segment of intestine may cure the urgency incontinence in more than 80 percent of the cases but the main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization for the rest of their life. It is sometimes the only choice when other treatments fail.

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.

Surgery for urinary incontinence (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 first to try to improve the 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 urethral incontinence, a sling is the procedure of choice. The patient can expect more than 80 to 90 percent cure or great improvement. Injectables can cure 30 percent of patients but may require multiple applications.

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) close to the point where it joins the bladder
• a balloon that regulates the pressure of the cuff
• 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