Incontinence: Modern Surgical Options | PDF
By M. Gaafar El-Mallah, MD
Bryn Mawr Hospital
Many women are plagued with urinary leakage. Therapeutic options
include medication, pelvic-floor exercises, biofeedback and surgery. Dr.
El-Mallah provides an excellent review of the current state-of-the-art
treatments for surgical management. — Beverly
Vaughn, MD, Medical Coordinator, Menopause and You Program
Defining Urinary Incontinence
Urinary incontinence is a common disorder afflicting a large percentage
of menopausal and perimenopausal women. Urinary incontinence is
generally divided into two major subgroups—urge urinary incontinence
(UUI) and stress urinary incontinence (SUI). Many women may have various
combinations of the two major types; this is known as mixed
incontinence. Risk factors, symptoms and treatments are dependent on
which variety of incontinence a woman has, which makes appropriate
diagnosis key to understanding and treating this disorder.
SUI presents with a history of leakage of urine while sneezing,
coughing, or laughing, or through rapid movement brought on by exercise,
such as walking or gardening. UUI, in contrast, presents with
involuntary urinary loss in the absence of movement. Oftentimes a person
will suddenly feel an overwhelming urge to urinate, and may or may not
be able to make it to the bathroom. It is felt that some combination of
UUI and SUI affects between 15% and 35% of adult American women. While
there are a several medical options available for treating urinary
incontinence, this article will focus on some of the surgical options
The evaluation of urinary incontinence starts with the clinician
performing a detailed history, physical examination, and laboratory
The history should include a “voiding diary,” in which the patient
records her urination and incontinence episodes over time. The presence
or absence of nocturia (waking up at night to urinate) or enuresis
(bedwetting) are important clues.
The physical examination includes looking for the presence of a
cystocele (dropped bladder), ruling out the presence of a pelvic mass
that may be pressing on the bladder, conducting a basic neurologic test,
and looking at the degree of estrogen effect in the vagina.
Laboratory testing starts with basic screening tests, such as urine
analysis and culture, and should include an assessment of post-void
residual urine measurement.
Modern assessment of urinary incontinence should now also include
urodynamic testing for any complex presentations, for all patients
contemplating surgery, and for patients who may have already failed a
surgical procedure. With the introduction of new technology, urodynamic
testing can almost always be performed in a doctor’s office, and is
neither painful nor embarrassing. Urodynamic testing can be very simple,
like filling cystometry (measuring pressure and volume during filling
and voiding) or the Q tip test (measuring bladder neck support), or it
can be more complex, like multichannel cystometry and video
cystourethrography. The more complex tests require the placement of
small sensors in the bladder and vagina, and allow the very sensitive
measurement of bladder function and weaknesses. The testing is very
significant not only in diagnosis, but also for the patient to
understand the problem, discuss her frustration, optimize her
expectations, and tailor the proper treatment for her specific disorder.
New Treatments for Incontinence
Just as there are no blanket treatments for heart disease or cancer, so
must the treatment for urinary incontinence be very carefully matched to
a patient’s specific disorder, needs, and desires. Treatments run the
range from medication to lifestyle changes and exercise to surgical
procedures, as well as combinations of all of these.
Surgical treatment has undergone a revolution in just the last few years
and is far more successful now than ever before. The single biggest
predictor for a successful surgery is a proper diagnosis, which is why
appropriate testing is so critical.
The basic philosophy in incontinence surgery is to restore normal
anatomy to the bladder and to increase the strength of the outlet, or
sphincter. Older operations used suture materials to fix the bladder
neck to the pubic bone (Marshall-Marchetti-Krantz procedure) or to
ligaments attached to that bone (Burch procedure). The disadvantages of
these operations are: they require either laparotomy or laparoscopy to
perform; they can result in significant bleeding; and they are followed
by a lengthy recovery.
Modern, permanent slings can now be placed through tiny
incisions, and, when performed by experienced physicians, the success
rates range from 80 percent to 95 percent. The use of tension-free
slings, called TVTs or TOTs, have largely replaced older procedures, and
can often be done as an outpatient, under minimal anesthesia, and in
medically frail patients. In the case of a TVT, an inert, permanent
sling is placed under the mid-urethra, using an incision that is less
than one inch long. The sling is passed with a needle behind the pubic
bone through two even smaller incisions through the pubic hair region.
The TOT, or transobturator tape, is a more recent innovation. This uses
the same vaginal incision, but the sling is passed out the groin,
reducing the risk of injury to the bladder. Both procedures take just a
few minutes to perform, and have very little pain or recovery time.
Oftentimes a cystocele repair, commonly called a “bladder lift,” will be
done at the same time as a sling. This is needed when the bladder
herniates through the pelvic floor, usually as a result of childbirth,
and bulges out the vagina. In this procedure the tear in the pelvic
floor will be identified and repaired, and the bladder will be lifted
back to its normal position.
Another advance in the treatment of intrinsic sphincter deficiency, or
bladder neck weakness, is the use of collagen injections next to the
urethra. This can help maintain bladder control without the need for any
anesthesia at all, and is especially helpful in the elderly or frail
New surgical approaches are being used for the treatment of UUI as well,
although medical therapy is still the primary treatment. Neuromodulation
of the sacral nerve root through electrodes implanted in the lower back
has shown some promise. The injection of Botox into the bladder wall may
also reduce bladder spasticity.
The modern diagnosis and treatment of urinary incontinence should
finally allow women to address and eliminate this disabling disorder.
Remember, no treatment can occur unless you acknowledge the problem and
discuss it with your physician.
This article is part of the Menopause and Youlibrary,
a web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own health care practitioner with your
specific concerns and questions.
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