Urinary Incontinence / Treatment
Surgical treatments
All forms of incontinence can be treated surgically. Surgical correction should be considered only after all conservative options have been exhausted. The long-term success rates are excellent with surgery, though complications do infrequently occur. These include infection, bleeding, continued incontinence, and even inability to urinate.
Retropubic suspensions. These techniques involve the placement of sutures (stitches) into the tissues around the urethra through an abdominal incision. These sutures are then secured to ligaments attached to the pubic bone ("retropubic" means behind the pubic bone). This technique has an 84% long-term (greater than four years) success rate in curing stress incontinence. Types of retropubic suspensions include the Burch colposuspension and the Marshall-Marchetti-Krantz cystourethropexy. See Figure 2.
Transvaginal needle suspensions are similar to retropubic suspensions, however the peri-urethral sutures are placed from the vaginal side and are then transferred to the abdomen through a separate abdominal incision. The sutures are then either tied to the abdominal wall or to the pelvic bone. Needle suspensions include the Gittes, Raz, and Stamey procedures, and the long-term cure rate is 65-95%. See Figure 2.
The pubovaginal sling procedure is the most popular type of repair for stress incontinence due to either urethral hypermobility or intrinsic sphincter deficiency. It has up to a 95 % long-term cure rate. This technique is performed partly through the vagina and partly through a small abdominal incision similar to the incision for transvaginal procedures. A hammock-like bolstering of the urethra is created by the placement of a supporting strip of material under the bladder neck. This strip is then secured to the pelvic bone or abdominal wall with permanent suture. The material used is strong connective tissue either from the patient's own body (as in the Raz vaginal wall sling) or from a cadaver. See Figure 3.
Artificial urinary sphincters. Artificial urinary sphincters are often used in men who develop incontinence after prostate surgery, and are a good option for the treatment of intrinsic sphincter deficiency. These are fluid-filled devices that are surgically placed around the urethra. When the sphincter cuff is closed, urine stays in the bladder. The patient then squeezes a pump (located in the scrotum) which causes fluid to leave the cuff and enter a balloon which is implanted in the space next to the bladder. This allows urine to flow out of the bladder. After the patient urinates, fluid then automatically returns to the cuff and closes around the urethra.
Sacral Nerve Stimulation. This is a promising new technique for people with urge incontinence that do not respond to medical treatment. This involves the implantation of a device that electrically stimulates the nerves that control voiding function. It essentially acts as a "pacemaker" of the bladder. These nerves travel to the bladder through the sacral bone, and are known as the sacral nerves. In the office, the patient undergoes a diagnostic test stimulation under local anesthesia. If an appropriate response is seen, then a temporarily stimulation lead is placed underneath the skin near the appropriate sacral nerve for 3-7 days. If this results in significant reduction of urge incontinence symptoms, then the patient is implanted with a stimulator that includes a lead and a pulse generator.
Other less invasive treatments. Substances, such as collagen, can be injected around the urethra to compress the urethra and prevent urine leakage. This can be quite helpful in mild cases of intrinsic sphincter deficiency. Pessaries are devices that can be worn by women to help support the bladder and improve control. They are placed into the vagina in a manner similar to the placement of a diaphragm.
