Introduction
Pubovaginal sling is a procedure used to manage urinary incontinence, which is an underdiagnosed and underreported medical problem. Because of social stigma, an estimated 50%-70% of women with urinary incontinence fail to seek medical evaluation and treatment. Of individuals with urinary incontinence, only 5% in the general community and 2% in nursing homes receive appropriate medical evaluation and treatment. Patients with urinary incontinence often endure this condition for 6-9 years before seeking medical therapy.
Stress incontinence affects 15%-60% of women. It is a disorder that affects both young and elderly individuals. For example, more than one fourth of nulliparous young college athletes experience stress urinary incontinence (SUI) when participating in sports.
Slings are becoming increasingly popular with urologists for the treatment of all types of female SUI. Pubovaginal slings have excellent overall success and durable cure rates. The procedure involves placing a band of sling material directly under the bladder neck (ie, proximal urethra) or mid urethra, which acts as a physical support to prevent bladder neck and urethral descent during physical activity. The sling also may augment the resting urethral closure pressure with increases in intra-abdominal pressure.
History of the Procedure
Von Giordano is usually credited with performing the first pubovaginal sling operation in 1907, using a gracilis muscle graft around the urethra. In 1914, Frangenheim used rectus abdominus muscle and fascia for pubovaginal slings. In 1942, Aldridge, Millin, and Read corrected urinary incontinence using fascial slings. In 1965, Zoedler and Boeminghous first introduced synthetic slings.
Problem
Female SUI may be broadly subcategorized into types I, II, and III, as follows:
- Type-I SUI is defined as urine loss occurring in the absence of urethral hypermobility. This is the mildest form of SUI.
- Type-II SUI is defined as urine loss occurring due to urethral hypermobility. This is also known as genuine stress urinary incontinence (GSUI).
- Type-III SUI is defined as urine leakage occurring from an intrinsic sphincter deficiency (ISD). ISD is a more complex form of female SUI.
The subcategories of female SUI can be ascertained by direct physical examination and by measuring an abdominal leak point pressure (ALPP). ALPP, also known as the Valsalva or stress leak point pressure, is defined as the lowest abdominal pressure necessary to cause urine leakage.
An ALPP less than 60 cm water is considered diagnostic of type-III SUI, whereas an ALPP of 90-120 cm water is consistent with type-II SUI. Values of 60-90 cm water reflect the presence of both type II and III, in combination. An ALPP greater than 120 cm water is considered diagnostic of type-I SUI.
Recent experience suggests that leak point pressures to not need to be stratified as they were in the past, as new slings manage all types of SUI. The types of incontinence listed above are noted for descriptive and historical purposes only.
Frequency
Urinary incontinence affects approximately 13 million people in the US, predominantly women. This incidence rate includes 10%-35% of adults and 50% of the 1.5 million residents in nursing homes. As many as 60% of nursing home patients are incontinent, while 30% of elderly people living at home are incontinent.
Of the 3 types of female SUI, type-II SUI occurs most commonly (37%), followed by type-III SUI (33%), types II and III in combination (16%), and type-I SUI (13%). McGuire has previously reported that ISD is a complication of simple hysterectomy and was present in 48% of 67 patients after hysterectomy.1
Etiology
The cause of SUI is complex. Many different factors contribute, including advancing age, multiparity, prolonged or difficult labor, and hysterectomy. Other factors that may increase the risk of developing incontinence include obesity, straining at stool as a child or young adult, heavy manual labor, chronic obstructive pulmonary disease, and smoking. For men, prostate surgery is the most common cause of SUI.
Pathophysiology
Two major types of SUI exist in women, urethral hypermobility and ISD. Male SUI results from loss of function of both the internal and the external sphincter mechanism. Unlike females with SUI, men develop only type-III SUI, ie, ISD.
Urethral hypermobility
This condition results from a weakened anatomic support of the urethra, whereas ISD arises from a defect within the urethra proper. When a loss of anatomic support occurs, the proximal urethra and the bladder neck descend to rotate away and out of the pelvis at times of increased intra-abdominal pressure. Because the bladder neck and proximal urethra move out of the pelvis (ie, outside of the abdomen), the bladder receives greater intra-abdominal pressure relative to the urethra. Because of this pressure differential, the urethra decreases intraurethral resistance and is more susceptible to involuntary urine loss.
Realize that the female urethra lies under the pubic symphysis, and the pubourethral ligaments suspend the anterior urethral wall to the pubic arch. During the Valsalva maneuver (eg, abdominal strain), the posterior wall of the urethra slides away from the anterior urethral wall to cause the bladder neck to open in patients with urethral hypermobility. The uneven pressure transmission, together with the opening of the bladder neck, results in involuntary urine loss during periods of physical activity, ie, type-II SUI.
Intrinsic sphincter deficiency
In this condition, the urethral sphincter is unable to coapt and generate enough resting urethral closing pressure to retain urine in the bladder.
The anatomic support is normal, but the urethra cannot remain closed owing to a lack of the mucosal seal mechanism. Inadequate bladder outlet resistance during times of physical activity results in involuntary urine loss, ie, type-III SUI. Again, newer thought processes suggest that all patients with SUI have some component of ISD. The distinctions between types I, II, and III are now less important than they once were.
Presentation
Stress urinary incontinence
This condition occurs during periods of increased intra-abdominal pressure. Typically, patients complain of involuntary urine loss during coughing, laughing, and sneezing. Their incontinence becomes worse during high-impact sports activities (eg, golf, tennis, aerobics). Furthermore, leakage is more common while standing than while lying down (eg, at night); thus, patients describe minimal symptoms of leakage at night, just during the day.
In general, women with SUI experience less urine loss than women with overactive bladder (OAB). SUI occurs at predictable times. Mixed urinary incontinence (MUI) is characterized by irritative voiding symptoms, including urinary frequency, urgency, and nocturia. SUI caused by urethral hypermobility results in a smaller amount of urine loss and requires the use of fewer pads than are required for ISD.
Urinary incontinence
Patients with symptoms of urinary incontinence should undergo a basic evaluation that includes a medical history, physical examination, measurement of postvoid residual urine, and urinalysis. Ideally, the physician should try to determine which aspects of quality of life (QOL) are affected by the patient’s incontinence. This can be assessed with various validated outcome measures.
Questions pertinent to the medical history include whether incontinence is associated with physical activity versus a sense of urgency. If the urine loss is coincident with coughing, laughing, and sneezing in the absence of irritative voiding symptoms, the patient is most likely describing SUI.
Pure SUI does not produce irritative voiding symptoms (eg, frequency, urgency, nocturia). Furthermore, this type of incontinence is usually predictable because the condition occurs only during periods of increased intra-abdominal pressure (eg, physical activity). The amount of urine lost is small and is usually reflected by the number and type of pads used. Typically, affected patients use thin to medium-thickness pads. The number of pads used ranges from 1-3 per day; however, the amount of urine loss and pad use increases with the complexity of SUI. Patients with ISD are likely to lose more urine and use more pads than women with type-II SUI.
If the symptoms of frequency, urgency, and nocturia are present, the patient is more likely describing urge incontinence or OAB or both SUI and OAB symptoms (MUI). Urinary incontinence caused by an OAB is often unpredictable, and the amount of urine lost is greater than that associated with SUI. When patients experience an uninhibited detrusor contraction, they expel the entire contents of their urinary bladder. Thus, patients with OAB tend to use more and thicker pads than women with SUI alone. Often, patients with OAB tend to be more distressed by their symptoms than women with SUI.
If the symptoms include urinary frequency, urgency, postvoid dribbling, and a sense of incomplete emptying, the patient may be describing overflow incontinence. This condition is considered a urologic emergency and should be ruled out when examining a patient with incontinence. Urinary retention may be the result of previous anti-incontinence surgery, idiopathic urethral stenosis, urethral carcinoma, diabetes, or excessive use of anticholinergic or antispasmodic drugs. Patients may also complain of suprapubic pain and abdominal distention.
If a woman reports total or continuous incontinence, she may have ISD or a fistula (eg, vesicovaginal, ureterovaginal). Because some women with ISD have such low urethral resistance, simply standing up from a sitting position evokes urine loss by gravity. This is similar to vesicovaginal or ureterovaginal fistula. These patients complain of being wet all the time and use excessive amounts of thick pads to stay dry. If suspecting a fistula, be sure to ask about previous surgical history, including a hysterectomy. Although uncommon, consider ectopic ureter/ureterocele in the differential diagnoses.
During the physical examination, a detailed pelvic examination is extremely important. Assess the external genitalia for the presence of atrophic vaginitis. Friable and irritated tissues around the vaginal introitus and labia minora suggest vaginitis. The presence of masses on the anterior vaginal wall should raise the suspicion of urethral caruncle, urethral diverticulum, urethral carcinoma, and Skene gland cyst.
Systematically inspect the anterior and posterior surface and the apex of the vagina for the presence of pelvic organ prolapse, including urethrocele, cystocele, rectocele, enterocele, and vaginal vault prolapse.
Some patients may need to provide additional information from a voiding diary, cotton swab test, cough stress test, cystoscopy, and urodynamics test.
Indications
The common indications for pubovaginal sling surgery in women include stress urinary incontinence (SUI) that affects QOL and potential incontinence in a patient undergoing prolapse repair. Conservative treatment measures, including diet modification, pelvic floor exercises, smoking cessation, and weight loss, have typically failed in such patients.
In addition, women at risk for generating high intra-abdominal pressures, including patients who are obese, vigorous athletes, and those with chronic obstructive pulmonary disease, are well served by pubovaginal slings.
In men who have undergone prostatectomy and have intrinsic sphincter deficiency (ISD), the artificial urinary sphincter (AUS) is the criterion standard therapy. Researchers recently introduced the male sling as an alternative to AUS in correcting postprostatectomy incontinence. During a male sling operation, the surgeon places a supporting strap of material under the bulbar urethra and secures the suspension sutures to the pubic arch, next to the bulbar urethra. The use of a male sling for SUI in men is still early in its experience, although many patients have undergone the procedure successfully and have had excellent results. A male sling seems best geared toward patients with milder degrees of incontinence (2-3 pads or fewer per day).
Relevant Anatomy
Female urethra
The female urethra is an elongated tube (4 cm) that is composed of an inner epithelial lining, a spongy submucosa, a middle smooth muscle layer, and outer fibroelastic connective tissue (see images below).
The female urethra is composed of 4 separate tissue layers that keep it closed. The inner mucosal lining keeps the urothelium moist and the urethra supple. The vascular spongy coat produces the mucus important in the mucosal seal mechanism. Compression from the middle muscular coat helps to maintain the resting urethral closure mechanism. The outer seromuscular layer augments the closure pressure provided by the muscular layer.
The female urethra contains an internal sphincter and an external sphincter. The internal sphincter is more of a functional concept than a distinct anatomic entity. The external sphincter is the muscle strengthened by Kegel exercises.
The spongy submucosa contains a rich vascular plexus that is responsible for providing adequate urethral occlusive pressure to create the washer effect, an important female continence mechanism. Urethral smooth muscle and fibroelastic connective tissues circumferentially augment the occlusive pressure generated by the submucosa.
All parts of the female urethra are influenced by estrogen. The lack of estrogen at menopause leads to atrophy and replacement of the submucosa (eg, vascular plexus) by fibrous tissue.
Previous bladder neck operations, radiation exposure, and neurogenic disease can affect the ability to achieve a perfect seal. When a postmenopausal woman with atrophic vaginitis takes estrogen, the mucosa regains its turgor and a simultaneous up-regulation of alpha-receptors and angiogenesis of the vascular plexus occurs. Lack of estrogen is one of the risk factors for intrinsic sphincter deficiency (ISD); replacement of estrogen may reverse the effects of ISD. Complete reversal of ISD is rare, but estrogen supplementation improves symptoms of type-III SUI.
Internal sphincter
The bladder neck and the prostate comprise the internal urinary sphincter in males.
Women do not have an anatomic internal sphincter; they have a functional internal sphincter. The bladder neck and proximal urethra comprise the female internal sphincter (see images below). Under normal circumstances, the resting urethral closure pressure of the internal sphincter exceeds the resting or stressed intravesical pressure of the bladder.
The female urethra contains an internal sphincter and an external sphincter. The internal sphincter is more of a functional concept than a distinct anatomic entity. The external sphincter is the muscle strengthened by Kegel exercises.
The pubourethral ligaments suspend the female urethra under the pubic arch.
External sphincter
The female external sphincter, ie, the rhabdosphincter, is composed of 2 types of striated muscle fibers, fast twitch and slow twitch. Fast-twitch fibers cause the sudden stopping of the urinary stream to provide the voluntary guarding reflex. Slow-twitch fibers maintain the constant tone of the external sphincter to provide continuous passive continence, the involuntary guarding reflex.
The rhabdosphincter has the most prominent effect on the female urethra at the urogenital triangle. Located approximately 1.8 cm distal to the bladder neck, it exerts influence for a distance of approximately 1.5 cm of urethral length (see images below).
The female urethra contains an internal sphincter and an external sphincter. The internal sphincter is more of a functional concept than a distinct anatomic entity. The external sphincter is the muscle strengthened by Kegel exercises.
The pubourethral ligaments suspend the female urethra under the pubic arch.
The male external sphincter is similar to that of female external sphincter, ie, the rhabdosphincter.
Pelvic diaphragm
The pelvic diaphragm lines the floor of the bony pelvis and is composed of 4 sheets of muscles, the pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus (see images below).
The pelvic diaphragm (ie, levator ani musculature) is composed of pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus muscles. It contains 3 openings through which the rectum, urethra, and cervix pass.
This is the side view of the pelvic diaphragm. The pelvic diaphragm supports the pelvic organs (eg, bladder, uterus, rectum).
Specialists often refer to the pelvic diaphragm as the levator ani. The levator ani musculature is attached to the inner sides of the bony pelvis by a condensation of pelvic fascia called the arcus tendineus.
The levator ani is the most important component of the pelvic diaphragm because the integrity of the pelvic floor depends upon its function. When the levator ani is damaged, stress urinary incontinence (SUI) and/or herniation of pelvic organs through the vagina may develop (see images below).
The pelvic diaphragm (ie, levator ani musculature) is composed of pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus muscles. It contains 3 openings through which the rectum, urethra, and cervix pass.
This is the side view of the pelvic diaphragm. The pelvic diaphragm supports the pelvic organs (eg, bladder, uterus, rectum).
Supporting ligaments and fascia
The urethropelvic ligament is a fibrous band of connective tissue that lines the undersurface of the bladder neck and attaches laterally to the arcus tendineus. The urethropelvic ligament provides the major support to the bladder neck and proximal urethra. Laxity of the urethropelvic ligament results in SUI.
The pubocervical fascia is a fibrous sheet of connective tissue that lines the base of the urinary bladder and inserts laterally into the arcus tendineus. An intact pubocervical fascia prevents the herniation of the bladder and the proximal urethra into the vagina. Damage to the pubocervical fascia may cause the bladder to herniate through the vagina, resulting in cystocele formation and SUI.
The cardinal ligaments arise from the arcus tendineus and anchor to the uterine cervix. The cardinal ligaments stabilize and support the uterus, vagina, and bladder. Weakening of the cardinal ligaments may cause a cystocele and uterine descensus (see image below).
This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet.
The uterosacral ligaments originate from condensation of the fibrous connective tissue overlying the sacral promontory and insert into the uterine cervix. The uterosacral ligaments stabilize the uterus in the bony pelvis. Weakening of the uterosacral ligaments may cause a prolapsed uterus or vaginal vault prolapse (see image below).
This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet.
Contraindications
A clear contraindication to pubovaginal sling surgery is pure urge incontinence or mixed urinary incontinence (MUI) in which urge is the predominant component. An inherent risk of any sling procedure is de novo or worsening urge symptoms; thus, surgeons must identify and treat the presence of an urge component before surgery.
Conversely, poor detrusor function is a relative contraindication to sling surgery because the potential for urinary retention is increased. Women with absent or poor detrusor function in the presence of stress urinary incontinence (SUI) are at a higher risk of experiencing prolonged postoperative urinary retention.
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Further Reading
Keywords
pubovaginal sling, incontinence, urinary incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, decompensated bladder, detrusor instability, Marshall test, Kegel exercises, detrusor hyperreflexia, overactive bladder, SUI, urethral hypermobility, intrinsic sphincter deficiency, ISD, sling, pubovaginal sling, bladder sling, suburethral sling, bladder neck suspension, urethropexy, transvaginal urethropexy, retropubic urethropexy, MUI, mixed urinary incontinence, stress urinary incontinence, urge urinary incontinence
