eMedicine Specialties > Urology > Incontinence

Urinary Incontinence, Surgical Therapies: Follow-up

Author: Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Coauthor(s): Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic; Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic; Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic
Contributor Information and Disclosures

Updated: May 8, 2009

Outcome and Prognosis

Retropubic suspensions and sling procedures are excellent operations for their indications in treating female stress urinary incontinence. Periurethral bulking agents are less durable in their success but offer an office-based procedure that may provide significant improvement with minimal morbidity for treating stress urinary incontinence. Sling surgeries may involve autologous tissue, synthetic biomaterials, and cadaver allografts. The particular type of operation chosen depends on the patient's needs combined with the surgeon's expertise. When performed properly, the long-term cure rate (supported recently by 11-year data) associated with retropubic suspensions and sling surgery should approach 90%, with minimal complications.

Future and Controversies

The management of long-term urinary retention after an anti-incontinence procedure remains controversial. Postoperative urinary retention may be treated with an indwelling catheter, intermittent catheterization, cutting of suspension sutures or sling material, or complete urethrolysis with or without a repeat sling procedure.

Acute urinary retention is initially treated with an indwelling urethral catheter or self-intermittent catheterization. If a suprapubic tube was placed intraoperatively, it is left in place. In most cases, patients are able to void spontaneously within 3 weeks and catheterizations are discontinued.

If urinary retention persists at 3 weeks, a pressure-flow study must be performed to document a well-functioning detrusor and to help rule out urethral obstruction. If the patient has an atonic detrusor, long-term catheterization, intermittent or otherwise, will be needed.

If the patient has normal detrusor function, an alternative to intermittent catheterization is to take down the suspension or sling procedure.

The timing of urethrolysis is controversial. If urinary retention occurs after a rectus fascial sling, urethrolysis is recommended after 3 months of urethral obstruction. If urethral obstruction results after a synthetic sling, urethrolysis should be performed as early as 2 weeks.

Formal urethrolysis of an autologous sling involves complete dissection circumferentially around the bladder neck and proximal urethra. Conversely, urethrolysis of a synthetic sling may require only an incision of one or both arms of the sling rather than complete dissection of an autologous sling.

After urethrolysis of a rectus fascial sling, one may choose to place another autologous sling to prevent recurrent stress incontinence. If a urethral injury is encountered, it is repaired primarily and a Martius fat pad (fat pad from the labia majora), omentum, or posterior peritoneum may be used to reinforce the closure. Whether to proceed with another sling at the time of urethrolysis should be tailored to each individual patient.

On October 20, 2008, the Food and Drug Administration (FDA) issued a public health notification regarding the use of mesh in the treatment of pelvic organ prolapse or stress urinary incontinence. The report outlined potential complications including mesh erosion, pain, urinary problems, and recurrent incontinence.

Despite these potential complications, realize that retropubic suspensions and sling procedures are excellent operations for their indications in treating female stress urinary incontinence. Sling surgeries may involve autologous tissue, synthetic biomaterials, and cadaver allografts. The particular type of operation chosen depends on the patient's needs combined with the surgeon's expertise. When performed properly, the long-term cure rate associated with retropubic suspensions and sling surgery should approach 90%, with minimal complications.

The future of anti-incontinence surgical therapy is bright and promising. With advances in biomechanical engineering, coupled with clinical and basic science research, the understanding of the incontinence disease process and the development of new surgical options are increasing rapidly. With the current evolution of stem cell research and genetic engineering, more minimally invasive and technologically advanced surgical procedures will be forthcoming in the near future.

 


More on Urinary Incontinence, Surgical Therapies

Overview: Urinary Incontinence, Surgical Therapies
Workup: Urinary Incontinence, Surgical Therapies
Treatment: Urinary Incontinence, Surgical Therapies
Follow-up: Urinary Incontinence, Surgical Therapies
Multimedia: Urinary Incontinence, Surgical Therapies
References
[ CLOSE WINDOW ]

References

  1. Fultz NH, Herzog AR, Raghunathan TE, Wallace RB, Diokno AC. Prevalence and severity of urinary incontinence in older African American and Caucasian women. J Gerontol A Biol Sci Med Sci. Jun 1999;54(6):M299-303. [Medline].

  2. Freeman EW, Grisso JA, Berlin J, Sammel M, Garcia-Espana B, Hollander L. Symptom reports from a cohort of African American and white women in the late reproductive years. Menopause. Jan-Feb 2001;8(1):33-42. [Medline].

  3. Howard D, Delancey JO, Tunn R, Ashton-Miller JA. Racial differences in the structure and function of the stress urinary continence mechanism. Obstet Gynecol. May 2000;95(5):713-7. [Medline].

  4. Romanzi LJ, Blaivas JG. Protracted urinary retention necessitating urethrolysis following tension-free vaginal tape surgery. J Urol. Dec 2000;164(6):2022-3. [Medline].

  5. Novara G, Galfano A, Boscolo-Berto R, Secco S, Cavalleri S, Ficarra V. Complication rates of tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials comparing tension-free midurethral tapes to other surgical procedures and different devices. Eur Urol. Feb 2008;53(2):288-308. [Medline].

  6. Appell RA, Vasavada SP, Rackley RR, Winters JC. Percutaneous antegrade collagen injection therapy for urinary incontinence following radical prostatectomy. Urology. Nov 1996;48(5):769-72. [Medline].

  7. Barber MD, Kleeman S, Karram MM, Paraiso MF, Walters MD, Vasavada S, et al. Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. Mar 2008;111(3):611-21. [Medline].

  8. Bidmead J, Cardozo L. The management of tape exposure after inserting tension-free vaginal tape. BJU Int. Mar 2001;87(4):414.

  9. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol. Nov 1991;146(5):1255-9. [Medline].

  10. Carlin BI, Klutke JJ, Klutke CG. The tension-free vaginal tape procedure for the treatment of stress incontinence in the female patient. Urology. Dec 4 2000;56(6 Suppl 1):28-31. [Medline].

  11. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol. Oct 1998;160(4):1312-6. [Medline].

  12. Culligan PJ, Koduri S, Heit MH, Rackley R, Thomson RB, Schwabe L. The safety of reusing injectable collagen: a multicenter microbiological study. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(4):232-4; discussion 235. [Medline].

  13. Culligan PJ, Rackley R, Koduri S, Thomson RB, Schwabe L, Sand PK. Is it safe to reuse a syringe of glutaraldehyde cross-linked collagen? A microbiological study. J Urol. Oct 2000;164(4):1275-6. [Medline].

  14. Das S. Comparative outcome analysis of laparoscopic colposuspension, abdominal colposuspension and vaginal needle suspension for female urinary incontinence. J Urol. Aug 1998;160(2):368-71. [Medline].

  15. Goldman HB, Rackley RR, Appell RA. The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction. J Urol. Jan 1999;161(1):196-8; discussion 198-9. [Medline].

  16. Goldman HB, Rackley RR, Appell RA. The in situ anterior vaginal wall sling: predictors of success. J Urol. Dec 2001;166(6):2259-62. [Medline].

  17. Hsu TH, Rackley RR, Appell RA. The supine stress test: a simple method to detect intrinsic urethral sphincter dysfunction. J Urol. Aug 1999;162(2):460-3. [Medline].

  18. Jones JS, Rackley RR, Berglund R, Abdelmalak JB, DeOrco G, Vasavada SP. Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2-year results. BJU Int. Jul 2005;96(1):103-6. [Medline].

  19. Jones JS, Vasavada SP, Abdelmalak JB, Liou L, Ahmed ES, Zippe CD. Sling may hasten return of continence after radical prostatectomy. Urology. Jun 2005;65(6):1163-7. [Medline].

  20. Langer R, Ron-el R, Newman M, et al. Detrusor instability following colposuspension for urinary stress incontinence. Br J Obstet Gynaecol. Jun 1988;95(6):607-10. [Medline].

  21. Leach GE, Dmochowski RR, Appell RA, et al. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol. Sep 1997;158(3 Pt 1):875-80. [Medline].

  22. Madjar S, Tchetgen MB, Van Antwerp A, et al. Urethral erosion of tension-free vaginal tape. Urology. Apr 2002;59(4):601. [Medline].

  23. McLennan MT, Melick CF, Bent AE. Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling. Obstet Gynecol. Oct 1998;92(4 Pt 1):608-12. [Medline].

  24. Morgan JE, Heritz DM, Stewart FE, et al. The polypropylene pubovaginal sling for the treatment of recurrent stress urinary incontinence. J Urol. Sep 1995;154(3):1013-4; discussion 1015-6. [Medline].

  25. Ng CS, Rackley RR, Appell RA. Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence. Urology. May 2001;57(5):911-3. [Medline].

  26. Nilsson CG, Palva K, Rezapour M, Falconer C. Eleven years prospective follow-up of the tension-free vaginal tape procedure for treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. Aug 2008;19(8):1043-7. [Medline].

  27. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. Sep 17 2008;300(11):1311-6. [Medline].

  28. Rackley RR. Office Evaluation of Urinary Incontinence. Contemporary Therapy in Obstetrics and Gynecology: Issues and Controversies. 2000.

  29. Rackley RR. Treatment of Stress Incontinence. Voiding Dysfunction. 2000.

  30. Rackley RR, Abdelmalak JB. Management of Female Urinary Incontinence. Essential Urology: A Guide to Clinical Practice. 2004;8:153-167.

  31. Rackley RR, Abdelmalak JB, Tchetgen MB, et al. Tension-free vaginal tape and percutaneous vaginal tape sling procedures. Tech Urol. Jun 2001;7(2):90-100. [Medline].

  32. Rackley RR, Appell RA. "When you build it, keep it simple": comment on "If you build it, they will come" (1998): Neurourol Urodynam 17:1-2. Neurourol Urodyn. 1998;17(5):565-9. [Medline].

  33. Rackley RR, Appell RA. Evaluation and management of lower urinary tract disorders in women with multiple sclerosis. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(2):139-43. [Medline].

  34. Rackley RR, El-Azab A. Injectable Therapy for Female Stress Incontinence. Pelvic Floor Dysfunction: A Multidisciplinary Approach, the Cleveland Clinic Mod. 2005.

  35. Rackley RR, Frenkl T. Surgical Management of Urinary Retention. Pelvic Floor Dysfunction: A Multidisciplinary Approach, the Cleveland Clinic Mod. 2005.

  36. Sears CL, Wright J, O'Brien J, Jezior JR, Hernandez SL, Albright TS, et al. The racial distribution of female pelvic floor disorders in an equal access health care system. J Urol. Jan 2009;181(1):187-92. [Medline].

  37. Serels SR, Rackley RR, Appell RA. In situ slings with concurrent cystocele repair. Tech Urol. Sep 1999;5(3):129-32. [Medline].

  38. Serels SR, Rackley RR, Appell RA. Surgical treatment for stress urinary incontinence associated with valsalva induced detrusor instability. J Urol. Mar 2000;163(3):884-7. [Medline].

  39. Smith DN, Appell RA, Rackley RR. Collagen injection therapy for post-prostatectomy incontinence. J Urol. Aug 1998;160(2):364-7. [Medline].

  40. Smith DN, Appell RA, Winters JC. Collagen injection therapy for female intrinsic sphincteric deficiency. J Urol. Apr 1997;157(4):1275-8. [Medline].

  41. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7(2):81-5; discussion 85-6. [Medline].

  42. Vasavada SP, Rackley RR, Appell RA. In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1998;9(6):379-84. [Medline].

  43. Winters JC, Appell RA, Rackley RR. Urodynamic findings in postprostatectomy incontinence. Neurourol Urodyn. 1998;17(5):493-8. [Medline].

  44. Wolin LH. Stress incontinence in young, healthy nulliparous female subjects. J Urol. Apr 1969;101(4):545-9. [Medline].

  45. [Best Evidence] Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ. Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc. Dec 2008;83(12):1332-43. [Medline].

  46. [Best Evidence] Schierlitz L, Dwyer PL, Rosamilia A, Murray C, Thomas E, De Souza A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol. Dec 2008;112(6):1253-61. [Medline].

  47. [Best Evidence] Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. Jan 29 2009;360(5):481-90. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

incontinence, urinary incontinence, stress incontinence, stress urinary incontinence, SUI, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, Foley catheter, decompensated bladder, detrusor instability, Q-tip test, cotton swab test, cotton-swab test, cough stress test, CST, Marshall test, Kegel exercises, detrusor hyperreflexia, detrusor hyper-reflexia, overactive bladder, urethral hypermobility, intrinsic sphincter deficiency, intrinsic sphincteric dysfunction, ISD, anterior vaginal repair, MMK procedure, MMK operation, Marshall-Marchetti-Krantz procedure, Marshall-Marchetti-Krantz operation, urethral obstruction, bladder neck suspension, pubovaginal sling, pubo-vaginal sling, retropubic urethropexy, urethral hypermobility, involuntary urine loss, artificial urinary sphincter, periurethral bulking agent, artificial urinary sphincter, sling procedure, sling operation

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Raymond Rackley, MD is a member of the following medical societies: American Urological Association
Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Coauthor(s)

Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic
Sandip P Vasavada, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, International Continence Society, and Society for Urology and Engineering
Disclosure: pfizer Honoraria Speaking and teaching; allergan Consulting fee Consulting; ndi medical, LLC Ownership interest Review panel membership; novartis Honoraria Speaking and teaching

Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic
Farzeen Firoozi, MD is a member of the following medical societies: American Medical Association and American Urological Association
Disclosure: Nothing to disclose.

Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic
Disclosure: Nothing to disclose.

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.