eMedicine Specialties > Urology > Incontinence
Urinary Incontinence, Surgical Therapies: Treatment
Updated: May 8, 2009
Treatment
Surgical Therapy
Operations for Urethral Hypermobility
Surgical procedures for mild-to-moderate intrinsic sphincter deficiency with urethral hypermobility reposition the mid urethra and/or bladder neck into a normal anatomic position at rest and during physical exertion. When the bladder neck is in the correct anatomic position, it stays closed during periods of increased abdominal pressure. The main types of procedures used for correction of intrinsic sphincter deficiency with urethral hypermobility include retropubic bladder neck suspensions and transvaginal sling procedures.
For severe intrinsic sphincter deficiency and urethral hypermobility, select a surgical procedure that stabilizes the anatomic support and compresses the urethra, which typically means using one of the retropubic sling procedures, not the transobturator approach.
Retropubic urethropexy
Retropubic suspension procedures have a long-term (>4 y) success rate of approximately 84% in curing stress incontinence caused by urethral hypermobility. The Agency for Health Care Policy and Research (AHCPR) reviewed 45 studies incorporating 3882 patients who underwent retropubic urethropexy. Long-term cure rates averaged 79%, and 84% of patients were cured or improved with retropubic surgery.
According to the AHCPR, the overall complication rates reported for retropubic operations averaged 18% (range, 6%-57%); the incidence of wound infections, urinary retention, de novo detrusor instability, and dyspareunia ranged from 3%-15%. Postoperative enterocele and rectocele was most prominent after Burch urethropexy, occurring in up to 12% of patients.
Sling procedures
Sling procedures create a hammocklike bolstering of the urethra. A supporting strip of material is placed under the mid urethra and/or bladder neck and secured to the abdominal wall or pelvic bone structures. Sling procedures have a more durable long-term cure rate of 90% after more than 11 years.
Operations for Intrinsic Sphincter Deficiency
Procedures for managing various degrees of intrinsic sphincter deficiency severity include sling procedures, periurethral bulking injections, and placement of an artificial urinary sphincter.
Sling procedures are recommended for women who have intrinsic sphincter deficiency alone or intrinsic sphincter deficiency with coexisting hypermobility. Periurethral bulking injections were initially recommended as first-line treatment in women with severe intrinsic sphincter deficiency who do not have coexisting hypermobility but are currently used in all patients with any form of stress urinary incontinence. Artificial sphincters are recommended for patients who are unable to perform intermittent catheterization and have severe intrinsic sphincter deficiency unresponsive to other surgical treatments.
Sling procedures
The various sling procedures all involve placing a sling made of autologous, synthetic, or cadaver material under the mid urethra or bladder neck (urethrovesical junction) and securing it to retropubic structures, abdominal structures, or both.
Periurethral bulking agents
Periurethral bulking injections currently involve the injection of materials under cystoscopic guidance into or around the incompetent urethra. The result is bulking of tissue. This helps the internal seal mechanism close off the flow of urine. Injection of these agents into the periurethral tissue restores the mucosal seal mechanism by effectively coapting the urethral mucosa at rest.
According to the AHCPR, combined data from 15 studies of 528 women indicate that after follow-up for up to 2 years, 49% of patients were cured (range, 8%-100%) and 67% were either cured or improved. Complications included urgency, UTI, and urinary retention.
Injectable bulking implant therapy for stress urinary incontinence (SUI). Using a bent needle for localizing the sublaminal plane in the bladder neck and mid urethra, implant material is injected in a periurethral approach under endoscopic guidance.
Injectable bulking implant therapy for stress urinary incontinence (SUI). Using a transurethral approach and an endoscopic needle for localizing the sublaminal plane in the bladder neck and mid urethra, implant material is injected via the cystoscope under endoscopic guidance.
Artificial urinary sphincter
The only surgical technique for incontinence that attempts to mimic the active mechanism of natural continence is the artificial urinary sphincter. The artificial urinary sphincter has been used in men and women with intrinsic sphincter deficiency.
According to the AHCPR, combined data from 8 studies of 192 women with intrinsic sphincter deficiency treated with artificial sphincter placement revealed that 77% were dry and 80% were cured or improved.
Complications included fluid leak, loose cuff, erosion or atrophy at the cuff site, kinked tubing, and infection.
The artificial urinary sphincter does not have a significant role in female stress urinary incontinence because of the availability of other types of surgery such as periurethral injection with bulking agents or sling procedures. However, the artificial urinary sphincter is still an option if other surgical modalities have failed.
Preoperative Details
Inform all patients about the potential complications of anti-incontinence surgery during the informed consent process. Complications common to any anti-incontinence surgery include urethral obstruction and de novo or worsening obstructive voiding symptoms.
Treat patients with preexisting urge incontinence with anticholinergic therapy preoperatively.
Counsel patients undergoing retropubic urethropexy or sling procedures on the possibility of performing self-catheterization in the event that urinary retention occurs postoperatively. With patients receiving synthetic slings, discuss the possibility of urethral erosion or vaginal extrusion.
Inform patients receiving an artificial urinary sphincter about the potential for mechanical malfunction that may require revisionary surgery.
Test the skin of eligible candidates for periurethral collagen injection for a possible allergic reaction 28 days before the scheduled injection therapy.
Preoperatively, clear all patients of any preexisting UTIs. Intravenous broad-spectrum antibiotics are administered on the morning of surgery, ideally 1 hour before starting the operation. Compressive pneumatic devices are placed on the lower extremities prior to induction of anesthesia to prevent deep venous thrombosis.
Intraoperative Details
Marshall-Marchetti-Krantz urethropexy
All patients receive intravenous antibiotics preoperatively. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position. The abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.
A transverse suprapubic incision is made, and the anterior rectus fascia is incised. The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placing a hand in the vagina facilitates identification of the bladder neck.
The prevesical fat is dissected off the bladder and the bladder neck. Two or 3 nonabsorbable suspension sutures (eg, 1-0 Prolene) are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the periosteum of the pubic symphysis and then tied securely.
The bladder neck is suspended by the sutures anchored to the undersurface of the pubic bone. The suspension sutures prevent bladder neck descent during periods of physical activity, but they do not pull up the bladder neck high behind the pubic symphysis. Take care to not tie the bladder neck against the pubic symphysis. Overzealous pulling up of the bladder neck causes iatrogenic urethral obstruction.
Marshall-Marchetti-Krantz bladder neck suspension. Suspension sutures (A) are placed next to the urethra and then to the pubic bone. Suspension sutures (B) are tied.
Burch urethropexy
Preoperative broad-spectrum intravenous antibiotics are administered. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position. Abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.
A transverse suprapubic incision is made, and the anterior rectus fascia is incised. The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placing a hand in the vagina facilitates identification of the bladder neck.
The prevesical fat is dissected off the bladder and the bladder neck. Two or 3 nonabsorbable suspension sutures (eg, 1-0 Prolene) are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the Cooper ligament and then tied securely.
The bladder neck is suspended by the sutures anchored to the Cooper ligament. The suspension sutures prevent bladder neck descent during periods of physical activity, but they do not pull up the bladder neck high behind the pubic symphysis. Overzealous pulling up of the bladder neck causes iatrogenic urethral obstruction. Leave enough space behind the suspension suture and the Cooper ligament to readily admit 2 fingers. This new position allows even disposition of external pressures on all surfaces of the bladder and the proximal urethra.
Burch bladder neck suspension. Suspension sutures (A) are placed at the bladder neck and the Cooper ligament. Suspension sutures (B) are tied.
Rectus fascia pubovaginal sling
All patients are administered intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. A combined abdominal-vaginal approach is used for the operation. A full, 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and draped in sterile fashion.
A transverse incision is made over the suprapubic area. The incision is carried down to the rectus fascia. Scarpa fascia overlying the rectus fascia is dissected off. A 2-cm X 13-cm strip of rectus fascia is harvested. The rectus fascia is stored in antibiotic saline solution until ready for use.
The abdominal fascia is closed using nonabsorbable sutures. Antibiotic-soaked gauze is placed into the abdominal incision.
A self-retaining vaginal retractor and a 16F Foley catheter are placed. The bladder neck is identified by visual inspection of the anterior vaginal wall and digital palpation of the Foley catheter.
A single vertical midline incision or an inverted-U incision is made at the level of the bladder neck. The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.
The rectus pubovaginal sling is constructed at the back table with 1-0 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4-0 Vicryl sutures. The suspension sutures are transferred suprapubically.
The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2-0 Vicryl suture in a continuous locking fashion. The suspension sutures are tied ipsilaterally and then across the midline loosely. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.
The subcutaneous tissues are approximated and the skin is closed with running subcuticular suture. For obese patients who are at risk for seroma formation, the author places a small, closed suction drain in the suprapubic area prior to skin closure.
One ampule of indigo carmine is administered intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates that the ureters have not been injured.
Povidone-iodine–soaked vaginal packing is inserted. A urethral catheter and/or suprapubic tube is placed depending on the surgeon's preference.
Retropubic suspending sling of rectus fascia, fascia lata, or synthetic sling material places a long strip of sling material under the bladder neck or mid urethra. The ends of the sling are fixed to the rectus fascia of the lower abdomen.
Fascia lata pubovaginal sling
All patients receive intravenous antibiotics preoperatively. A combined thigh-abdominal-vaginal approach is used for the operation. The patient is placed in the supine position with the inner leg stretched out and the outer leg in a slightly bent position. All pressure points are adequately padded to prevent pressure necrosis.
The outer thigh is prepared with povidone-iodine solution and draped in a sterile fashion. A skin incision is made on the outer thigh. A 2-cm X 13-cm strip of fascia lata is harvested. A special fascial stripper may be used for the harvest. A small Penrose drain is placed, and the thigh incision is closed. A compressive dressing is applied.
The patient is repositioned in a lithotomy position. A full, 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and draped in sterile fashion.
A transverse suprapubic incision is made. The incision is carried down to the rectus fascia. The Scarpa fascia is dissected off the rectus fascia. Antibiotic-soaked gauze is placed into the wound.
A 16F Foley catheter and self-retaining vaginal retractor are placed. The bladder neck is identified. A vertical midline incision or an inverted-U incision is made at the level of the bladder neck.
The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.
The fascia lata sling is constructed at the back table with 1-0 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4-0 Vicryl sutures. The suspension sutures are transferred suprapubically.
The suspension sutures are tied ipsilaterally and then across the midline loosely. Alternatively, the ends of the sling may be sewn to the rectus fascia. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.
The subcutaneous tissues are approximated, and the skin is closed with running subcuticular sutures. For obese patients who are at risk of seroma formation, the author places a small, closed suction drain in the suprapubic area prior to skin closure.
One ampule of indigo carmine is administered intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates that the ureters have not been injured.
The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2-0 Vicryl sutures in a continuous locking fashion. Povidone-iodine–soaked vaginal packing is inserted. A urethral catheter and/or suprapubic tube are placed.
Midurethral polypropylene vaginal tape procedures: retropubic or transobturator approaches
Polypropylene meshed tape that measures 1.1 X 30 cm may be placed at the mid urethra or bladder neck using retropubic or transobturator approaches.
Broad-spectrum intravenous antibiotics are administered. Perform the operation through the vagina with 2 small, lower-abdominal incisions above the pubic bone for a retropubic approach versus over the mid to lower medial aspect of the obturator foramen. The procedure may be performed with local, regional, or general anesthetic.
Place the patient in the dorsal lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place an 18F urethral catheter in the bladder.
Apply local anesthetic to the skin just above the pubic tubercle on both sides of the midline for retropubic procedures or the obturator foramen in transobturator procedures. Apply local anesthetic to the anterior vaginal wall. Make a small vertical incision on the anterior vaginal wall at the mid urethra. Dissect the vaginal wall tissue off the urethra to expose the mid urethra, and dissect paraurethrally toward the endopelvic fascia.
Depending on the approach chosen, use the appropriate trocars to place the polypropylene tape in the perivesical pocket.
Fill the bladder with 250 mL of saline. Perform a cystoscopy with the needle in situ to help rule out bladder and urethral injury.
Note that the success of this operation is predicated on performing a proper tension test. Although devices are marketed as tension-free, the surgeon must ensure that it is tension-free by performing a proper tension test. Close the vaginal, perineal, or abdominal incisions.
Periurethral injection therapy
The patient is placed in the lithotomy position. Vaginal and periurethral areas are prepared and draped with sterile technique. A 2% lidocaine jelly is injected into the urethra for local analgesia.
A short-beaked female cystoscope with either 30° or 0° lens is inserted into the urethra. The stopcock for the irrigant is turned on halfway. The incompetent bladder neck is identified. The cystoscope is withdrawn to the mid urethra.
For transurethral or periurethral injection approaches, the injectable needle is advanced into the submucosal plane approximately 2 cm from the bladder neck. Care is taken to not advance the needle too proximal because it may exit the urethra and enter the bladder.
The implant is slowly injected until complete mucosal coaptation is seen. Depending on the adequacy of the bladder neck closure, additional injection sites may be used. The amount of implant required to achieve complete bladder neck coaptation may vary from 1 to 5 mL.
Artificial urinary sphincter
All patients are administered intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. The abdomen and genitalia are prepared with povidone-iodine solution and draped in sterile fashion. A Foley catheter is placed. A transverse lower abdominal incision is made. The Retzius space is entered, and the bladder neck is dissected circumferentially from the surrounding tissues and vagina.
An appropriate-size cuff is placed circumferentially around the bladder neck. Following placement of the cuff, the pressure-regulating balloon is implanted into the preperitoneal space and the control pump is placed through the inguinal ring into the labia majora.
Temporary connections are made, and the sphincter is cycled. The pressure reservoir is filled with a final volume of 20 mL of filling solution. Excess tubing is trimmed. Final connections are made in the subcutaneous space of the abdomen. The sphincter is cycled again, and the cuff is left in a locked-open position. The abdominal wound is closed in layers, and a Foley catheter is left in place.
Artificial urinary sphincter. The sphincter cuff is placed around the bladder neck, the balloon reservoir is implanted in the prevesical space, and the pump is inserted into the vaginal labia.
Postoperative Details
Retropubic urethropexy
Intravenous antibiotics are administered for 48 hours, followed by an oral cephalosporin. On the morning after surgery, the urethral catheter and intravenous lines are discontinued. Patients are discharged on the second or third day after surgery. They may perform normal physical activities after 4-6 weeks.
Sling procedures
Oral antibiotics are administered for several days. The urethral catheter and the vaginal packing are typically removed shortly after the procedure or on the morning following the operation.
Periurethral bulking injections
Oral antibiotics are administered preoperatively but are not needed postoperatively. If stress urinary incontinence recurs or persists, repeat injection or a sling procedure may be necessary.
Artificial urinary sphincter
Intravenous antibiotics are administered for 24 hours, and an oral cephalosporin is continued for several days. The sphincter is left deactivated for 6 weeks. The device is activated, and the patient is instructed on its use after 6 weeks of healing.
Complications
Serious complications from operations used to correct stress incontinence are very rare. Complications common to retropubic bladder neck suspensions and sling procedures include urinary retention, de novo or worsening obstructive voiding symptoms, UTI, suture abscess, wound infection, retropubic bleeding, vaginal granuloma, vesicocutaneous fistula, de novo pelvic prolapse, bladder perforation, prolonged suprapubic pain, and ilioinguinal nerve entrapment. Reports of serious vascular injury, bowel perforations, thigh abscess, and death due to these complications are not unique to pelvic surgeries but appear to be associated with the newer midurethral sling approaches.
The current incidence rate of urethral obstruction ranges from 5%-10% for anti-incontinence operations. Urinary retention is temporary in most cases, but it may last a month or more. While the condition lasts, clean intermittent catheterization should be performed. Less serious complications, such as wound infection, occur more frequently but are easily treated with antibiotics. The likelihood of needing a blood transfusion is less than 5% for all procedures.
Retropubic bladder neck suspension
Abdominal wound infection, urinary retention, de novo urge incontinence, and dyspareunia occur in 3%-15% of patients. Up to 12% of patients experience postoperative enterocele and rectocele after a Burch urethropexy.
Rectus fascia pubovaginal sling
In the literature, the incidence rate of urethral obstruction after sling surgery is 2%-10% and the incidence rate of obstructive voiding symptoms is 5%-25%. De novo detrusor instability requiring anticholinergic therapy occurs in 15%-20% of cases.
Potential intraoperative complications include injury to the urethra, bladder, or ureters during the dissection and during transfer of the suspension sutures.
Fascia lata pubovaginal sling
As with any sling surgery, patients with a fascia lata sling surgery may have difficulty with volitional voiding postoperatively. In some, detrusor instability may result in urge incontinence. Other potential complications of sling surgery include erosion of the urethra, prolonged or permanent urinary retention, injury to the bladder or ureters, and detrusor instability. Leg pain is a complication unique to the fascia lata sling operation.
Synthetic pubovaginal sling
Complications of synthetic slings include urethral erosion, nonhealing of the vaginal wall (sling extrusion), abscess, and, rarely, vesicovaginal fistula formation.
Periurethral bulking injections
UTI and irritative voiding symptoms are the most common adverse effects after periurethral implant injections. Symptoms of urinary frequency and urgency are self-limited.
Permanent urinary retention has not been reported. Urinary retention responds well to temporary catheterization. Acute urinary retention after implant injection should not be treated with an indwelling urethral catheter; otherwise, it can mold the implant and defeat the success of the operation. Rather, intermittent catheterization is preferred. If an indwelling catheter is required in unusual situations, a suprapubic catheter can be placed percutaneously to protect the implant.
Artificial urinary sphincter
Complications of an artificial urinary sphincter include urethral injury during surgery, tissue atrophy, and delayed urethral erosion.
Mechanical problems include fluid leak from the system, kinked tubing, and obstruction from particulate matter. Infectious complications include suprapubic or perineal cellulitis and periprosthetic abscesses. Infection may lead to erosion and necessitate a repeat surgery to remove a portion or even the entire device.
Patient Education
For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Bladder Control Problems, Cystoscopy, and Prolapsed Bladder.
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[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].
[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].
Further Reading
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
