Urinary Stress incontinence is more common in women who have had children and can be severe enough to limit their ability to undertake normal daily activity. It can also cause social isolation and loss of self-confidence.
It is due to a loss in the sphincter control and results in the uncontrollable loss of urine when there is raised intra-abdominal pressure. Commonly this happens with exercise like jumping or with coughing etc. hence the name stress incontinence.
Pelvic floor physiotherapy has traditionally been the first resort for treatment. Whilst it may be curative in mild cases, in more severe ones, it would be helpful at best. Such physiotherapy is best managed by specialist Pelvic Floor Physiotherapists. Thus surgery is usually the mainstay of treatment.
Surgery has been used for this condition for many years – all with varying degrees of success. By its nature, surgery does carry risks as well. These will vary depending on the method used. There are a large number of surgical approaches to this vexed problem. Here I will discuss some of the variety of procedures.
Broadly speaking I divide them into 3 categories:
- Surgery that push up the bladder
- Surgery that pull up the bladder
- Blocking surgery
Surgery that push up the bladder:
In Gynaecology, this is the traditional vaginal repair. Performed through the vagina, the bladder is tightened by the use of stitches. One of the oldest is called a Kelly plication of the neck of the bladder. Whilst it can work, the success is low and the recurrent nature of the problem is high. They are not generally not difficult procedures and do not require complex manoeuvres to try to strengthen the bladder. It can be done as part of the vaginal repair for prolapse. Due to the fact that their success rate is lower, these techniques have been replaced by more efficient and successful methods.
Blocking surgery:
In this technique, materials are inserted adjacent to the urethra (drainage tract from the bladder) acting as a bulking agent. This is injected next to the urethra and the agent causes a narrowing of the urethra. The materials used range from collagen to synthetic materials. It has a moderate degree of success but may require more than 1 injection. Also long term success is not clear. In general it is used in people who cannot tolerate more major surgery.
Surgery that pull up the Bladder:
There are many versions of this. Numerous techniques have been tried over the years. The most successful have involved using some form of support either in the form of stitches, through to fibrous tissue and more lately artificial mesh slings. Essentially, they all either form a sling under the bladder or they hitch the vagina under the bladder up towards the front of the tummy. Some will require a big cut in the tummy, others use a keyhole approach or small cuts only. They all have varying degrees of success but overall have the better outcomes in comparison to the vaginal approaches. Currently these techniques are the favoured ones.
Of all the above techniques, the ones with the best outcomes are those that rely on pulling the bladder up. They do generally carry greater risks but the longer term success is better. Which technique is best for you will be dependent on many factors and will need to be individualised. If you have concerns, I am happy to assess your problems and provide advice on the management for you.
These notes reflect my personal opinion and are intended for general advice only. It should not be relied upon for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation.