Incontinence Information

Urinary incontinence, an involuntary leakage of urine, is a common disorder in females. Over 10 million women in the United States suffer this disorder. The symptoms are common in women who have been pregnant and given birth. After menopause, the disorder occurs more frequently. Leakage during physical effort such as lifting, jumping, coughing, or sneezing is called stress urinary incontinence. Eighty-five percent of all women with incontinence experience stress urinary incontinence (SUI).

Pelvic Structures

Two of the urogenital structures and organs in the lower female pelvis are the bladder, which is the reservoir for urine, and the urethra, the conduit of urine and the continence-functioning organ. Functions of the urethra and defects in the structures surrounding the urethra are important factors in stress incontinence. The surrounding structures include: (1) the ligaments that fix the urethra to the back of the pelvic bone, (2) the vaginal wall where the urethra lies, (3) the pelvic floor muscles that support the urethra and vaginal wall, and (4) the connective tissue interconnecting them.

Possible Causes

Researchers offer several theories on stress incontinence. What is certain is that there are two main causes for stress urinary incontinence. Genuine stress incontinence (GSI) is leakage as a result of poor pelvic support. Intrinsic sphincter dysfunction (ISD) is a result of the sphincter mechanism not working properly. With no consensus about the reasons behind these two causes for stress urinary incontinence, many therapies, both conservative and surgical, have been introduced.

Nonsurgical Therapies

Exercise of the pelvic floor muscles (Kegel exercises) to strengthen the support of the urethra may be effective for some patients. In postmenopausal women, local or systemic treatment with estrogens has also been used.

Another non-surgical alternative is injection of different substances around the urethra. This ambulatory procedure is done through a cystoscope and is effective for women with good pelvic support and ISD.

Surgical Methods

Surgery is required in more severe cases of stress incontinence. More than 150 different surgical procedures have been described in the literature, but no procedure is 100% effective.

Bladder Neck Repositioning

The aim is to bring the bladder neck back under the influence of the abdominal pressure by elevating the bladder neck from above via an abdominal surgical approach.

1. Needle Suspension Technique – long needles are used to attach suture to the bladder neck via an abdominal approach.
2. Retropubic Colposuspension – through an abdominal incision, sutures are placed lateral to the bladder neck and urethra and connected to the pubic bone or ligaments. Highly skilled surgeons can perform this procedure laparoscopically.

Both of these options are designed to increase support under the urethra.

Sling Procedures

The objective of a sling procedure is to support the bladder neck with a graft material. Different types of sling material have been used, including the patient’s fascia (the sheath that surrounds muscles) and synthetic materials like nylon or polypropylene. 1. Tension-free Vaginal Tape (TVT) technique is a new technique for stress incontinence. TVT, which creates new pubourethral ligaments, has been introduced in Scandinavia and Europe and is available in the United States and other countries. The new technique is less complex than other surgical options, offering the potential for a quick recovery and return to normal activity.

The main objectives for TVT technique are:

1. To support the midurethra so the closing abilities of the organ are most effective
2. To ensure that the urethra is not lifted but rather just supported tension-free in the correctional position through the creation of a new urethral ligament
3. To lighten the vaginal wall under the midurethra
4. To reinforce the connective tissue that connects the ligaments, vaginal wall, urethra, and pelvic floor muscles so these structures will act in concert

Clinical Outcomes

Thus far more than 11,000 patients have undergone TVT procedures. The results are encouraging, with the elimination of symptoms in 84% of cases and significant improvement in an additional 6%. Neither age nor obesity appears to hinder this procedure, and the majority of patients are released from the hospital on the same day without a catheter or voiding problems. The best news is that the PROLENE* polypropylene mesh used in TVT causes a minimal reaction to the tissue into which it is implanted. Including the time for local anesthetic to take effect, the entire TVT operation takes less than 25 minutes.

Recovery time normally requires only 2 weeks to avoid heavy lifting and one month abstaining from sexual intercourse. Often an oral antibiotic is required and a follow-up visit is scheduled. There should be very little interference with your normal daily activities. However, you should consult with your own doctor to determine your own situation.

*PROLENE is a registered trademark from Ethicon, Inc., a Johnson & Johnson Company.