Surgical Treatment Options for Urinary Incontinence

R. Mark Ellerkmann, M.D., FACOG, Director of The Urogynecology Center at Mercy, specializes in the treatment of urinary incontinence in women of all ages. He is among a small group of urogynecologists who are Board Certified in both Obstetrics and Gynecology and Female Pelvic Medicine and Reconstructive Surgery. Dr. Ellerkmann was recently asked to address the issue of surgical options for urinary incontinence. His response is below.

When we talk about urinary incontinence, there are many reasons for it. That is, many types. The two most common types of urinary incontinence are what we refer to with stress urinary incontinence (activity related) and urge related incontinence (overactive bladder which, in turn is defined as urinary urgency and/or urinary frequency and/or Nocturia (greater than two voids per night) and/or urge related incontinence. In general, first-line therapy for both stress and urge urinary incontinence consists of behavioral and dietary strategies. Specifically, for stress urinary incontinence, this includes pelvic floor physical therapy, Kegel exercises and modest weight loss. For symptoms of overactive bladder and urge urinary incontinence, behavioral strategies including scheduled voiding practices, urge suppression techniques and avoidance of known dietary bladder irritants. Second line therapies, however, are different. For stress urinary incontinence, second line therapies including transurethral bulking and mid urethral sling operations. Colposuspension's have fallen out of favor and thus out of use due to their suboptimal long-term efficacy.

Since you are interested in writing an article about female stress urinary incontinence and treatments for it, the two most commonly performed surgical procedures are transurethral bulking and mid urethral slings. There are many different bulking agents on the market. I am currently utilizing a bulking agent called Bulkamid (you can google this product) which is utilized to narrow the bladder neck (urethrovesical junction or UVJ) by injecting the bulking agent into the urethra mucosa. This is a procedure performed under local anesthesia. It takes approximately 15 minutes. Long-term success rates relating to transurethral bulking are typically quoted in the 65 to 85 percent range. Associated complications are rare and the procedure is typically well-tolerated under local anesthesia.

In contrast to transurethral bulking, synthetic mid-urethral slings have become the leading treatment for female stress urinary incontinence because of their long-term success rates and low complication rate. Some studies have suggested 20-year success rates of 80 to 90 percent. Sling operations, of course are not new, dating back to the early 1900s.  Various tissues have been used for sling operations ranging from muscle to tendon to fascia to xenograft's (bovine & porcine tissue) to allografts (cadaveric fascia) and various synthetic materials. In 1998, tension-free vaginal tape (TVT) was FDA approved for the treatment of female stress urinary incontinence. There are numerous mid-urethral slings now on the market; they all essentially work the same way and have become the leading treatment for female stress urinary incontinence worldwide. This polypropylene tape is placed either in a U-shaped configuration behind the pubic bone or in a hammock-shape configuration (transobturator approach) to provide support to the mid urethra and to provide a backstop against which the urethra can be compressed closed with increases in intra-abdominal pressure such as coughing, sneezing and exercise.

Recovery following transurethral bulking is quick. There are no restrictions following the procedure. Patients can typically drive themselves home. In contrast, even though a mid-urethral sling operation is an outpatient surgery, patients may or may not go home with a catheter for a day or two (typically they do not go home with a catheter). Because there is a small incision underneath the urethra, typically patients are asked not to engage in sexual intercourse for four weeks. They should also refrain from any heavy lifting or straining for a week or so following the procedure. Because the procedure is performed under anesthesia, they need someone to drive themselves home from the surgery center or hospital.

Dr. Ellerkmann treats pelvic organ prolapse, interstitial cystitis, recurrent urinary tract infections, fecal incontinence, overactive bladder, pelvic floor dysfunction and the special gynecologic needs of aging and handicapped women. The Urogynecology Center is a division of The Gynecology Center at Mercy and part of the renowned Weinberg Center for Women's Health & Medicine at Mercy Medical Center.