Urinary incontinence surgery — Understand surgical options for treating stress incontinence and overactive bladder.
Sometimes symptoms of stress incontinence or overactive bladder don't respond to conservative treatment. When urinary incontinence markedly disrupts your life, surgery may be an option.
Urinary incontinence surgery is usually a treatment of last resort. Surgery is more invasive and has a higher risk of complications than do other therapies, but it can also provide a long-term solution in severe cases. Most surgical options are used to treat stress incontinence, although low-risk surgical alternatives are now available for severe urge incontinence as well.
Things to consider
Before you choose urinary incontinence surgery, you need an accurate diagnosis. Different types of incontinence require different surgical approaches. Your doctor may refer you to an incontinence specialist, such as a urologist or urogynecologist, for further diagnostic testing.
Surgery generally isn't recommended if you plan on having children. The strain of pregnancy and delivery on your bladder, urethra and supportive tissues may "undo" any prior surgical fix.
In some cases, surgery won't completely cure incontinence. Surgery can only correct the problem it's designed to treat. If you have mixed incontinence, for instance, surgery for stress incontinence won't help with your urge incontinence, and you may need to take medications after surgery to address the urge incontinence. For incontinence caused by nerve and muscle damage, surgery can only compensate for the damage; it cannot repair the damaged nerves and muscles.
Urinary incontinence surgery may itself give rise to different urinary and genital problems, such as:
- Difficulty urinating and incomplete emptying of the bladder (urinary retention), although this is usually temporary
- Development of an overactive bladder, which could lead to urge incontinence
- Pelvic organ prolapse
- Urinary tract infection
- Difficult or painful intercourse
Talk with your doctor to understand the risks and benefits of the different types of surgery and to help you decide which one may be best in your situation.
Surgery for stress incontinence
Several procedures have been developed to treat stress incontinence. Most surgical procedures fall into two main categories: bladder neck suspension procedures and sling procedures.
Bladder neck suspension procedures
These procedures are designed to provide support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra. The more common procedure is retropubic suspension. Needle suspension, also known as transvaginal suspension, was an alternative in the past but is rarely used anymore.
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Retropubic suspension. For this procedure, your surgeon makes a 3- to 5-inch incision in your lower abdomen. Through this incision, he or she places stitches (sutures) in the tissue near the bladder neck and secures the stitches to a ligament near your pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz, or MMK, procedure). This has the effect of bolstering your urethra and bladder neck so that they don't sag.
Retropubic suspension generally has the highest likelihood of curing stress incontinence. The downside of this procedure is that it involves major abdominal surgery. It's done under general anesthesia and usually takes about an hour. Recovery takes about six weeks, and you'll likely need to use a catheter until you can urinate normally.
- Needle suspension. Needle (transvaginal) suspension has a higher risk of failure and a lower long-term cure rate than does retropubic suspension. Most urogynecologists and urologists don't recommend needle suspension procedures except in rare circumstances. To do this procedure, a surgeon uses incisions in the vagina to place supportive stitches around the bladder neck and urethra. After the stitches are placed through the vaginal incisions, they're passed through a tiny abdominal incision and attached to the abdominal wall or pelvic bone.
Sling procedures
A sling procedure — the most common surgery to treat stress incontinence — uses strips of tissue or synthetic tape to create a pelvic sling or hammock around your bladder neck and urethra. The sling provides support to keep the urethra closed — even when you cough or sneeze.
In a conventional sling procedure, the surgeon inserts a sling through a vaginal incision and brings it around the bladder neck. The sling may be made of a synthetic tape, or occasionally your own tissue or animal tissue may be used. The surgeon brings the ends of the sling through a small abdominal incision and attaches them to pelvic tissue (fascia) or to the abdominal wall with stitches to achieve the right amount of tension.
A more recent trend is to use tissue friction to hold a synthetic mesh tape in place. No stitches are used to attach the mesh sling. Instead, tissue itself holds the sling in place initially. Eventually scar tissue forms in and around the tape to keep it from moving.
Sling procedures take less time than do retropubic bladder neck suspension procedures, and because they're less invasive, they can be done under local anesthesia on an outpatient basis. The advantage of having local anesthesia is that the surgeon can adjust the tension of the sling while you're awake by asking you to cough. This minimizes the risk of over-tightening the sling, which can lead to urinary retention and prolonged catheterization after the operation. In addition, because of the instrumentation used, the tension-free sling requires less cutting at the neck of the bladder.
Recovery time for tension-free slings is fairly short — it's usually only a week or two before you're able to return to your regular activities.
Bulking agents
Bulking agents are materials, such as collagen, injected into tissue surrounding the urethra to tighten the urethral sphincter and stop urine from leaking.
A bulking agent procedure — usually done in a doctor's office — requires minimal anesthesia and takes about five minutes. The downside of the procedure is that most available bulking agents lose their effectiveness over time, and repeat injections are usually needed every six to 18 months. New and improved bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.
The standard method of injecting a bulking agent is through a needle, which is inserted several times in different positions with the assistance of a cystoscope — a slender, tube-like instrument that allows the surgeon to view the urethral area.
Some materials that might be used as bulking agents include:
- Collagen. Collagen is a natural fibrous protein found in connective tissue, bone and cartilage of humans and animals. Collagen can produce an allergic reaction in some people. For this reason, your doctor is required to give you a skin test before performing the procedure to see if you have a reaction. Over time, collagen tends to deteriorate within your body. Often, multiple repeat injections are required.
- Carbon-coated zirconium beads. Carbon-coated zirconium beads consist of synthetic, nonallergenic material, which means they don't carry the risk of causing an allergic reaction. So far, carbon-coated zirconium beads appear to be as effective as collagen. Scientists hope that this bulking agent will last much longer in the body than does collagen and require fewer repeat injections.
- Gel. A thick gel injected into the wall of the urethra provides relief for some women with stress incontinence. Once injected, the gel adds bulk to the urethral walls, bringing them closer together to prevent urine from leaking.
- Fat. Abdominal fat, withdrawn through liposuction, also has been used as a bulking agent. Its advantages are that it's readily available, and it's compatible with your body, so it's unlikely to cause an allergic reaction. However, a potential rare side effect is pulmonary embolism, in which a fat particle escapes and creates an obstruction in an artery in a lung. This condition can lead to severe respiratory problems and even death. When compared with collagen, fat appears to have a substantially lower cure rate for urinary incontinence. As a result, fat is rarely used as a bulking agent.
Things to consider
Before you choose urinary incontinence surgery, you need an accurate diagnosis. Different types of incontinence require different surgical approaches. Your doctor may refer you to an incontinence specialist, such as a urologist or urogynecologist, for further diagnostic testing.
Surgery generally isn't recommended if you plan on having children. The strain of pregnancy and delivery on your bladder, urethra and supportive tissues may "undo" any prior surgical fix.
In some cases, surgery won't completely cure incontinence. Surgery can only correct the problem it's designed to treat. If you have mixed incontinence, for instance, surgery for stress incontinence won't help with your urge incontinence, and you may need to take medications after surgery to address the urge incontinence. For incontinence caused by nerve and muscle damage, surgery can only compensate for the damage; it cannot repair the damaged nerves and muscles.
Urinary incontinence surgery may itself give rise to different urinary and genital problems, such as:
- Difficulty urinating and incomplete emptying of the bladder (urinary retention), although this is usually temporary
- Development of an overactive bladder, which could lead to urge incontinence
- Pelvic organ prolapse
- Urinary tract infection
- Difficult or painful intercourse
Talk with your doctor to understand the risks and benefits of the different types of surgery and to help you decide which one may be best in your situation.
Bulking agents
Bulking agents are materials, such as collagen, injected into tissue surrounding the urethra to tighten the urethral sphincter and stop urine from leaking.
A bulking agent procedure — usually done in a doctor's office — requires minimal anesthesia and takes about five minutes. The downside of the procedure is that most available bulking agents lose their effectiveness over time, and repeat injections are usually needed every six to 18 months. New and improved bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.
The standard method of injecting a bulking agent is through a needle, which is inserted several times in different positions with the assistance of a cystoscope — a slender, tube-like instrument that allows the surgeon to view the urethral area.
Some materials that might be used as bulking agents include:
- Collagen. Collagen is a natural fibrous protein found in connective tissue, bone and cartilage of humans and animals. Collagen can produce an allergic reaction in some people. For this reason, your doctor is required to give you a skin test before performing the procedure to see if you have a reaction. Over time, collagen tends to deteriorate within your body. Often, multiple repeat injections are required.
- Carbon-coated zirconium beads. Carbon-coated zirconium beads consist of synthetic, nonallergenic material, which means they don't carry the risk of causing an allergic reaction. So far, carbon-coated zirconium beads appear to be as effective as collagen. Scientists hope that this bulking agent will last much longer in the body than does collagen and require fewer repeat injections.
- Gel. A thick gel injected into the wall of the urethra provides relief for some women with stress incontinence. Once injected, the gel adds bulk to the urethral walls, bringing them closer together to prevent urine from leaking.
- Fat. Abdominal fat, withdrawn through liposuction, also has been used as a bulking agent. Its advantages are that it's readily available, and it's compatible with your body, so it's unlikely to cause an allergic reaction. However, a potential rare side effect is pulmonary embolism, in which a fat particle escapes and creates an obstruction in an artery in a lung. This condition can lead to severe respiratory problems and even death. When compared with collagen, fat appears to have a substantially lower cure rate for urinary incontinence. As a result, fat is rarely used as a bulking agent.
One step at a time
Finding an effective remedy for urinary incontinence may take time, with several steps along the way. If a particular treatment approach isn't working for you, ask your doctor if there may be another solution to your problem.
Last Updated: 03/23/2007
