Urinary incontinence surgery: When other treatments aren't enough

For some women, the symptoms of stress incontinence or overactive bladder don't respond to conservative treatment. When urinary incontinence markedly disrupts your life, urinary incontinence surgery may be an option.

Urinary incontinence surgery for women is usually considered only if more-conservative strategies aren't helping. Urinary incontinence surgery is more invasive and has a higher risk of complications than do many other therapies, but it can also provide a long-term solution in severe cases. Most options for urinary incontinence surgery are used to treat stress incontinence. However, low-risk surgical alternatives are also available for other bladder problems, including severe urge incontinence, which is also called overactive bladder and nonobstructive urinary retention.

Things to consider

Before you choose urinary incontinence surgery, get an accurate diagnosis. Different types of incontinence require different surgical approaches. Your doctor may refer you to an incontinence specialist, urologist or urogynecologist for further diagnostic testing.

If you plan on having children, your doctor may recommend holding off on surgery until you're finished with childbearing. The strain of pregnancy and delivery on your bladder, urethra and supportive tissues may "undo" any prior surgical fix.

Surgery can only correct the problem it's designed to treat and, in some cases, won't cure your incontinence. If you have mixed incontinence, for instance, surgery for stress incontinence may not improve your urge incontinence. You may need medications and physical therapy after surgery to treat the urge incontinence. Incontinence is caused by weak or damaged nerves and muscles, and surgery can only compensate for the damage. It can't repair the damaged nerves and muscles.

Know the risks

Like any surgical procedure, stress urinary incontinence surgery comes with risks and potential complications. For instance, surgery itself may 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 include 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.

Surgery for stress incontinence

Several procedures have been developed to treat stress incontinence. Most surgical procedures fall into two main categories: sling procedures and bladder neck suspension procedures.

Sling procedures
A sling procedure — the most common surgery to treat stress incontinence — uses strips of your body's tissue or synthetic material such as mesh to create a pelvic sling or hammock around your bladder neck and the tube (urethra) that carries urine from the bladder. The sling provides support to keep the urethra closed — especially when you cough or sneeze. Slings typically have high rates of effectiveness and low risks of complications.

Categories of slings include:

• Tension-free slings. No stitches are used to attach the tension-free sling, which is made from a synthetic strip of mesh. Instead, tissue itself holds the sling in place initially. Eventually scar tissue forms in and around the mesh to keep it from moving. Though rare, serious complications from the surgical mesh can occur, including erosion, infection and pain.

  Within the category of tension-free slings there are two approaches: retropubic, also known as suprapubic, and transobturator.

  For the retropubic procedure, a small incision is made inside the vagina just under the urethra, and then two small openings are made above the pubic bone. These openings are just large enough for a needle to pass through. The surgeon uses a needle that is holding the sling to place the sling inside the body. Stitches are not needed to keep the sling in place, although the vaginal incision is closed with a few absorbable stitches and the needle sites may be sealed with skin glue or sutures.

  The newer, transobturator approach involves a slight modification to the retropubic approach. Here, the surgeon uses a similar vaginal incision, but sling arms are not passed between the pubic bone and bladder. This approach lowers the risk of urethral and bladder injury. The needle enters next to the labia and is threaded under the urethra. Like the retropubic approach, stitches are not needed to hold the sling in place, and the needle site may be sealed with skin glue.

• Adjustable slings. Doctors are studying a sling that can be adjusted during and after surgery. After the sling is placed and while the person is awake, the doctor tests and adjusts the sling's tension according to the person's needs. Adjustments can continue to be made months or years later and require only a local anesthetic to access the adjustable portion. More study is needed to determine how effective adjustable slings are over time.
• Conventional slings. The surgeon inserts a sling through a vaginal incision and brings it around the bladder neck. The sling may be made of a synthetic material, or occasionally your own tissue, animal tissue or tissue from a deceased donor 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. Conventional slings sometimes require a larger incision and an overnight stay in a hospital. A temporary catheter may be necessary after surgery as the bladder heals. Conventional slings aren't proven to be better than newer tension-free slings.

Most sling procedures use synthetic materials. Using natural sling materials taken from animals or deceased donors may be less effective than natural materials from your body or synthetics, because there's a tendency for the body to absorb animal and deceased donor material.

Sling procedures take less time than retropubic bladder neck suspension procedures, and because they're less invasive, sometimes they can be done under local anesthesia and on an outpatient basis. But in some cases, more invasive procedures may be the right ones based on your medical history and test results. Discuss with your doctor which procedure is right for you.

Recovery time for tension-free sling surgery varies. Doctors may recommend two to six weeks of healing before returning to normal activities.

Bladder neck suspension procedure
This procedure is designed to provide support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra.

For this procedure, an incision is made in your lower abdomen. Through this incision, your surgeon 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 procedure). This has the effect of reinforcing your urethra and bladder neck so that they don't sag.

The downside of this procedure is that it involves an abdominal incision. It's done under general or spinal anesthesia. Recovery takes about six weeks, and you may need to use a catheter until you can urinate normally.

Bladder neck suspension

Bladder neck suspension

Bladder neck suspension surgery adds support to the bladder neck and urethra, reducing the risk of stress incontinence. The Burch procedure involves placing sutures in vaginal tissue near the neck of ...

Sling procedures

Sling procedures

A sling is a piece of human or animal tissue or a synthetic tape that a surgeon places to support the bladder neck and urethra. Two sling techniques are shown — the retropubic and ...

Bulking agents

Bulking agents are materials, such as collagen, that are injected into tissue surrounding the urethra to help keep the urethra closed and reduce urine leakage.

A bulking agent procedure — usually done in a doctor's office — requires minimal anesthesia. The downside of the procedure is that bulking agents may lose their effectiveness over time and may require repeat injections.

The standard method of injecting a bulking agent is through a needle, which is inserted in different positions with the assistance of a cystoscope — a slender, tube-like instrument that allows the surgeon to view the urethral area.

Materials 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 will apply a skin test before performing the procedure to see if you have a reaction.
• Carbon-coated zirconium beads. Durasphere is a bulking agent that uses carbon-coated zirconium beads that consist of synthetic material to bulk up the tissue surrounding the urethra. Durasphere doesn't require allergy tests.
• A component of bones and teeth. Coaptite is a bulking agent that's made from particles of calcium hydroxylapatite, which is a component of bones and teeth. Coaptite doesn't require allergy tests.
• Silicone implant. Macroplastique is a bulking agent that's made from synthetic, rubber-like silicone. Macroplastique doesn't require allergy tests.

One material isn't necessarily better than another. If you try one and it doesn't seem to help, your doctor may suggest trying another material. New bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.

Surgery for overactive bladder

Surgery for overactive bladder may involve implanting a nerve stimulation device or increasing your bladder's capacity.

Sacral nerve stimulation
Sacral nerve stimulation inhibits messages sent by an overactive bladder to your brain, signaling a need to urinate. Sacral nerve stimulation works by continuously sending small, electrical impulses to the nerves that control urination. The impulses are generated by a small, pacemaker-like device surgically placed under the skin, usually in your buttock. Attached to the device — called a stimulator — is a thin, electrode-tipped wire that passes under your skin, carrying these impulses to the sacral nerve.

Because sacral nerve stimulation doesn't work for everyone, you can try it out first by wearing the stimulator externally, after the attached wire is placed under your skin in a minor surgical procedure. If the stimulator substantially improves your symptoms, then you can have it implanted.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia and mild sedation. You may be advised to limit activities for three or more weeks as your incisions heal. Your doctor can adjust the level of stimulation with a hand-held programmer, and you also have a control to use for adjustments. The stimulation doesn't cause pain and may improve or successfully treat people with urge incontinence who haven't had success with medications or lifestyle changes.

Tibial nerve stimulation
Tibial nerve stimulation is a procedure to stimulate a nerve in the leg (tibial nerve). The electrical stimulation travels along the tibial nerve to the spine, where it connects with the nerves that control the bladder.

Called percutaneous tibial nerve stimulation, the procedure involves placing a needle through the skin near the ankle to reach the tibial nerve. An electric impulse is sent through the needle. The procedure takes about 30 minutes and is initially done weekly for about 12 weeks.

Tibial nerve stimulation may be an option if you've tried other treatments without success and you don't want to undergo surgery. Tibial nerve stimulation is an alternative to sacral nerve stimulation.

Botox injection
Doctors are studying injections of OnabotulinumtoxinA (Botox) to see whether this medication, often used to relax muscles, may relax the bladder muscles. Botox injections for overactive bladder involve taking a medication to relax you. Your doctor then injects Botox into the bladder muscles using a needle. This usually needs to be repeated in six to nine months.

Bladder augmentation
Bladder augmentation is a procedure used to increase the size of your bladder. The operation is complex and involves major abdominal surgery. An incision is made in your abdomen and an opening is made at the top of your bladder. Your surgeon then takes a strip of tissue, usually from your intestine or stomach, and attaches it onto the bladder opening. This added tissue patch increases the size of your bladder.

Recovery generally requires staying in the hospital until you're able to start drinking and eating again. It usually takes six weeks after you leave the hospital for you to return to your normal schedule. Many people require lifelong use of a catheter after the procedure. Bladder augmentation doesn't always cure incontinence and can have complications such as infection. Bladder augmentation may be an option if other treatments haven't helped.

Sacral nerve stimulation

Sacral nerve stimulation

During sacral nerve stimulation, a surgically implanted device delivers electrical impulses to the nerves (sacral nerves) that regulate bladder activity. The unit is placed beneath the skin of the ...

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's another solution to your problem.

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