Urinary incontinence


How common is urinary incontinence?

Are there different types?

What treatments are available?

What types of surgeries are available?











Urinary incontinence

Dr Orford offers mesh free, laparoscopic surgery for the relief from urinary incontinence.

Urinary incontinence is uncontrolled leakage of urine, which causes quality of life issues.


How common is urinary incontinence?

Are there different types?

GSI (Genuine Stress Incontinence) :

Women with this type of urine incontinence report urine leakage at times of sudden raised pressure in the abdomen, classically:
  - coughing / sneezing / laughing
  - running / exercise / playing sport

This can affect quality of life greatly and lead to withdrawal from activities, and less enjoyment of life

This type is usually associated with abnormal descent of the bladder neck at these times of increased pressure.

This is the type of urinary incontinence that can be improved by elevating / strengthening the pelvic floor beneath the neck of the bladder - either through training (pelvic floor exercises) or sometimes through surgery.

OAB /DI (over active bladder / detrusor instability) :

women with this type of incontinence usually report urinary frequency ( emptying the bladder more than 8 times a day), often having to get up during the night more than once. They report urgency (a very strong urge to empty the bladder) sometimes leading to incontinence before they reach the toilet.

It is caused by an abnormality in the normal storage / emptying mechanisms of the bladder - resulting in contraction of the detrusor muscle (the muscle in the wall of the bladder which contracts while it is emptying) and escape of urine at the wrong time.

This type of incontinence is not corrected by surgery, and in fact can be made worse by the procedures used to correct GSI.

Treatment for OAB/DI includes physio / bladder "retraining" and some medications aimed at relaxing the detrusor muscle.

Mixed :  some patients have a mixture of types of urine incontinence. Usually conservative (non surgical) treatments are tried first to see how much relief of symptoms can be obtained.

What treatments are available? 

What types of surgeries are available?

  1. Anterior vaginal repair:
    This is one of the earliest operations, performed via the vagina to reduce any lump protruding through the vaginal from the front (anterior) wall. Whilst it has a place, it does not lead to very good results with respect to urinary continence, with approximately 35-50% of patients still incontinent post surgery. It is used more when women have good bladder control but wish to reduce the sensation of a lump.

  2. Open burch colposuspension:
    This operation was first performed in 1961, and still remains the "gold standard" by which new procedures are compared to. It involves an incision similar to a caesarean section incision, followed by a dissection over the front of the bladder and down behind the pubic bone onto the front part of the pelvic floor. Sutures were then used to support / suspend the pelvic floor / vaginal  fascia (strong connective tissue) to a ligament behind the pubic bone.

    This led to a "cure" rate of about 85-90%.

    This surgery required a hospital stay (due to the relatively large incision) of 4-5 days, and 6 weeks recuperation, and so our profession has sought ways to reduce these times, through minimally invasive methods.


  3. Laparoscopic burch colposuspension:
    In this operation exactly the same procedure is performed as the "open" burch (above), however it is done through minimally invasive (laparoscopic) surgery. It is done with a 1cm incision in the belly button to introduce the camera, and three 5mm incisions across the bikini line for instruments.

    It takes about an hour to perform, and a catheter is left in overnight.

    The following day the catheter is removed, and assuming the patient is able to empty her bladder normally she is able to go home on the 1st day post operatively.

    It is accepted that laparoscopic burch colposuspension has the same success rates, that is 85-90% of women report either a cure or marked improvement in symptoms at the 6 week follow up, and again 5 years later.

Complications of this surgery include:

  1. failure to treat symptoms about 10%
  2. urine retention (inability to empty bladder): about 10% on the 1st day (which may require replacement of the catheter), decreasing to 1% by about the 3rd to 4th day, and even less by 1-2 weeks. Very rarely sutures may need to be removed to allow normal emptying to occur.
  3. urinary tract infections: 2-3% of cases - usually respond quickly to antibiotics
  4. urgency symptoms: about 5% but are usually transient
  5. damage to the bladder or ureters, about 1%
  6. heavy surgical bleeding < 1%
  7. blood clots forming in the legs, lodging in lungs <1%
  8. having to convert to open surgery < 1%
4.    TVT / TVT(o):
For about 10-15 years gynaecologists have been using mesh tapes to treat urinary incontinence. The tapes are made of permanent mesh, which will not dissolve. Varying types / weaves / methods of placement of mesh have been trialled on women over the years with varying success and complications. Currently the mesh tapes are introduced through small incisions in the front wall of the vagina (under the urethra - urinary opening) and brought out through the lower abdomen or the inner thigh, with the help of "trocars" (long sharp instruments about the diameter of a knitting needle). The mesh tape sits under the bladder neck or urethra and prevents the descent of the bladder neck / urethra that causes incontinence.

After 10 years + of experience with mesh tapes around the world it is believed that Mesh tapes have:
  1. a similar success rate to both open burch and laparoscopic burch colposuspension
  2. a 10-15% failure rate
  3. 5-10% bladder irritability
  4. a small chance of the trocar being passed through the wall of the bladder
  5. most concerning is the risk of mesh complication, initially thought to be rare but now less so. these include -
  6. mesh being rejected, or infected - requiring removal of the mesh. This can be difficult to do
  7. mesh erosion. This is when the mesh erodes through the vaginal wall (or sometimes the bladder wall) and becomes exposed. This causes pain, discharge, bleeding, painful intercourse and again requires that some or all of the mesh be removed. This can take more than 1 operation to remove. This is reported to occur anywhere from 3-5% to 10-15% of cases.

Recovery:

These surgeries aim to cause some support to the pelvic floor / bladder neck, largely through creating some fibrosis in the area, with tapes or sutures assisting to hold things in place. This can take 3 months to complete, but particular care should be taken in the first 6 weeks to avoid excessive straining / pressure on the area. This means avoiding heavy lifting, coughing if possible and straining with constipation (through diet, gentle stool softeners)

If your work is not in any way heavy it is possible to return at about 3-4 weeks to light duties.

Lap Burch  Vs  TVT (mesh tapes):
It is sometimes difficult to know which procedure is best for yourself, and you will get varying opinions from different specialists.

A minimally invasive procedure is obviously desirable, but other comparisons are: 

My practice is to offer / suggest laparoscopic burch as the primary procedure, and if this is unsuccessful to consider a mesh procedure. 

Laparoscopic Burch Colposuspension is generally considered to be a quite advanced laparoscopic procedure, due to the need to manipulate suture needles in a small space with 2 dimensional views on a monitor. For this reason there are very few surgeons performing this procedure. It requires surgeons to remained skilled in these techniques.

I made a decision early in my career that I would not be involved in performing mesh surgery, as I believe it has a quite limited place in gynaecological surgery, and I believe should only be performed by the specialists in our field who can deal with the significant complications that can occur. This is a decision I am even more comfortable with considering the recent announcement by the US FDA regarding the use of mesh in vaginal surgery. (link to http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm262435.htm )

If a patient either decides that they would prefer a mesh procedure first up, or due to ongoing symptoms after burch requests a mesh tape, then I facilitate a referral to a sub-specialist on the coast who regularly performs them.