Urinary Incontinence Surgery: When Other Treatments Aren't Enough

Surgery for urinary incontinence includes a variety of procedures, from minimally invasive injection of bulking agents to major surgical intervention. Find out which procedure might be an option for you.

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.

• 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.

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 spinal cord reflexes that control urination. The impulses are generated by a small, pacemaker-like device surgically placed in a "pocket" of fat beneath the skin of your buttock just below the belt line. 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 permanently.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia. You may be advised to limit activities for three or more weeks as your incisions heal. Once the stimulator is implanted, it functions for several years. After that, it can be replaced during an outpatient procedure. 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 cure more than half the people with difficult-to-treat urge incontinence or urinary retention leading to overflow incontinence. The device can be removed at any time.

Hydrodistention
Hydrodistention involves filling your bladder with fluid until it's stretched beyond its normal capacity, allowing it to remain distended for several minutes. Stretching your bladder in this way can be painful, so the procedure is performed under general or local anesthesia, usually in a hospital. Most of the time, you're able to go home the same day. The effects of treating overactive bladder with hydrodistention are temporary — lasting around three months — and success rates vary widely.

After the procedure, you may experience some pain in your pelvic area, especially when urinating the first few times. Your urine may contain some blood, but this is normal after the procedure. Discomfort may continue for a few weeks, but your doctor can prescribe pain relief medication to ease any pain or burning. Potential complications of hydrodistention include bleeding, urinary retention and bladder perforation, although these are fairly uncommon. Another potential complication is interstitial fibrosis, which leads to stiffening of your bladder wall.

Bladder augmentation
Bladder augmentation is an older procedure used to increase the size of your bladder. The operation is complex and involves major abdominal surgery. Your surgeon makes an incision in your abdomen and an opening at the top of your bladder. He or she 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. The surgery is done under general anesthesia and may take several hours.

Recovery generally requires staying in the hospital until you're able to start drinking and eating again. It usually takes a few weeks after you leave the hospital for you to return to your normal schedule. Many people, especially those with underlying nerve damage, require lifelong use of a catheter after the procedure.

Bladder augmentation doesn't always cure incontinence and can have complications such as infection and chronic diarrhea. Two rare but potentially serious complications are spontaneous perforation of the bladder and development of bladder cancer.

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.

Updated March 11, 2008

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