Urinary Incontinence Surgery

Stress Incontinence occurs when the pressure on the bladder overcomes the mechanisms in place to keep urine from leaking. To begin with, stress incontinence must be differentiated from urge incontinence or detrussor instability. Urge incontinence occurs when the bladder muscle begins to contract in an attempt to empty the bladder. The most common occurrence with this type of incontinence is feeling the urge to go and not being able to make it to the restroom in time. This type of incontinence is treated with medicines as opposed to surgery.

Stress incontinence can be divided into two categories: 1. Urethral hypermobility and , 2. Instrinsic sphincter deficiency. Urethral hypermobility occurs usually in conjunction with other anatomic pelvic prolapse. Normally the bladder and bladder neck is supported within the realm of the abdominal and pelvic cavity. As the pressure within the abdomen increases, the rise in pressure also surrounds the bladder neck helping to close off the area where urine leaves the bladder and enters the urethra. If this area has lost its support, the increased pressure can no longer be used to assist in controlling the urine. The entire increase in pressure is transmitted to the dome or “balloon” part of the bladder. This in effect causes a greater force of urine on the bladder neck. The muscles surrounding the urethra are often not strong enough to hold the urine in.

Intrinsic sphincter deficiency occurs when the bladder and bladder neck are held in a normal position, but the closing pressure of the muscle surrounding the bladder neck is insufficient to prevent urine from leaking.

It is not uncommon for patients to have “mixed incontinence.” This includes a combination of stress and urge incontinence. In difficult cases or in patients with medical complications affecting the bladder innervation, special urodynamic testing can be performed to evaluate the pressures of the bladder and the muscle activity.

Common procedures for “stress incontinence” include: Burch urethropexy, suburethral sling procedures, and injection procedures. For many years the Burch procedure was and is considered the “gold standard.” This is performed with through and open “c-section” type incision or can be performed laparoscopically. The area behind the pubic bone is entered and the tissue on either side of the urethra is grasped with permanent suture and attached to a ligament on the pubic bone. This provides support to the urethra and bladder neck to prevent leaking.

Suburethral slings have been a remarkable addition to the surgical treatment of stress incontinence. Data regarding slings is very promising and studies have shown the efficacy to rival or exceed that of the Burch. A small incision (1-2 cm) is made in the vaginal mucosa underneath the urethra and the area is dissected with a scissor tip to the space behind the pubic bone. Two 1 cm incisions are then made just above the pubic bone. A permanent mesh is then passed underneath the urethra, behind the pubic bone, and through the incisions on the abdomen. This procedure is much less invasive than the Burch procedure and patients go home the same day after a voiding trial.

Some physicians can also perform bulking or injection procedures to assist in closing off the urethra. These injections are good procedures for patients who are not good candidates for longer more complex surgeries.

I perform suburethral sling procedures as well as laparoscopic Burch procedures for patients with stress incontinence.