Incontinence & Pelvic Floor Disorders
Doctors may suggest surgery to improve bladder control if other treatments have failed. Surgery helps only urinary stress urinary incontinence and it has proven to be very effective. The best surgical procedures improve or cure the incontinence associated with coughing laughing sneezing and exercise in about 85% of women.
Also referred to as the Tension-free Vaginal Tape procedure (TVT). This procedure involves placing a strap of graft material underneath the mid to upper portion of the urethra or neck of the bladder to provide support during activities that increase abdominal pressure such as coughing or lifting something heavy. The support helps to prevent urine from leaking out through the urethra. Over the years, numerous graft materials have been used. Today, the sling is most often made of polypropylene mesh.
The mid-urethral mesh sling is inserted through three small half inch incisions: one in the vagina (underneath the urethra) and two above or along side the pubic bone. The sling can be placed at the time of another procedure or it can be done independently as an outpatient procedure under minimal anesthesia. The continence rates after the sling are equivalent or slightly superior to the traditional Burch procedure demonstrated in clinical trials.
Burch or Marshall Marchetti Krantz (MMK) Colposupension
The Burch or MMK procedures have been performed for over 50 years through a lower abdominal incision. In this operation, stitches are placed into the vagina wall along side the urethra at the bladder neck and then secured to ligaments nearby in the pelvis or into the strong tissue that covers the back of the pubic bone. The stitches lift the vaginal wall that the urethra rests upon and provides support to the bladder neck and urethra. These procedures can also be done laparoscopically. The procedure produces a long-term improvement in more than 70% of patients with stress incontinence.
Peri-urethral Bulking Agent Injections
In this procedure, a long acting or permanent paste-like substance (such as collagen or others) is injected into the muscular wall of the urethra using a cystoscope. This injection causes the tube of the urethral to narrow which results in less urine leakage. Although the rate of continence is less after this procedures when compared to the sling type or the Burch procedures, it is much less invasive, does not require incisions, has a low complication rate and can be performed in an office or on an outpatient basis. Seven out of 10 women who have a bulking agent injection report that their leakage is improved or has stopped. This improvement lasted about 1-2 years at which point, if the leakage returns and is disturbing, the same procedure may be repeated or an alterative treatment may be chosen.
Periurethral bulking agent injections are frequently recommended for women in poor medical health for whom more invasive surgery or anesthesia is not safe; on blood thinner medications; cannot take time off to recover from surgery; or who continue to leak after other incontinence surgery.
Many times surgery is chosen when a vaginal pessary is either not desired or cannot be retained comfortably. There are several different surgical techniques which are effective. Often the choices offered to a women depends upon her anatomy, overall health, her prior surgeries and current medical conditions, her desire to retain sexual function and the experience and training of her surgeon. Deciding whether or not to have surgery for prolapse is an individual decision.
The most important aspect of a prolapse repair (when maintaining sexual function is desired) is restoration of the support of the top of the vagina which is also called the vaginal apex or vault.
Common procedures that do this are:
- Abdominal Sacral Colpopexy (ASC) – At Silver Cross, the ASC is performed through an abdominal incision (about 3-4 inches long) or laparoscopically (through 4 half inch incisions). In this procedure straps of graft material are used to reinforce the front and back walls of the vagina. These straps are then attached to a strong ligament overlying the sacrum. The end result is that the vagina is suspended over the pelvic muscles to the back-bone. The mesh graft straps replace the original natural support provided by the uterosacral ligaments.
- Uterosacral or Sacrospinous Ligament Fixation – When a vaginal incision is preferred, the top of the vagina is most often suspended to a woman’s own uterosacral ligament or the sacrospinous ligaments. Traditionally these procedures did not use graft material. Recently, more surgeons are adding graft reinforcement to the natural ligament suspensions in an effort to improve the durability of the prolapse repair when surgeons find the vaginal wall to be weak.
Anterior Vaginal Suspension
A bulge of the front wall of the vagina usually results in loss of support to the bladder that rests upon this part of the vagina. The goal of a cystocele repair is to elevate the anterior vaginal wall back into the body and support the bladder. This can be done either vaginally or at the same time as ASC. Anterior colporrhaphy is a commonly performed repair of a bulges. In an anterior colporrhaphy, an incision is made in the front wall of the vagina. The vaginal skin is separated from the bladder wall behind it. The weak or frayed edges of the deep vaginal wall are found and the strong tissue next to edges are sutured to each other lifting the bladder and recreating the strong ”wall” underneath it. The vaginal incision is then closed with dissolving stitches. Unfortunately, this part of the pelvic floor is subjected to significant pressure with each cough or when picking up heavy things. As many as one third of women will develop recurrent anterior prolapse after an anterior colporrhaphay. To reduce this recurrence of prolapse, a surgeon may chose to place a “patch” of graft material over the repair line to reinforce the repair.
Posterior Vaginal Prolapse Repair
A bulge of the back wall of the vagina is most often repaired by a vaginal procedure called posterior colporrhaphy. A bulge may also be fixed abdominally at the time of ASC. Posterior colporrhaphy is a procedure that repairs the rectal bulge protruding through the back wall of the vagina. During the procedure, an incision is made in the back wall of the vagina. The vaginal skin is separated from the rectal wall underneath. The weak or frayed edges of the deep vaginal wall tissue are identified. The strong tissue next to edges are sutured to each other recreating the strong ”wall” between the rectum and the vagina. The vaginal incision is then closed. At times, a surgeon may chose to place a “patch” of graft material over the repair line to reinforce the repair. Studies are ongoing to help understand the role of these graft materials in rectocele repair. Your surgeon will most likely close the incision with self-dissolving stitches.
For those women who do not need to maintain sexual function, an obliterative procedure may be the quickest and least risky method to correct prolapse. Obliterative operations correct prolapse by narrowing and shortening the vagina. These procedures support the pelvic organs with the patient’s own pelvic muscles in such a way as to make the vagina too small to accommodate a penis for sexual intercourse. The skin overlying the vaginal bulge is removed, and the front and back walls of the vagina are sewn to each other. A woman who has undergone this surgery will look the same on the outside of her genital area and she will be able to have bowel movements and urinate normally. Her ability to have an orgasm with clitoral stimulation is similar to before her surgery. There are two main types of obliterative surgery: Partial (colpocleisis) and complete (colpectomy). Both are very effective and durable in correcting prolapse. Prior surgeries often influence which procedure is offered to women. The benefit of obliterative surgery is that it is very durable, does not involve the risks of graft materials, tends to be less invasive and therefore is associated with a quicker recovery.
Ask your physician if surgery is right for you. Contact a doctor who specializes in surgery to treat urinary stress incontinence: