A common problem, urinary stress incontinence is the involuntary passage of urine when there is a sudden increase in the pressure in the tummy. Typically it happens with coughing, jumping or sneezing. It can be experienced in all ages but more frequently, it happens in the older woman who has experienced childbirth or menopause.
It is caused by the weakness in the sphincter control mechanisms of the bladder. When faced with a sudden rise in the pressure in their tummy, the muscles are not strong enough to prevent the leakage of urine. This can limit one’s ability to enjoy the normal activities in life like sports and may lead to embarrassment and even social isolation in severe cases.
Whilst some women may have a genetic tendency to weak muscles, for most, it is due to the trauma of childbearing which is then aggravated by the loss of hormonal support in menopause. Increasing weight also plays a significant part. The presence of a prolapse of the bladder is not necessarily the cause of the problem, but simply a co existent finding.
In managing this problem, I undertake a number of investigations including:
- Assessment of the pelvic floor support to check for prolapse
- Evaluation of the pelvic floor muscle integrity and strength
- Ultrasound of the bladder to check the bladder support
- Urodynamic studies to check the bladder function
- Urine test to exclude infection
Once the results of these are available then a plan of management can be devised. The common options are:
- Pelvic Floor Physiotherapy. This is a cornerstone of management. Improvement of the strength of the pelvic muscles by itself may alleviate the symptoms for many women. It is best undertaken under the guidance of a specialist trained Pelvic Floor Physiotherapists.
- Magnetic therapy. This uses magnetic waves to stimulate the pelvic floor muscles. It can stimulate the muscles stronger than is possible by physiotherapy alone. I use it as an additional tool to complement physiotherapy. It also helps raise a woman’s awareness of the pelvic floor muscles.
- When physiotherapy alone is insufficient, then surgery may need to be undertaken. This is particularly so, if there is a large prolapse of the bladder present as well.
Surgery for Stress incontinence goes back a long way. There are a multitude of operations devised over the years to deal with this difficult problem. The aim is to try to improve the support of the bladder. The most common way is to use different materials to do so. Some of the common methods are as follows:
- Vaginal repair. This is a longstanding traditional method using stitches to strengthen the bladder. It can work well but the success rate is lower than current techniques and it may not be long lasting.
- Burch colposuspension. This was described as the gold standard for many years. It involved putting in stitches into the vagina and pulling the bladder up by anchoring the stitches to the back of the pubic bone. It is performed through the tummy. Although very effective, it commonly had a long hospital stay and recovery as it would commonly be performed through a big cut in the tummy. The risks were also higher due to the need for a big cut.
- Tissue slings under the bladder. This is a sling fashioned from the woman’s own muscle tissue and slid under the bladder. Again very effective but required a big cut in the tummy leading to a longer hospital stay and increased risks associated with the need for a big cut. A typical example of such a sling would be the Aldridge sling.
- Synthetic slings. With the advent of synthetic slings there came a significant change in the management of this problem. The slings were inserted using small instruments that were passed through different parts in the pelvis. The instruments were small and so the cuts required to insert them were small. This immediately had the effect of providing an effective method of dealing with stress incontinence whilst at the same time avoiding the need for big cuts and their associated risks. Studies performed using these slings indicated a success rate as good if not better than the Burch colposuspension technique.There was a myriad of techniques used to insert the slings. The instruments had to be devised to pass through the pelvis which is a very complex region as there were a number of major organs and structures like major blood vessels and muscles. Each technique therefore had their own set of specific problems. Nonetheless, they did work well.The slings themselves are made of mesh. This is the same mesh used for prolapse repair that has been subject to controversy and litigation in 2017. Like the prolapse mesh, they have the same types of risks associated with their use. However, unlike the prolapse mesh, they are smaller and do not need anchor points which contributed to a lot of the difficulties encountered with prolapse repair. Also unlike the prolapse mesh, the Therapeutic Goods Administration have not issued a ban on their use and so they continue to be available to be utilised.Despite all these problems synthetic slings are still the favoured choice, at least amongst Gynaecologists. They have a high rate of success and a lower risk compared to the other techniques. Hospital stay can be as short as overnight with a 1-2 week recovery.
If surgery is required, a detailed discussion is required to choose the optimal technique for the individual. The important thing to remember is that no one technique will guarantee 100% success forever. At best success rates will be about 90%. Whilst it may be effective for a long time, it is not uncommon for the problems to recur over time.
Dealing with Stress incontinence can be difficult. There are effective means to improve the symptoms. It does require commitment on the woman’s part as well. The importance of ongoing pelvic floor muscle exercises, management of weight and avoidance of excessive straining are all important facets that will help to maintain the success that is achieved from initial treatment.
If you have issues with this problem, feel free to make an appointment to see me so we can explore the options available to you.
These notes reflect my personal opinion and are intended for general advice only. It should not be used for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation.