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For
a small number of women, exercise and other "conservative" methods are not
enough. If these treatments do not produce results after a reasonable period,
you may wish to discuss the option of surgery with your doctor. This is
rarely a first resort and even in the best circumstances the results can
never be guaranteed.
There are several well established operations in use to cure stress incontinence.
They are all aimed at assisting the function of the pelvic floor muscles
by either lifting the neck of the bladder so as to help it remain closed
or simply supporting it so that it does not leak when it is put under stress
by coughing or other sudden increases in pressure inside your abdomen. They
are not minor operations and most will normally involve you in a hospital
stay of at least several days with maybe 6-8 weeks’ convalescence.
Success rates
Very broadly speaking, the more minor, less invasive an operation is, the
lower the chance of long-term success. With any particular type of operation,
your chance of long-term success will also depend on your own general health,
age, weight, previous operations, and other personal circumstances (such
as whether you simultaneously need - for example - a hysterectomy). These
are the factors that will direct your surgeon’s choice of which operation
to recommend for you.
As a rough guide, the chance of long-term success for the different techniques
in general use ranges from about 4 out of 10 up to about 9 out of 10.
What you should discuss with your surgeon
Before consenting to an operation, you should discuss it fully with your
surgeon. Make a list of questions you want to ask, such as the following: |
# what exactly is he or she going to do? (You will find below
a description of the commonest procedure and information about some
other operations, but there are alternatives not mentioned here.)
# what cut will he or she make, what stitches will there be, and
what sort of scar will be left?
# how long will you be in hospital, how long will you be off work
or convalescing?
# what permanent changes in your lifestyle will result - maybe
improvements, maybe limitations?
# how often has your surgeon performed the operation? with what
results?
# what are the chances of a complete cure for your incontinence?
of a substantial improvement?
# will the change be permanent? if not, how long will it last?
# what adverse effects may there be? how likely are they? are
they treatable? how?
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The
most common operation
The best known and most often used technique is called the Burch Colposuspension
and it produces the highest rates of long-term success - up to 85-90% success
at five years after the operation. Like most of the established operations,
it involves (in layman’s terms) creating a cradle of threads from back to
front of the pelvic region, stitched at each end to suitable strong fibrous
tissues.
You will normally be admitted to hospital the previous day, and you will
not be allowed to eat or drink for several hours before the operation, which
is usual before having a general anaesthetic.
After you are asleep the surgeon will make a small horizontal "bikini line"
cut just below the hairline. He or she will then put in the stitches described
above.
When you come round from the operation, you will probably find you have
a tube from the wound to drain away any excess fluid. This will be removed
after about 24 hours. You will also have a catheter - either coming out
through the wound or through your urethra (bladder outlet), which you will
need because at first you will not be able to pass all your urine, leaving
some in the bladder that will need to be removed by the catheter.
You will be in hospital for up to a week, depending on how quickly you recover.
After you go home it will take you up to six weeks to recover fully, during
which you should build up your activity by stages. You will probably be
recommended not to drive for about four weeks as your soreness will inhibit
your quick reactions in an emergency.
Side Effects and Complications: Operations for stress
incontinence carry the same unavoidable risks that any operation does. In
particular, up to 1 in 5 women may develop some form of complication, such
as: |
# an overactive bladder - so that you have to rush to the
toilet and/or go more frequently even though you no longer leak with
coughing, physical exertion etc.;
# inability to completely empty the bladder, which may need treatment,
perhaps involving intermittent self-catheterisation for a protracted
period while your normal bladder function returns;
# other symptoms of the weakness of your pelvic floor, such as
the possibility of prolapse of the womb;
# (for a few people) discomfort during sexual intercourse - known
as "dyspareunia".
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Keyhole Surgery: Sometimes the new keyhole ("laparoscopic")
technique is used to do the same operation. This involves making two or
three very small cuts of only about a quarter inch (0.5 - 1 centimetre).
This may reduce your stay in hospital and length of convalescence. However,
it is not yet proven that the results of colposuspension by keyhole techniques
are as good as with traditional surgery.
Alternative operations
Other established types of operation in use include "anterior repair
of the vaginal wall", "Stamey" or "needle bladder neck suspension",
"Marshall-Marchetti-Krantz colposuspension" and varieties of
"sling procedure". Your surgeon may suggest that one of these is a
better option for you than the Burch colposuspension, either because of
your general health or because of some specific features relevant to you
- for example, the "anterior repair" technique is only appropriate if
your primary need is to repair a prolapse and the cure for stress incontinence
is less important. Your surgeon should be willing to explain what factors
have led him to suggest one of these operations if you wish to discuss
the matter with him.
A new type of surgery that is being evaluated at present is the creation
of a sling using "tension-free vaginal tape" (TVT). This
synthetic tape is inserted through small incisions just above the pubic
area and remains permanently in place, with body fibres soon growing into
it, and provides support for the bladder neck when it is put under stress
by coughing, laughing etc. The operation is usually performed under local
anaesthetic and your stay in hospital (one or two days) and convalescence
(about two weeks) will be much shorter than for the operations mentioned
above. The TVT procedure has been in use only for a few years. It is showing
promising early results with fewer short-term complications than with
traditional methods but it remains experimental with no long-term data
on success rates or possible later complications yet available.
A comparatively minor procedure is the injection of a bulking agent
to help keep the outlet closed. There are two types of material in use
for these injections - synthetic polymers and a natural material called
collagen. This is a simple operation: depending on the surgeon, it may
be done under full or local anaesthetic, involving an overnight stay or
as a day-case. It may need to be repeated if a single injection proves
insufficient.
The effectiveness of this treatment has not yet been fully proven. The
injected material loses its effect as it is slowly absorbed by or dispersed
in the body over a period of a few years and studies show that for 4 out
of 10 women the effects will last for less than two years and for 8 out
of 10 less than three years. However, the procedure is a minor one and
is readily repeatable.
Your surgeon will take all your particular characteristics into account
before recommending an operation. You should discuss the reasons for his
recommendation with him before agreeing to the operation. It is a good
idea to write down your questions before you go for your appointment.
Remember: it is your decision.
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Return to Stress Incontinence
[Revised 24 February 2001]
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