Surgery for Stress Incontinence in Women

NOTE: Separate sections deal with surgery for men and surgery for problems with bowel incontinence.

For some women, pelvic floor exercises and other "conservative" methods are not enough. If these treatments do not produce results after trying to carry them out over 3 to 6 months, you may wish to discuss the option of surgery with your doctor. This is rarely a first resort and even in the best circumstances complete cure cannot be guaranteed.

There are a number of well-established operations in use to cure stress incontinence. All the procedures aim to improve the closure of the bladder outlet (urethra) during coughing or other sudden increases in pressure inside your abdomen, so that leakage does not occur. They vary from minor to major operations and most involve a hospital stay. Recovery after the operation varies greatly from a week to 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 type of urinary incontinence. 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 cure after 5 years for the different techniques 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 procedures 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 problems might occur after the operation? how likely are they? are they treatable? how?

The commonest operations

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 hammock around the urethra. the hammock attaches to the back of the pubic bone being stitched 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 have a catheter - either coming out through the wound or through your urethra (bladder outlet), this is needed as 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 may also have a tube from the wound to drain away any excess fluid. This will be removed after about 24 hours.

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 abdominal soreness would stop quick reactions in an emergency.

A newer type of surgery that is also offered as a first line therapy is the creation of a hammock using a "tension-free vaginal tape" (TVT). A synthetic tape is inserted through the vagina, up behind the pubic bone to pass through two small incisions (7mm wide) in the lower abdomen. The tape remains permanently in place, with the body fixing it in position with its own scar tissue, this provides support for the middle of the urethra when it is put under stress by coughing, laughing etc. The operation is usually performed under local anaesthetic with sedation, or under general anaesthetic. Your stay in hospital is one or two days and convalescence is about two weeks, this is much shorter than for the colposuspension. The TVT procedure has been in use for over eight years and has a similar cure rate to the Burch colposuspension (measured at 2 years after the operation). It is showing promising results but the long-term results and complications (greater than 10 years) of this procedure are unknown.

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.;
· not being able to empty your bladder, which may need treatment such as using a catheter 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".

Alternative operations

Other established types of operation in use include "anterior repair of the vaginal wall", "Stamey" or "needle bladder neck suspension", keyhole ("laparoscopic") technique, "Marshall-Marchetti-Krantz operation" , “trans-obturator tape (TOT)”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 not a cure for stress incontinence. 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 comparatively minor and less invasive procedure is the injection of a bulking agent. This involves the injection of a substance around the neck of the bladder where it joins the urethra and helps keep it closed during coughing. There are many different materials which are used for injection - silicone and carbon particles, complex sugar solutions, particles of bone cement and a natural material called collagen. This is a simple operation: depending on the surgeon, it may be done under full or local anaesthetic as a day case or with an overnight stay. It may need to be repeated if a single injection proves insufficient. Recovery is rapid from this procedure. (In 2005 the National Institute of Clinical Excellence carried out a consultation about these procedures. Advice sheets for both clinicians and patients should be available in the autumn.)

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.

Revised February 2005
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