AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Urinary incontinence is an underdiagnosed and underreported medical problem. Because of social stigma, an estimated 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment. Of individuals with urinary incontinence, only 5% in the general community and 2% in nursing homes receive appropriate medical evaluation and treatment. Patients with urinary incontinence often endure this condition for 6-9 years before seeking medical therapy.

Stress incontinence affects 15-60% of women. It is a disorder that affects both young and elderly individuals. For example, more than one fourth of nulliparous young college athletes experience stress incontinence when participating in sports.

Pubovaginal slings are becoming increasingly popular with urologists for the treatment of all types of female stress urinary incontinence (SUI). Pubovaginal slings have excellent overall success and durable cure rates. The procedure involves placing a band of sling material directly under the bladder neck (ie, proximal urethra) or mid urethra, which acts as a physical support to prevent bladder neck and urethral descent during physical activity. The sling also may augment the resting urethral closure pressure with increases in intra-abdominal pressure.

History of the Procedure

Von Giordano is usually credited with performing the first pubovaginal sling operation in 1907, using a gracilis muscle graft around the urethra. In 1914, Frangenheim used rectus abdominus muscle and fascia for pubovaginal slings. In 1942, Aldridge, Millin, and Read corrected urinary incontinence using fascial slings. In 1965, Zoedler and Boeminghous first introduced synthetic slings.

Problem

Female SUI may be broadly subcategorized into types I, II, and III, as follows:

• Type-I SUI is defined as urine loss occurring in the absence of urethral hypermobility. This is the mildest form of SUI.
• Type-II SUI is defined as urine loss occurring due to urethral hypermobility. This is also known as genuine stress incontinence (GSI).
• Type-III SUI is defined as urine leakage occurring from an intrinsic sphincter deficiency (ISD). ISD is a more complex form of female SUI.

The subcategories of female SUI can be ascertained by direct physical examination and by measuring an abdominal leak point pressure (ALPP). ALPP, also known as the Valsalva or stress leak point pressure, is defined as the lowest abdominal pressure necessary to cause urine leakage.

An ALPP less than 60 cm water is considered diagnostic of type-III SUI, whereas an ALPP of 90-120 cm water is consistent with type-II SUI. Values of 60-90 cm water reflect the presence of both type II and III, in combination. An ALPP greater than 120 cm water is considered diagnostic of type-I SUI.

Recent experiences suggest that leak point pressures to not need to be stratified as they were in the past. This is because of the new slings that manage all types of SUI. The types of incontinence listed above are noted for descriptive and historical purposes.

Frequency

Urinary incontinence affects approximately 13 million people in the US, predominantly women. This incidence rate includes 10-35% of adults and 50% of the 1.5 million residents in nursing homes. As many as 60% of nursing home patients are incontinent, while 30% of elderly people living at home are incontinent.

Of the 3 types of female SUI, type-II SUI occurs most commonly (37%), followed by type-III SUI (33%), types II and III in combination (16%), and type-I SUI (13%). McGuire has previously reported that ISD is a complication of simple hysterectomy and was present in 48% of 67 patients after hysterectomy.

Etiology

The cause of SUI is complex. Many different factors contribute, including advancing age, multiparity, prolonged or difficult labor, and hysterectomy. Other factors that may increase the risk of developing incontinence include obesity, straining at stool as a child or young adult, heavy manual labor, chronic obstructive pulmonary disease, and smoking. For men, prostate surgery is the most common cause of SUI.

Pathophysiology

Two major types of SUI exist in women, urethral hypermobility and ISD. Male SUI results from loss of function of both the internal and the external sphincter mechanism. Unlike females with SUI, men only develop type-III stress incontinence, ie, ISD.

Urethral hypermobility

This condition results from a weakened anatomic support of the urethra, whereas ISD arises from a defect within the urethra proper. When a loss of anatomic support occurs, the proximal urethra and the bladder neck descend to rotate away and out of the pelvis at times of increased intra-abdominal pressure. Because the bladder neck and proximal urethra move out of the pelvis (ie, outside of the abdomen), the bladder receives greater intra-abdominal pressure relative to the urethra. Due to this pressure differential, the urethra decreases intraurethral resistance and is more susceptible to involuntary urine loss.

Realize that the female urethra lies under the pubic symphysis, and the pubourethral ligaments suspend the anterior urethral wall to the pubic arch. During the Valsalva maneuver (eg, abdominal strain), the posterior wall of the urethra slides away from the anterior urethral wall to cause an opening of the bladder neck in patients with urethral hypermobility. The uneven pressure transmission, together with the opening of the bladder neck, result in involuntary urine loss during periods of physical activity, ie, type-II SUI.

Intrinsic sphincter deficiency

In this condition, the urethral sphincter is unable to coapt and generate enough resting urethral closing pressure to retain urine in the bladder.

The anatomic support is normal, but the urethra cannot remain closed due to a lack of the mucosal seal mechanism. Inadequate bladder outlet resistance during times of physical activity results in involuntary urine loss, ie, type-III SUI. Again, newer thought processes suggest that all patients with SUI have some component of ISD. The distinctions between types I, II, and III are now less important than they once were.

Clinical

Stress incontinence

This condition occurs during periods of increased intra-abdominal pressure. Typically, patients complain of involuntary urine loss during coughing, laughing, and sneezing. Their incontinence becomes worse during high-impact sports activities (eg, golf, tennis, aerobics).

In general, women with SUI experience less urine loss compared to those women with overactive bladder (OAB). SUI occurs at predictable times. Irritative voiding symptoms, including urinary frequency, urgency, and nocturia, typically are absent. SUI caused by urethral hypermobility results in a smaller amount of urine loss and requires the use of fewer pads than are required for ISD.

Urinary incontinence

Patients with symptoms of urinary incontinence should undergo a basic evaluation that includes a medical history, physical examination, measurement of postvoid residual urine, and urinalysis.

Questions pertinent to the medical history include whether incontinence is associated with physical activity versus a sense of urgency. If the urine loss is coincident with coughing, laughing, and sneezing in the absence of irritative voiding symptoms, the patient most likely is describing stress incontinence.

Pure stress incontinence does not produce irritative voiding symptoms (eg, frequency, urgency, nocturia). Furthermore, this type of incontinence usually is predictable because the condition occurs only during periods of increased intra-abdominal pressure (eg, physical activity). The amount of urine lost is small and usually is reflected by the number and type of pads used. Typically, affected patients use thin to medium-thickness pads. The number of pads used ranges from 1-3 per day; however, the amount of urine loss and pad use increases with the complexity of stress incontinence. Patients with ISD are likely to lose more urine and use more pads than women with type-II SUI.

If the symptoms of frequency, urgency, and nocturia are present, the patient more likely is describing urge incontinence or OAB. Urinary incontinence caused by an OAB often is unpredictable, and the amount of urine lost is greater than that associated with stress incontinence. When patients experience an uninhibited detrusor contraction, they expel the entire contents of their urinary bladder. Thus, patients with OAB use more and thicker pads than women with stress incontinence. Often, patients with OAB tend to be more distressed by their symptoms than women with stress incontinence.

If the symptoms include urinary frequency, urgency, postvoid dribbling, and a sense of incomplete emptying, the patient may be describing overflow incontinence. This condition is considered a urologic emergency and should be ruled out when examining a patient with incontinence. Urinary retention may be the result of an antiincontinence surgery, idiopathic urethral stenosis, urethral carcinoma, or excessive use of anticholinergic or antispasmodic drugs. Patients also may complain of suprapubic pain and abdominal distention.

If a woman reports total or continuous incontinence, she may have ISD or a fistula (eg, vesicovaginal, ureterovaginal). Because some women with ISD have such low urethral resistance, simply standing up from a sitting position evokes urine loss by gravity. This is similar to vesicovaginal or ureterovaginal fistula. These patients complain of being wet all the time and use excessive amounts of thick pads to stay dry. If suspecting a fistula, be sure to ask about previous surgical history, including a hysterectomy. Although uncommon, consider ectopic ureter/ureterocele in the differential diagnosis.

During the physical examination, a detailed pelvic examination is extremely important. Assess the external genitalia for the presence of atrophic vaginitis. Friable and irritated tissues around the vaginal introitus and labia minora suggest vaginitis. The presence of masses on the anterior vaginal wall should raise the suspicion of urethral caruncle, urethral diverticulum, urethral carcinoma, and Skene gland cyst.

Systematically inspect the anterior and posterior surface and the apex of the vagina for the presence of pelvic organ prolapse, including urethrocele, cystocele, rectocele, enterocele, and vaginal vault prolapse.

Some patients may need to provide additional information from a voiding diary, cotton swab test, cough stress test, cystoscopy, and urodynamics test.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The common indications for pubovaginal sling surgery in women include SUI that affects ones quality of life and potential incontinence in a patient undergoing prolapse repair.

In addition, those women at risk for generating high intra-abdominal pressures, including patients who are obese, vigorous athletes, and those with chronic obstructive pulmonary disease, are well-served by pubovaginal slings.

For men who have undergone prostatectomy and have ISD, the artificial urinary sphincter (AUS) is the criterion standard therapy. Researchers recently introduced the male sling as an alternative to AUS in correcting postprostatectomy incontinence. During a male sling operation, the surgeon places a supporting strap of material under the bulbar urethra and secures the suspension sutures to the pubic arch, next to the bulbar urethra. The use of a male sling for SUI in men is still early in its experience, although many patients have undergone the procedure successfully and have had excellent results. A male sling seems best geared toward patients with milder degrees of incontinence (2-3 pads or less per day).

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Female urethra

The female urethra is an elongated tube (4 cm) that is composed of an inner epithelial lining, a spongy submucosa, a middle smooth muscle layer, and outer fibroelastic connective tissue (see Image 1 and Image 2).

The spongy submucosa contains a rich vascular plexus that is responsible for providing adequate urethral occlusive pressure to create the washer effect, an important female continence mechanism. Urethral smooth muscle and fibroelastic connective tissues circumferentially augment the occlusive pressure generated by the submucosa.

All parts of the female urethra are influenced by estrogen. The lack of estrogen at menopause leads to atrophy and replacement of the submucosa (eg, vascular plexus) by fibrous tissue.

Previous bladder neck operations, radiation exposure, and neurogenic disease can affect the ability to achieve a perfect seal. When a postmenopausal woman with atrophic vaginitis takes estrogen, the mucosa regains its turgor and a simultaneous upregulation of alpha-receptors and angiogenesis of the vascular plexus occurs. Lack of estrogen is one of the risk factors for ISD; replacement of estrogen may reverse the effects of ISD. Complete reversal of ISD is rare, but estrogen supplementation improves symptoms of type-III stress incontinence.

Internal sphincter

The bladder neck and the prostate comprise the internal urinary sphincter in males.

Women do not have an anatomic internal sphincter; they have a functional internal sphincter. The bladder neck and proximal urethra comprise the female internal sphincter (see Image 2 and Image 3). Under normal circumstances, the resting urethral closure pressure of the internal sphincter is more than the resting or stressed intravesical pressure of the bladder.

External sphincter

The female external sphincter, ie, the rhabdosphincter, is composed of 2 types of striated muscle fibers, fast twitch and slow twitch. Fast-twitch fibers cause the sudden stopping of the urinary stream to provide the voluntary guarding reflex. Slow-twitch fibers maintain the constant tone of the external sphincter to provide continuous passive continence, the involuntary guarding reflex.

The rhabdosphincter has the most prominent effect on the female urethra at the urogenital triangle. Located approximately 1.8 cm distal to the bladder neck, it exerts influence for a distance of approximately 1.5 cm of urethral length (see Image 2 and Image 3).

The male external sphincter is similar to that of female external sphincter, ie, the rhabdosphincter.

Pelvic diaphragm

The pelvic diaphragm lines the floor of the bony pelvis and is comprised of 4 sheets of muscles, the pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus (see Image 4 and Image 5).

Specialists often refer to the pelvic diaphragm as the levator ani. The levator ani musculature is attached to the inner sides of the bony pelvis by a condensation of pelvic fascia called the arcus tendineus.

The levator ani is the most important component of the pelvic diaphragm because the integrity of the pelvic floor depends upon its function. When the levator ani is damaged, SUI and/or herniation of pelvic organs through the vagina may develop (See Image 4 and Image 5).

Supporting ligaments and fascia

The urethropelvic ligament is a fibrous band of connective tissue that lines the undersurface of the bladder neck and attaches laterally to the arcus tendineus. The urethropelvic ligament provides the major support to the bladder neck and proximal urethra. Laxity of the urethropelvic ligament results in SUI.

The pubocervical fascia is a fibrous sheet of connective tissue that lines the base of the urinary bladder and inserts laterally into the arcus tendineus. An intact pubocervical fascia prevents the herniation of the bladder and the proximal urethra into the vagina. Damage to the pubocervical fascia may cause the bladder to herniate through the vagina, resulting in cystocele formation and SUI.

The cardinal ligaments arise from the arcus tendineus and anchor to the uterine cervix. The cardinal ligaments stabilize and support the uterus, vagina, and bladder. Weakening of the cardinal ligaments may cause a cystocele and uterine descensus (see Image 6).

The uterosacral ligaments originate from condensation of the fibrous connective tissue overlying the sacral promontory and insert into the uterine cervix. The uterosacral ligaments stabilize the uterus in the bony pelvis. Weakening of the uterosacral ligaments may cause a prolapsed uterus or vaginal vault prolapse (see Image 6).

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

A clear contraindication to pubovaginal sling surgery is pure urge incontinence or mixed incontinence where the predominant component is urge. An inherent risk of any sling procedure is de novo or worsening urge symptoms; thus, surgeons must identify and treat the presence of an urge component before surgery.

Conversely, poor detrusor function is a relative contraindication to sling surgery because the potential for urinary retention is increased. Women with absent or poor detrusor function in the presence of SUI are at a higher risk of experiencing prolonged postoperative urinary retention.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• Urinalysis and urine culture: Urinary tract infection can cause irritative voiding symptoms and urge incontinence.
• Chem 7 profile
• • Check the blood urea nitrogen (BUN) and creatinine (Cr) if compromised renal function is suspected. This is especially important in the case of a stage-III or stage-IV cystocele (see Image 6).
  • Stage-I cystocele is when the bladder drops to the mid vagina with abdominal strain.
  • Stage-II cystocele is when the bladder drops to within approximately 1 cm of the hymen.
  • Stage-III cystocele is when the bladder protrudes out of the vaginal introitus to greater than 1 cm outside of the hymenal ring upon abdominal strain.
  • Stage IV cystocele is when, at rest, the bladder protrudes out of the vagina to greater than 3 cm from the hymen.
  • When the bladder herniates out of the vagina, it may drag ureters with it. Both ureters can become trapped and obstructed at the bony pelvis, causing hydroureteronephrosis. This results in elevated BUN and azotemia.

Imaging Studies

• Static lateral cystogram
• • A static cystogram (eg, anteroposterior [AP], lateral) helps to confirm the presence of SUI, the degree of urethral motion, and the presence of a cystocele.
  • Perform a static cystogram during videourodynamics under fluoroscopy. When the bladder is halfway full (ie, 200-250 mL), obtain AP and lateral images of the bladder and bladder neck at rest and using Valsalva and coughing maneuvers.
  • ISD is evidenced by an open bladder neck. The presence of a vesicovaginal fistula also may be identified.
• Voiding cystourethrogram
• • This test can assess bladder neck and urethral function (ie, internal sphincter, external sphincter) during the filling and voiding phases.
  • A voiding cystourethrogram (VCUG) can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux. A static cystogram or VCUG may be performed with videourodynamics.
• Beaded-chain cystourethrogram
• • In the past, physicians commonly employed this method to assess urethral hypermobility and the degree of bladder descent. This test largely has been replaced by videourodynamics (see Videourodynamics) and other studies.
  • Incontinence experts no longer recommend the beaded-chain cystogram test, which is mentioned here only for historical interest.

Other Tests

• Voiding diary
• • A voiding diary is a daily record of a patient's bladder activity.
  • The diary is an objective documentation of a patient's voiding pattern, incontinent episodes, and any inciting events associated with urinary incontinence.
• Pad test
• • The pad test is an objective test that documents urine loss.
  • Intravesical methylene blue test, oral Pyridium, or oral Urised may be used. Methylene blue and Urised turn the urine blue. Pyridium turns the urine orange.
  • Patients should resume their usual physical activities while wearing a Peri-pad. A Peri-pad is a sanitary pad placed against the vagina and the perineum. If the pads turn orange or blue, the patient is experiencing urine loss. If the pads remain white, the discharge most likely is normal vaginal fluid.
  • Provocative pad tests may entail a patient performing activity for 1 hour or longer to demonstrate how much leaks into the pad within that time frame. The patient then has the pads weighed.
• Cotton swab test
• • An abnormal upward deflection of the cotton swab (>30°) during the Valsalva maneuver is evidence of urethral hypermobility (see Image 7).
  • The absence of hypermobility suggests that the cause of the SUI is ISD.
• Supine cough stress test
• • A critical part of the pelvic examination is direct observation of urine using the cough stress test (CST) or Marshall test.
  • Place the patient in a dorsolithotomy position. Insert a sterile catheter into the urethra, and fill the bladder with 200-250 mL of water. Remove the catheter. Instruct the patient to perform the Valsalva maneuver and cough in gradients (ie, mild, moderate, severe). Leakage during the Valsalva maneuver or cough denotes a positive CST.
  • If the CST is positive, a Marshall test may determine if the urine loss is caused by urethral hypermobility. In this test, place the index finger and the middle finger on either side of the bladder neck to provide anatomic support. With the bladder halfway full (ie, 200-250 mL), repeat the CST. The index finger and the middle finger provide anatomic support for the bladder neck and prevent urethral descent during the CST. If urine does not leak with this maneuver during the CST, the Marshall test is positive.
  • Some clinicians have criticized the Marshall test for giving false-positive results due to examiner error. If one is not careful, the supporting fingers may accidentally occlude the urethra (ie, rather than supporting the bladder neck) and cause a false-positive result.
• Standing cough stress test
• • If the cough leak test initially is performed while the patient is in the lithotomy position and leakage is not observed, repeat this test with the patient in the standing position.
  • The patient stands upright with feet shoulder-width apart. Place a large towel under patient's feet. Instruct patient to perform the Valsalva maneuver and cough in gradients (ie, mild, moderate, severe). Observable urine leakage in this position constitutes a positive test.
• Standing pelvic examination
• • Perform a standing pelvic examination when pelvic organ prolapse is suspected. If doubt exists about pelvic organ prolapse, examine patients while they are in the standing position.
  • The patient stands with feet shoulder-width apart. Direct the patient to place 1 foot on the ground and the other foot resting on a step stool. Instruct the patient to perform the Valsalva maneuver in gradients (ie, mild, moderate, severe). When the patient performs the Valsalva maneuver, the force of gravity helps the pelvic organs (ie, uterus, rectum, bladder) slide down the vagina to enhance the diagnosis.
  • Stress incontinence may be masked by pelvic organ prolapse. Grade-III and grade-IV cystoceles may cause kinking of the urethra as they herniate out of the vagina. Urethral kinking hides preexisting SUI and causes a false-negative CST.
  • If a pelvic organ prolapse is present, push the prolapsed organ up with either a pessary or gauze. Repeat the cough stress test with the patient in the standing position. If the CST is positive, the patient has SUI in addition to pelvic organ prolapse.
• Urodynamic studies
• • Urodynamics are a means of evaluating the pressure-flow relationship between the bladder and the urethra. Specialists use many different types of urodynamic tests, as described below.
  • Simple urodynamic tests involve performing a noninvasive uroflow, obtaining a postvoid residual (PVR) urine sample, and performing a single-channel cystometrogram (CMG). A single-channel CMG (ie, simple CMG) is used to assess the first sensation of filling, fullness, and urge. Bladder compliance and the presence of uninhibited detrusor contractions (eg, phasic contractions) can be noted during this filling CMG. A simple CMG may be performed using water or gas (carbon dioxide). Water is the most common filling medium.
  • Multichannel urodynamic studies are more complex than simple urodynamics and can be used to obtain additional information, including a noninvasive uroflow, PVR urine, filling CMG, ALPP, voiding CMG (pressure-flow), and electromyogram (EMG). Water is the fluid medium used for multichannel urodynamics.
  • The most sophisticated study is videourodynamics, the criterion standard in the evaluation of a patient with incontinence (see Image 8). In this study, the following are obtained: noninvasive uroflow, PVR urine, filling CMG, ALPP, voiding CMG (pressure-flow), EMG, static cystogram, and VCUG (see Image 9). The fluid medium used for videourodynamics is radiographic contrast.
• Performing urodynamics
• • Instruct the patient to arrive at the urodynamic laboratory with a full bladder. Perform a noninvasive uroflow and PVR urine test. Place the patient in the dorsolithotomy position. Prepare her genitalia, and drape using sterile technique.
  • Perform flexible cystoscopy. Survey the entire bladder urothelium and then retroflex the cystoscope to examine the bladder neck. Fill the bladder with 250 mL of water. Commence bladder filling using room temperature water. Cold water may evoke false-positive detrusor contractions (phasic contractions). Fill the bladder at a medium rate (eg, 60 mL/min).
  • Next, perform the CST and cotton swab test as described previously. Perform a detailed speculum examination with one half of the gynecology speculum pointing at the anterior, posterior, and vaginal apex for a view of pelvic organ prolapse. During the pelvic examination, assess the functional integrity of the pelvic floor muscles by examining the perineal body and checking the rectal tone. The presence of levator ani muscle dysfunction or tenderness may be elicited by gentle palpation of the levator ani musculature in the paravaginal fornices.
  • Perform a standing CST and/or pelvic examination as needed (see Supine cough stress test and Standing pelvic examination).
  • Drain the bladder. Place a urodynamic urethral catheter (ie, 7 Fr Cook dual-lumen pigtailed catheter), rectal tube, and EMG electrodes.
  • Rotate the patient to a sitting position, and equalize transducers. Commence bladder filling using room-temperature contrast (Conray). Cold water may evoke false-positive detrusor contractions (ie, phasic contractions). Fill the bladder at a medium rate (eg, 60 mL/min). Assess the first sensation of filling fullness, and assess urge. Note bladder compliance, and mark the presence of uninhibited detrusor contractions.
  • When the bladder fills to 250 mL, measure the ALPP. Instruct the patient to perform the Valsalva in gradients (ie, mild, moderate, severe) followed by cough (ie, mild, moderate, severe). Observe the urine leakage fluoroscopically and by direct inspection. At this point, note the activity of the bladder neck, urethral mobility, and the presence of cystocele using fluoroscopy (static cystogram).
  • Upon completion of ALPP, finish the filling CMG to completion. When the patient has a strong desire to void, perform a voiding CMG (pressure-flow). At this point, note urodynamic parameters, such as maximal flow rate (Qmax) and detrusor pressure at maximal flow rate (PdetQmax).
  • During the voiding CMG, note the activity of the EMG electrodes and voiding cystogram for possible detrusor sphincter dyssynergia (DSD). The presence of DSD is confirmed by increases in EMG activity during detrusor contraction or closure of the external sphincter on VCUG during voiding.
  • After the patient voids to completion, the videourodynamic study is complete. The patient is informed about the findings and is sent home with an oral antibiotic.

Diagnostic Procedures

• Postvoid residual urine volume
• • This measurement is part of the basic evaluation for urinary incontinence.
  • Healthy women usually have PVR urine volume of less than 100 mL.
  • If the PVR urine volume is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions cause urinary retention from overflow incontinence.
• Uroflow rate
• • The uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction.
  • The uroflow rate is the volume of urine voided per unit of time. Women have no absolute normal maximal flow rate; however, a Qmax greater than 15 mL/s may be considered normal.
  • Low uroflow rates (<15 mL/s) may reflect urethral obstruction, a weak detrusor, or a combination of both.
  • This test alone cannot distinguish between obstruction and an acontractile detrusor.
• Filling cystometrogram
• • In 40% of patients, stress and urge incontinence coexist. In many instances, SUI may lead to the development of urge incontinence. A filling CMG is used to assess bladder capacity, compliance, and the presence of phasic contractions. Most commonly, liquid filling medium is used. An average adult bladder holds approximately 450-500 mL of urine. During the test, provocative maneuvers, such as coughing, hand washing, sitting on the commode for 1 full minute, and heel jouncing, may help to unveil bladder instability.
  • A filling cystometry may be performed using the following techniques:
  • • Insert a catheter (connected to a special computer) into the bladder for single-channel cystometry. Information recorded by the computer is interpreted.
    • Eyeball cystometry does not require special computers. Perform bedside cystometry by inserting a catheter into the bladder, hanging the irrigant bag at a predetermined height (eg, 100 cm water), and observing the fluctuation of the meniscus within the water chamber during uninhibited detrusor contractions.
    • Eyeball cystometry using a flexible cystoscope is the same as eyeball cystometry except that the flexible cystoscope acts as the connection tubing. This allows simultaneous cystoscopy.
    • Multichannel cystometry is a more sophisticated method of measuring filling CMG where intravesical pressure (Pves), intra-abdominal pressure (Pabd), detrusor pressure (Pdet), and Qmax are recorded simultaneously.
• Abdominal leak point pressure
• • As discussed above, ALPP should be measured when the bladder is half full (eg, 250 mL), and both the Valsalva and coughing maneuvers should be performed. Initially, instruct the patient to bear down in gradients (ie, mild, moderate, severe), and then note the ALPP as the lowest Pves at which leakage is observed. If Valsalva maneuvers fail to produce the desired response, instruct the patient to cough in gradients (ie, mild, moderate, severe) to obtain the ALPP. The Pves at which leakage is seen is the ALPP. The ALPP obtained with Valsalva maneuver is more accurate than the cough-induced ALPP. However, if Valsalva maneuvers fail to manifest SUI, both techniques should be employed.
  • Alternatively, both Valsalva and cough-induced ALPP may be repeated by increasing the bladder volume in 100-mL gradients. Increasing the bladder volume reportedly increases the sensitivity of detecting ALPP.
• Voiding cystometrogram (pressure-flow study)
• • A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow.
  • This is the only test that can assess bladder contractility and the extent of a bladder outlet obstruction.
  • Pressure-flow studies can be combined with a voiding cystogram and videourodynamic study for complicated cases of incontinence.
• Cystogram
• • A static cystogram (eg, AP, lateral) helps to confirm the presence of SUI, the degree of urethral motion, and presence of cystocele. ISD is evident by the presence of an open bladder neck. Presence of a vesicovaginal fistula also may be noted.
  • A voiding cystogram can assess bladder neck and urethral function (ie, internal, external sphincter) during filling and voiding phases. A voiding cystogram can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
• Electromyography
• • EMG helps to ascertain the presence of coordinated or uncoordinated voiding. Failure of urethral relaxation during a bladder contraction results in uncoordinated voiding (DSD).
• Cystoscopy
• • The precise role of cystoscopy in the evaluation of female urinary incontinence is controversial. Fewer than 2% of bladder tumors have been identified by routinely performing cystoscopy in women with incontinence. However, cystoscopy allows discovery of bladder lesions (eg, stitch in the bladder, bladder cancer, bladder stone) that would remain undiagnosed by urodynamics alone. A visual inspection of the urethra helps to establish the presence of urethral stricture or gross evidence of poor urethral closure.
  • Generally, cystoscopy is indicated for patients complaining of persistent irritative voiding symptoms or hematuria. Obvious causes of bladder overactivity, including cystitis, stones, and tumors, can be diagnosed easily. This information is important in determining the etiology of the incontinence and may influence treatment decisions.
  • The authors routinely use a flexible cystoscope (see Image 10) rather than a rigid cystoscope. A flexible cystoscope has excellent optics and enhances patient comfort during the examination. The authors also perform urethroscopy to assess the structure and function of the urethral sphincter mechanism.
• Dynamic retrograde urethroscopy
• • The cystoscope is introduced into the bladder, which is filled to 250 mL with irrigant.
  • Turn off the flow of the irrigant. Withdraw the cystoscope to the mid urethra. Observe the activity of the urethral sphincter mechanism at rest and with Valsalva maneuvers.
  • Patients with a normal urethra have a closed bladder neck at rest, but with stress maneuvers, they demonstrate an excellent guarding reflex (see Image 11). Patients with type-II incontinence have a closed bladder neck at rest, with an intact voluntary guarding reflex (see Image 12). Patients with type-III incontinence have an open bladder neck at rest but have an impaired voluntary guarding reflex (see Image 13).
• Videourodynamics
• • Videourodynamics combine the radiographic findings of VCUG and multichannel urodynamics. Videourodynamics is the most sophisticated diagnostic test for a patient with incontinence. Videourodynamics may be used for evaluating any patient with lower urinary tract voiding dysfunction.
  • In the absence of videourodynamics, the clinician may obtain adequate information from the following:
  • • Noninvasive uroflow and PVR urine tests
    • Simple cystometry in combination with cystoscopy
    • Detailed speculum examination
    • CST and cotton swab test
    • Dynamic retrograde urethroscopy

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

Initial trial of pelvic floor rehabilitation

Patients with mild incontinence symptoms benefit from an initial trial of pelvic floor rehabilitation with or without biofeedback. For those women with mild SUI without vaginal prolapse, a success (ie, cure, improvement) rate of 75-80% may be attained by properly performed Kegel exercises.

Pelvic floor exercise (ie, Kegels) is a rehabilitation technique used to tighten and tone up the pelvic floor muscles (ie, levator ani) that become weak over time. These exercises empower the external urinary sphincter to prevent stress incontinence and build up the pelvic floor muscles to avert impending pelvic prolapse.

Individuals who benefit most tend to be young healthy women who can identify the levator muscles accurately. Older adults with weak pelvic muscle tone or women who have difficulty recognizing the correct muscles need adjunctive therapy such as biofeedback or electrical stimulation.

Pelvic floor exercises work best in mild cases of stress incontinence associated with urethral hypermobility but not ISD. These rehabilitation exercises may be used for urge incontinence and mixed incontinence. They also benefit men who develop urinary incontinence following prostate surgery.

Patients can perform pelvic floor muscle exercises by drawing in or lifting up the levator ani muscles, as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner-thigh muscles.

For stress incontinence, recommended exercise programs differ. For beginners, the authors instruct the individual to perform the squeezing exercise 5 times, holding each contraction for a count of 5. Five contractions equal 1 set. Patients should do 1 set every hour while they are awake, whether driving, reading, or watching television. An alternate program requires 1 set of exercises every time the patient uses a bathroom. Soon after starting the exercises, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation. The exercises must be performed daily for at least 3-4 months to be effective.

The beneficial effects of pelvic floor muscle exercises alone are well documented. Successful reduction rates in urinary incontinence range from 56-95%. Pelvic floor exercises are effective even after multiple antiincontinence surgeries.

Conjugated estrogens help renurture lead-pipe urethra in postmenopausal women. Conjugated estrogens (ie, oral, topical, or both) may restore the mucosal seal and allow upregulation of alpha-receptors to the female urethra. Conjugated estrogen increases the tone of the urethral muscle by upregulating the alpha-adrenergic receptors in the surrounding area. Conjugated estrogens enhance the alpha-adrenergic contractile response to strengthen the pelvic muscles. In addition, the improved mucosal turgor of the periurethral tissue from proper nourishment enhances urethral mucosal coaptation. The result is an improved mucosal seal effect, important in urethral function. Unfortunately, data have not proven the utility of this approach. In fact, recent Women's Health Initiative data suggest systemic estrogens (oral or patch) may even worsen incontinence.

Unfortunately, pharmacologic agents rarely are effective, and, when they are, the results are short-lived because of adverse effects. Behavior and dietary modifications have a rather limited role in the treatment of ISD.

Sympathomimetic drugs, estrogen, and tricyclic agents increase bladder outlet resistance to improve symptoms of SUI. The bladder neck contains high concentrations of receptors that are sensitive to alpha-agonists. Alpha-agonists increase bladder outlet resistance by contracting the bladder neck.

Tricyclic antidepressant drugs historically have been used to treat major depression. These drugs, however, have an additional use for treatment of bladder dysfunction by increasing norepinephrine and serotonin levels. In addition, they exhibit an anticholinergic and a direct muscle relaxant effect on the urinary bladder. Tofranil has a direct inhibitory and local anesthetic effect on the bladder smooth muscle, similar to Ditropan; however, Tofranil also increases bladder outlet resistance at the level of the bladder neck. Thus, the combination of these drugs produces a synergistic effect to relax the unstable bladder, allowing it to better hold urine and preventing urge incontinence. Recent concerns about prescribing antidepressants in this situation have limited their use.

Drug Category: Alpha-adrenergic drugs

Drug Category: Estrogens

Premarin vaginal cream is available in a package with a plastic applicator and a tube that contains 42.5 g of conjugated estrogens. Each gram contains 0.625 mg of conjugated estrogens. When vaginal cream is used, 2-4 g (one half to one full applicator) of cream may be administered intravaginally daily in the usual cyclic regimen. Estrogen cream is readily absorbed through the skin and mucous membranes.

When Premarin cream is used for treatment of atrophic vaginitis, the cream may be placed intravaginally or applied topically around the vaginal tissues. When estrogen is used long-term, addition of progestin therapy is recommended to prevent endometrial hyperplasia in women with intact uteruses. Progestin (eg, medroxyprogesterone 2.5-10 mg/d) is needed for 10-13 d to provide maximum maturation of endometrium and to eliminate any hyperplastic changes. Progestin may be given continuously or intermittently.

Pharmacologic therapy using estrogen derivatives results in few cures (0-14%) but may cause subjective improvement in 29-66% of women. Limited evidence suggests that oral or vaginal estrogen therapy may benefit some women with stress and mixed urinary incontinence. Other potential beneficial effects of estrogen use include decreased bone loss and resolution of hot flashes during menopause.

The authors do not recommend routinely prescribing conjugated estrogens to premenopausal women. This medication should be used in postmenopausal women with incontinence who have had a hysterectomy. For postmenopausal women with an intact uterus, the authors cautiously recommend short-term low-dose Premarin, with frequent monitoring. In addition, some benefit appears to be derived from giving topical vaginal estrogen, even if the patient is on oral estrogen. This is useful especially in the setting of atrophic vaginitis or ISD. Again, the data do not prove its utility in SUI, but estrogens may be beneficial in some cases of severe vaginal atrophy.

Surgical therapy

Autologous urethral sling procedures have an approximately 83% overall long-term cure rate. Recent outcome analysis reveals the lasting cure rate may be less than previously reported.

Sling materials

Surgeons currently use a number of materials for constructing pubovaginal slings: autologous tissues, allogenic grafts, and synthetic biomaterials. Synthetic slings may be fashioned from polypropylene, Gore-Tex, Marlex, Mersilene, or MycroMesh Plus. For treating ISD, the long-term success rates of the synthetic slings are greater than 85%. The long-term cure rates of cadaver tissue are pending at this time.

Serious complications from sling surgery are uncommon. However, urethral obstruction is a complication unique to all sling surgeries. The incidence of sling infection and erosion is higher when using synthetic materials. The potential complications must be weighed against the durable cure rates of synthetic slings.

The ideal sling material that produces consistently lasting results and minimizes morbidity remains elusive. In theory, the ideal sling material should last the lifetime of the patient. Researchers hope that advances in surgical techniques, biomechanical engineering, and design will produce the ideal sling material in the future.

Autologous tissue

Materials include rectus fascia, fascia lata, and the anterior vaginal wall. Surgeons harvest autologous sling materials at the time of sling surgery. If a standard pubovaginal sling procedure is performed, harvest a 10 cm by 2 cm piece of tissue.

If the suburethral sling procedure is employed, a much smaller piece of tissue (2 cm by 4 cm) is harvested. Suburethral or patch slings use a small section of tissue suspended by permanent suture at either end that is placed under the bladder neck (eg, similar to a child's swing).

Allogenic grafts

These grafts include cadaveric fascia lata and rectus fascia that have been processed by freeze-drying, gamma irradiation, or solvent dehydration. These tissues are harvested from cadaver donors and must be rehydrated at the time of sling surgery.

The advantages of allografts include shorter operating time and decreased morbidity. Disadvantages include the risk of bacterial infection and the possibility of transmitting intact genetic material to the recipient. Recently, the use of some cadaver allografts has been criticized for early degradation resulting in recurrent SUI.

Synthetic materials

Surgeons use the following materials: Gore-Tex (polytetrafluoroethylene, PTFE), Mersilene (polypropylene), Silastic, MycroMesh Plus (Gore-Tex mesh impregnated with antibiotic), and tension-free vaginal tape (TVT).

The benefits of synthetic materials are decreased operating time, less morbidity (ie, no need for large suprapubic incision), and the potential for better long-term durability. Potential risks of synthetic slings include vaginal and urethral tissue erosion.

Constructing a nonobstructive sling

One should adhere to fundamental principles when performing a proper sling surgery. The 5 basic principles are as follows: (1) the sling is only as strong as its weakest link, (2) sling size does matter, (3) force vectors are important, (4) sling should be tension-free, and (5) slings should be biocompatible.

The weakest link of any sling may be the graft material, the suspension suture, or the origin or insertion site of the suspension sutures. Usually, the weakest link in an autograft or cadaver allograft is the sling edge where the suspension suture has been sutured in place. Suture pull-through at the sling edge is more common with autologous or cadaver patch slings.

Sling sizes in use today include classic pubovaginal slings, hemislings, and patch slings. The authors define a pubovaginal sling as a long strip of supporting material (ie, 2 cm by 14 cm) that spans from one edge of rectus abdominis to the other. A hemisling is defined as a sling with a shorter strip of supporting material (ie, 2 cm by 7 cm) hung by suspension sutures. A patch sling is defined as a sling with a short graft (ie, 2 cm by 4 cm) hung by suspension sutures. Success of a pubovaginal sling is predicated upon having the sling become completely engrafted or scarred in the retropubic space as the tissue remodels postoperatively. If the graft material simply disappears and engraftment or scarring does not take place, recurrent stress incontinence may occur.

A critical element is tying the suspension sutures to ensure continence without obstruction. Techniques that have been used include the following:

• Vaginal packing, developed by Nichols in 1973
• Spacer size of forefinger, developed by Benderev in 1994
• Cystoscope at 30°, developed by Raz in 1997
• Two fingers under the sutures, developed by McGuire in 1998
• Transvaginal ultrasound, developed by Yamada in 1998
• Tension-free vaginal tape, developed by Ulmsten in 1999

The biocompatibility of the sling material and the host is best when autologous tissues are used. Vaginal and urethral erosions resulting from unfavorable interaction between synthetic slings and the host tissue are well documented.

Some synthetics seem to be more predisposed to tissue rejections than others. Polyester meshes have relatively rigid and rough surfaces that cause intense inflammatory responses, with a 27% erosion rate. On the other hand, polypropylene mesh slings appear to have lower erosion rates (0-3%) compared to other synthetics. The meshlike matrix of the sling allows polypropylene to become incorporated into the host tissue, with minimal bacterial colonization and decreased erosion.

The biocompatibility of cadaver allografts with the host has been variable. While some authors have reported excellent early cure rates, others have reported poor results using cadaver fascia lata. Lack of a durable cure is theorized to be due to early degradation of the cadaver allograft within the implanted host tissue. Whether this is due to differences in tissue processing remains unclear at this time.

Preoperative details

Preoperative counseling

Counseling should include potential risks and complications (eg, bleeding, infection, persistent SUI, de novo urge incontinence, worsening urge incontinence, urinary retention).

Inform all patients undergoing pubovaginal sling surgery of the possible need for postoperative self-catheterization. Complications unique to synthetic slings are sling infection, vaginal tissue erosion, and urethral transection.

Sterile urine culture

All patients should have preoperative sterile urine culture. Administer broad-spectrum intravenous antibiotics 1 hour prior to skin incision.

Identify any coexisting vaginal prolapse before surgery so that vaginal reconstruction may be performed simultaneously.

Intraoperative details

Rectus fascia pubovaginal sling

Historically, surgeons used the rectus fascia pubovaginal sling for complex SUI after a failed antiincontinence operation (see Image 17). In addition, surgeons performed this operation extensively for treatment of primary ISD.

In this procedure, detach a ribbon of connective tissue from the strong fascia of the lower abdomen. Secure one end of the fascial ribbon to one side of the abdominal wall while the other end descends to loop around and underneath the bladder neck and swings up to rest on the opposite side of the abdominal wall. The bladder neck rests on the middle of the loop. Adjust the tension on the rectus pubovaginal sling to provide adequate compression and coaptation of the bladder neck.

Surgical technique

Perform this operation through the vagina and through a suprapubic incision above the pubic bone.

After the patient is completely anesthetized, place the patient in a dorsal lithotomy position. Using sterile procedures, prepare and drape the vagina, perineum, and suprapubic areas. Place a Foley catheter in the bladder.

Make a transverse lower abdominal incision (Pfannenstiel) over the suprapubic area. Harvest a long ribbon of rectus fascia (eg, 10 cm by 2 cm) from the lower abdomen.

Next, make a trapdoor incision on the anterior vaginal wall. Dissect the vaginal wall flap off the urethra to expose the bladder neck. Center the white fascial ribbon at the bladder neck. Bring up both ends of the rectus sling to the lower abdominal wall, and affix both ends of the sling to the abdominal fascia on either side.

The bladder neck now is nestled in the middle of the sling. Pull up the vaginal wall flap to cover the sling in its entirety. Close the vaginal and abdominal incisions with absorbable sutures. Place a small suprapubic tube. Inspect the quality of the operation using cystoscopy. At the end of the operation, place antibiotic-soaked vaginal packing. Routinely, the packing is removed the morning after the operation.

Fascia lata pubovaginal sling

Historically, surgeons have used the fascia lata sling (see Image 17) for recurrent SUI after a failed antiincontinence operation. Furthermore, this operation is used extensively for the treatment of primary ISD. If the abdominal tissues are weak and attenuated or when the vaginal tissues are atrophied or in short supply, constructing a pubovaginal sling from the leg fascia lata is an excellent choice.

In this operation, harvest a long ribbon of tissue from strong fascia of the outer thigh. Secure one end of the fascial ribbon to the abdominal wall while the other end descends to loop around and underneath the bladder neck and swings up to rest on the abdominal wall again. The bladder neck rests on the center of the fascia lata sling.

Construction of the fascia lata sling is more involved than the creation of the rectus fascial sling. The fascia lata sling gently compresses the bladder neck and increases the urethral resistance.

Surgical technique

Use a combined thigh-abdominal-vaginal approach for this operation. After satisfactory induction of general anesthesia, position the patient on her side with one leg slightly flexed. Next, prepare and drape the outer thigh using sterile technique.

Initially, the surgeon makes a single 5-cm skin incision on the outer thigh. Using a special stripper, create an extended transverse thigh fascial flap. Harvest a strong glistening white fascia lata (eg, 10 cm by 2 cm). Place a small Penrose drain in the incision, and close the thigh wound.

Reposition the patient in the dorsal lithotomy position. Using sterile procedure, prepare and drape the vagina, perineum, and suprapubic areas. Place a Foley catheter in the bladder.

Next, make a transverse incision over the suprapubic area. Then, make a small vertical incision on the anterior vaginal wall. Position the fascia lata sling underneath the bladder neck, and pass both ends of the sling up to either side of the abdominal wall. Sew the 2 ends of the fascia lata sling onto the abdominal wall.

Close the vaginal and the abdominal incisions. Place a small suprapubic tube. Check the quality of the operation using cystoscopy. At the end of the operation, place antibiotic-soaked vaginal packing that will be removed the following morning.

Rectus fascia suburethral sling

An alternative to a long rectus sling is construction of a short sling from a much smaller piece of abdominal fascia (see Image 18). The surgical procedure is similar to that used for the rectus fascia pubovaginal sling, except the harvested fascial tissue is much smaller and the operation time is shorter. Convert the small piece of fascia into a sling by using permanent sutures.

The advantage of this procedure is its simplicity. No extensive dissection in the suprapubic area is necessary, and the postoperative result is similar to that of the full-length fascial strip sling.

Surgical technique

This operation is performed through the vagina and through a lower abdominal incision above the suprapubic area. After anesthetizing, place the patient in the dorsal lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place a Foley catheter in the bladder.

Initially, the surgeon makes a short transverse suprapubic incision in the lower abdomen. Retrieve a small rectangular rectus fascia (eg, 3 cm by 4 cm) from the suprapubic area. Anchor the 4 corners of the rectangular fascia with permanent nonabsorbable sutures.

Next, make a trapdoor incision on the anterior vaginal wall. Dissect the vaginal flap off the urethra to expose the bladder neck. Position the suburethral patch sling under the bladder neck. Then, transfer the suspension sutures from the vaginal side to the abdominal side, where they are tied securely.

Close the vaginal and abdominal incisions. Place a small suprapubic tube, and perform cystoscopy. At the end of the operation, place antibiotic-soaked vaginal packing. Routinely, the packing is removed the morning after the operation.

Fascia lata suburethral sling

An alternative to a long fascia lata sling is the use of a postage–stamp-sized patch of fascia lata from the outer thigh (see Image 18). The surgical procedure is similar to that for the fascia lata pubovaginal sling, except the harvested fascia is much smaller. The patch sling keeps the bladder neck gently compressed with permanent sutures to restore appropriate urethral resistance.

This operation does not require extensive dissection in the thigh area, and the postoperative result is similar to that of the full-length fascia lata strip sling. Postoperative convalescence is shorter than that of the fascia lata pubovaginal sling procedure.

Surgical technique

Use a combined thigh-abdominal-vaginal approach for the operation. After inducing the anesthetic, position the patient on her side with one leg slightly flexed. Next, prepare and drape the outer thigh using sterile technique.

Make a single short incision on the outer thigh, and create a small thigh fascial flap. Harvest a white rectangular fascia lata (eg, 3 cm by 4 cm), and close the thigh incision.

Then, reposition the patient in the lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place a Foley catheter in the bladder.

Next, make a small 5-cm suprapubic incision in the lower abdomen. The 4 corners of the rectangle are affixed with nonabsorbent suspension sutures. Make a trapdoor incision on the anterior vaginal wall. Dissect the vaginal wall off the urethra to expose the bladder neck. Position the fascia lata patch sling at the bladder neck. Then, transfer the suspension sutures from the vaginal side to the abdominal side, and securely tie over the lower abdomen. Close the vaginal flap to cover up the sling.

Reapproximate the vaginal and abdominal incisions with absorbable sutures. Place a small suprapubic tube. Check the quality of the operation using cystoscopy. At the end of the operation, place antibiotic-soaked vaginal packing. Remove the packing next morning.

Vaginal wall suburethral sling

In this operation, fashion a small rectangular patch of vaginal tissue as a sling to buttress the bladder neck (see Image 19). The vaginal sling helps restore urethral resistance by increasing urethral compression and improving mucosal coaptation of the bladder neck. A pair of sutures fastened over the lower abdomen suspends the vaginal sling in place.

This operation is attractive because it is simple and easy to perform. Postoperative complications are minimal, and the recuperative period is short. Vaginal sling surgery is relatively contraindicated in elderly women with atrophic vaginitis. If recognized prior to surgery, the atrophied vaginal wall may be revitalized with the administration of vaginal estrogen cream or tablets for 3-6 months.

Surgical technique

Perform this operation through the vagina and through a small incision in the lower abdomen. After anesthetizing, place the patient in the lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place a Foley catheter in the bladder.

Initially, circumscribe an A-shaped incision within the vagina. Harvest a rectangular island of vaginal tissue, and create a proximal vaginal wall flap. Tailor the size of the vaginal island to the length and width of the urethra (eg, 1.5 cm by 3.5 cm). Anchor the 4 corners of the rectangular island of vaginal wall with nonabsorbable suspension sutures.

Next, make a transverse suprapubic incision. The suspending sutures pass from the vaginal side to the suprapubic side. Advance the proximal vaginal wall flap to cover up the sling and to restore the integrity of the vagina. Tie the suspending sutures over the lower abdomen.

Close the vaginal and abdominal incisions, and place a small suprapubic tube. Examine the quality of the operation using cystoscopy. At the end of the operation, place antibiotic-soaked vaginal packing. The packing is removed the morning after the operation.

Gore-Tex patch sling

Gore-Tex is a white soft synthetic biomaterial that surgeons use widely, from general to cardiovascular surgery. In the past, surgeons used a long strap of Gore-Tex as a pubovaginal sling for recurrent SUI when the individual's native tissues were in short supply or of poor quality. A beltlike strap of Gore-Tex was wrapped around the bladder neck to compress and increase the urethral resistance (see Image 20).

Although the continence rates were quite good, this technique fell out of favor because of a high rate of sling complications. Researchers observed that when using Gore-Tex as a long strap, the incidence of bacterial infection was significant, requiring removal of the sling in 23% of patients. However, when using Gore-Tex as a short patch (eg, small postage-stamp sized), the risk of infection and erosion remained low (3%), while the continence rate remained excellent.

The Gore-Tex patch sling compresses the bladder neck and restores the necessary urethral resistance to prevent involuntary SUI.

Surgical technique

Perform this operation through the vagina and through a transverse lower abdominal incision above the pubic bone. After anesthetizing, place the patient in the lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place a Foley catheter in the bladder.

Initially, make a transverse incision over the suprapubic area. Fashion an individually tailored suburethral Gore-Tex patch (eg, 1.5 cm by 3.5 cm). Lace the lateral edges of the patch with permanent nonabsorbable suspension sutures to convert the patch into a sling.

Next, make a small vertical incision on the anterior vaginal wall. Dissect the vaginal wall off the urethra to expose the bladder neck. Position the Gore-Tex sling under the bladder neck. Transfer the suspension sutures from the vaginal side to the abdominal side. Securely tie the suspension sutures over the lower abdomen.

Close the vaginal and abdominal incisions, and place a small suprapubic tube. Check the quality of the operation by cystoscopy, and place antibiotic-soaked vaginal packing.

Tension-free vaginal tape

Recently introduced, tension-free vaginal tape (TVT) is a polypropylene-meshed tape that is placed at the mid urethra (see Image 37). The TVT device consists of polypropylene mesh tape (1.1 cm by 40 cm) covered by a plastic sheath and held by 2 stainless steel needles on both ends.

Surgical technique

Perform the operation through the vagina, with 2 small lower abdominal incisions above the pubic bone. The procedure may be performed with either local or general anesthetic.

Place the patient in the dorsal lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place an 18-Fr Foley catheter in the bladder.

Apply local anesthetic to the skin just above the pubic tubercle on both sides of the midline. Continue the application of the anesthetic on each side, through the rectus fascia, the rectus abdominis muscles, and into the space of Retzius.

Apply local anesthetic to the anterior vaginal wall. Make a small vertical incision on the anterior vaginal wall at the mid urethra. Tease the vaginal wall tissue off the urethra to expose the mid urethra, and dissect paraurethrally toward the endopelvic fascia.

Insert the rigid catheter guide (included with the device) into the Foley catheter. Have an assistant pivot the handle of the guide to the surgeon's left side to expose the patient's left endopelvic fascia. Puncture the patient's left endopelvic fascia with the TVT needle, and advance the needle through the space of Retzius and to the anterior abdominal wall. The needle must hug the posterior wall of pubic symphysis during this maneuver. Tent up the abdominal skin with the needle. Incise the skin over the needle, and allow the needle to emerge.

Fill the bladder with 250 mL saline. Perform cystoscopy with the needle in situ to rule out bladder and urethral injury. Empty the bladder. Advance the needle and the tape above the abdominal wall. Leave the needle in the abdomen.

Repeat the same procedure on the contralateral side. Make sure the tape does not twist during the insertion. Cut the tape at both abdominal ends, and remove the needles; however, leave the plastic sheath in place. The manufacturer recommends performing the tension test by filling the bladder with 250 mL of saline and having the patient cough. The tape should be pulled upward on both sides until only a few drops leak out when the patient coughs. Note that the success of this operation is predicated upon performing a proper tension test. Although this device is marketed as tension-free, the surgeon must make sure that it is tension-free by performing a proper tension test.

Remove the plastic sheath from the tape, and close the vaginal and abdominal incisions.

Transobturator slings represent similar approaches vaginally to the TVT; however, the needle passers are placed in the medial portion of the obturator canal inside the groin creases at the level of the clitoris laterally. Tensioning is performed similar to TVT and placed tension-free.

Postoperative details

After surgery, administer intravenous antibiotics for 24 hours, followed by an oral antibiotic for several days. On the following morning, remove vaginal packing and intravenous lines. Also, remove the dressing over the incision. Discharge patients from the hospital with pain medications, 1-3 days after surgery

If suprapubic tubes are placed, instruct patients to check postvoid residuals via the suprapubic catheter. Remove the suprapubic catheter when patients are able to void spontaneously; this may be as early as a day after surgery or may take as long as 3 weeks. If patients still are experiencing retention at 3 weeks, remove the suprapubic tube and teach the patient self-intermittent catheterization.

Most patients undergoing midurethral tension-free slings can be discharged without a catheter because most void in the recovery area.

Follow-up

Patients return to the clinic for follow-up after surgery for removal of the catheter if it is left indwelling. Otherwise, the patient returns later if the catheter was removed in the recovery room.

Patient Education:

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Bladder Control Problems, Cystoscopy, and Prolapsed Uterus.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Serious complications from sling surgery are uncommon. However, urethral obstruction is common with any sling surgery. Urethral obstruction occurs because the surgeon tied the sling too tightly. The degree of obstruction reflects the patient's voiding symptoms. Complete obstruction results in urinary retention, whereas partial obstruction manifests with voiding symptoms (eg, hesitancy, straining, urgency, urge incontinence).

Hemorrhage

Bleeding during transvaginal sling surgery often is troublesome and may be challenging to correct. Bleeding invariably occurs when the surgeon punctures through the endopelvic fascia to facilitate the passage of suspension sutures. The technique of puncturing through the endopelvic fascia is performed by many surgeons blindly under digital guidance. If one is not careful, heavy bleeding may ensue.

To prevent transvaginal hemorrhage, the authors advocate dissecting the anterior vaginal wall off the endopelvic fascia under direct vision. The plexus of veins is located at the 10- and 2-o'clock positions at the level of the bladder neck. Injury to these veins causes severe hemorrhage. Thus, proper anatomic dissection under direct vision allows preservation and avoidance of these veins when the endopelvic fascia is punctured through. If one is concerned that these veins may become lacerated, these veins may be ligated prophylactically using 4-0 Vicryl in a figure-eight fashion.

If heavy bleeding is encountered, direct pressure applied to the anterior vaginal wall slows down the bleeding to allow more time to obtain better exposure. Then, one may suture-ligate the offending vessel under direct vision. These vessels always are located at the edges of the endopelvic fascia. Then, the sling is placed quickly, and the suspension sutures are tied. The authors do not advocate packing the space of Retzius through the hole in the endopelvic fascia because this may worsen the bleeding. Furthermore, stopping the bleeding suprapubically is not necessary because the offending vessel is never identified.

Urethral obstruction

An important complication unique to any sling surgery is urethral obstruction. Urethral obstruction occurs because the sling has been tied too tightly. The degree of obstruction reflects the patients' voiding symptoms. Complete obstruction results in urinary retention, whereas partial obstruction manifests with voiding symptoms, including hesitancy, straining, urgency, and urge incontinence.

Methods to prevent urethral obstruction include placing 2 fingers under the suspension sutures, using a spacer, placing vaginal packing, angling a cystoscope at 30°, and using transvaginal ultrasound to assess the proper urethrovesical angle as the suspension sutures are tied. In spite of all of these precautions, the risk of urethral obstruction still exists, and the experience of the surgeon determines whether obstruction occurs.

Stress incontinence

Approximately 5-10% of patients have recurrent or persistent SUI after sling surgery. Reasons for failure include (1) suture pull-through from the edge of the sling, (2) early degradation of sling material, (3) improper placement of the sling, and (4) making the sling too loose.

Suture pull-through from the sling edge is more common with autologous and cadaver tissues, whereas early degradation of sling material is isolated to cadaver allografts. Both of these conditions result in loss of either anatomic support or adequate resting urethral closure pressure. If the sling is placed too proximally (eg, bladder) or too loosely, inadequate resistance to the proximal urethra develops.

If the sling is too loose, the authors recommend suprapubic sling revision before resorting to complete sling reconstruction. A suprapubic sling revision is performed with the patient in the dorsolithotomy position. A suprapubic incision is made, and the suspension sutures are dissected out. Ipsilateral suspension sutures are pulled up. The cotton swab test and bladder leak test are performed. The cotton swab should be at zero degrees with respect to the floor, and the bladder should leak moderately when filled with 500 mL of water. The suspension sutures are affixed to the rectus fascia on the contralateral side, and the incision is closed.

Urge incontinence

Potential complications unique to any sling surgery include new-onset urge incontinence or worsening urge incontinence. Approximately 10-30% of patients may develop de novo urge symptoms, whereas 50-60% may experience resolution or improvement of preoperative urge incontinence. De novo urge incontinence usually is temporary and resolves over several weeks. Persistent urge incontinence may be treated successfully with pelvic floor exercises and bladder relaxant medications, alone or in combination. De novo urge symptoms and frequency may be a sign of bladder outlet obstruction, even without high postvoid residual.

Urinary retention

Women who undergo surgery to construct a sling are at a significant risk of urinary retention. Although temporary in most cases, urinary retention may last a month or more. Permanent urinary retention may occur after 2-30% of pubovaginal sling surgeries. While the condition persists, institute self-catheterization. As an alternative to catheterization, take down the surgery by either cutting the suspension suture or by freeing up the sling (ie, urethrolysis). Successful urethrolysis allows spontaneous voiding in 77-85% of women with urinary retention. To prevent recurrence of stress incontinence after surgery, some surgeons perform the operation again at the time of urethrolysis.

Other

Complications unique to the use of autologous, cadaver, and synthetic slings include sling infection and tissue erosion. The incidence of sling infection and erosion is higher when a synthetic biomaterial is used. Bowel perforation is a unique complication of TVT surgery. Specialists have detected intact DNA material in commercially processed cadaver allografts. Whether these genes are truly infectious remains unknown. Proper informed consent must be obtained when using cadaver allografts.

Methods to avoid sling erosion include the following:

• Maximize the surgical exposure, operate under direct vision; the authors use a headlight and a self-retaining Lone-Star retractor
• Meticulous surgical technique and gentle handling of tissues
• Dissecting in a nice avascular anatomic plane between the pubocervical fascia and the anterior vaginal wall to create thick anterior vaginal wall flaps and use of smaller midline incisions
• Making sure the sling is unfurled completely using the 6-point fixation
• Tying the suspension sutures loose enough to prevent obstruction, yet snug enough to cure the incontinence; the authors use the weight-adjusted spacing nomogram

Vaginal erosion associated with woven polyester slings treated with pressure-injected bovine collagen (Protegen) and Gore-Tex is treated with simple excision of the sling. The patient is placed in the dorsolithotomy position under general anesthesia. Vaginal inspection reveals the exposed sling. Often, the sling material is protruding through the vaginal incision. The sling material is either dissected out or simply pulled down with an Allis clamp, and the body of the sling is excised, leaving the suspension sutures intact. The vaginal wall is irrigated with antibiotic solution and closed.

As an alternative to formal excision and removal, a more conservative revision may be applied to Mersilene (polyethylene terephthalate) slings. Surgical revision consists of trimming the exposed mesh as needed, excision of granulation tissue, and re-covering of the erosion in 2 layers.

For urethral erosions, the sling may be excised transvaginally, transurethrally, or both in combination. Then, the urethra is reconstructed using a Martius labial fat pad graft as necessary. The vaginal wall is irrigated with antibiotic solution and closed.

Bowel perforation is a unique complication of TVT surgery and should not occur with other sling procedures. Intact DNA material has been detected in commercially processed cadaver allografts. Whether these genes truly are infectious remains unknown. Proper informed consent must be obtained when using cadaver allografts.

Rectus fascia pubovaginal sling

Potential complications include injury to the urethra, bladder, or ureters during the dissection. Bowel injury may occur during the insertion of the suprapubic tube; however, this injury is rare. Abdominal hernia formation is another potential risk.

If the sling is oversuspended or if excessive scarring occurs, delayed voiding or urethral obstruction may develop. New-onset urge incontinence occurs in 15-20% of individuals and requires anticholinergic therapy. Temporary urinary retention, requiring self-intermittent catheterization, is rare (approximately 5%) but may occur following surgery.

Studies show an incidence rate of 3% for urethral obstruction by the sling. Chronic urinary retention from urethral obstruction may be corrected by urethrolysis or treated with lifelong intermittent catheterization.

Fascia lata pubovaginal sling

Potential complications specific to this operation are urethral or bladder perforation during the dissection of the bladder neck. In addition, postoperative leg pain m