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 a medical condition that has significant negative effects on quality of life and may cause social stigma, financial hardship, and associated medical problems. Affected individuals often delay seeking treatment due to shame and embarrassment. Urinary incontinence is not a normal part of the aging process. This condition has multiple etiologic factors.

With recent advances in medical technology and better understanding of female anatomy and physiology, many innovative surgical methods are available for correcting stress incontinence. This article reviews these surgical options.

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 Bladder.

History of the Procedure

Described by Kelly in 1913, anterior vaginal repair is the oldest surgical procedure for correcting stress incontinence. Kelly believed the cause of stress incontinence was an incompetent urethra. Anterior vaginal repair was designed to correct this condition.

In 1949, the Marshall-Marchetti-Krantz (MMK) operation was described. The suspension sutures were placed within the urethral wall and tied to the periosteum of the pubic symphysis. The original MMK operation was complicated by urethral obstruction and erosion because the surgical sutures were placed directly into the urethral wall.

In 1961, Burch reported a modification of the MMK operation. The modifications involved placing the surgical sutures at the bladder neck and tying them to the Cooper ligament.

The original transvaginal bladder neck suspension was described by Pereyra in 1959. Many modifications of the Pereyra transvaginal bladder neck suspension exist today. They include Stamey (1975), Raz (1981), and Gittes (1987) bladder neck suspensions. Although initial success rates were quite promising, the long-term success rate with transvaginal bladder neck suspensions has been disappointing; they are now considered substandard treatment options.

In contrast, sling procedures are gaining in popularity for all types of female stress urinary incontinence (SUI). Historically, the indication for a sling procedure was limited to women with severe intrinsic sphincter deficiency. However, it has been expanded to include all types of stress incontinence.

Problem

SUI is defined as the involuntary loss of urine coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction. Currently, no accepted classification of SUI is used in clinical practice because SUI is caused by a continuum of intrinsic sphincter deficiency severity with or without significant urethral hypermobility. For historical purposes, the most widely accepted classification by Blaivas and others is as follows:

• Type I SUI is defined as urine loss occurring in the absence of urethral hypermobility. This is the mildest form of SUI. Patients with type I SUI have a Valsalva cotton-swab angle less than 30° and an abdominal leak-point pressure (ALPP) of greater than 120 cm water.
• Type II SUI is defined as stress incontinence due to urethral hypermobility. Patients with urethral hypermobility have a Valsalva cotton-swab angle greater than 30° and an ALPP of more than 90 cm water.
• Type III SUI is defined as stress incontinence due to intrinsic sphincteric dysfunction (ISD). Patients with ISD have a Valsalva cotton-swab angle less than 30° and an ALPP of less than 60 cm water.

Frequency

Urinary incontinence affects approximately 13 million people in the United States, predominantly women. This includes 10-35% of adults and 50% of the 1.5 million nursing home residents. Up to 60% of nursing home patients are incontinent, while 30% of elderly persons living at home are incontinent.

Urinary incontinence is an underdiagnosed and underreported medical problem. An estimated 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma. Only 5% of incontinent individuals in the community and 2% in nursing homes receive appropriate medical evaluation and treatment. Incontinent patients often have with this condition for 6-9 years before seeking medical therapy.

Stress incontinence affects 15-60% of women. Stress incontinence is a disorder of young and old persons. More than a quarter of nulliparous, young college athletes experience stress incontinence when participating in sports.

Etiology

The causes of intrinsic sphincteric deficiency that leads to SUI are complex and may include advancing age, multiparity, prolonged or difficult labor, and hysterectomy. Other factors that may increase the risk of SUI include obesity, straining at stool as a child or young adult, heavy manual labor, chronic obstructive pulmonary disease, and smoking. Previous pelvic surgery, radiation therapy, and sympathetic nerve dysfunction are all etiologic factors.

Pathophysiology

Intrinsic sphincter deficiency arises from a defect within the urethra proper.

Although urethral hypermobility results from weakened anatomic support of the urethra, SUI does not develop unless ISD is also present. 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, more pressure is transmitted to the bladder. During this process, the posterior wall of the urethra shears off the anterior urethral wall to cause opening of the bladder neck when ISD is present.

The uneven pressure transmission and the opening of the bladder neck secondary to ISD results in involuntary urine loss due to excessive urethral hypermobility during periods of physical activity.

Intrinsic sphincter deficiency is a condition in which the urethral sphincter is unable to coapt and generate enough urethral closing pressure to retain urine in the bladder at rest or when urethral hypermobility is induced with physical stress on the urethral and bladder neck support mechanisms. When the anatomic support is normal but the urethra cannot remain closed because of sphincteric incompetence, severe incontinence may result, even when the bladder and urethral support are not under physical stress. In the past, this was referred to as type III SUI.

Clinical

Stress incontinence occurs during periods of increased intra-abdominal pressure. Typically, patients report involuntary urine loss during coughing, laughing, and sneezing. Incontinence worsens during high-impact sports activities such as golf, tennis, or aerobics.

In general, women with stress incontinence experience less urine loss than women with overactive bladder. Stress incontinence occurs at predictable times. Irritative voiding symptoms, such as urinary frequency, urgency, and nocturia, are typically absent. Urethral hypermobility results in a smaller amount of urine loss and fewer pads needed compared to intrinsic sphincteric deficiency.

Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, and urinalysis. Additional information from a patient's voiding diary, cotton-swab test, cough stress test, measurement of postvoid residual (PVR) urine volume, cystoscopy, and urodynamic studies may be needed in selected patients. Videourodynamic studies are the criterion standard for the evaluation of an incontinent patient but are typically reserved to evaluate complex cases of SUI.

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 type of surgery required depends on the severity of ISD present that causes SUI. Individuals often have more than one cause for stress incontinence.

According to the treatment guidelines released by American Urologic Association (1997), surgery offers good long-term results as either initial or second-line treatment. Surgery may be offered as an initial form of treatment for selected women with SUI.

Surgery must be individualized for each patient, and it must follow standard recommendations for appropriate surgery. The option selected depends on the surgeon's training and expertise in a vaginal or abdominal approach.

The most important factor in choosing a surgical procedure is the specific nature of the patient's incontinence problem and any coexisting vaginal pathology. Patient preference, surgical complications, and comorbid medical conditions also play roles in the decision-making process.

The surgical management of stress incontinence can be divided into procedures designed to restore the active mechanism of continence (artificial urinary sphincter), to restore poor anatomic support that unmasks mild-to-moderate ISD (bladder neck suspensions, sling procedures), or to manage severe ISD in the setting of adequate anatomic support (pubovaginal sling, periurethral bulking agent, artificial urinary sphincter).

The surgical objective for mild-to-moderate ISD that worsens with excessive urethral hypermobility is to improve the support of the sphincter unit by preventing the descent of the bladder neck without causing significant outflow obstruction during urination. The goal of surgery for severe ISD with or without excessive urethral hypermobility is to increase urethral coaptation and resistance in order to compensate for the sphincteric incompetence. All procedures compensate for the ISD that leads to SUI by increasing urethral outlet resistance. No surgical intervention designed to support the bladder neck or mid urethra cures ISD, but rather compensates for ISD that worsens with excessive urethral movement or is present with minimal or no urethral support defects.

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

The female urethra is a 4-cm, elongated tube composed of an inner epithelial lining, a spongy submucosa, a middle smooth muscle layer, and outer fibroelastic connective tissue. 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 serve to 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 (vascular plexus) by fibrous tissue. Lack of estrogen is one of the risk factors for ISD; replacement of estrogen may reverse the effects of ISD. When estrogen is administered to a postmenopausal woman with atrophic vaginitis, the mucosa regains its turgor, with simultaneous up-regulation of alpha receptors and angiogenesis of the vascular plexus. Previous bladder neck operations, radiation, and neurogenic disease can also affect the ability to achieve a perfect seal.

Internal sphincter

Women do not have an anatomic internal sphincter like males, but women have a functional internal sphincter. The female internal sphincter is composed of a bladder neck and proximal urethra. Under normal circumstances, the pressure of the internal sphincter is much higher than that in the bladder.

External sphincter

The female external sphincter is known as the rhabdosphincter and is composed of 2 types of striated muscle fibers, fast- and slow-twitch. Fast-twitch fibers cause 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 involuntary passive continence called the involuntary guarding reflex.

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

Pelvic diaphragm

The pelvic diaphragm lines the floor of the bony pelvis and is composed of 4 sheets of muscles, including pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus.

The pelvic diaphragm is often referred to 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, and the integrity of the pelvic floor depends on its function. When the levator ani is damaged, SUI and/or herniation of pelvic organs through the vagina may occur.

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. It 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 herniation of the bladder and proximal urethra into the vagina. Damage to the pubocervical fascia may cause the bladder to herniate through the vagina, resulting in cystocele formation.

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 cystocele and uterine descensus.

The uterosacral ligaments originate from a condensation of fibrous connective tissue overlying the sacral promontory and insert into the uterine cervix. Uterosacral ligaments stabilize the uterus in the bony pelvis. Weakening of the uterosacral ligaments may result in uterine or vaginal vault prolapse.

CONTRAINDICATIONS

Section 5 of 12  

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

Severe ISD is a contraindication for bladder neck suspension of all types (ie, transvaginal, retropubic, or laparoscopic). Performing bladder neck suspension for severe ISD leads to persistent SUI.

Performing a bladder neck suspension alone is contraindicated in the presence of moderate or severe cystocele because urethral obstruction may occur or the cystocele may worsen. In this situation, bladder neck suspension must be accompanied by a formal cystocele repair at the time of surgery.

The presence of atrophic vaginitis and intrinsic sphincter deficiency are contraindications for an in situ vaginal wall sling.

Severe urge incontinence is a contraindication for any type of antiincontinence surgery. Preoperative urge symptoms should be controlled with anticholinergic therapy prior to antiincontinence surgery.

The absolute contraindications for a female artificial urinary sphincter include uncontrolled detrusor overactivity and high-grade vesicoureteral reflux. Relative contraindications include the presence of urinary tract infections (UTIs) and a lack of manual dexterity to manipulate the pump. Patient motivation is the foremost consideration because the potential exists for surgical revision for mechanical problems.

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: UTIs can cause irritative voiding symptoms and urge incontinence.
• Urine cytology: Carcinoma in situ of the urinary bladder can cause symptoms of urinary frequency and urgency. Irritative voiding symptoms disproportionate to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy.
• Chem 7 profile: Blood urea nitrogen and creatinine levels are checked if compromised renal function is suggested. These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Other Tests

• Voiding diary: A voiding diary is a daily record of the patient's bladder activity. It is an objective documentation of the patient's voiding pattern, incontinent episodes, and inciting events associated with urinary incontinence.
• Pad test
• • This is an objective test that documents urine loss. Intravesical methylene blue or oral Pyridium or Urised may be used. Methylene blue and Urised turn urine blue; Pyridium turns urine orange.
  • Patients should resume their usual physical activities while wearing a peri-pad. If the pads turn to orange or blue, the patient is experiencing urine loss. If the pads remain white, it is most likely normal vaginal fluid.
• Cotton-swab test
• • Although urethral hypermobility is usually quantitated visually, some physicians prefer to quantitate the urethral movement with a cotton-swab test, although this test has never been clinically validated. To properly perform a cotton-swab test, place the patient in a dorsal lithotomy position. Make sure the examining table is parallel to the floor. Insert a sterile, well-lubricated cotton swab into the urethra until the cotton portion is completely in the bladder. Then, gently pull back on the cotton swab until the cotton is snug against the bladder neck.
  • Measure the angle between the cotton swab and the floor with a protractor. Women with normal pelvic anatomy should have a resting cotton-swab angle of 0° with respect to the floor. Ask the patient to Valsalva (strain) and cough. An abnormal upward deflection of the cotton swab (>30°) by Valsalva maneuver is evidence of urethral hypermobility.
  • The absence of hypermobility suggests that the cause of the stress incontinence is intrinsic sphincter deficiency.
• Cough stress test
• • A critical part of the pelvic examination is the direct observation of urine using the cough stress test or Marshall test.
  • A sterile catheter is inserted into the urethra, and the bladder is filled to 200-250 mL with water. The catheter is removed. Observation of leakage during Valsalva or cough denotes a positive test result.
• Standing pelvic examination
• • A standing pelvic examination is performed if the pelvic examination results fail to demonstrate urine loss or if pelvic organ prolapse is suggested.
  • If the cough leak test is initially performed with the patient in the lithotomy position and no leakage is observed, then this test should be repeated with the patient in the standing position. Observable urine leakage in this position constitutes a positive test result.
  • If any doubt remains about pelvic organ prolapse, the patient should be examined in the standing position. The patient stands with legs apart with one foot resting on a step stool. When the patient performs the Valsalva maneuver, the force of gravity helps the pelvic organs (ie, uterus, bladder) slide down the vagina to enhance the diagnostic potential. If pelvic prolapse is present, the prolapsed organ should be pushed up either with a pessary or gauze and the cough stress test should be repeated with the patient in the standing position.

Diagnostic Procedures

• PVR volume
• • The PVR urine measurement may be a part of the basic evaluation for urinary incontinence if symptoms of failure to empty urine are noted. To determine the PVR urine volume, either a bladder ultrasound or urethral catheter may be used.
  • If the PVR volume is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions cause urinary retention with overflow incontinence.
• Uroflow test
• • Uroflow is a useful screening test mainly for evaluating bladder outlet obstruction. Uroflow is the volume of urine voided per unit of time.
  • A low uroflow rate may reflect urethral obstruction, a weak detrusor, or a combination of both. These test results alone cannot help distinguish between obstruction and acontractile detrusor. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
• Filling cystometrogram
• • In 40% of patients, stress and urge incontinence coexist. In many instances, stress incontinence may lead to the development of urge incontinence.
  • A filling cystometrogram helps 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 help to unveil bladder instability.
• Abdominal leak-point pressure
• • An important component of multichannel urodynamic studies is the determination of ALPPs. ALPPs allow SUI to be classified based on the severity of ISD. Importantly, note that a normal leak-point pressure should approach infinity. In other words, patients with a normal continence mechanism can generate intra-abdominal pressures high enough to cause fainting but not to provoke stress incontinence. The historical references of ALPP associated with outdated classification systems are as follows:
  • • Type I SUI - ALPP of greater than 120 cm water
    • Type II SUI - Urethral hypermobility and ALPP of 90-120 cm water
    • Type II/III SUI - Urethral hypermobility, intrinsic sphincter deficiency, and ALPP of 60-90 cm water
    • Type III SUI - Intrinsic sphincter deficiency and ALPP of 0-60 cm water
  • The ALPP should be measured when the bladder is half full (ie, 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 intravesical pressure 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 lowest intravesical pressure at which leakage is seen is the ALPP. The ALPP obtained with a Valsalva maneuver is more accurate than the cough-induced ALPP. However, both techniques should be used if Valsalva maneuvers fail to manifest SUI.
  • Alternatively, both Valsalva and cough-induced ALPP may be repeated by increasing the bladder volume in 100-mL increments beyond 250 mL. 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 urinary flow rate. This is the only test able to help assess bladder contractility and the extent of a bladder outlet obstruction.
  • Pressure-flow studies can be combined with a voiding cystogram (VCUG) and videourodynamic studies for complicated cases of incontinence.
• Cystogram
• • A static cystogram (anteroposterior and lateral) helps to confirm the presence of stress incontinence, degree of urethral motion, and presence of cystocele. Intrinsic sphincter deficiency is evident by the presence of an open bladder neck. The presence of a vesicovaginal fistula may also be noted.
  • A VCUG can help assess bladder neck and urethral function (internal and external sphincter) during both filling and voiding phases. The results of a VCUG can help identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
• Electromyography
• • Findings from electromyography (EMG) help to ascertain the presence of coordinated or discoordinated voiding.
  • Failure of the urethra to relax during bladder contraction results in discoordinated voiding (detrusor sphincter dyssynergia [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 incontinent women.
  • On the other hand, cystoscopy helps detect bladder lesions, such as stitch in the bladder, bladder cancer, and bladder stones, which would otherwise remain undiagnosed if only urodynamic findings are assessed. A visual inspection of the urethra helps establish the presence of urethral stricture or gross evidence of poor urethral closure.
  • The general agreement is that cystoscopy is indicated for patients with persistent irritative voiding symptoms or hematuria. Obvious causes of bladder overactivity, such as cystitis, stone, and tumor, can be easily diagnosed. This information is important in determining the etiology of the incontinence and may influence treatment decisions.
  • Many urologists perform urethroscopy to assess the structure and function of the urethral sphincter mechanism.
• Dynamic retrograde urethroscopy
• • The cystoscope is introduced into the bladder. The bladder is filled to 250 mL with irrigant. The flow of the irrigant is turned off. The cystoscope is withdrawn to the mid urethra. The activity of the urethral sphincter mechanism is observed at rest and with Valsalva maneuvers.
  • Patients with mild ISD have a closed bladder neck at rest and have an intact voluntary guarding reflex. Patients with severe ISD have an open bladder neck at rest and have an impaired voluntary guarding reflex.
• Videourodynamics
• • Videourodynamic studies are the criterion standard for the evaluation of an incontinent patient. Videourodynamic studies combine the radiographic findings of a VCUG and multichannel urodynamics. A videourodynamic study is the most sophisticated diagnostic test for an incontinent patient.
  • The testing begins by draining the bladder. A urodynamic urethral catheter (ie, 7F Cook dual-lumen pigtailed catheter), rectal tube, and EMG electrodes are then placed.
  • Rotate the patient to a sitting position and equalize the transducers. Commence bladder filling using room-temperature contrast (Conray). Cold water may evoke false-positive detrusor contractions (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 is filled to 250 mL, measure the ALPP. Instruct the patient to perform Valsalva maneuvers in gradients (ie, mild, moderate, severe), followed by cough (ie, mild, moderate, severe). Observe for urine leakage fluoroscopically and by direct inspection. At this point, assess the activity of the bladder neck, urethral mobility, and the presence of cystocele using fluoroscopy (static cystogram).
  • Upon completion of ALPP testing, finish the filling cystometrogram to completion. When the patient has a strong desire to void, perform a voiding cystometrogram (pressure-flow study). At this point, note urodynamic parameters, such as maximal flow rate and detrusor pressure at maximal flow rate.
  • During the voiding cystometrogram, note the activity of the EMG electrodes and VCUG for possible DSD. Confirm the presence of DSD by increases in EMG activity during detrusor contraction or closure of the external sphincter on VCUG images during voiding.
  • After the patient voids to completion, the videourodynamic study is complete.

TREATMENT

Section 7 of 12  

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

Surgical therapy

Operations for urethral hypermobility

Surgical procedures for mild-to-moderate ISD with urethral hypermobility reposition the mid urethra and/or bladder neck into a normal anatomic position at rest and during physical exertion. When the bladder neck is in the correct anatomic position, it stays closed during periods of increased abdominal pressure. The main types of procedures used for correction of ISD with urethral hypermobility include retropubic bladder neck suspensions and transvaginal sling procedures.

For severe ISD and urethral hypermobility, select a surgical procedure that stabilizes the anatomic support and compresses the urethra, which typically means using one of the retropubic sling procedures, not the transobturator approach.

Retropubic urethropexy

Retropubic suspension procedures have a long-term (>4 y) success rate of approximately 84% in curing stress incontinence caused by urethral hypermobility. The Agency for Health Care Policy and Research (AHCPR) reviewed 45 studies incorporating 3882 patients who underwent retropubic urethropexy. Long-term cure rates averaged 79%, and 84% of patients were cured or improved with retropubic surgery.

According to the AHCPR, the overall complication rates reported for retropubic operations averaged 18% (range 6-57%); the incidence of wound infections, urinary retention, de novo detrusor instability, and dyspareunia ranged from 3-15%. Postoperative enterocele and rectocele was most prominent after Burch urethropexy, occurring in up to 12% of patients.

Sling procedures

Sling procedures create a hammocklike bolstering of the urethra. A supporting strip of material is placed under the mid urethra and/or bladder neck and secured to the abdominal wall or pelvic bone structures. Sling procedures have a more durable long-term cure rate of 85% after more than 5 years.

Operations for intrinsic sphincter deficiency

Procedures for managing various degrees of ISD severity include sling procedures, periurethral bulking injections, and placement of an artificial urinary sphincter.

Sling procedures are recommended for women who have ISD alone or ISD with coexisting hypermobility. Periurethral bulking injections were initially recommended as first-line treatment in women with severe ISD who do not have coexisting hypermobility but are currently used in all patients with any form of SUI. Artificial sphincters are recommended for patients who are unable to perform intermittent catheterization and have severe ISD unresponsive to other surgical treatments.

Sling procedures

The various sling procedures all involve placing a sling made of autologous, synthetic, or cadaver material under the mid urethra or bladder neck (urethrovesical junction) and securing it to retropubic structures, abdominal structures, or both.

Periurethral bulking agents

Periurethral bulking injections currently involve the injection of materials under cystoscopic guidance into or around the incompetent urethra. The result is bulking of tissue. This helps the internal seal mechanism close off the flow of urine. Injection of these agents into the periurethral tissue restores the mucosal seal mechanism by effectively coapting the urethral mucosa at rest.

According to the AHCPR, combined data from 15 studies of 528 women indicate that after follow-up for up to 2 years, 49% of patients were cured (range, 8-100%) and 67% were either cured or improved. Complications included urgency, UTI, and urinary retention.

Artificial urinary sphincter

The only surgical technique for incontinence that attempts to mimic the active mechanism of natural continence is the artificial urinary sphincter. The artificial urinary sphincter has been used in men and women with intrinsic sphincter deficiency.

According to the AHCPR, combined data from 8 studies of 192 women with ISD treated with artificial sphincter placement revealed that 77% were dry and 80% were cured or improved.

Complications included fluid leak, loose cuff, erosion or atrophy at the cuff site, kinked tubing, and infection.

The artificial urinary sphincter does not have a significant role in female SUI because of the availability of other types of surgery such as periurethral injection with bulking agents or sling procedures. However, the artificial urinary sphincter is still an option if other surgical modalities have failed.

Preoperative details

Inform all patients about the potential complications of antiincontinence surgery during the informed consent process. Complications common to any antiincontinence surgery include urethral obstruction and de novo or worsening obstructive voiding symptoms.

Treat patients with preexisting urge incontinence with anticholinergic therapy preoperatively.

Counsel patients undergoing retropubic urethropexy or sling procedures on the possibility of performing self-catheterization in the event that urinary retention occurs postoperatively. With patients receiving synthetic slings, discuss the possibility of urethral erosion or vaginal extrusion.

Inform patients receiving an artificial urinary sphincter about the potential for mechanical malfunction that may require revisionary surgery.

Test the skin of eligible candidates for periurethral collagen injection for a possible allergic reaction 28 days before the scheduled injection therapy.

Preoperatively, clear all patients of any preexisting UTIs. Intravenous broad-spectrum antibiotics are administered on the morning of surgery, ideally 1 hour before starting the operation. Compressive pneumatic devices are placed on the lower extremities prior to induction of anesthesia to prevent deep venous thrombosis.

Intraoperative details

MMR urethropexy

All patients receive intravenous antibiotics preoperatively. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position. The abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.

A transverse suprapubic incision is made, and the anterior rectus fascia is incised. The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placing a hand in the vagina facilitates identification of the bladder neck.

The prevesical fat is dissected off the bladder and the bladder neck. Two or 3 nonabsorbable suspension sutures (eg, 1-0 Prolene) are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the periosteum of the pubic symphysis and then tied securely.

The bladder neck is suspended by the sutures anchored to the undersurface of the pubic bone. The suspension sutures prevent bladder neck descent during periods of physical activity, but they do not pull up the bladder neck high behind the pubic symphysis. Take care to not tie the bladder neck against the pubic symphysis. Overzealous pulling up of the bladder neck causes iatrogenic urethral obstruction.

Burch urethropexy

Preoperative broad-spectrum intravenous antibiotics are administered. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position. Abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.

A transverse suprapubic incision is made, and the anterior rectus fascia is incised. The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placing a hand in the vagina facilitates identification of the bladder neck.

The prevesical fat is dissected off the bladder and the bladder neck. Two or 3 nonabsorbable suspension sutures (eg, 1-0 Prolene) are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the Cooper ligament and then tied securely.

The bladder neck is suspended by the sutures anchored to the Cooper ligament. The suspension sutures prevent bladder neck descent during periods of physical activity, but they do not pull up the bladder neck high behind the pubic symphysis. Overzealous pulling up of the bladder neck causes iatrogenic urethral obstruction. Leave enough space behind the suspension suture and the Cooper ligament to readily admit 2 fingers. This new position allows even disposition of external pressures on all surfaces of the bladder and the proximal urethra.

Rectus fascia pubovaginal sling

All patients are administered intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. A combined abdominal-vaginal approach is used for the operation. A full, 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and draped in sterile fashion.

A transverse incision is made over the suprapubic area. The incision is carried down to the rectus fascia. Scarpa fascia overlying the rectus fascia is dissected off. A 2 X 13-cm strip of rectus fascia is harvested. The rectus fascia is stored in antibiotic saline solution until ready for use.

The abdominal fascia is closed using nonabsorbable sutures. Antibiotic-soaked gauze is placed into the abdominal incision.

A self-retaining vaginal retractor and a 16F Foley catheter are placed. The bladder neck is identified by visual inspection of the anterior vaginal wall and digital palpation of the Foley catheter.

A single vertical midline incision or an inverted-U incision is made at the level of the bladder neck. The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.

The rectus pubovaginal sling is constructed at the back table with 1-0 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4-0 Vicryl sutures. The suspension sutures are transferred suprapubically.

The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2-0 Vicryl suture in a continuous locking fashion. The suspension sutures are tied ipsilaterally and then across the midline loosely. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.

The subcutaneous tissues are approximated and the skin is closed with running subcuticular suture. For obese patients who are at risk for seroma formation, the author places a small, closed suction drain in the suprapubic area prior to skin closure.

One ampule of indigo carmine is administered intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates that the ureters have not been injured.

Povidone-iodine–soaked vaginal packing is inserted. A urethral catheter and/or suprapubic tube are placed depending on the surgeon's preference.

Fascia lata pubovaginal sling

All patients receive intravenous antibiotics preoperatively. A combined thigh-abdominal-vaginal approach is used for the operation. The patient is placed in the supine position with the inner leg stretched out and the outer leg in a slightly bent position. All pressure points are adequately padded to prevent pressure necrosis.

The outer thigh is prepared with povidone-iodine solution and draped in a sterile fashion. A skin incision is made on the outer thigh. A 2 X 13-cm strip of fascia lata is harvested. A special fascial stripper may be used for the harvest. A small Penrose drain is placed, and the thigh incision is closed. A compressive dressing is applied.

The patient is repositioned in a lithotomy position. A full, 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and draped in sterile fashion.

A transverse suprapubic incision is made. The incision is carried down to the rectus fascia. The Scarpa fascia is dissected off the rectus fascia. Antibiotic-soaked gauze is placed into the wound.

A 16F Foley catheter and self-retaining vaginal retractor are placed. The bladder neck is identified. A vertical midline incision or an inverted-U incision is made at the level of the bladder neck.

The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.

The fascia lata sling is constructed at the back table with 1-0 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4-0 Vicryl sutures. The suspension sutures are transferred suprapubically.

The suspension sutures are tied ipsilaterally and then across the midline loosely. Alternatively, the ends of the sling may be sewn to the rectus fascia. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.

The subcutaneous tissues are approximated, and the skin is closed with running subcuticular sutures. For obese patients who are at risk of seroma formation, the author places a small, closed suction drain in the suprapubic area prior to skin closure.

One ampule of indigo carmine is administered intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates that the ureters have not been injured.

The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2-0 Vicryl sutures in a continuous locking fashion. Povidone-iodine–soaked vaginal packing is inserted. A urethral catheter and/or suprapubic tube are placed.

Midurethral polypropylene vaginal tape procedures: retropubic or transobturator approaches

Polypropylene meshed tape that measures 1.1 X 30 cm may be placed at the mid urethra or bladder neck using retropubic or transobturator approaches.

Broad-spectrum intravenous antibiotics are administered. Perform the operation through the vagina with 2 small, lower-abdominal incisions above the pubic bone for a retropubic approach versus over the mid to lower medial aspect of the obturator foramen. The procedure may be performed with local, regional, 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 18F urethral catheter in the bladder.

Apply local anesthetic to the skin just above the pubic tubercle on both sides of the midline for retropubic procedures or the obturator foramen in transobturator procedures. Apply local anesthetic to the anterior vaginal wall. Make a small vertical incision on the anterior vaginal wall at the mid urethra. Dissect the vaginal wall tissue off the urethra to expose the mid urethra, and dissect paraurethrally toward the endopelvic fascia.

Depending on the approach chosen, use the appropriate trocars to place the polypropylene tape in the perivesical pocket.

Fill the bladder with 250 mL of saline. Perform a cystoscopy with the needle in situ to help rule out bladder and urethral injury.

Note that the success of this operation is predicated on performing a proper tension test. Although devices are marketed as tension-free, the surgeon must ensure that it is tension-free by performing a proper tension test. Close the vaginal, perineal, or abdominal incisions.

Periurethral injection therapy

The patient is placed in the lithotomy position. Vaginal and periurethral areas are prepared and draped with sterile technique. A 2% lidocaine jelly is injected into the urethra for local analgesia.

A short-beaked female cystoscope with either 30° or 0° lens is inserted into the urethra. The stopcock for the irrigant is turned on halfway. The incompetent bladder neck is identified. The cystoscope is withdrawn to the mid urethra.

For transurethral or periurethral injection approaches, the injectable needle is advanced into the submucosal plane approximately 2 cm from the bladder neck. Care is taken to not advance the needle too proximal because it may exit the urethra and enter the bladder.

The implant is slowly injected until complete mucosal coaptation is seen. Depending on the adequacy of the bladder neck closure, additional injection sites may be used. The amount of implant required to achieve complete bladder neck coaptation may vary from 1 to 5 mL.

Artificial urinary sphincter

All patients are administered intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. The abdomen and genitalia are prepared with povidone-iodine solution and draped in sterile fashion. A Foley catheter is placed. A transverse lower abdominal incision is made. The Retzius space is entered, and the bladder neck is dissected circumferentially from the surrounding tissues and vagina.

An appropriate-size cuff is placed circumferentially around the bladder neck. Following placement of the cuff, the pressure-regulating balloon is implanted into the preperitoneal space and the control pump is placed through the inguinal ring into the labia majora.

Temporary connections are made, and the sphincter is cycled. The pressure reservoir is filled with a final volume of 20 mL of filling solution. Excess tubing is trimmed. Final connections are made in the subcutaneous space of the abdomen. The sphincter is cycled again, and the cuff is left in a locked-open position. The abdominal wound is closed in layers, and a Foley catheter is left in place.

Postoperative details

Retropubic urethropexy

Intravenous antibiotics are administered for 48 hours, followed by an oral cephalosporin. On the morning after surgery, the urethral catheter and intravenous lines are discontinued. Patients are discharged on the second or third day after surgery. They may perform normal physical activities after 4-6 weeks.

Sling procedures

Oral antibiotics are administered for several days. The urethral catheter and the vaginal packing are typically removed shortly after the procedure or on the morning following the operation.

Periurethral bulking injections

Oral antibiotics are administered preoperatively but are not needed postoperatively. If SUI recurs or persists, repeat injection or a sling procedure may be necessary.

Artificial urinary sphincter

Intravenous antibiotics are administered for 24 hours, and an oral cephalosporin is continued for several days. The sphincter is left deactivated for 6 weeks. The device is activated, and the patient is instructed on its use after 6 weeks of healing.

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 operations that correct stress incontinence occur very infrequently. Complications common to retropubic bladder neck suspensions and sling procedures include urinary retention, de novo or worsening obstructive voiding symptoms, UTI, suture abscess, wound infection, retropubic bleeding, vaginal granuloma, vesicocutaneous fistula, de novo pelvic prolapse, bladder perforation, prolonged suprapubic pain, and ilioinguinal nerve entrapment. Reports of serious vascular injury, bowel perforations, thigh abscess, and death due to these complications are not unique to pelvic surgeries but appear to be associated with the newer midurethral sling approaches.

The current incidence rate of urethral obstruction ranges from 5-10% for anti-incontinence operations. Urinary retention is temporary in most cases, but it may last a month or more. While the condition lasts, clean intermittent catheterization should be performed. Less serious complications, such as wound infection, occur more frequently but are easily treated with antibiotics. The likelihood of needing a blood transfusion is less than 5% for all procedures.

Retropubic bladder neck suspension

Abdominal wound infection, urinary retention, de novo urge incontinence, and dyspareunia occur in 3-15%. Up to 12% of patients experience postoperative enterocele and rectocele after a Burch urethropexy.

Rectus fascia pubovaginal sling

In the literature, the incidence rate of urethral obstruction after sling surgery is 2-10% and the incidence rate of obstructive voiding symptoms is 5-25%. De novo detrusor instability requiring anticholinergic therapy occurs in 15-20% of cases.

Potential intraoperative complications include injury to the urethra, bladder, or ureters during the dissection and during transfer of the suspension sutures.

Fascia lata pubovaginal sling

As with any sling surgery, patients with a fascia lata sling surgery may have difficulty with volitional voiding postoperatively. In some, detrusor instability may result in urge incontinence. Other potential complications of sling surgery include erosion of the urethra, prolonged or permanent urinary retention, injury to the bladder or ureters, and detrusor instability. Leg pain is a complication unique to the fascia lata sling operation.

Synthetic pubovaginal sling

Complications of synthetic slings include urethral erosion, nonhealing of the vaginal wall (sling extrusion), abscess, and, rarely, vesicovaginal fistula formation.

Periurethral bulking injections

UTI and irritative voiding symptoms are the most common adverse effects after periurethral implant injections. Symptoms of urinary frequency and urgency are self-limited.

Permanent urinary retention has not been reported. Urinary retention responds well to temporary catheterization. Acute urinary retention after implant injection should not be treated with an indwelling urethral catheter; otherwise, it can mold the implant and defeat the success of the operation. Rather, intermittent catheterization is preferred. If an indwelling catheter is required in unusual situations, a suprapubic catheter can be placed percutaneously to protect the implant.

Artificial urinary sphincter

Complications of an artificial urinary sphincter include urethral injury during surgery, tissue atrophy, and delayed urethral erosion.

Mechanical problems include fluid leak from the system, kinked tubing, and obstruction from particulate matter. Infectious complications include suprapubic or perineal cellulitis and periprosthetic abscesses. Infection may lead to erosion and necessitate a repeat surgery to remove a portion or even the entire device.

Patient Education

For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Cystoscopy.

OUTCOME AND PROGNOSIS

Section 9 of 12  

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

Retropubic suspensions and sling procedures are excellent operations for their indications in treating female SUI. Periurethral bulking agents are less durable in their success but offer an office-based procedure that may provide significant improvement with minimal morbidity for treating SUI. Sling surgeries may involve autologous tissue, synthetic biomaterials, and cadaver allografts. The particular type of operation chosen depends on the patient's needs combined with the surgeon's expertise. When performed properly, the long-term cure rate associated with retropubic suspensions and sling surgery should approach 90%, with minimal complications.

FUTURE AND CONTROVERSIES

Section 10 of 12  

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

The management of long-term urinary retention after an anti-incontinence procedure remains controversial. Postoperative urinary retention may be treated with an indwelling catheter, intermittent catheterization, cutting of suspension sutures or sling material, or complete urethrolysis with or without a repeat sling procedure.

Acute urinary retention is initially treated with an indwelling urethral catheter or self-intermittent catheterization. If a suprapubic tube was placed intraoperatively, it is left in place. In most cases, patients are able to void spontaneously within 3 weeks and catheterizations are discontinued.

If urinary retention persists at 3 weeks, a pressure-flow study must be performed to document a well-functioning detrusor and to help rule out urethral obstruction. If the patient has an atonic detrusor, long-term catheterization, intermittent or otherwise, will be needed.

If the patient has normal detrusor function, an alternative to intermittent catheterization is to take down the suspension or sling procedure.

The timing of urethrolysis is controversial. If urinary retention occurs after a rectus fascial sling, urethrolysis is recommended after 3 months of urethral obstruction. If urethral obstruction results after a synthetic sling, urethrolysis should be performed as early as 2 weeks.

Formal urethrolysis of an autologous sling involves complete dissection circumferentially around the bladder neck and proximal urethra. Conversely, urethrolysis of a synthetic sling may only require an incision of one or both arms of the sling rather than complete dissection of an autologous sling.

After urethrolysis of a rectus fascial sling, one may choose to place another autologous sling to prevent recurrent stress incontinence. If a urethral injury is encountered, it is repaired primarily and a Martius fat pad (fat pad from the labia majora), omentum, or posterior peritoneum may be used to reinforce the closure. Whether to proceed with another sling at the time of urethrolysis should be tailored to each individual patient.

Despite these potential complications, realize that retropubic suspensions and sling procedures are excellent operations for their indications in treating female SUI. Sling surgeries may involve autologous tissue, synthetic biomaterials, and cadaver allografts. The particular type of operation chosen depends on the patient's needs combined with the surgeon's expertise. When performed properly, the long-term cure rate associated with retropubic suspensions and sling surgery should approach 90%, with minimal complications.

The future of antiincontinence surgical therapy is bright and promising. With advances in biomechanical engineering, coupled with clinical and basic science research, the understanding of the incontinence disease process and the development of new surgical options are increasing rapidly. With the current evolution of stem cell research and genetic engineering, more minimally invasive and technologically advanced surgical procedures will be forthcoming in the near future.

MULTIMEDIA

Section 11 of 12  

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

Media file 1:  Marshall-Marchetti-Krantz bladder neck suspension. Suspension sutures (A) are placed next to the urethra and then to the pubic bone. Suspension sutures (B) are tied.
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Media file 2:  Burch bladder neck suspension. Suspension sutures (A) are placed at the bladder neck and the Cooper ligament. Suspension sutures (B) are tied.
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Media type:  Image

Media file 3:  Retropubic suspending sling of rectus fascia, fascia lata, or synthetic sling material places a long strip of sling material under the bladder neck or mid urethra. The ends of the sling are fixed to the rectus fascia of the lower abdomen.
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Media type:  Image

Media file 4:  Injectable bulking implant therapy for stress urinary incontinence (SUI). Using a bent needle for localizing the sublaminal plane in the bladder neck and mid urethra, implant material is injected in a periurethral approach under endoscopic guidance.
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Media type:  Image

Media file 5:  Injectable bulking implant therapy for stress urinary incontinence (SUI). Using a transurethral approach and an endoscopic needle for localizing the sublaminal plane in the bladder neck and mid urethra, implant material is injected via the cystoscope under endoscopic guidance.
	View Full Size Image
Media type:  Image

Media file 6:  Artificial urinary sphincter. The sphincter cuff is placed around the bladder neck, the balloon reservoir is implanted in the prevesical space, and the pump is inserted into the vaginal labia.
	View Full Size Image
Media type:  Image

REFERENCES

Section 12 of 12

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

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Article Last Updated: Jun 27, 2006