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FEMALE URINARY INCONTINENCE
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FEMALE URINARY INCONTINENCE
Urinary incontinence (UI) is the sudden, uncontrolled release of urine from the bladder. It affects 13 million people in the United States, with 85% of those being women. An estimated 35% of women over age 50 suffer from some degree of incontinence, and 15 % report leaking at least once daily. If these numbers come as a surprise, it’s probably because urinary incontinence is one of those things that no one finds particularly easy to talk about. It can be a nuisance (changing clothes or wearing pads). It can be embarrassing (smelling of urine or wetting oneself). It can be uncomfortable. And sometimes, it is much more - urinary incontinence can limit your life so that you end up restricting or avoiding physical activity, travel or social relationships because if it. This embarrassing condition can significantly inhibit a woman's quality of life, often causing her to avoid an active lifestyle or to shy away from social situations. Only 5 % of the women with UI receive treatment. Embarrassment keeps 50-70 % of women who leak from ever seeking treatment. Patients often cope with this condition for 6-9 years before asking for help. Many women who leak are not only embarrassed by their problem, but alsow may have the mistaken belief that their problem can't be bettered. Nothing could be further from the truth. Current treatments are highly successful.
TYPES OF INCONTINENCE
There are several types of incontinence, each with different causes and treatments. The two most common are stress and urge incontinence. They can occur separately or together. Defining the type of leakage greatly improves the success of treatment. In our office, an interview and examination of the patient, along with a simple bladder test (urodynamics), are all that is needed to accurately define which type is present . Approximately 60% of women who leak urine have stress incontinence.
STRESS URINARY INCONTINENCE (SUI)
Stress Incontinence is the uncontrolled leak of urine with coughing, laughing, lifting, sneezing, exercise or any activity that raises abdominal pressure. Though it can occur at any age, this is often seen in women who have had multiple children. Gravity, time, pregnancies, deliveries and prior pelvic surgeries (hysterectomy etc) all weaken the pelvic floor and urethral sphincter muscle, both of which are needed to stay dry. The decrease in estrogen that occurs with menopause magnifies the effect of these factors.
Treatment: SUI is best treated surgically. Non-surgical pelvic floor exercises (such as Kegel exercises), can strengthen muscles of the sphincter area and help those who's leakage is minimal. Only surgery can secure long lasting favorable results in more significant cases of SUI. Over the years, many surgical approaches have been tried, with various successes. To officially clarify which did work for the public, the American Urologic Association, in 2001, stated that only two types of "bladder suspension" procedures for SUI have effective long term cure rates. These procedures are: the open abdominal anterior urethropexy (Burch or MMK procedure), and the “sling procedure", which is done completely vaginally.
With patient demand for minimally invasive treatments, the vaginal sling procedure has pretty much replaced every other type of surgery for the treatment of SUI. The introduction of the Tension-free Vaginal Tape procedure in the late 90's (TVT, SPARC) revolutionized the treatment of SUI. Dr. Muench was the first Urologist to perform the TVT procedure in Wilmington, and has performed this procedure exclusively since then.
TENSION - FREE VAGINAL TAPE
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The TVT is a doctor-applied, ribbon- like strip that stops urine leakage the way your body was designed to- by supporting the urethra (the short channel your bladder empties through). The TVT device uses a mesh sling to give support to the middle of the urethra, the section that is strained during physical activities. This positioning of the device provides support only when needed, and so creates a “tension- free" treatment solution that reduces the risk of over- correcting.
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The TVT procedure is a simple, quick (usually less than 30 minutes), minimally invasive treatment for women with SUI. Patients are ready to be released from the hospital the day-of or the morning-after their sling placement. The recovery period following the procedure is short. Most women return to their regular routine in just a day or two. Patients experience few complications.
Once urodynamic testing does document SUI, indicating a sling would help alleviate your symptoms, my office will schedule it on a date convenient for you. Patients are usually pre-treated with estrogen cream applied to the vagina three times a week for a month prior to any sling placement. This makes the tissues really healthy and receptive to the sling placement. The estrogen cream application is usually continued for a month post -op,during which it speeds healing. It may be discontinued thereafter.
Patients will leave the surgicenter or hospital the day-of or morning-after their sling placement, no longer leaking, voiding freely,and without a catheter. For two thirds of patients, this improvement is immediate. For one third, minor swelling may require a temporary catheter for a day or two. Patients report minimal post -op discomfort. The TVT is placed through punctures rather than incisions, greatly easing recovery and making this truely "band-aid surgery".Patients will usually return to light activities and work (non-physical, office work ) in a week. Patients should refrain from lifting, straining or sexual relations for 3 to 4 weeks after a sling placement.
Long Lasting Success of TVT
Long-term studies show that five years after treatment, nearly 85 percent of the women treated remained completely dry and 10 percent remained significantly improved. Researchers defined "dry" as having a negative stress- test result (i.e., no urine loss while coughing), a negative 24-hr pad-weighing test result, and if quality-of-life improved by at least 90%.
These studies suggest there is no significant decline in efficacy over an extended period
Currently there is more clinical data available for TVT than for any other mid-urethral sling. The TVT product was shown to be superior to its competition with a higher cure and lower complication rate. It has proven effective in many different patient types: from advanced elderly women, and obese women, to women who failed other prior procedures.
Long-term follow-up studies showed post-operative complications were few and required no surgical intervention.
To date more than 150,000 women have been treated with the TVT. As with any surgery of this kind , the procedure should not be performed in pregnant women or in patients planning future pregnancies. Although rare, complications associated with the device include injury to blood vessels of the pelvic sidewall and abdominal wall, difficulty urinating and bladder and bowel injury.The incidence of serious complications reported was less than .03%. The risk of post-op retention is less than 3%.
With an excellent safety record and high success rate ( 98% of women who participated in a study begun seven years ago are still dry, or experiencing significantly less leakage), TVT treatment can end urinary incontinence so you can take control of your life. For those who suffer from urinary incontinence, its important to know it can be treated- you don't have to "just live with it."
PATIENT COMMENTS AFTER HAVING A TVT
Curing a woman's stress incontinence is one of the most rewarding things I do. Patients generally have quietly endured their symptoms for quite some time before seeking treatment. During that time, they have learned to cope with leakage, usually by giving up activities they love. They generally have seen the progression of their problem despite their best efforts, and have finally decided they could no longer hide it or cope with it. Seeing their initial despair change to post-op joy is very dramatic and gratifying for me as their physician. They usually come in for their post-op visit beaming with happiness. They are amazed they can resume those activities they previously thought they'd have to give up forever. Not only is their improvement immediate and dramatic, but they realize how minimal their post op discomfort and recovery were. Many new patients say they chose to come to me after hearing a satisfied patient of mine talk about their successful sling results.
URODYNAMICS
Urodynamic testing is done to diagnose which type of incontinence a patient has. It is done before any treatment. This in-depth examination evaluates bladder and urinary sphincter function as the bladder is filled and emptied. A small tube (known as a catheter) is placed through the urethra into the bladder to measure the pressure inside the bladder. At the same time, a tiny catheter is placed inside the rectum to measure the pressure in the abdomen. This test also assesses whether the patient has normal bladder sensation and capacity. The whole evaluation takes about 30-45 minutes.
Urodynamics is a simple, easy test that quickly looks at every aspect of bladder function. It will explain why a patient has the symptoms they do, and also can identify any other problems the current symptoms may mask. This information helps the patient's treatment succeed.
The following questions, which identify the type of leakage a woman has, are answered by urodynamics:
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Does the bladder sense its own filling correctly?
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Is it over- or under- sensitive?
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Does it react to filling appropriately?
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Does it store and empty as it should?
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Is it overactive?
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Does the opening of the bladder open and close correctly?
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Is the bladder in the correct position, or has it dropped with pelvic floor weakening?
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If the bladder neck has dropped , has anything else dropped with it that needs to be addressed for treatment to be successful?
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Do the muscles of the pelvic floor contract as they should?
The test has three parts. In the first part, bladder, bowel, and pelvic floor muscles are monitored during bladder filling. The information provided quickly answers many of these questions. The types of incontinence each have their own particular appearance, so, in the second part, a skinny telescope (cystoscope) passed into the bladder helps identify them with just a look. The absence of other, potentially more serious problems, (such as bladder cancer) is also confirmed here.
In the third part of the test, the patient is asked to cough with a full bladder, to demonstrate their leakage. They then cough again, this time with their bladder gently held up in the position a sling would hold it, to see that the leakage no longer occurs-(indicating a sling would solve the patient's problems). At this point, all the test's findings would be summarized and explained. Patients who's tests show they do have SUI, would benefit from a TVT, and are started on their one month of pre-op estrogen cream applications and scheduled for their actual procedure.
Preparing for your urodynamic testing.
Patients should report for the testing with a comfortably full bladder.
Do not empty just before the test, as it will delay getting started.
Five days before the urodynamics, stop any medications you might be taking to help your bladder function. Medicines you'd be asked to stop include detrol (tolterodine), ditropan (oxybutinin), probanthine (propantheline), tofranil (imipramine), urispas, dibenzyline, minipress, and cystospaz. We don't want to measure the effect of these medications on your bladder. We want the test to measure your bladder's problem without them. Stopping these 5-days before will ensure they are out of your system and don't falsely effect the test results.
If one of your bladder medicines is elmiron, don't stop that for the testing. (Elmiron doesn't affect the test.)
Do not stop your regular medications, such as heart, blood pressure or diabetic medications.
There is a slight risk of getting a urinary infection from the catheterizations of urodynamics, so a short course of antibiotics is usually given before or after the testing.
TRANSOBTURATOR TAPE (TOT)
When the mid-urethral transvaginal slings (such as the TVT) create a result by supporting the bladder in a mesh, the final effect is very similar to a hammock hanging between two trees. (The ends of the hammock lying above its middle give support to whatever puts downward pressure on the middle.) If the TVT set -up is like a hammock, the transobturator sling is like a trampoline, stretched under the bladder. The benefit of this TOT approach is that the procedure to place such a sling travels laterally, under the bladder, rather than upward alongside the bladder, where there can potentially be damage to the bladder, bowel or pelvic blood vessels. Although serious complications were reported to be less than .03% with the transvaginal TVT approach ( i.e., extremely rare ), they certainly couldn't happen at all if the approach never traveled near them, as with the transobturator route( TOT). The cure and complication rates of the TOT are comparable to other tension-free slings at one year. Longer follow-up is needed to see if the intial success is durable. The TOT may be particularly useful in morbidly obese patients who's large belly size is too big to allow the TVT.
PERIURETHRAL BULKING AGENTS
Although a sling is the ideal treatment for urine leakage due to a bladder opening that wont close (incompetent urethra) or a dropped bladder, some patients (the very elderly, or those with severe medical problems needing to avoid anesthesia) may see improvement ( lessening ) of their incontinence with the simple injection of bulking agents around the opening of their bladder. Though such a procedure couldn't possibly correct the leakage as effectively as a sling (a sling provides more of the necessary resistance), the benefit they could provide, coupled with their minimal risk and ease of performing, may make them worthwhile to try. There are several bulking agents available, Contigen and Coaptite being two of the most popular. With newer sling approaches becoming less and less invasive and more and more effective all the time, periurethral injections may be used even less often in the future.
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