When treatment with pelvic muscle exercises does not work, it is reasonable to consider surgery to improve your bladder control. Over a hundred procedures for bladder control have been developed over the last century. Unfortunately, many of them have turned out to be ineffective, & some have proven to be dangerous. For over a century the simple repair of bladder prolapse (called a “bladder tack” by many patients) was performed routinely for bladder control. This procedure generally works well to fix the bladder bulge, but it has an extremely poor cure rate for urinary incontinence (<30% at 5 years). Over the last decade, safe & effective procedures have been developed & proven for the treatment of urinary incontinence.
Which procedure is right for you?
Once the decision to proceed with surgery is made, it is vital to make sure that you are getting the right procedure performed for your type of leakage. Some procedures will actually make certain types of leakage worse. This is particularly a concern in women who have overactive bladder or urge incontinence. Surgery can make the symptoms of urgency, having to go all the time, & having to get up at night to void even worse. These symptoms will improve sometimes when there is repair of vaginal prolapse, but there is no way to predict if that will happen. This is why it is very important to undergo bladder testing prior to any surgical procedure. Some surgeons will guess as to what is going on & recommend surgery based on your symptoms & exam; but multiple studies have shown that even experienced physicians are often wrong about what is causing leakage when compared to testing. Bladder testing can help to determine what is going on & what your best options are.
Once bladder testing has shown that surgery is an option for you, the next decision is to select the best procedure. Many surgeons only know one procedure, & that is what they will recommend; but there are several types of surgery, each with its advantages & disadvantages. The major decision is to decide whether to perform the surgery through a vaginal or an abdominal approach. It is generally best to perform vaginal surgery, since it is less complicated, less painful after, & the recovery is faster.
Any surgery for bladder control has to find a balance between improving leakage & avoiding making it difficult to empty. Many procedures in the past have resulted in temporary or permanent trouble emptying. Current procedures rarely cause trouble emptying, & most of the time you can empty the same or the next day.
Vaginal Bladder Control Surgery– Recent studies have demonstrated that the best & safest vaginal bladder control procedure is what is called a pubovaginal sling, or “sling” procedure. There are dozens of different types of slings which have been tried over the last century, & many have resulted in trouble emptying the bladder, difficulty healing (“erosion”), &/or have not held up with time. The current version of the sling is what is termed a “tension-free vaginal tape” which, unlike many prior sling procedures, is not sewn to the pubic bone or abdominal wall, but remains in place by your body’s tissues growing through the mesh material. This type of sling is very effective & is rarely associated with trouble voiding. The Gynecare tension-free vaginal sling is the best studied procedure for urinary control, & over 1 million have been performed world-wide with over 50,000 in the US (see www.controlsuddenurineloss.com for details). Given this sling’s safety record & the amount of studies which have shown it to be effective, it is our sling procedure of choice. We have performed over 2000 of these slings since they started being used in 2003. In our hands, this is a usually a 10-20 minute procedure. It does require anesthesia, but is performed as a same-day surgery procedure when done by itself or with less complicated vaginal repairs.
The above picture shows the sling coming out above the pubic bone through two small abdominal incisions. This is called a “retropubic” sling. The sling can also be positioned so that it comes out the inner thighs. That is called a “transobturator” sling. Both approaches are safe & effective, but some patients with certain types of leakage may do better with one or the other approach. Some new variations which are performed with a single incision & do not come through the skin when they are positioned are being studied.
Abdominal Bladder Control Surgery– Abdominal surgery for bladder control was considered the standard approach for many decades. In the 1990’s studies demonstrated that the pubovaginal sling procedure is as effective if not more, & is has fewer risks & complications with a much easier recovery.
“Which Way Is Best?” As noted above, our preference is to perform vaginal surgery if possible. We have performed thousands of the procedures each way, so as surgeons we are comfortable either way. Recent studies have suggested that the vaginal sling procedure holds up better with time. There is no question that the vaginal procedure is much easier to go through & to recover from.
Injections for Bladder Control– For women who have good support of the bladder & whose leakage is due to a weakening of the muscles around the opening of the bladder, injections in the office may be an option. Most surgical procedures will not help this type of leakage. This condition usually occurs in older women. Injections are probably not a great option under the age of 60, since they sometimes have to be repeated. Injections are very safe & can be performed without major anesthesia with minimal discomfort in 5 minutes or so. The injection itself takes a few seconds. We have performed injections in over 1000 women & found that most women have minimal pain after the treatment, & there is no recovery time. You can drive immediately after the treatment. But you may avoid riding a horse for a few days. In some women with severe muscle weakness it may take up to 3 injections to get an improvement, & about 60% of women will improve. Most women require either 1 or 2 injections. With time the nerve weakness may worsen, & the injection may need to be repeated in several months or years. For an older woman who is trying to avoid surgery, it is still a good option since it is so much less to go through, & it can be performed if a woman is using a pessary for vaginal prolapse.