Type of Surgery
Last updated: 02/17/2009
Incontinence is very common and not fully understood. Generally defined as the involuntary loss of urine, incontinence comes in many forms and has many etiologies. Four established types of incontinence, according to the Agency for Health Care Policy...
and Research, affect approximately 13 million adultsâ€”most of them older women. Actual prevalence may be higher because incontinence is widely underreported and underdiagnosed. The four types of incontinence are: stress incontinence, urge incontinence (detrusor overactivity or instability), mixed incontinence, and overflow incontinence. There are also other types of incontinence tied to specific conditions, such as neurogenic bladder in which neurological signals to the bladder are impaired.
Stress incontinence is the most frequently diagnosed form of incontinence and occurs largely with physical activity, laughter and coughing, and sneezing. The inability to hold urine can be due to weakness in the internal and external urinary sphincter or due to a weakened urethra. These two conditions, intrinsic sphincter deficiency (ISD) and urethral hypermobility or genuine stress incontinence (GSI), pertain to the inability of the "gatekeeper" sphincter muscles to stay taut and/or the urethra failing to hold urine under pressure from the abdomen. In women, as the pelvic structures relax due to age, injury, or illness, the uterus prolapses and the urethra becomes hypermobile. This allows the urethra to descend at an angle that permits loss of urine and puts pressure upon the sphincter muscles, both internal and external, allowing the mouth of the bladder to stay open.
Urge incontinence, the other frequent type of incontinence, pertains to overactivity of the sphincter in which the muscle contracts frequently, causing the need to urinate. Stress incontinence is often allied with sphincter overactivity and is often accompanied by urge incontinence.
Severe stress incontinence occurs most frequently in women younger than 60 years old. It is thought to be due to the relaxation of the supporting structures of the pelvis that results from childbirth, obesity, or lack of exercise. Some researchers believe that aging, perhaps due to estrogen deficiency, is a major cause of severe urinary incontinence in women, but no link has been found between incontinence and estrogen deficiency. Surgery for stress or mixed incontinence is primarily offered to patients who have failed, are not satisfied with, or are unable to comply with more conservative approaches. It is often performed during such other surgeries as urethra prolapse, cystocele surgery, urethral reconstruction, and hysterectomy.
The sling procedure gets its name from the tissue attached under the mid- or proximal urethra and sutured at its ends onto a solid structure like the rectus sheath, pubic bone, or pelvic side walls. The procedure is used in the severest cases of stress incontinence, particularly those that have a concomitant sphincter inadequacy (ISD). The sling supports the urethra as it receives pressure from the abdomen and helps the internal sphincter muscles to keep the urethral opening closed. The procedure is the most popular because it has the highest success rate of all surgical remedies for severe stress incontinence related to sphincter inadequacies in both men and women.
The sling procedure, or suburethral sling procedure, refers to a particular kind of surgery using ancillary material to aid in closure of the urethral sphincter function of the bladder. It is performed as a treatment of severe urinary incontinence. The sling procedure, also known as the suburethral fascial sling or the pubovaginal sling, has many forms due to advances in the types of material used for the sling. Some popular types of sling material are Teflon (polytetrafluoroethylene), Gore-TexÂ®, and rectus fascia (fibrous tissue of the rectum). The surgery can be done through the vagina or the abdomen and some clinicians perform the procedure using a laparoscopeâ€”a small instrument that allows surgery through very small incisions in the belly button and above the pubic hairline. The long-term efficacy and durability of the laparoscopic suburethral sling procedure for management of stress incontinence are undetermined. A new technique, the Tension-Free Vaginal Tape Sling Procedure (TVT), has gained popularity in recent years and early research indicates high success rates and few postoperative complications. This procedure is done under local anesthetic and offers new opportunities for treatment of stress incontinence. However, TVT has not been researched for its long-term effects. Finally, there are many surgeons who use the sling procedure for all forms of incontinence.
As a urologist, I've found it's easier to do the PSA test and then sit down with the patient and say here's what the results mean for you. Given what we know right now, that seems a very sensible approach.
-Dr. Evan Vapnek
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