by Diane K. Newman, DNP, FAAN, BCB-PMD
Standard treatment for urinary incontinence has been surgery, particularly in woman with stress incontinence. Surgery works by elevating the bladder neck and restoring the urethro-vesicular angle (angle between the bladder neck and urethra). There are over 100 surgical procedures that are used to correct stress incontinence.
Types of surgery for urinary incontinence
The first true urinary incontinence procedure was the Marshall-Marchetti-Krantz anterior urethral suspension first performed in the 1940's and its subsequent modifications (Burch Colposuspension, etc.) This procedure involves an incision in the lower abdomen and behind the bladder to suspend the urethra and bladder neck to the pelvic bone.
In the properly selected person the procedure did result in a modest number of cures. The problems with the operation were the lack of knowledge regarding the various subtypes of incontinence and subsequent application to all persons.
Then in the 1980's, Dr. Thomas Stamey popularized the Stamey Urethropexy. This procedure is a modification of the original Pereyra procedure. The operation is through the wall of the vagina to suspend the urethra. It has undergone a number of changes and is still very popular. The advantage of this operation is a shorter hospital stay and less postoperative problems.
Success rates for urinary incontinence surgery
The success rate for surgery is not as high for elderly persons as in younger persons and these procedures are not without complications. There is no long term information to evaluate these procedures past the five year mark and it is well known that with time the failure rate increases. Estimates for long-term success rates vary but are reported between 75 to 90 percent for five years.
Surgery for recurrent urinary incontinence is difficult and carries a very high failure rate. There may also be late complications from surgery including bladder instability with urge incontinence, urinary tract infections, and erosion of the sutures used. As with medication therapy, surgery appears to be effective for a small, highly selected group of women for a short period of time.
Artificial urinary sphincter surgery for urinary incontinence
An artificial sphincter is an implantable device made of silicone rubber. The sphincter surrounds the bladder neck and compresses the urethra. It is activated by pressing a valve placed in soft tissues near the urethra. It is effective for a highly selected group of men with post-prostatectomy urinary incontinene. An artificial urinary sphincter may be appropriate for clients with incontinence associated with spina bifida, myelomeningocele, spinal cord injury, pelvic trauma, postradical prostatectomy incontinence, and in female stress incontinence which has not been helped by other treatment modalities. An inflate/deflate mechanism is placed in the male's scrotum or female's labia and the pressurized balloon is placed in the pelvic/bladder space. As the bladder fills with urine, the cuff is pressurized with fluid around the bladder neck or urethra to prevent leakage. When the client squeezes the deflate bulb, fluid moves from the cuff into the pressurized balloon which allows voiding. The cuff then repressurizes, automatically restoring compression of the urethra or bladder neck. Success rates range from 60 to 90% but replacement of the sphincter is usually required within 6 to 8 years. Candidates for the artificial sphincter should be referred to a urologist who is experienced in this type of surgery.
Peri-urethral injections (Contigen) for urinary incontinence
Collagen is a sterile, nonpyrogenic bovine dermal collagen. Collagen is injected through a needle in the tissues of the urethra. This creates bulking of the urethra and coaptation in the urethra to increase resistance and decrease incontinence. It is used in persons with urinary incontinence caused by intrinsic urethral deficiency and careful selection is recommended.
Prior to the use of collagen, a skin test of the more immunogenic non-crosslinked variety is placed intradermally to rule out the rare client who may have an allergic reaction. The major disadvantage is the potential for multiple treatments because it is difficult to know how much to inject and the very high cost of the collagen itself.
References
Newman, DK. Managing and Treating Urinary Incontinence. Health Professions Pr. 2002.
October 2003
