Urinary incontinence (UI) is a common and embarrassing problem being far more widespread than most think; it remains underreported by the public. Urinary incontinence can lead to social isolation, depression and infections and has a significant negative impact on patients and society. Many people think it is inevitable and do not seek advice and treatment.
There are two main types of urinary incontinence and obtaining true prevalence figures can be difficult.
- Stress urinary incontinence is the involuntary loss of urine on effort or exertion (ie when coughing or sneezing).
- Urge urinary incontinence, as the name suggests, is the involuntary loss of urine, immediately preceded by a strong desire to pass urine.
- Mixed incontinence is where the individual suffers from both types, although often one symptom predominates.
Around one in four women suffer from incontinence and this figure rises with age. In women, stress urinary incontinence accounts for 50%, approximately 35% have mixed symptoms and the rest have urge urinary incontinence. The prevalence of urge urinary incontinence appears to be the same in men, and this prevalence also becomes worse with age (reaching up to 40% of men and women). The condition is also dynamic and variable over time.
The department of Urology at Addenbrookes Hospital is able to assess and treat patients with urinary incontinence. The majority of patients referred with incontinence will undergo a number of investigations which often include examination of the urinary tract under vision and bladder pressure tests (see Urodynamics and Videourodynamics). Non-surgical measures are available for the treatment of urinary incontinence:
- Male Lower Urinary Tract Symptoms: Lifestyle Advice, Bladder Training and Pelvic Floor Exercises
- Pelvic floor exercises in women: frequently-asked questions
- Bladder training: frequently-asked questions
The below describes surgical treatments for these conditions.
Stress urinary incontinence treatment in women:
Intra-urethral bulking agents:
These agents act by increasing the co-aptation/closure of the mucosal layer of the urethra and thus increase the outlet resistance, making the patient less likely to leak. There are a number of agents in routine use including collagen and hydogels. The submucosa is injected under cystoscopic control. Although the procedure is simple, there is good evidence to show that the results are short-lived and in modern practice, this procedure is restricted to patients with mild stress incontinence or those who are unfit or elderly.
Mid-urethral Slings in women:
These synthetic slings are placed, tension-free, under the urethra and stabilize it. They have become wildly popular in the last 10 years or so because of the ease of insertion and quicker convalescence compared to the traditional colposuspension and the excellent success rates obtained.
Although mid-urethral slings offer an average success rate of 85%, there are potential complications of which the patient needs to be aware of. Commonly used synthetic slings are the TVT (Tension-free vaginal tape) and the TOT (trans-obturator tape). Occasionally we use a sling using tissue from the patients body, this is called a puvaginal fascial sling.
Still considered the gold standard for stress incontinence surgery because of the impressive long-term data, the Burch colposuspension elevates the bladder neck and causes closure of the urethra with rises in intra-abdominal pressure. The 20-year data show a success rate of 78%. The advantages, apart from the obvious longevity of response, is that no synthetic material is used. The recovery time is, however, significantly longer compared with slings.
Stress urinary incontinence treatment in men:
Advance male sling:
Male slings work by compressing the bulbar urethra. The sling is superficial and inserted via a perineal incision (the area between the scrotum and anus) and tensioned during the operation. The exact patient population which is suitable for the sling is yet to be accurately defined. There are no long-term data for slings and it is not known whether the success is maintained in the long term. Success rates are around 70-90% in the short-medium term. The problem with potential infection, retention and erosion and pain are similar to the female sling.
Artificial Urinary Sphincter (AUS):
The AUS is the gold standard for the treatment of male stress incontinence and has been shown to maintain good results in the long-term. It is suitable for moderate to severe stress incontinence in men. It is a device consisting of a cuff, which sits around the urethra providing compression and thus continence, a reservoir and a pump. A simple hydraulic system allows the patient to press the pump and transfer the fluid from the cuff to the reservoir allowing the user to void. It is also successful when used in women, however they tend to get more complications and so most surgeons avoid the AUS in the female with stress incontinence. The success rate in the post-prostatectomy population is around 90%. Most complications occur due to infection, erosion into the urethra, urethral atrophy and mechanical failure of the device.
In conclusion, there are a myriad of surgical solutions for stress incontinence in both men and women. It is critical that patients are counseled about the advantages and disadvantages of all the alternative procedures which are appropriate for them and that a skilled surgeon performs the procedure. This maximizes the success for the patient.
Urge urinary incontinence treatment in men and women:
The main surgical options for treatment of urge related incontinence include:
- Intradetrusor botulinum toxin injection (BoNT)
- Sacral nerve stimulation
- Clam Cystoplasty
- Ileal Conduit
Intradetrusor botulinum toxin injection
This treatment, performed under a local anaesthetic with a flexible cystoscopy, works very well for patients with neuropathic overactive bladder (eg multiple sclerosis patients who are catheter-dependent who leak with bladder spasms) and also for those with unknown (idiopathic) causes for their overactive bladder It’s efficacy is in the region of 70% but problems include urinary retention (around 15% will need to have a urinary catheter or perform clean intermittent self catheterisation) and the need for repeat injections (on average every nine months). To date, no significant problems have been encountered after multiple repeat injections. There has also been no reported loss in efficacy and no ultrastructural changes in the bladder with repeated injections.
Sacral nerve stimulation (SNS) is a continuous use of mild electrical impulses delivered through an implanted device mainly to S3 nerve root in the sacrum. The exact mechanism of action is not known but is thought to modulate the local neuronal reflexes and inhibit bladder contractions. (SNS) is delivered through an implanted device in the lower back with the lead positioned near S3 nerve root.
This is a minimally invasive procedure and can be performed under local or general anaesthesia. It is generally performed as a 2-stage procedure.
The first stage is known as percutaneous nerve evaluation. It is required to assess whether neuromodulation will be effective for a given patient. The surgeon uses a small needle to place a thin wire in contact with S3 nerve root. The other end of the wire is taped to the back and connected to a temporary stimulator control unit, which is worn on the belt. This is worn for one to three weeks to assess the response. The response rate is between 60-80%. If the treatment is effective, then the permanent implant is inserted.
The permanent device is implanted in the lower back/buttock area so it cannot be felt. A handheld wireless patient programmer is used to adjust levels of stimulation as prescribed by the surgeon. The stimulation parameters can be adjusted as needed and the programmer can be switched on and off. The battery has an average life of 7 years and requires replacing after this time.
This is a major undertaking and should only be done for intractable urgency related incontinence where this is having a major impact on the patient’s quality of life. The principle is to bivalve the bladder and patch the defect with a piece of bowel, often a segment of ileum. This leads to an increase in bladder capacity and decrease in bladder contractions. This is the most definitive procedure to control urgency related incontinence but comes at the highest price. The complications include need for self catheterization (30%), mucus production, stone formation, bacteriuria & urinary tract infections, biochemical abnormalities and long term risk of cancer. Hence, these patients require life long follow up with regular blood tests and yearly cystoscopies from 10 years post operatively.
Ileal conduit urinary diversion
This is the most drastic option for control of intractable urgency incontinence. It is a type of non-continent urinary diversion. To create an ileal conduit, the ureters are divided from the bladder and a uretero-ileal anastomosis performed with a 10 cm isolated piece of ileum. The other end of the ileum is brought out through a stoma generally in the right iliac fossa. The stoma bag is on continuous drainage and must be periodically emptied of urine, and about once a week, it must be replaced.
Incontinence is a common problem that is often ignored by patients. There are many simple, successful conservative measures available which can be successfully supplemented by appropriate specialist surgery.
Useful link: Bladder and Bowel Foundation