Normal Bladder Function Would Be Indicated By The Following:

• A residual urine volume (bladder volume when voiding has been completed) of less than 50 ml.
• The first desire to void occurs when there is between 150 and 200 ml of urine in the bladder.
• A bladder capacity of between 400 and 600 ml.
• No rise in bladder pressure during filling of the bladder and whilst standing. A rise in bladder pressure usually produces symptoms such as the urgent desire to urinate, the need to urinate frequently and also leakage related to urgency.
• The absence of systolic detrusor contractions (these are unprovoked spasms of the muscle of the bladder).
• No leakage of urine during actions such as coughing, sneezing, laughing, during exercise or intercourse.
• When emptying the bladder the maximum flow rate should be greater than 15 ml/s for a voided volume of at least 150 ml (when less than 150ml is emptied from the bladder, the maximum flow rate is less reliable).

Symptoms of Female Urinary Dysfunction

Symptom

'Any departure from the normal in structure, function, or sensation, experienced by the woman and indicative of disease or a health problem.'

Urinary Incontinence Symptoms

Urinary Incontinence	Involuntary loss of urine.
Stress (urinary) Incontinence	Urinary leakage associated with different types of physical exertion (coughing, laughing, walking, gym, standing up, intercourse etc).
Urgency Incontinence	Urinary leakage associated with urinary urgency.
Postural Incontinence	Involuntary loss of urine associated with change of body position, for example, rising from a seated or lying position.
Nocturnal Enuresis	Involuntary urine loss which occurs during sleep.
Mixed (urinary) Incontinence	Involuntary urine loss associated with urgency and also with physical exertion or on coughing or sneezing.
Continuous (urinary) Incontinence	Continuous involuntary loss of urine.
Insensible (urinary) Incontinence	Urinary incontinence where the woman has been unaware of how it occurred.
Coital Incontinence	Urinary incontinence during coitus (penetration &/or orgasm).

 

Bladder Storage Symptoms

Increased daytime urinary Frequency	Complaint that micturition (voiding) occurs more frequently during waking hours than previously deemed normal by the woman.
Nocturia	Interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep.
Urgency	Sudden, compelling desire to pass urine which is difficult to defer.
Overactive Bladder (OAB, urgency) Syndrome	Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or obvious pathology.

 

Sensory Symptoms

(Normally, the individual is aware of increasing sensation with bladder filling up to a strong desire to void)

Increased bladder sensation	The desire to void during bladder filling occurs earlier or is more persistent to that previously experienced.
Reduced bladder sensation	Complaint that the definite desire to void occurs later to that previously experienced despite an awareness that the bladder is filling.
Absent bladder sensation	Complaint of both the absence of the sensation of bladder filling and a definite desire to void.

 

Voiding and Postmicturition Symptoms

(Voiding symptoms: a departure from normal sensation or function, experienced by the woman during or following the act of micturition)

Hesitancy	Delay in initiating micturition.
Slow stream	Urinary stream perceived as slower compared to previous performance or in comparison with others.
Intermittency	Complaint of urine flow that stops and starts on one or more occasions during voiding.
Straining to void	The impression of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain, or improve the urinary stream.
Spraying (splitting) of urinary stream	Complaint that the urine passage is a spray or split rather than a single discrete stream.
Feeling of Incomplete bladder emptying	Bladder does not feel empty after micturition.
Need to immediately re-void	Complaint that further involuntary passage of urine is necessary soon after passing urine.
Postmicturition leakage	Further involuntary passage of urine following the completion of micturition.
Position-dependent micturition	Having to take up specific positions to be able to micturate spontaneously or to improve bladder empyting.
Dysuria	Complaint of burning or other discomfort during micturition. Discomfort may be intrinsic to the lower urinary tract or external (vulvar dysuria).

Urinary Retention

The inability to pass urine despite persistent effort.

 

Lower Urinary Tract Pain

Bladder pain	Suprapubic or retropubic pain, pressure or discomfort, related to the bladder, and usually increasing with bladder filling. It may persist or be relieved after voiding.
Urethral pain	Pain felt in the urethra and the woman indicates the urethra as the site.

 

Lower Urinary Tract Infection

Urinary tract infection (UTI)	Microbiological evidence of significant bacteriuria and pyuria usually accommpanied by symptoms such as increased bladder sensation, urgency, frequency, dysuria, urgency urinary incontinence, and/or pain in the lower urinary tract.
Recurrent UTIs	At least 3 symptomatic and medically diagnosed UTI in the previous 12 months. The previous UTIs should have resolved prior to a further UTI being diagnosed.

 

 

The International Continence Society has defined Urinary Incontinence as 'the involuntary loss of urine which is both a social and hygienic problem.'

Signs of Female Urinary Dysfunction

Sign

'Any abnormality indicative of disease or a health problem, discoverable on examination of the patient; an objective indication of disease or a health problem.'

Urinary Incontinence Signs

Urinary Incontinence	Observation of involuntary loss of urine on examination: this may be urethral or extraurethral.
Stress (urinary) Incontinence	Observations of involuntary leakage from the urethra synchronous with effort or physical exertion, or on coughing or sneezing.
Urgency (urinary) Incontinence	Observation of involuntary leakage from the urethra synchronous with the sensation of a sudden, compelling desire to void that is difficult to defer.
Extraurethral Incontinence	Observation of urine leakage through channels other than the urethral meatus; for example, a fistula.
Stress Incontinence on Prolapse reduction (occult or latent stress incontinence)	Stress incontinence only observed after reduction of the co-existent prolapse.

 

Major Causes of Urinary Incontinence

• Stress Urinary Incontinence (SUI)
• Detrusor Instability
• Detrusor hyper-reflexia
• Overflow incontinence
• Fistulae (vesicovaginal, ureterovaginal, urethrovaginal)
• Congenital (epispadias, ectopic ureter)
• Urethral diverticulum
• Temporary (UTI, faecal impaction, drugs)
• Functional (immobility)

Factors That Predispose Towards SUI

Raised Intra-Abdominal Pressure due to:

• Pregnancy
• Chronic Bronchitis
• Other causes of chronic coughing (i.e reflux, asthma)
• Abdominal/Pelvic Mass
• Ascites
• Obesity

Damage to the Pelvic Floor due to:

• Pregnancy
• Childbirth
• Pelvic Surgery
• (Menopause)
• Connective tissue disorders

Scarred (Drainpipe) Urethra due to:

• Vaginal Surgery
• Surgery for urinary incontinence
• Urethral Dilatation
• Recurrent Urethritis
• Radiotherapy

Detrusor Instability (Detrusor Overactivity/Bladder Overactivity)

Definition (International Continence Society):

'A condition in which the detrusor is shown objectively to contract either spontaneously or on provocation, during bladder filling, whilst the subject is attempting to inhibit micturition.'

Detrusor Instability:

• Is a common condition
• Occurs in up to 10% of the population
• Is the second most common cause of urinary incontinence in women
• Incidence increases with age
• Is the most common cause of incontinence in the elderly
• Is called 'detrusor hyperreflexia' if there is a demonstrable neurological disease (such as spinal cord injury, multiple sclerosis, Parkinson's disease, cerebral aneurysm etc)

Basic management of detrusor instability:

• Sensible fluid restriction (typically drinking about 1000-1500ml per day)
• Decreasing/avoiding intake of fluids with a high caffeine content or which are carbonated (such as tea, coffee and fizzy drinks which includes carbonated water)
• Decreasing/avoiding intake of foods with a high caffeine content (such as chocholate)
• Changing voiding habits
• Use of effective pads, liners and underwear

Further management of detrusor instability:

• Common therapies
  • Drug treatment
  • Pelvic floor retraining
  • Maximal electrical stimulation
  • Acupuncture
  • Behaviour therapy
    • hypnotherapy
    • bladder drill
    • biofeedback
• Complex therapies (resistant cases)
  • Sacroneuromodulation
  • Botox injections into bladder muscle
  • Augmentation cystoplasty

Clinical Assessment Of The Woman With Urinary Incontinence

The Doctor will ask questions relating to:

General:

• Neurological abnormalities.
• Congenital abnormalities.
• Previous urinary infections.
• Previous relevant surgery.
• Assessment of menstrual, sexual and bowel function.
• Obstetric history.

Specific:

• Symptoms related to storage and evacuation of the Lower Urinary Tract (LUT is composed of the bladder and urethra).

A Physical Examination will be conducted:

• General
• Urological
• Gynaecological
• Neurological:
  • Perineal sensation
  • Perineal reflexes
  • Anal sphincter tone and control

The Role of Urodynamic Investigations

Taking a medical history and performing a physical examination are not always enough to work out exactly the way in which the lower urinary tract is malfunctioning. Think about how many times you went to the toilet yesterday, can you be certain? What were you doing when the incontinence occurred and was it associated with a need to empty the bladder urgently. Did you know when the incontinence occurred or were you just aware that your pad or panty liner was damp/wet?

In addition to the difficulty that might be involved in answering these questions accurately, there is the problem that many of the symptoms overlap between the potential causes:

SYMPTOM	PROPORTION WITH SUI (n = 100)	PROPORTION WITH DI (n = 100)
Stress Incontinence	89	49
Urge Incontinence	53	39
Nocturnal Enuresis	14	13
Frequency	28	56
Difficulty Voiding	6	9
Pelvic Organ Prolapse	42	18

It is clearly difficult clinically to differentiate genuine stress incontinence (GSI, also known as stress urinary incontinence, SUI) from detrusor instability secondary to stress and this is one of the main uses of urodynamics.

Investigations of Bladder Function

Common Tests -

• Midstream specimen of urine specimen (MSSU)
  • Clean catch specimen of urine sent for lab analysis to exclude a urinary tract infection (UTI). The sample can also be sent for cytology where the urine is analysed for the presence of abnormal cells.
  • Mandatory for all patients presenting with LUT symptoms.
  • Pure growth of >100,000 organisms/ml urine.
  • When positive is not a common cause of incontinence.
  • Infection aggravates the symptoms of urinary dysfunction.
  • UTI may invalidate results of any investigation performed.

• Urinary diary (Frequency-Volume Chart) This is a chart given to the patient to complete at home over a continuous period lasting between 48 hours and 1 week.
  • Records fluid intake and urine output per 24-hour period.
  • Gives objective information on the number of voids, the distribution of voids between daytime and nighttime and each voided volume.
  • Can be used to record episodes of urgency, leakage and the number of incontinence pads used.

(*Paucity of completion by patients often makes the exercise worthless).

	Volume/Frequency/Accident Chart
			Name
	Date chart commenced
	Day 1	Day 1	Day 2	Day 2	Day 3	Day 3
Time	In	Out	In	Out	In	Out
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
Midnight
1am
2am
3am
4am
5am
Waking
Retiring
Number of
pads used
	In = Volume + type of fluid drunk (water/tea/fizzy)			Out = Volume of urine voided
*Episodes of incontinence should be documented by the use of a (W) under the column marked 'Out"

 

Urinary Diary

• Residual volume
  • This is the volume of urine remaining in the bladder after voiding has been completed.
  • The volume would normal be expected to be less than 50ml.
  • This volume can be measured simply and non-invasively using a bladder scanner which is placed over the lower abdomen (suprapubic area) or by emptying the bladder with a catheter which is more invasive and is associated with a small risk of introducing a bladder infection.
  • Retention is the symptom of retaining too much urine in the bladder; incomplete voiding or complete inability to void.

  (*voiding in unfamiliar surroundings may lead to unrepresentative results, as may voiding on command with a partially filled or overfilled bladder)

• Uroflowmetry
  • This is an assessment of the pattern of voiding, the duration of voiding and the maximum rate (ml/sec) at which urine flows our from the bladder during micturition (voiding).
  • The simplest and often the most useful investigation of voiding dysfunction.
  • Non invasive.
  • Helps to confirm bladder outlet obstruction objectively.
  • Helps identify patients who are at higher risk of obstruction following incontinence surgery.
  • Identifies patients who require more extensive urodynamic evaluation.
  • Measured uroflow is dependent upon a number of factors including:
    • detrusor (bladder muscle) contactility
    • relaxation of the urethral sphincter mechanism
    • patency (ability to open and close) of the urethra
  (The flow rate can be normal in the early stages of obstruction due to a compensatory increase in detrusor contractility resulting in a high voiding pressure.)

• Cystometry (Bladder studies/Urodynamics)
  • The bladder can be thought of as a muscular sphere. It would not be appropriate to give a capacity as this derives more from the sensitivity of the individual than morphological constraints. The wall of the bladder consists mainly of layers of smooth muscle called the detrusor.
  • In urodynamics we frequently talk of detrusor pressure which is the contribution to intravesical pressure (pressure inside the bladder) exerted by this muscle. A triangular region between the 2 ureteric orifices and the bladder neck is called the trigone, a different type of muscle but the detrusor is usually assumed to determine urodynamic characteristics.
  • Cystometry is performed to evaluate the complaince and stability of the detrusor muscle.
  • 85% of all incontinence occurs in women, and 75% of that is stress incontinence (i.e., Leakage in the absence of bladder overactivity). Cystometry allows us to understand better the parameters of an individuals bladder function. The main issue is the stability of the detrusor muscle.
  • The normal bladder should be stable under all conditions of filling or stress. The compliance of the bladder is also of interest as is its capacity and the patient's sensations of strength of desire to void.
  • Two pressure Channels are typically measured, rectal pressure and bladder (intravesical).
  • The rectal pressure responds to any changes of the abdominal cavity due to straining or stress.
  • These can then be subtracted from the intravesical to give the true intrinsic bladder pressure generaed by the detrusor muscle (the detrusor pressure).
    • Compliance refers to the elastic property of the detrusor muscles. An evaluation of compliance is an evaluation of the ability of the bladder to "stretch" to "normal" capacity while maintaining low pressures.
    • Stability is evaluated by observing the detrusor activity while filling the bladder to normal capacity. The evaluation determines the presence or absence of detrusor overactivity (or instability).
    • Vesical Pressure (pves) is the pressure that is measured inside the bladder, with a catheter that was specifically designed for pressure monitoring in the urinary tract. The pressure information obtained is a combination of the pressure being exerted on the bladder by the abdominal contents, the weight or pressure of any urine in the bladder and the force that the detrusor muscle is exerting on that fluid. The pressure in an empty bladder is usually called Resting Pressure. Resting pressure changes with position. Normal bladder resting pressures may vary between 8 and 40 cmH2O, depending upon the particular patient and position during study.
    • Abdominal Pressure (pabd) is measured by placing a special catheter either in the rectum or the vagina. Abdominal pressure information is significant because the bladder is contained in the floor of the abdominal cavity and it is important to isolate pressures and activities occurring in the bladder itself.
    • The Detrusor Pressure is a subtracted pressure that is calculated by subtracting the abdominal pressure from the intravesical pressure. A detrusor pressure channel will display a waveform tracing that represents the actual activities taking place in the bladder during the cystometogram. Artifact from abdominal straining, gas and the weight of the abdominal contents are removed from the information being processed from the catheter in the bladder. The ability to provide this calculated information is one of the many benefits of using digital urodynamic equipment.
• Videocystourethrography (complex urodynamics)
  • The bladder is filled with contrast media to allow simultaneous screening of the bladder and outflow tract during filling and voiding.
  • Situations in which VCU provides more information than subtraction cystometry:
    • During bladder filling a vesicoureteric reflux can be seen. Detrusor contractions and leakage can be noted and evaluated.
    • During voiding, vesicoureteric reflux, trabeculations and bladder and urethral diverticula can be noted.
    • The level of any outflow obstruction in the lower urinary tract can be evaluated.
    • Assessment of the degree of support to the bladder base during coughing can be made.
• Urethral Pressure Profilometry (UPP)
• Pressure information from the urethra can be obtained and utilized in several ways. The pressure in the urethra should be equal or greater than the vesical pressure, during bladder filling. When the bladder and urethra are in their proper anatomical place, any pressure increases in the abdominal cavity, from strain or any other cause, will also affect the urethra, preventing leakage. Thus for a patient to remain dry, the pressures in the urethra must remain greater than the pressure in the bladder, during filling.
• With aging, or after childbearing, the female pelvic floor can relax, causing the base of the bladder and the bladder neck to fall below the pelvic floor.
  The UPP is a pressure curve that is obtained by withdrawing the catheter at a constant rate from the urethra. These studies provide information about the transmission of increased abdominal pressure to the upper urethra, as well as the Functiona Urethral Length (length of the urethra where the urethral pressure is equal to or exceeds the vesical pressure),
• Maximum Urethral Pressure (the major pressure represented in the profile) and Maximum Urethral Closure Pressure (the maximum urethral pressure minus the simultaneously recorded vesical pressure).

• Ultrasound
  • Simple and non-invasive when a specific bladder scanner is used.
  • Trans-abdominal scanning is also uncomplicated and non-invasive. Can allow assessment of the kidneys and ureters.
  • Trans-vaginal scanning is more invasive but can produce better definition of the pelvic organs and allow assessment of prolapses and urethral mobility.
  • Can be used to:
    • Assess postmicturition (postvoid) urine residual volume.
    • Examine for urethral cysts and diverticula.
    • Assess the bladder neck (better images using transperineal approach).
    • Localize the site for periurethral collagen injections for stress incontinence treatment.
    • Look for evidence of bladder wall thickening (thought to be increased in the presence of detrusor instability).
• Radiological tests
  • IVP (intravenous pyelogram).
• Cystoscopy and urethroscopy (cystourethroscopy when combined)
  • Direct visualisation of the bladder and urethra using a telescope. This can be done with the patient awake, under sedation or under a short general anaesthetic.
  • It can be used to diagnose bladder tumours (cancerous and non-cancerous).
  • Conditions such as intersitial cystitis, non-specific cystitis, ureteroceles, bladder trabeculations and bladder divertucula.

When you have a urinary problem, your doctor may use a cystoscope to look inside your bladder and urethra. The urethra is the tube that carries urine from the bladder to the outside of the body. The cystoscope has lenses like a telescope or microscope. These lenses let the doctor focus on the inner surfaces of the urinary tract. Some cystoscopes use optical fibers (flexible glass fibers) that carry an image from the tip of the instrument to a viewing piece at the other end. The cystoscope is as thin as a pencil and has a light at the tip. Many cystoscopes have extra tubes to guide other instruments for procedures to treat urinary problems.

Cystoscopy may be recommended for a number of reasons including the following:

• Recurrent urinary tract infections
• Blood in your urine (haematuria)
• Loss of bladder control (incontinence) or overactive bladder
• Unusual cells found in urine sample
• Need for a bladder catheter
• Painful urination, chronic pelvic pain, or interstitial cystitis
• Urinary blockage such as prostate enlargement, stricture, or narrowing of the urinary tract
• Stone in the urinary tract
• Unusual growth, polyp, tumor, or cancer

Cystoscopy:

There are 2 types of cystoscopes, the standard rigid cystoscope and the flexible cystoscope. The method for insertion of the cystoscope varies, but the test is the same. The choice of which scope to use depends on the purpose of the exam and the surgeon’s preference. The procedure usually takes between 5 and 20 minutes. The urethra is cleansed and a local anesthetic is applied. The scope is then inserted through the urethra into the bladder.

• Water or saline is inserted through the cystoscope and fills the bladder.
• As the fluid fills the bladder, it stretches the bladder wall, enabling Dr Onuma to view the entire bladder wall.
• If any tissue appears abnormal, a small specimen can be taken and this is sent for histological analysis.

Cystoscoy can reveal a healthy bladder by direct visualisation. It can also reveal a range of conditions including bladder cancer, diverticulae, trabeculations, interstitial cystitis and the presence of a foreign body.

A mild infection in the urinary tract may occur after cystoscopy. Dr Onuma reduces the risk of this occurring by giving intravenous antibiotics during the procedure. Some women may feel the need to urinate frequently af-ter the procedure and may experience some burning during and after urination for a day or two. Drinking plenty of fluids will help to minimize the burning and to prevent a urinary tract infection.

Tests that are usually reserved for research:

• Pad test
  • Simple, non-invasive and objective method of:
    • quantifying the degree of urinary loss.
    • documenting urinary leakage when the results of other tests are negative.
• Magnetic resonance imaging (useful in voidying dysfunction to evaluate brain and spinal cord)
• Urethral electrical conductance
• Ambulatory monitoring (complex urodynamics)
• Electrophysiological studies

Some tests are fairly simple and others are much more complex. The test ordered for each patient should be based on each individual’s situation. Tests such as the MSSU which checks for the presence of a UTI should always be performed. Studies such as electrophysiological studies and urethral electrical conductance are not performed outside of research studies.

The Management of Urinary Incontinence

The management of urinary incontinence can be divided into non-surgical (conservative) and surgical solutions. The two methods of management are not mutually exclusive and it may be appropriate to treat some women with one or the other or both.

Non-Surgical Management of Urinary Incontinence

• Absorbent devices
  • There are a plethora of available pads, nappies and other devices to soak up the urine. These are probably not the best option for the majority of women and are very expensive; however they are used by a significant number of women for a considerable time before they seek help for their incontinence.
• Urinary catchment devices
  • Now only of historical interest for females (but useful in males)
• Permanent catheters.
  • These risk infection, but can be useful.
• Intravaginal pressure devices
  • e.g. Contiform. Expensive due to frequent replacement, and not universally effective.
  • Other pessaries that can also be used to control prolapse. Rings, Gelhorn etc.
• Fluid restriction
  • Not recommended but is practiced by many women in order to try to reduce their urinary frequency. Unfortunately, fluid restriction results in a concentrated urine in the bladder which is more irritative and gradually decreases the bladder capacity because it is never allowed to fill.
• Regular toileting.
  • Useful in Nursing Home scenario.
• Reduction of bladder stimulants
  • e.g. coffee, tea, coke, pure fruit juices etc.
• Increase water intake
• Check Oestrogen status
• Check for medication that could be causing urgency or incontinence e.g.Surgam and some newer anti-psychotropic drugs
• Pelvic Floor Muscle Training (PFMT)
  • PFMT is better than no treatment for stress incontinence, mixed incontinence and urge incontinence with a 65-75% cure / improvement rate
  • Factors influencing outcome
    • 'the knack' and functional training
    • Individual assessment
    • 50% unable to contract correctly with brief verbal instruction
  • An individual program with a specific strength training regimen is required
  • Assessment of correct technique, tone, strength and endurance with employment of deep abdominal muscle co-activation
  • Daily exercise - 2-3 sets of 6-8 contractions
  • Bladder training
  • Constipation management / defaecation strategies
  • Weight loss / lifting technique / fitness
  • Adherence strategies
  • Outcome measures:
    • bladder diary, stress test
  • Adjunctive therapies
    • Biofeedback
    • Electrical Stimulation
    • Vaginal Cones
      
• Anticholinergic Drugs for Bladder Instability
  • Antidepressants- Tricyclics only, as SSRI can cause incontinence.
  • Donnatabs, Atrobel
  • Probanthine
  • Sudafed
  • Ditropan
  • Newer generation drugs with fewer side-effects such as Vesicare, Detrusitol, Enablex and newer formulations of Ditropan (slow release)
  • Side Effects
    • Dry mouth (this is the most common complaint)
    • Blurred vision
    • Bloating
    • Constipation
    • Mental fuzziness
    • Fluid retention
    • Heartburn and oesophagitis

Surgical Management of Urge Incontinence

• Electrical stimulation of sacral nerves:
  • Reserved for end stage or severe urge incontinence (also urinary frequency, voiding dysfunction, faecal incontinence and chronic pain). The Interstim device, produced by Medtronic is implanted after appropriate testing so that it provides continuous stimulation of the sacral nerves.
  • The device is expensive and within Australia is not currently covered by Medicare and not all private health insurance funds.

Images reprinted with the permission of Medtronic, Inc. 2004

• Botox:
  • Experimental, but showing promise for extreme cases, and should work but will require serial injections.

Surgical Management of Stress Urinary Incontinence

There are over 150 operations described for the treatment of stress incontinence! Many have not stood the test of time and it goes without saying that the perfect operation that is suitable for all women with a zero complication rate and 100% cure rate has not yet been invented.

There are some operations still used that have been shown to be ineffective in the long term successful treatment of this disorder. An example of this is the anterior vaginal repair. This is no longer regarded as a useful procedure for stress incontinence, even with suggested modifications with success rates at 1 year of about 65% (but less than 25% at 5 years). In the past it may have been a useful for procedure debilitated patients, but the TVT sling procedure is now considered to be much better and is also minimally invasive.

{*The anterior vaginal repair remains a suitable procedure for correction of an anterior vaginal wall prolapse}.

Burch Colposuspension

• • Effective long term, and can be performed as a minimally invasive procedure (when done laparoscopically).
  • For a long time this was considered to be the gold standard for first line operation for stress incontinence {more recently this title belongs to the retropubic TVT sling procedure}
  • Long term success 87%

Open operation complications:	Laparoscopic surgery complications:
Bladder perforation 3-4%	Bladder perforation 3-4%
De Novo urgency 15%	De Novo urgency 10%
Long term retention 1-2%	Long term retention 1-2%

 

• Sub-Urethral Slings
  • Mersilene tape, or fascia from abdominal wall
  • Various retropubic slings using bone anchors.
  • Excellent results short and long term, BUT there is a high complication rate: Infected or rejected implant up to 20%, requiring difficult surgery for removal.
    • De novo urgency up to 15%
    • Long term retention up to 15%
    • Thus often used as the operation of last resort (because of the complication rate)

• Tensionless Vaginal Tape Slings (TVT slings)
  
  • This is a sub-urethral sling procedure that has several differences from previous operations.
  • These differences have resulted in a much lower complication rate, but equal effectiveness as other sub-urethral sling procedures.
  • The tape is open weave rather than close woven, allowing incorporation of tape into tissues rather than fibrosis around tape. This has resulted in a much reduced rejection and erosion rate.
  • The tape is flexible in all directions and not rigid.
  • The tape is not sutured in position, but held by surrounding tissues.
  • Rejection and infection are extremely rare.
  • Postoperative urinary retention that lasts more than a few days can be simply treated by simply cutting or loosening the tape.
  • The de novo urgency <10%.
  • This minimally invasive procedure to insert a sub-urethral Prolene tape sling can be performed under local or regional anaesthesia (or general) with a short operating time, short hospitalization time, rapid recovery (although patients must avoid heavy effort for 6 weeks).
  • Cure rate > 89% after 1 year (maintained to 7 years so far ).
  • Suitable for all ages
  • Especially good for patients with:
    • Short urethra
    • Low urethral closing pressures
    • Hypermobile urethra
    • Intrinsic sphincter deficiency (70% cure rate, vs Burch 45%)
  • Some evidence it may also help with urinary urgency

Images reprinted with the permission of Johnson & Johnson

The transobturator approach to the TVT placement has been more recently developed with a view to reducing the risk of injury to the bladder, bowels and blood vessels during placement. Evidence is currently being gathered to see if it is efficacious as the retropubic approach. Current indications are that this newer technique will prove to be even safer, quicker to perform and as effective.

Image courtesy of American Medical Systems

DAY CASE SURGERY

The TVT procedures can be performed as day case procedures in well motivated women who opt to have local anaesthesia combined with sedation for their surgery instead of regional anaesthesia (spinal anaesthetic) or a general anaesthetic. When done in this fashion women do not remember undergoing the operation but have the benefit of limited anaesthesia, rapid recovery and a short hospital stay.

• What is Tension-free Support?
  • TVT Tension-free Support is an innovative, minimally-invasive and simple surgical device alternative for the effective treatment of female stress urinary incontinence. Clinical studies have demonstrated that 85 percent of patients were dry after treatment and an additional 11 percent reported a significant improvement.
    
  • How does the treatment alleviate stress urinary incontinence?
    • Female stress urinary incontinence is caused predominantly by an improperly functioning urethra; it is not a problem of the bladder. Normally, the urethra - when properly supported by strong pelvic floor muscles and healthy connective tissue - maintains a tight seal to prevent involuntary urine loss. When a woman suffers from stress urinary incontinence, however, weakened muscle and pelvic tissue don't support the urethra adequately. As a result, the urethra doesn't maintain a tight seal during exercise or other movement and urine escapes.
      
  • TVT Tension-free Support combines the use of safe material, PROLENE polypropylene mesh, and a variation of a traditional operation known as a sling procedure to correct stress urinary incontinence. The PROLENE mesh is inserted through the vagina and positioned underneath the urethra, creating a supportive sling. During movement or exercise, the mesh supports the urethra, allowing it to maintain its seal to prevent urine loss. The tape, therefore, uniquely provides support only when needed, without any unnecessary tension on the urethra (tensions-free).
    
• What are the key benefits of TVT Tension-free Support?
  • Simple procedure. A procedure using TVT Tension-free Support can be completed within 30 minutes under local anesthesia and patients may return home the same day. TVT Tension-free Support offers short recovery time with minimal pain. Most patients will not require catheterization after surgery.
  • In contrast, many surgical treatments currently in use for treating SUI involve general anesthesia, extensive surgery and a lengthy recuperation.
  • As the tape passes through several pelvic tissue layers, friction is created, which secures the tape in place. Over time, the natural in-growth of tissue into the mesh further secures the tape.
  • The procedure can be performed under local anesthesia with IV sedation. In addition to the avoidance of general anesthesia, this also allows the surgeon to make any necessary adjustments to the mesh tape intra-operatively utilizing a cough test, which improves placement of the sling and the success rate.
  • The mesh tape loosely supports the middle of the urethra and therefore, uniquely provides support only when needed without tension. This reduces the need for catheterization.
    
• Are there risks associated with a procedure using TVT Tension-free Support?
  • All surgical procedures present risks. Although rare, complications associated with the system include injury to blood vessels of the pelvic sidewall and abdominal wall, difficulty urinating and bladder and bowel injury.
    
• Is the TVT Tension-free system appropriate for pregnant women or women who want to become pregnant?
  • As with any surgery of this kind, this procedure should not be performed in pregnant patients. Additionally, because the mesh-like tape will not stretch significantly, TVT Tension-free Support should be used with caution in women who plan future pregnancy.