Laser Vaginal Rejuvenation Institute of Adelaide

Female Urinary Dysfunction

Normal Bladder Function Would Be Indicated By The Following:

• A residual urine volume (bladder volume when micturition has been completed) of <50 ml.
• If the first desire to void occurred at between 150 and 200 ml.
• A bladder capacity of between 400 and 600 ml.
• No detrusor pressure rise during filling of the bladder and whilst standing.
• The absence of systolic detrusor contractions.
• No leakage of urine during coughing.
• A voiding detrusor pressure rise of <70 cmH2O with a peak-flow rate of >15 ml/s for a volume of 150 ml.

 

Types of Female Urinary Dysfunction

 

Stress Incontinence	Urinary leakage associated with different types of physical exertion (coughing, laughing, walking, gym, standing up, intercourse etc).
Urgency	The sensation of an immediate desire to void associated with the fear of leakage of urine.
Urgency Incontinence	Urinary leakage associated with urinary urgency.
Frequency	Voiding more than 8 times during the day.
Nocturia	Voiding more than 1or 2 times (depending on age) at night.
Hesitancy	Being unable to start voiding without delay.
Postmicturition Dribbling	Leakage of small volumes or urine immediately after the apparent end of voiding or during getting up off the seat.
Poor Flow	A slow urine flow rate (less than 15ml/sec) identified by many women who find that their friends seem to spend much less time emptying their bladders.
Interrupted Flow	Describes a 'stop-start' pattern of voiding which is sometimes associated with dribbling towards the end and the learned technique of straining in order to ensure that the bladder does empty.
Overflow Incontinence	Urinary incontinence associated with an overfull bladder and typically is one in which there is a constant leakage of urine.
Urinary Retention	Inability to empty the bladder resulting in the bladder filling up with urine.
Recurrent Urinary Tract Infection's	Greater that 4 urinary tract infections in any 12 months.
Haematuria (Frank or Microscopic)	The presence of blood in the urine which can be seen with the naked eye (Frank or macroscopic) or under a microscope (microscopic).

 

 

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

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
• Abdominal/Pelvic Mass
• Ascites
• (Obesity)

Damage to the Pelvic Floor due to:

• Childbirth
• Radical Pelvic Surgery
• (Menopause)

Scarred (Drainpipe) Urethra due to:

• Vaginal Surgery
• Surgery for SUI
• Urethral Dilatation
• Recurrent Urethritis
• Radiotherapy

Detrusor Instability (detrusor overactivity/bladder overactivity)

• Urodynamic assessment (bladder studies) is required to make the diagnosis.
• The pathophysiology (abnormality) is poorly understood.
• The underlying cause is rarely found.
• Women usually present with multiple symptoms:
  • Urgency
  • Urge incontinence
  • Frequency
  • Nocturia

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.

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
• Gynecological
• 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 >105 organisms/ml urine.
  • 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.
  • Confirm bladder outlet obstruction objectively.
  • Help identify patients who are at higher risk of obstruction following incontinence surgery.
  • Identify patients who require more extensive urodynamic evaluation.
  • Measured uroflow is dependent upon a number of factors including:
    • detrusor contactility
    • relaxation of the sphincter mechanism
    • patency 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/rodynamics)
  • 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 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 from the detrusor muscle (the detrusor pressure).
    • Compliance is simply 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 vesical 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 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.
• 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
  • Can be use to:
    • Assess postmicturition residual volume.
    • Examination for urethral cysts and diverticula.
    • Assessment the bladder neck (better images using transperineal approach).
    • Localize the site of periurethral collagen injections for stress incontinence.
    • Look for evidence of bladder wall thickening (? Related to incidence of detrusor instability).
• Radiological tests
• Cystoscopy and urethroscopy (cystourethroscopy)

 

When you have a urinary problem, your doctor may use a cystoscope to see 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.

 

Normal bladder urothelium. Both ureteric orifices (where ureters enter the bladder) are seen

Cystoscopy can pick up benign (non-cancerous conditions) such as an increase in trabeculations suggestive of bladder overactivity.

Significant bladder trabeculations

More significant lesions such as a transitional cell carcinoma of the bladder can also be visualized and treated via cystoscopy.

Transitional cell carcinoma of the bladder

 

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 after 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 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
  • Detrusitol and other newer generation drugs with fewer side-effects are not freely available in Australia (Detrusitol became available in Australia in April 2005 but is not on the PDS)
  • Side Effects
    • Dry mouth
    • 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.

   

The Interstim device (hand held controller and implanted stimulator)	Device implanted and stimulating sacral nerve	Pre-implantation testing with stimulation of sacral nerves

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 Sling (TVT sling)
  
  • 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

This is a truly minimal access procedure

The tape is sited behind the pubic pone

The relationship between the sited tape and the pelvic organs Images courtesy 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.

 

The tape is seen to pass below the midurethra and through the obturator membrane (not retropubically)

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 not be used in women who plan future pregnancy.