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Surgery for urinary incontinence

Urinary incontinence is involuntary leakage of urine from the bladder.

There are many causes for urinary incontinence in women including :

  • Overactive bladder: This refers to the bladder contracting and pushing the urine out before it becomes full . This may be due to inflammed bladder as in bladder infection which can be treated with antibiotics or due to a bladder non-bacterial inflammatory process called  interstitial cystitis which can be treated with a combination of medications. In older women ,overactive bladder could improve with local hormonal treatment.  On many occasions, no specfic cause is found and the condition is treated with medications that help the bladder relax.
  • Stress incontinence: This refers to involuntary leakage of urine when pressure inside the abdomen is increased such as while coughing or sneezing or lifting heavy objects. This is usually due to a mobile urethra due to its detachment from its natural attachments in the pelvis. In severe cases , the urethra is not only mobile but its muscles are also weak ( Intrinsic sphinctor defeciency) . Weak urethral muscles could be due to advanced age or due to previous surgery or difficult vaginal delivery.  Mild cases can be improved by pelvic muscles exercises while more severe cases will need surgical intervention . The surgical options include 2 common procedures:

1- Tension free vaginal tape (TVT) . This involves placing a tape under the urethra to provide support to muscles and reduce urethral mobility. This is accomplished through a 1 inch incision under the urethra in the vaginal wall and 2 other small incisions either on the inner thighs or in abdomen just above pubic bone (suprapubic). This procedure is a same day procedure . It does not require laparoscopy and works well for incontinence due to hypermobility alone or due to hypermobility and weakness of urethral muscles (Intrinsic sphincter defeciency). When intrinsic sphincter deficiency is present , the tape should be placed -preferably-utilizing the suprapubic approach .

2- laparoscopic Burch procedure. This procedure works very well for incontinence due to hypermobile urethra but it is not as good when there is weak urethral muscles ( intrinsic sphincter deficiency). It is a procedure where sutures are placed on the sides of the urethra on one end and to a pelvic ligament on the otherend to limit hypermobility of the urethra.

It is usually used when other laparoscopic pelvic procedures are performed at the same time such as laparoscopic uterine suspension.

The following video is a laparoscopic Burch procedure.

3- Urethral bulking: When urethral muscles are weak but with out hypermobility of the urethra, a situation that may arise from old age or previous multiple surgical interventions , injecting a bulking material into the proximal part of urethra at its junction with bladder helps control the symptoms for about a year or so after which re-injection may be necessary.

The substance injected could be patient’s own body fat or other substances not very different from ones used in plastic surgery to augment lips and cheek albight last for longer periods of time.

A repeat injection may be needed once a year.

The following is a video of urethral bulking using Bulkamid- a synthetic bulking agent

4- Vesicovaginal fistula: An abnormal opening between the bladder and vagina causing continuous leakage of urine from the vagina. This is usually due to pelvic surgery , radiation or a complicated child birth.

Treatment is by repairing (closing) the fistula . This can be performed vaginally for a low fistula or laparoscopically for a high fistula. This surgery is not common since vesicovaginal fistula is not a common condition.
In the following video , you can see part of the urinary catheter showing through a vesicovaginal fistula. Tissue from inside the right labia majora (Bulbocavernosus flap)is being prepared to be placed between the bladder and the vagina at the site of fistula to help prevent recurrence.