Stress Urinary Incontinence 2017-09-06T16:43:46+00:00

STRESS URINARY INCONTINENCE

DEFINITION

Stress urinary incontinence is the loss of urine that occurs due to physical activities that increase abdominal (belly) pressure such as sneezing, coughing, laughing, and exercising.

CAUSE

Increase in the abdominal pressure puts pressure on the bladder, which behaves like a balloon filled with liquid. The rise in pressure on the bladder can push urine out through the urethra, especially when the supports to the urethra have weakened. (The urethra is the tube that carries urine from the bladder to the outside).

DIAGNOSIS

  • History: We ask the patients to fill certain specific questionnaires that help us understand the condition and differentiate between the different types of urine leakage.

  • Exam: Patient is asked to strain down or cough in the lying, sitting, and eventually the standing positions to confirm urine leakage.

  • Post-void residual (PVR)  test is done with a bladder ultrasound in the office to see how well the patient has emptied her bladder. This is a very quick test and is very useful to make sure that the bladder is empty.

  • Urinalysis, sometimes includes a urine culture, to rule out an infection.

  • Urinary voiding diaries are very important as they help us understand how many times leakage episodes happen over a 3-4 day period, how much fluid she is drinking and how often she uses the bathroom. This is the most helpful test from the patient’s side.
  • Urodynamic testing is a very important test that we perform in the office. This test helps us correlate the patient’s complaints with the actual type of incontinence. This is especially of relevance when the patient has multiple complaints such as leakage with stress and urgency, or if she has failed prior treatment. This is the most helpful test from the doctor’s side.

  • Cystoscopy is looking inside the bladder with a camera and a light. It is done in the office under local anesthesia.

SUBURETHRAL SLING PROCEDURE:

This is the main procedure done for SUI which involves the placement of a sling under the urethra to support.

Single incision mid-urethral sling procedure (SIMUS) This is performed through a small fingernail length incision in the vagina (1.5 cm) just under the urethral opening. The sling is then positioned under the urethra and attached to the internal pelvic muscles on each side creating a hammock to support the urethra. 

How long is the single incision sling? We are presently using the Solyx sling which is only 8 cm long and 1.1 cm wide. The sling placed under the urethra acts as a backstop and prevents the urethra from falling backward during acts of straining.

This is the technique developed by our Medical Director, Dr Khandwala. It stands for Dynamic Interactive Standing Sling Technique. The most important part of this procedure is that the sling is done with the patient completely awake. This allows us to test the sling right there in the operating room. For the DISST™, the patient is made to stand upright in the operating room with a full bladder and asked to cough to evaluate how well the sling is working. If she continues to leak, the sling is made tighter until there is no further leakage.

Every woman is different in build, weight, height, pelvic muscles, and finally how hard she coughs. Thus, the only way to truly know if the procedure works is to test it for that particular patient. The DISST™ technique allows us to tailor the procedure to each individual based upon her body frame and also her bladder volume.

In our study of 75 patients who were followed up at least one year, our success with this approach was 98.3%. In other words, 74 women were cured of the problem. The remaining one patient had some leakage but was essentially improved and did not want anything further done. We now have patients who are 2 years out from surgery and remain dry. We have now performed this technique in over 300 women and continue to see excellent results.

Our success rate is 98.3%. The other studies that have been done using the single incision sling have success rates of 60%. This low success, in fact, prompted the FDA to ask for more studies as the results were so poor. Thus, the DISST™ success rates are far superior.

1- The long slings are placed with the help of needles (trocars) that penetrate the deeper tissues of the pelvis and come out either in the groin or in the lower abdomen.

On the other hand, the DISST™ procedure involves placement of a much smaller sling that is attached to the inside pelvic muscles and does not exit the skin.

2- The DISST™ procedure is done under local anesthesia in a completely awake state whereas most of the traditional long slings have to be done with the patient asleep and under anesthesia. Thus, it is difficult to check the success of the long slings.

3- As the long slings have a deeper tissue penetration, they have the potential to cause more complications and pain. The up and down TVT sling has a far greater risk of injuring the bladder and difficulty urinating as the sling could become tight quite easily. In our DISST™ technique we have not had any injuries and almost all patients went home urinating on their own.

The sling is strongly anchored into the muscle and should not budge. It is important for you to keep the pelvic muscles strong by doing the Kegel exercises as we have instructed. Also, you should avoid putting excessive strain on your pelvic floor by avoiding activities such as prolonged coughing, chronic constipation, and significant weight gain. If you take proper precautions, the sling should continue to work. We have yet to see any loss in success from the 6 month to the 2 year mark.

Like NASCAR racing we have coined this term for the DISST™ procedure:

  • Arrive about 1 hour prior to the procedure
  • Procedure lasts about 1 hour (including the prep)
  • Discharge home 1 hour after surgery
  • Can return to sedentary (light duty) in 1 day
  • Avoid heavy lifting/intercourse for 1 month

After any sling procedure complications could happen. However, the likelihood of complications after the DISST™ procedure is very low. We have yet to have had a major complication or injury. We cannot even put a number on our complications as we have really not had any (which is a good thing!).

Almost all our patients go home urinating on their own and do not need a catheter during the procedure or after the procedure. In our study only one patient went home needing to catheterize, and this only lasted 4 days. The need for postoperative catheterization is less than 1%, with no one needing to catheterize for a prolonged period.

In our study we found that many women with mixed leakage (stress and urgency) also noticed improvement in their urgency symptoms. However, please remember that the sling is designed for leakage with coughing, laughing and sneezing i.e. stress incontinence. Therefore, if you have exclusively urge leakage then the sling is not indicated and you will need specific overactive bladder treatment such as medications.

Did You Know?

  • Most women do not seek help for leakage because
    they do not know who to go to.

  • The negative information on TV by the lawyers
    regarding the sling is totally wrong.

Imagine this scenario: Here you are lying down on the OR table with an empty bladder and leaking with coughing. Now, once the sling is in place, I have you stand up with a full bladder and you are coughing hard and there is absolutely no leakage. It is all but over!

There is so much on TV about the problems with the sling and the mesh? Is this true?

The FDA came out with an advisory stating that mesh complications are not rare. This mainly pertains to mesh that is used for prolapse and not the sling that is used for stress leakage. The lawyers have lumped everything together in order to increase the number of cases for the class action lawsuits.This is a complete attorney driven fear factor. All medical societies unanimously agree that the slings are safe and do not pose the risks exaggerated on TV. Even the FDA has stated that the risks for the sling and mesh are different.

The long slings (TVT and TOT) and Pelvic floor therapy are the other treatment options for SUI. We rarely perform any of the long sling procedures as we have had excellent results with the DISST procedure. Sometimes, pelvic floor therapy is recommended after the DISST procedure especially if the patient has a strenuous occupation.

No. I have not done a bladder suspension for the past 15 years! Bladder suspension lifts the urethra up and can cause overcorrection with a higher risk of difficulty with urination. Moreover, it has to be done by either opening the belly or doing a laparoscopy. Both of these surgical approaches are much more invasive as compared to a fingernail size incision in the vagina.