Incontinence is defined as the uncontrolled loss of urine which causes a social or hygienic problem. The most common forms of incontinence are stress incontinence and urge incontinence.
Stress incontinence is a loss of urine associated with stress events like coughing, laughing, sneezing, lifting heavy things, and exercise. Stress incontinence is the most common form of incontinence in women under the age of 50. In fact approximately 1 in 4 college women athletes has incontinence episodes while performing her sport.
Stress incontinence is typically due to an anatomical problem with the urethra. Specifically there is a loss of support to the urethra. This support is necessary to increase the resistance of the flow of urine through the urethra to prevent the loss of urine with stress events.
Occasionally stress incontinence is due to a weakening of the muscle of the urethra and is also called intrinsic sphincter deficiency (ISD).
Stress Incontinence Treatment
Stress incontinence is treated with physical therapy, medication or surgery.
Physical therapy such as Kegel exercises, biofeedback, and electrical stimulation may be used with some success. Kegel exercises are best described as the contraction (or squeezing) of the pelvic floor muscle required to stop the flow of urine mid-stream. If you can do this, performing the exercise for 10 repetitions 3 to 4 times per day will help strengthen the pelvic floor. As many as 20% to 30% of women will have improvement of her symptoms with these exercises. Sometimes additional physical therapy is required, which would include Kegel exercises with biofeedback or electrical stimulation. In these situations a physical therapist helps train the pelvic floor to function normally.
Medical therapy for stress incontinence is limited. There are several medications which are used in an off label manner that is not recommended by the food and drug administration to treat stress incontinence. Some of these medications have been approved for treatment of stress incontinence in other countries. The best of these medications helps as many as 30% of women with stress incontinence. However, these medications must be taken for a lifetime and may have significant side effects which are undesirable.
Typically the management for stress incontinence involves surgery. This has become more prevalent as the surgery has become less invasive. The surgical procedure involves placement of a supportive sling made of polypropylene under the mid-urethra. This may be done with as little as one incision or as many as 3, all under 1 cm (one third inch) in length. Cure rates are reported to be approximately 85% and have been noted in numerous studies to be sustained. The surgeries are usually outpatient and require little down time from work.
Pelvic prolapse is a disorder affecting almost every woman over the age of 60. While this problem affects most women, most do not require surgery for treatment. At this time, approximately two to three out of 10 will have surgery for pelvic organ prolapse in their lifetime. Pelvic prolapse is a different name to describe hernias of organs through the vaginal tissue. These hernias can occur in three places:
- Cystocele (Bladder): At the front side of the vagina, the bladder may herniate into the vagina. This is also known as a cystocele. Symptoms of a cystocele include but are not limited to: pressure in the vagina, pain with intercourse, difficulty with urination, recurrent bladder infections, the need to splint (provide support with your fingers) in order to urinate, the need to urinate and then to go again in 10 to 15 minutes in order to empty completely. As this is an anatomical problem, it is usually corrected by repairing the anatomy. This may be done with “pessaries”, nonsurgical devices which lift the vagina back in position, but the anatomical repair is most commonly performed surgically.
- Enterocele/Uterine Procidentia (Uterus or top of the vagina): At the top of the vagina (the deepest point) the uterus and/or (in cases of hysterectomy) the small intestine may herniate into the vagina. This is also known as a uterine procidentia, when the uterus herniates or an enterocele when the small intestine herniates. Symptoms of an enterocele include but are not limited to: Pressure in the vagina, pain with intercourse, frequent urination, difficulty with constipation, and vaginal dryness.
- Rectocele (Rectum): On the back side of the vagina, the rectum herniates into the vagina. This is also known as a rectocele. Symptoms of a rectocele include but are not limited to: Pressure in the vagina, pain with intercourse, difficulty with evacuation of stool, constipation, the need to splint (provide support with your fingers) in order to defecate, the need to have a bowel movement and then an additional bowel movement 10 to 15 minutes later, and rectal incontinence. As this is an anatomical problem, it is usually corrected by repairing the anatomy. This may be done with pessaries, nonsurgical devices which lift the vagina back in position, though the procedure is most commonly performed surgically.
Surgical correction of vaginal prolapse does not require a hysterectomy although one may be performed in conjunction with prolapse surgery. Surgical options range from traditional abdominal procedures, to laparoscopic procedures, single incision laparoscopic procedures, robot (DaVinci®) assisted laparoscopic procedures, to vaginal approaches. Typically the surgeries are performed using the native tissue of the patient in order to restore normal support.
At times, particularly if there has been recurrence, it may be necessary to use mesh to augment the repair. Mesh is made of polypropylene, an inert material with excellent strength. Like rebar adds strength to concrete, this mesh adds strength to your tissue. In fact, for abdominal wall hernias, mesh is used almost all the time. However, the vagina is a thinner walled organ than the abdominal wall and is more prone to complications with mesh.
The complications associated with mesh can occur in as many as 15 to 20% of patients. These complications may include but are not limited to: vaginal mesh erosion or extrusion, pain with intercourse, erosion into another viscus structure (i.e. bladder, bowels), infection, abscess and pain. The most common forms of complications such as erosion into the vagina or pain with intercourse are often dealt with in the office with medication and time. Major complications will require additional surgery and/or a significantly more complicated course.