Treatments for Stress Incontinence
Treatment for incontinence depends not only on the type of incontinence a person has but also the gender of the patient. Certain treatment options are optimal for men while others are better suited for females. Below are the various treatment options for both men and women.
What are the treatment options for stress incontinence in women?
In most cases of incontinence, conservative or minimally-invasive management is the first line of treatment. This may include fluid management, bladder training or pelvic floor exercises. However, when the symptoms are more severe, when conservative measures are not helpful or are unsatisfactory the next best treatment option is surgery.
Mild to moderate stress incontinence in the female is initially treated with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.
Pelvic Floor Muscle Training
Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.
One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to assist the closing of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Bulking material is injected into the urethral sub mucosal layer under direct vision. Unfortunately, the cure rate with this treatment is only 10 to 30 percent despite multiple formulations on the market for use. This treatment can be repeated and sometimes acceptable results are seen after multiple injections. The operation is minimally invasive but the cure rates are lower compared to the other surgical procedures.
Sub Urethral Sling Procedures
The most common and most popular surgery for stress incontinence is the sling procedure. Today, most of these procedures are being called by the names TVT or TOT. In this operation, a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better and more sustainable outcomes. However, synthetic meshes have been found to have the ease of use with no need for harvest as well as superior long term results.
Another option is abdominal surgery in which the vaginal tissues or periurethral tissues are affixed to the pubic bone. The long-term results are positive, but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. This procedure can also be performed laparoscopically, however long-term results are typically not as good as with the open procedure.
Bladder Neck Needle Suspension
A long needle is used in these procedures to thread sutures from the vagina to the abdominal wall. The suture incorporates paraurethral tissue at the level of the bladder neck. These procedures were found to be less effective than open retropubic suspensions and slings and as a result are rarely done today.
Anterior Vaginal Repair
Sutures are placed in the periurethral tissue and fascia in order to elevate and support the bladder neck. This procedure has also fallen out of favor for inferior long-term outcomes compared to open retropubic suspensions and slings.
What are the side effects associated with the corrective surgeries for stress incontinence?
The potential adverse outcomes of surgical treatment include bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, pelvic organ prolapse, and failure of surgery to fix leakage. With the use of mesh materials there is a very small risk of erosion of the material into the bladder, urethra or vagina.
What additional treatment options are available for stress incontinence in men?
Men should also initially be managed with behavioral modifications and pelvic floor exercises. Periurethral injections can be used in men as well. If these measures fail, surgical options are available, which are different from those performed in women.
In male patients with stress incontinence, an alternative is to perform a urethral compression procedure, called a male sling. This is done with the use of a segment of cadaveric tissue or soft mesh to compress the urethra against the pubic bone. It is placed through an incision in the perineum (the area between the scrotum and the rectum). The results show decent success rates in patients with low volume incontinence, poor success is seen with severe incontinence. Long-term data is not currently available.
Artificial Urinary Sphincter
The most effective treatment for male incontinence is implantation of an artificial urinary sphincter. This device is made from silicone and has three components that are implanted into the patient. The cuff is the portion that provides circular compression of the urethra and therefore prevents leakage of urine from occurring. This is placed around the urethra after an incision is made in the perineum. A small fluid-filled pressure-regulating balloon is placed in the abdomen and a small pump is placed in the scrotum, to be controlled by the patient. The fluid in the abdominal balloon is transferred to the urethral cuff, closing the urethra and preventing leakage of urine. When the patient needs to urinate he presses the scrotal pump which releases the fluid back to the abdominal balloon opening the urethra and allowing the patient to void.
Information provided by the American Urological Association.