Stress Incontinence

What is Stress Incontinence?

Stress incontinence refers to the involuntary loss of urine that is generally associated with activities such as coughing, sneezing, or laughing. It is also described when patients are active, including sports activities.  Stress urinary incontinence is extremely common, affecting an estimated 12 million people in the United States alone.  Stress incontinence is thought to result from a weakness of the urinary sphincter, which is the muscle band around the base of the bladder that prevents urine loss. Weakness of this muscle is unfortunately something that happens to varying degrees with aging. Other factors contributing to the weakening of the sphincter muscle includes child birth, vaginal surgeries and body weight. As a result, we see patients of all ages presenting with this problem.

Treatment Options

There are a variety of treatments available for stress incontinence. These treatments offer a comprehensive and minimally invasive approach to treating your incontinence. Conservative treatments refer to those not requiring surgery, such as medications.  Surgical treatments offered are minimally invasive and do not require an overnight hospital stay.

Non-Surgical Treatments

Drug Therapies
A number of drug therapies have been tried for stress incontinence. Unfortunately, none of these have proven to be successful. The medications to help with leakage that are advertised on television treat a different kind of incontinence called urge incontinence.

Pelvic Floor Exercises (Physical Therapy)
Pelvic floor exercises are designed to strengthen the pelvic muscles, more specifically the urinary sphincter.  This exercise strengthens the muscles, thereby improving stress incontinence. The best known pelvic floor exercises are called Kegel exercises.  Pelvic floor exercises are not the gold standard for incontinence therapy; however, they are a wonderful initial therapy and are non-invasive. In some cases, they can provide great relief.  While most patients do not experience complete relief of incontinence, pelvic floor exercises have provided significant improvement in many patients. 

What does this treatment involve?

Pelvic floor exercises are taught by a physical therapist that is part of the Virginia Urology team.  The physicians and our patients have found that this provides a relaxed atmosphere where patients can focus on learning the pelvic floor exercises. Initially, Appointments are generally held once per week. Once you feel comfortable with the exercises, you and your physical therapist may decide to decrease the number of visits.

Surgical Treatments

Urethral Bulking Agents
Urethral bulking agents are injections that are placed on the inside of the urethra. They are designed to decrease the size of the urethra, and provide resistance against the leakage of urine.  They are similar to collagen that is injected in a patient’s lips for cosmetic surgery, but are placed inside the urethra. Several agents are currently used, but the choice mostly depends on the preference of your doctor. Current agents include a natural substance collagen, and synthetics durasphere and macroplastique.  While there are minor differences, in general the success rates and risks of all are fairly similar.

What does this treatment involve?

Injections are performed in the clinic by first using a numbing liquid that is placed in the bladder by a catheter, and no anesthesia is required. Injections are performed with a small camera that is inserted into the bladder so your doctor can see where to place the injections. The entire procedure takes about 5 minutes.

What are the success rates?

Many studies have found that between 50-70% of women see improvements from this treatment.  It is important to note, this therapy is a temporary therapy as it requires reinjection to maintain the effects.  Most studies show the effects last between 6 to 12 months.  Because it is temporary, bulking agents are often a good option for patients who want to avoid a surgical procedure, or whose health issues may increase the risk of surgery.

What are the possible complications?

You doctor will review and discuss potential complications with you.  One possible complication of urethral bulking agents is urination difficulty due to the increase force required to empty the bladder.   As a result, about some patients need help emptying their bladder for several days.  This can be done by wearing a catheter or, if you are comfortable, by teaching you how to catheterize yourself several times daily so that a catheter does not need to be left in.

The Sling

Urethral slings are the gold standard therapy for stress incontinence.  Slings often are U-shaped materials that are placed underneath the urethra to recreate the support that has been lost due to pelvic floor weakness.  Slings have been around for over 100 years now, however, they have changed significantly over the years.  There are a variety of slings now available, and we have included a description of these slings in order to help you understand your treatment options.

The Mid-Urethral Sling

This type of sling gets its name from a synthetic material being placed under the middle of the urethra. It is the most common type of sling used today.  Many different companies make mid-urethral slings just like there are many different makers of cars.  Each company gives their sling a different name, just like cars have different names.  Don’t let the number of slings confuse you—many studies have shown that in general they all have similar success rates.  In general, each surgeon chooses a sling the he or she feels comfortable with and uses that sling.  Here are some sling names that you may see on the internet:

• Monarc
• SPARC 
• TVT
• ObTape
• IVS Tunneler    
• TVT-O
• ObTryx
• Obturator IVS
• UraTape
• Aris

What are the success rates?

If you do not have incontinence associated with your prolapse, a sling is often placed to prevent incontinence from occurring.  In this case, slings are highly successful in preventing incontinence.
If you do have incontinence associated with prolapse, a sling is placed to help stop your leakage.  Dr. Rapp has done extensive training and research regarding the success rates of slings.  Based on these reports, patients can expect very favorable post-surgery outcomes. After surgery, most women report no incontinence or rare leakage episodes. It is important to note, that with any surgical procedure, there is no guarantee that the problem will be permanently fixed.  There are a small percentage of women will unfortunately continue to experience leakage. 

What are the possible complications?

You doctor will review and discuss potential complications with you.  Sling placement is a minimally invasive surgery with low risk.  One possible complication of the sling is urination difficulty due to the increase force required to empty the bladder.  As a result, about 5% of patients will need help emptying their bladder for several days.  This can be done by wearing a catheter or, if you are comfortable, by teaching you how to catheterize yourself several times daily so that a catheter does not need to be left in.  If this complication persists, you doctor will discuss with you about adjusting the sling to restore normal urination.  Also, possible risks include erosion of the tissue around the synthetic material due to irritation. These complications may resolve on their own but in other cases may require the removal of the mesh as described earlier.

What does this all mean?

Overall, the sling has enhanced the way incontinence is treated.  Not too long ago, there were few options that were highly successful in treating incontinence, and were somewhat invasive. The sling offers a minimally invasive and very successful option to greatly improving or curing incontinence in many women.  As a result, thousands of women are now able to experience an improved quality of life without worrying about the embarrassing effects of incontinence.