Surgery may be considered if conservative measures are unsuccessful. Before making this decision, a woman should discuss the risks and benefits of surgery with her consultant specialist.
A number of different surgical procedures can be used. Only surgeons who have had specialist training in incontinence surgery should carry out these operations.
Tension free vaginal tape procedure for stress incontinence
TVT procedure is currently suspended
NHS England announced a national 'pause' on use of TVT tape to treat stress urinary incontinence
Tension free vaginal tape is a piece of a narrow, synthetic polypropylene tape inserted through an incision inside the vagina and threaded behind the urethra to provide dynamic support, stopping leakage from the bladder. The middle part of the tape supports the urethra, and the two ends are threaded through two 5mm incisions in the lower abdomen. This is called a mid-urethral sling procedure or tension-free vaginal tape procedure (TVT).
Mid-urethral slings (or TVTs) are minimally invasive procedures developed in Europe in the mid 1990s to treat female stress urinary incontinence. These slings have been shown to be as effective as more invasive traditional surgery but have the advantages of shorter operating and admission times, and a quicker return to normal activities, together with lower rates of complications. This has resulted in the TVT sling becoming the operation of choice in Europe, the United Kingdom and the USA for treatment of stress urinary incontinence.
There is robust evidence to support the use of TVT slings from over 2,000 publications making this treatment the most extensively reviewed and evaluated procedure for female stress urinary incontinence now in use. For this reason it is the operation we tend to recommend to 'friends and family'
Autologous fascial 'natural tissue' sling for stress incontinence
The autologous fascial sling operation involves making a sling from your own natural tissue (the fascia - a layer of strong tissue beneath your skin) that is harvested from your abdominal wall (tummy). This 'natural tissue' sling is then used to support your urethra.
The fascial sling is inserted in a similar manner to themid-urethral synthetic sling (TVT). The success rate of synthetic TVT slings and fascial slings appear similar, in the range of 70-95%, although less data has been published on the fascial sling. Because fascial sling procedures involve making a bigger incision on the tummy, the recovery afterwards takes longer than TVT sling. The benefit of a fascial sling procedure is that no synthetic material is used.
Laparoscopic colposuspension for stress incontinence
In laparoscopic colposuspension, stitches are placed between the vaginal wall either side of the neck of the bladder and some fibrous tissue behind the pubic bone. This lifts the neck of the bladder to give it better support. Originally this operation required a bikini line cut in the tummy but it can now be done through laparoscopic (keyhole) surgery meaning a quicker recovery. This operation has been performed for over forty years and so we have good information about how well it works, although most of the studies reported on women who had open rather than keyhole surgery. 80% of women will be cured of stress incontinence following this operation.
Bladder neck bulking injections for stress incontinence
In bladder neck bulking, a bulking agent is injected into the walls of the urethra. This increases the size of the urethral walls and allows the urethra to stay closed. This is less invasive than other surgical treatments, as it does not require any incisions. However, it is less effective than the other options, and this effectiveness reduces with time.
Bladder 'BOTOX' (Botulinum toxin A) injections for urge incontinence
Bladder Botox injections: many people have heard of Botox for the treatment of face wrinkles! Botox works for the bladder by relaxing the muscle of the bladder wall (the detrusor muscle) reducing urinary urgency and incontinence. The latest evidence suggests that this may cure incontinence or improve symptoms by 70-90%. The effects can last for up to 12 months.
The Botox therapy for OAB is recommended by NICE when other measures such as physiotherapy or medicines fail to control problems.
- IUGA: statement on mid-urethral slings
- NICE: the management of urinary incontinence in women
- NHS: urinary incontinence treatment options
- Continence Foundation