When you leak urine when you sneeze, cough, or laugh, it's known as stress incontinence. If you aren't having much luck controlling your symptoms with noninvasive approaches, you may be considering surgery.
These days, operations to treat stress incontinence are often successful, covered by health insurance, and done on an outpatient basis. (If you have urge incontinence, check out slides 14-16.) Here are key facts to know if you're considering urinary incontinence surgery.
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Success is variable
Think about your goals, and whether you might be able to achieve them without an operation.
"Everyone needs to make their own decision," says Harvey Winkler, MD, co-chief of urogynecology and director of female pelvic medicine and reconstructive surgery at North Shore–Long Island Jewish Health System in Great Neck, N.Y. Surgery is the best approach, he says, "if you're looking for the one-shot deal that's going to give you the best dryness option."
It's no guarantee of a cure, but studies have found that 85% to 90% of women are completely dry within a year after surgery.
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Try Kegels first
Exercises to strengthen the pelvic floor, known as Kegels, are the most basic and noninvasive approach to treating stress incontinence.
If you're willing to do these exercises several times a day, indefinitely, you can expect a 70% improvement in your symptoms, says Dr. Winkler.
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Consider bulking agents
There are outpatient procedures in which bulking materials like collagen or silicone are injected around the urethra. Although these procedures can offer short-term relief, especially for people who don't respond to surgery, they have to be done repeatedly because your body will eventually eliminate the injected material.
There also are several medications that are sometimes prescribed, including drugs for treating muscle spasms and antidepressants, but they tend to be more effective for treating mild or moderate stress incontinence.
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The sling's the thing
The most popular surgical treatment for stress incontinence is the mid-urethral sling or tension-free sling procedure.
The surgeon loops a thin strip of materialusually synthetic mesh, but occasionally some of your own tissue or tissue taken from a cadaverto support the bladder and urethra.
This helps you shut off the flow of urine when you sneeze, cough, or do something else that could cause leakage, says Thinh Duong, MD, an associate at Southern California Permanente Medical Group, in Los Angeles.
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Mesh can be a problem
You may have heard warnings about the use of mesh in gynecological surgery. The FDA says side effects of mesh are potentially serious and include urinary problems, infections, and pain during sex, although it is still reviewing the risk associated with slings for incontinence.
Dr. Duong says the risk of complications is low for sling procedures because they require a relatively small piece of mesh (other procedures use larger pieces of mesh). In addition, synthetic materials that have been associated with higher rates of infection have been taken off the market.
You should seek a surgeon who has done a fellowship in urogynecology or female pelvic medicine and reconstructive surgery, Dr. Winkler says. Ask how many procedures he or she does a year. Some gynecologists go to weekend training sessions to learn how to place a particular type of sling, but this isn't enough, Dr. Duong says.
It's also key, he says, to ask about the complications associated with the procedure, as well as which complications your potential surgeon has seen and how he or she dealt with them.
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It's often an outpatient procedure
Sling procedures are often done on an outpatient basis, meaning you don't have to spend the night in a hospital.
They can be done under local anesthesia, Dr. Winkler says, whereas a different type of procedure called retropubic suspension is usually done under general or spinal anesthesia and involves a hospital stay.
Post-surgical pain can usually be tamed with ibuprofen, he says.
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You may need a catheter at first
You may go home with a catheter after surgery if you have difficulty urinating on your own, or can only urinate very slowly.
You may need to use a catheter at first to empty your bladder a few times a day. Difficulty in urinating rarely persists, and you may need to have the sling readjusted or removed.
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You'll need to limit activity
After surgery, you'll want to avoid stressing the surgical area so your body can heal. Your surgeon will advise you to avoid heavy lifting, exercise, having intercourse, or using tampons, typically for at least a couple of weeks.
If, at this point, you aren't leaking or experiencing pain, your doctor may allow you to return to your normal activities.
"I tell people to plan for a week off," says Dr. Winkler, although he says some of his patients have had the procedure on a Thursday and gone back to work on a Monday.
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Complications are possible
As is the case with any type of surgery, complicationsincluding bleeding, infection, or damage to surrounding blood vessels and organscan occur.
Major complications, such as significant bleeding and blood vessel injuries, occur about 1% of the time, says Dr. Duong.
The mesh may also find its way out of the vaginal incision, and while this can be distressing, it's an easy complication to fix.
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You may need a repeat surgery
About 15% to 20% of the time, the sling surgery is unsuccessful, and may need to be repeated.
You can take steps to help make the second surgery more successful, such as making sure you get adequate rest after the procedure, losing weight if you are overweight, not smoking, and keeping your pelvic muscles strong with Kegels. But if you did all these things and the surgery still didn't work for you, your chances might not be as good the second time around.
In general, Dr. Duong tells patients to expect a 50% to 60% success rate with repeat surgery.
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It may change your life
Debbie S., 42, had been living with stress incontinence for years.
"I have four kids and I just was at the point where I couldn't sneeze or laugh without leaking," she recalls. After talking with friends, she opted for the sling. "It's just a quick, easy, in-and-out procedure," she says.
"It was actually, literally, a life-changer," says Debbie, about a year after having the surgery. She says she can now enjoy a good laugh with no fear of leaking. "I would really recommend it to anybody."
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Surgery is less common for urge incontinence
Behavioral therapy, physical therapy, and medication are still the first-line therapies for urge incontinence, which is most common in the elderly and involves frequent urination with little warning.
Medications for urge incontinence, which can be caused by overactive bladder, usually work by relaxing the overly twitchy organ.
Bladder training, which involves teaching yourself to urinate less frequently, can also be effective.
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Options for urge incontinence
The most common surgical option for severe urge incontinence is bladder augmentation surgery, whichjust like it soundsinvolves enlarging the bladder so it can hold more urine.
There's also neuromodulation, which involves implanting a wire in the sacrum at the base of the spine, with the goal of delivering electrical impulses to the nerves controlling the bladder, thus helping it relax. Your doctor first tests how well you respond to this therapy by delivering impulses to your skin. If the therapy gives you at least a 50% improvement in symptoms, you could be eligible to have the stimulator implanted.
Botox injections also are being researched as a bladder relaxer.
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Tibial nerve stimulation
Insurers recently started covering a technique called tibial nerve stimulation, in which a needle containing an electrode is placed near your ankle, stimulating one of the nerves responsible for bladder control.
A 2010 study found that about half of people reported a significant improvement in their urge incontinence symptoms after 12 weeks of once-weekly half-hour sessions, compared with 20% of people in the placebo group.
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