Cough (Stress) Incontinence
Urinary incontinence in women is a very common problem. One in three women will have some degree of incontinence in their lifetime. Stress incontinence occurs on exertion (running, bending), coughing or sneezing.
Symptoms and signs
The degree of stress incontinence can vary considerably. For some women the leak is small and is managed by avoiding exertion and mapping toilets. For other women underwear changes and incontinence pads are a regular and distressing necessity.
Some women are also aware of prolapse symptoms including bulging descent (a lump) of the vagina, dragging sensation and discomfort. Pelvic and low back pain can also be symptoms
Mixed incontinence describes a combination of stress incontinence and urge incontinence symptoms (see Urge Incontinence) and the two causes of urinary leak are often seen together.
Your doctor will question you on your symptoms and your previous medical, surgical and obstetric history.
An examination of your abdomen and pelvis will be a part of this assessment. All examinations are chaperoned by qualified nursing staff. You may be asked to complete questionnaires and fluid charts as part of your assessment.
The gold standard investigation to assess incontinence is called a Urodynamic study. This involves the passage of a fine catheter into the bladder and rectum to measure pressures as the bladder fills and empties. The rectal catheter is used to subtract the abdominal pressure to give an accurate bladder reading. The urodynamic test is combined with Voiding Cytourethrography – Xray images – in order to get both pressures and pictures of your pelvic floor support. The urodynamic study takes approximately 30 minutes to perform and is not painful. Your consultant will give further details.
Fig 1 – Video-urodynamic equipment.
Fig 2 – X-ray picture showing bladder prolapse through the pelvic floor.
Pelvic Floor Exercises
Pelvic floor exercises help improve the tone (strengthen) the muscles of the pelvic floor. This helps to support the bladder and tighten around the bladder neck and urethra (water-pipe) during times of increased abdominal pressure (eg bending or running). Specific exercise can be taught to try and tighten the muscle. These exercises can be augmented by the use of vaginal cones (weights), biofeedback monitors or electrical stimulation. Pelvic floor exercises are taught by physiotherapists and need practised regularly at home to be effective. Pelvic floor exercises can improve stress incontinence in up to 70% of women, but only work if the exercises are continued.
Injections of silicone (Macroplastique) or polyacramide hydrogel (Bulkamid) can be performed using a cystoscopy telescope.
The injections tighten the lining of the urethra (water-pipe). The procedure is simple to do, often as a day case procedure, and has success rates between 30 and 60%. Injections may have to be repeated to maintain their effect.
Mid urethral mesh slings (TVT and TVTO)
Mid urethral mesh procedures have been used since 1997.
The procedures use a polypropylene mesh (plastic tape) around the urethra designed to act like a hammock, supporting the urethra and helping it to close more tightly when abdominal pressure is raised during coughing or exercising. The tape stays in place permanently.
Fig 1 – The tension free trans vaginal (TVT) tape passes around the urethra to the abdominal wall above the pubis.
Fig 2 – The tension free trans vaginal obturator (TVTO) tape passes around the urethra to the inner aspect of the thigh.
The procedures are performed under a general or spinal anaesthetic. A small incision (about 2 cm) is made in the vagina just below the opening of the urethra and the polypropylene tape (similar to the material used for surgical sutures) is passed upward (TVT) to exit through small (0.5 cm) incisions above the pubic bone; or outwards (TVTO) through small (0.5 cm) incisions made in the inner thigh. The tape is positioned without tension under the urethra and acts as a ‘backboard’ to support the urethral continence mechanism (sphincter) when coughing. The incisions are the closed with dissolvable stitches which disappear within 2-3 weeks of surgery. The TVT-O procedure takes about 30 minutes.
TVT and TVT-O are effective with over 80% completely dry or much improved after surgery. Most women are able to be as active as they like after placement of a transobturator tape, for example, lifting children, dancing or exercising. As a result, 18 out of every 20 women are satisfied by the results of the procedure.
Both TVT and TVT-O procedures carry a low risk of complications. The most common of these is difficulty voiding (passing urine). Urinary retention (inability to pass urine) occurs in 1-5% of patients having TVT and 1-2% of patients having TVT-O. In such cases patients would have to use catheters to empty the bladder or have the tape divided (cut) at a subsequent procedure. TVT and TVT-O can also cause bladder irritation causing frequency or urgency in 1-5% of patients.
Awareness of mesh complications
In recent years, there has become increasing awareness of (long term) complications of mesh in urogynaecological surgery. A small number of women have reported long-term issues with pelvic (TVT and TVT-O) pain and thigh pain (TVT-O). Mesh can also erode through tissues and become exposed in the vagina, or enter the bladder or urethra (water-pipe). These complications occur in approximately 1-3% of patients. As such, the use of mesh tapes for stress incontinence has been reviewed separately in a Scottish Government Independent Report and the NHS England Mesh Oversight Group Report published in 2017.
At the present time, both organisations agree that the benefits of tape surgery, and the simplicity of the procedure substantively exceed the risk of complications. They recommend that both procedures are offered as long as patients are adequately counselled of risks. Please see Vaginal mesh complications for more information.
Autologous rectus fascia slings
This operation works in a similar way to the TVT procedure (see Mid urethral mesh slings (TVT and TVTO) above). In this operation a sling is made from the tissues of abdominal wall and the sling is mounted on surgical sutures as a ‘sling on a string’ to be placed around the urethra.
The procedure therefore needs both a vaginal and abdominal incision.
Success rates and complications are similar to those of the TVT synthetic sling, but using your own tissue avoids the risks of complications related to mesh. In patients with more severe incontinence the sling can be tightened to increase the chances of success. However, tightening the sling more also increasing the risk of urinary retention and catheter dependency. The pros and cons of sling tightening can be discussed with your consultant.
In this operation sutures are placed in the vagina either side of the bladder neck to elevate the bladder as a pelvic floor ‘face lift’. The operation corrects stress incontinence and prolapse simultaneously. Success rates are 80-90% although it can cause secondary prolapse of the bowel (rectocoele) in 1-8%. It is sometimes combined with a Sacrocolpopexy (see section on prolapse) to give complete pelvic floor support. Colposuspension can be performed through Bikini line ( Pfannensteil) incisions or keyhole (laparoscopic) incisions.
Artificial urinary sphincter
This surgery is usually reserved for women who have failed a primary (first) operation for stress incontinence. A plastic prosthesis – an artificial sphincter- is implanted to replace the function of the failed natural sphincter through an abdominal incision. The device is worked through a pump (button) system placed in the labia. Artificial urinary sphincters are successful in 80-90% of cases but risk erosion through the urethra (water pipe) or labia and infection in 10-20%. In such circumstances, they would have to be removed. The artificial sphincter lasts 10-15 years.
More information on Artificial urinary sphincter can be found via the BAUS leaflets at BAUS and downloading the leaflet on Insertion of an artificial urinary sphincter (AUS) in women.
A comparison of all the different options for female stress incontinence can be found at BAUS and downloading the leaflet COMPARISON OF TREATMENT OPTIONS FOR STRESS URINARY INCONTINENCE (SUI) IN WOMEN