Dr. med. Dirk Manski



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Stress Urinary Incontinence in Women (3/3)

Treatment of Stress Urinary Incontinence (SUI)

Conservative treatment:

Weight loss, regular micturition to avoid a full bladder, pelvic floor exercises and topical (vaginal) estrogen treatment are conservative treatment options of stress urinary incontinence.

Drug Therapy for SUI:

Drug therapy for pure stress incontinence has not been promising until recently. The first promising substance is duloxetine. Anticholinergic treatment is the option of first choice if mixed stress incontinence with overactive bladder symptoms or overactive detrusor action is present.

Duloxetine:

Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SSRI) on spinal level and reinforces the strength of the sphincter contraction. Duloxetine may achieve a reduction of incontinence episodes by 50–60% (vs. 20–40% in the placebo group). Dosage and side effects, see section pharmacology of duloxetine. Duloxetine is approved for treatment of mild stress urinary incontinence in Europe. Duloxetine failed the US approval for stress urinary incontinence amidst concerns over liver toxicity and suicidal events.

Electromagnetic Stimulation of the Pelvic Floor Muscles:

Perineal nerves are stimulated by am electromagnetic chair, this leads to a contraction of the pelvic floor. The treatment option is used for stress incontinence, overactive bladder, and in the mixed incontinence. Randomized trials could only demonstrate a small and temporary treatment effect with electromagnetic stimulation of the pelvic floor (Gilling et al, 2009) (Quek, 2005).

Periurethral Injections:

Collagen, teflone, silicone, polydimethylsiloxane, or autologous fat are used for periurethral injections to improve sphincter function. In the long term, however, poor cure rates are reported (30–40%). If the periurethral injection is successful in the short term, the prognosis for a definitive cure with surgery (e.g. TVT, see below) is good.

Surgical Treatment of Female Stress Urinary Incontinence

Suprapubic and Abdominal Approach:

The Burch colposuspension has success rates of 70% in the long term. Any other (less invasive) treatment options have to compete with this success rate, unfourtunately controlled trials are often not available. However, a significant decrease of abdominal procedures in favor of vaginal procedures is observable.

Burch colposuspension:

The paravaginal fascia is attached to the arcus tendineus ligament with mattress sutures which elevate the the urethra and bladder neck. The Burch colposuspension can also be performed laparoscopically with fewer side effects, the success rate is somewhat lower (Dean et al, 2006).

Abdominal sacrocolpopexy:

Abdominal sacrocolpopexy is suitable to repair level 1 defects and to restore functional vaginal length and vaginal axis. The vaginal cuff is mobilized and fixed to the os sacrum with a prolene mesh. Surgery can be done with a laparoscopic or open approach.

Marshall-Marchetti-Krantz Procedure:

The Marshall-Marchetti-Krantz procedure is a cystourethropexy: suspension of urethra and bladder neck to the symphysis. Due to unfavorable results (outlet obstruction) and complications (osteitis pubis) it is no longer recommended.

Vaginal Approach for the Surgical Treatment of SUI:

The vaginal approach is most commonly used for surgical treatment of stress urinary incontinence.

Alloplastic Urethral Slings:

All steps of the operation are carried out by vaginal approach with the patient in lithotomy position. A small incision of the anterior vaginal wall is done to enable minimal dissection of the urethra. Two stab incisions for the urethral sling exit points are created suprapubic (TVT) or near the origin of the gracilis muscle (TOT). A 1 cm wide urethral sling is placed around the midurethra using a special needle device and exiting at the two stab incisions. Wound healing and scarring leads stability of the urethra and restores pressure transmission to the urethra with rising abdominal pressure. Details of the surgical techniques and complications see chapter urologic surgery section alloplastic midurethral slings.

Suprapubic alloplastic midurethral slings have been first described as tension free vaginal tape (TVT) (Ulmsten et al, 1998). TVT showed comparable 5-year results in randomized trials compared to the Burch colposuspension (Ward et al, 2006). Meanwhile, several medical companies with different sling material and surgical technique are present on the market [fig. alloplastic vaginal midurethral sling].


figure alloplastic vaginal midurethral sling  

Suprapubic alloplastic midurethral sling. With kind permission of American Medical Systems, Minnetonka, Minnesota, USA.


Transobturator slings are known by the acronym TOT (transobturator tape). Randomized studies showed comparable results for TOT vs. TVT, however, long-term results are lacking (Latthe et al, 2010). As with suprapubic alloplastic midurethral slings, several medical companies with different sling materials and surgical techniques are present on the market [fig. Transobturator midurethral sling (TOT)].


Transobturator midurethral sling (TOT). With kind permission of American Medical Systems, Minnetonka, Minnesota, USA.
fig. Transobturator midurethral sling or transobturator tape (TOT).

Minimally invasive alternatives to TVT or TOT are short midurethral devices (short tapes), which are inserted via a single vaginal incision and are anchored in the paraurethral tissue and pelvic floor muscles. Controlled studies with long term results are not available.

Anterior colporrhaphy:

Anterior colporrhaphy (anterior vaginal wall repair) is indicated for correction of a cystocele and uses a vaginal approach. The procedure may be combined with a alloplastic midurethral slings to treat stress urinary incontinence. When anterior colporrhaphy is used alone for the treatment of stress urinary incontinence, only 55% of the patients will improve and only 19% will be cured. Since recurrence of cystocele is not uncommon and approach 40%, anterior colporrhaphy is often combined with the repairs using grafts or mesh (see complex pelvic floor reconstruction).

Posterior colporrhaphy:

Posterior colporrhaphy (posterior vaginal wall repair) is indicated for the correction of a enterocele or rectocele and uses also a vaginal approach.

Complex pelvic floor reconstruction:

Stress urinary incontinence is often caused by combined defects of the pelvic floor. Combined defects can corrected by combining above mentioned procedures. An alternative is using vaginal repair kits using multi-arm (4–6) prolene mesh to reconstruct all defects of the pelvic floor (e.g. Prolift system by Ethicon or Apogee/Perigee by AMS). The mesh is inserted along the anterior and posterior vaginal wall [fig. reconstruction of the anterior pelvic floor compartment and reconstruction of the posterior pelvic floor compartment]. Controlled long-term data regarding the safety of mesh implantation do not exist. The FDA has issued a warning regarding the safety of mesh implantation for the repair of pelvic organ prolapse.


Reconstruction of the anterior pelvic floor compartment using the Prolift vaginal kit. With kind permission of Johnson & Johnson MEDICAL GmbH, Ethicon Endo-Surgery.
figure reconstruction of the anterior pelvic floor compartment using the Prolift vaginal kit.


Reconstruction of the posterior pelvic floor compartment using the Prolift vaginal kit. With kind permission of Johnson & Johnson MEDICAL GmbH, Ethicon Endo-Surgery.
figure reconstruction of the posterior pelvic floor compartment using the Prolift vaginal kit.

Needle bladder neck suspension:

Needle suspension of the bladder neck is becoming rare after the development of alloplastic midurethral slings. The procedure starts with suprapubic and vaginal incisions, followed by special stitches elevating the bladder neck with a special needle.

Vaginal sling procedures using autologous fascia:

Two slings of autologous fascia are raised from the aponeurosis of the external oblique muscle or from the rectus muscle on both sides. After mobilizing the retropubic space and urethra, the slings are positioned around the midurethra and used to raise the urethra. Vaginal sling procedures using autologous fascia are becoming rare after the development of alloplastic midurethral slings.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Dean, N. M.; Ellis, G.; Wilson, P. D. & Herbison, G. P.
Laparoscopic colposuspension for urinary incontinence in women.
Cochrane Database Syst Rev, 2006, 3, CD002239


Gilling, P. J.; Wilson, L. C.; Westenberg, A. M.; McAllister, W. J.; Kennett, K. M.; Frampton, C. M.; Bell, D. F.; Wrigley, P. M. & Fraundorfer, M. R.
A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.
BJU Int, 2009, 103, 1386-1390


Latthe, P. M.; Singh, P.; Foon, R. & Toozs-Hobson, P.
Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials.
BJU Int, 2010, 106, 68-76


Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.:
[The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
In: Urologe A
44 (2005), Nr. 7, S. W803–18; quiz W819–20

Petros, P. E. & Ulmsten, U. I.
An integral theory of female urinary incontinence. Experimental and clinical considerations.
Acta Obstet Gynecol Scand Suppl, 1990, 153, 7-31.


Quek, P.
A critical review on magnetic stimulation: what is its role in the management of pelvic floor disorders?
Curr Opin Urol, 2005, 15, 231-235


Ward, K. L.; Hilton, P.; K., U. & Group, I. T. T.
Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.
BJOG, 2008, 115, 226-233


Viktrup u.a. 2004 VIKTRUP, L. ; SUMMERS, K. H. ; DENNETT, S. L.:
Clinical practice guidelines for the initial management of urinary incontinence in women: a European-focused review.
In: BJU Int
94 Suppl 1 (2004), S. 14–22


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