Choosing a treatment for female incontinence
There are a variety of treatments for female incontinence, and the best treatment for an individual patient depends on the type of incontinence, the severity of the incontinence, the presence of other types of pelvic prolapse, and a woman’s feelings about the balance between invasiveness and effectiveness of treatments. The following is an overview of how your doctor may counsel women regarding treatment.
Urge Incontinence
Woman with solely or mostly urge incontinence are usually not treated with surgery. If a woman is post-menopausal and has vaginal atrophy we will usually recommend a 3 month trial of vaginal estrogen cream. If the amount of incontinence is moderate or severe we will usually also recommend a trial of medication. There are several effective medications for urge incontinence, including Enablex, Vesicare, Detrol LA, Ditropan XL, and Oxytrol patches. Patients are usually given samples of a medication and can expect results within 1-2 weeks.
Woman with fairly minor urge and stress incontinence should consider a 6 week trial of pelvic floor biofeedback therapy because it is non-invasive, does not require medications, and has a reasonable chance of significant improvement. Patients with more severe urge and stress incontinence may want to consider surgery to correct the stress incontinence, since the urge incontinence will also go away in 2/3 of cases.
Patients with urge incontinence that does not improve with medication still have other options. A relatively new option is intra-vesical Botox therapy. This is a minor surgery done with a telescope to look into the bladder and inject Botox into the bladder. Approximately 70% of patients who fail to improve with medications will have a good response to Botox therapy. The downside of Botox therapy is that the treatment does not last forever, and usually needs to be repeated every 8-12 months. Also, approximately 10-15% of women can have difficulty urinating for the first few weeks after the injection, and rare patients will need to leard to catheterize themselves until they are able to urinate again.
Another option for women who do not improve with medication is a trial of Interstim® sacral nerve root modulation. This is an innovative procedure which uses a small pacemaker-like device to stimulate the nerves that go to the bladder and decrease bladder overactivity. A minor surgery is performed to place an electrode next to the nerves that go to the bladder, and a permanent pacemaker is placed if patients have a good response. Interstim has the potential of providing long-term improvement in urge incontinence, but not all patients get long-term relief and many require additional surgery to replace the electrodes or remvove the device. Some patients’ lives are dramatically changed after successful treatment with sacral nerve stimulation.
Stress Incontinence
Stress incontinence is not usually curable with medication, but patients with mixed urge and stress incontinence are usually given a trial of medication to see if they get much improvement. Many women will also get some improvement with estrogen vaginal cream, and vaginal estrogen will make surgery easier and safer. Woman with smaller amounts of stress incontinence will frequently get significant improvement from a 6 week course of pelvic floor biofeedback therapy.
Women with more severe incontinence and those with prolapse (bulging) of the bladder and uterus will usually be happiest with surgery to correct the weakness in urethral support. In addition, women who want the treatment with the highest chance of long-term cure of stress incontinence will usually choose surgery. For women with stress incontinence but no problem with significant bulging of the bladder or uterus, we perform an operation that places a small strip of mesh under the urethra to support it and prevent incontinence. There are several varieties of sub-urethral slings, including TVT by Gynecare, Inc., and the Mini-ARC and Monarc female sling systems from American Medical Systems. These outpatient operations are performed through a small (1 inch) incision in the vagina and use a synthetic mesh sling to hold the urethra in place and prevent incontinence. More than 90% of women are dry after this surgery and return to normal living within days of the surgery. Learn more about this state-of-the-art surgery by clicking here.
A urethral sling holds the bladder and urethra in position to prevent stress incontinence
For women with stress incontinence and bulging of the bladder and/or uterus we will perform a vaginal surgery to correct all of the problems in one surgery. Hysterectomy can be performed by a woman’s gynecologist, and we can repair the support of the bladder and urethra during the same operation. We usually use a surgical system that uses a piece of strong mesh to fix bulging of the bladder or rectum, hold the urethra in place, and correct the stress incontinence. Women who require these more complex operations usually spend one night in the hospital but are back to normal activities within 1-2 weeks from surgery.