A. Non-Surgical Treatment
- General - Fluid intake, weight loss, smoking, cough. Distance to toilet - bedside urinal, underwear with Velcro, pads.
- Estrogen - stimulates mucosal proliferation, improving mucosal coaptation and enhancing urethral smooth muscle response to alpha-adrenergic stimulation. It widens the vascular lumen up to fourfold and increases the vascular pulsations in the urethral bed. The decline in estrogen is associated with relative decline in volume of striated muscle and blood vessels and an increase of connective tissue of the urethra. These translate clinically, into a decrease in the urethral closure mechanism leading to urethral problems, particularly incontinence. Estrogen supplements in post-menopausal women could improve urethral closure and outlet resistance.
- Stop Alpha Blockers (Cardoxan) - this relaxes urethral smooth muscle.
- Alpha-adrenergic agonists. For example, Sudomyl (pseudoephidrine). Alpha stimulants have a direct stimulatory action on the alpha receptors in the bladder neck and could be used to treat mild degrees of stress urinary incontinence. These agents could be considered in conjunction with other non-surgical modalities. One should however, be aware of the side-effects such as hypertension, tachycardia, arrhythmia and insomnia, and they should be used with great caution in elderly patients.
- Bladder relaxants - e.g. Detrusitol (Tolterodine), Ditropan (Oxybutynin), Imipramin (Imipramine). These drugs should be considered only in the presence of urgency and urge incontinence.
- Physiotherapy - Pelvic Floor Muscle exercises, Bio-feedback and electro stimulation. Patients should perform these exercises for 8 - 12 weeks before they may experience benefit.
B. Surgery for Hypermobility of the Urethra
The pathology in these patients is malposition of a normal sphincteric unit and therefore, the goal of surgery is repositioning of the bladder neck and urethra to a high retropubic position (Bladder Neck Suspension).Burch Colposuspension is still one of the operations with the best long-term results. This operation also corrects small to moderate cystocoeles. It can be done Laparoscopically, or by open surgery, depending on the circumstances. With the Laparoscopic technique, the patient is normally discharged after two nights and could return to work within one to two weeks. Burch Colposuspension is carried out through the retropubic space and the vaginal wall and urethropelvic ligament (endopelvic fascia), is elevated and fixed to the lateral pelvic wall by attaching it to Cooper's Ligament with Ethibond Sutures. Because all loose fatty and connective tissue is stripped off the vaginal wall and urethropelvic ligament, it adheres to the pelvic wall and should cause permanent fixation in this position.
There are more than 100 other operations, but most other suspension operations done trans-vaginal do not create the same raw surface and therefore, do not have the same amount of fixation due to fibrosis, to the pelvic wall. The failure rate is therefore higher. There is also a higher incidence of post operative retention, or difficulty passing urine, where the elevating sutures are very close to the urethra and bladder neck.
Treatment of Intrinsic Sphincter Deficiency
A. Urethral Slings
In this condition, there is damage or paralysis of the sphincteric unit which could even be in a normal position. The goal of surgery for Intrinsic Dysfunction is coaptation, support, and compression of the damaged sphincteric unit. Simple suspension of the bladder neck is unlikely to correct the problem. Urethral Sling Procedures are the best to achieve the goal.A sling is put around the mid-urethra. There are different suburethral slings which include Sparc sling, TVT and IVS.
B. Periurethral Injections
In patients with good support of the bladder neck, but with Intrinsic Sphincter Deficiency, injections of substances, such as Macroplastique and Collagen, can cause coaptation of the urethral mucosa.
C. Artificial Sphincter
Complications of Surgery
- Detrusor Overactivity, with urgency and even urge incontinence (normally only temporary). Could be treated with muscle relaxants (Detrusitol (Tolterodine), Ditropan (Oxybutynin), Imipramin (Imipramine))
- Urinary retention or incomplete bladder emptying: - Treatment options - catheterisation, triple voiding, Alpha Blockers. Anterior bladder neck incision. Ubetrid for detrusor underactivity.
- Utrine prolapse or Vaginal vault prolapse- Treated by Laparoscopic Sacrohysteropexy or Sacrocolpopexy.
- Enterocoele and rectocoele: Could be fixed with sacrocolpopexy or posterior repair.