Ever Since I Had My Baby

by Roger Goldberg

  Patches and caps. These devices, made of soft silicone or foam, are designed to stick over the urethra, creating a seal to block the flow of urine. They are removed before urination, then replaced. Most patches are recommended to be worn for five hours during the daytime and through the night.

  Impress Softpatch. A small disposable foam pad coated with a gentle adhesive.

  FemAssist. A nipple-shaped suction cup that affixes to the flat area around the urethral opening and sticks with the help of a bit of lubricating jelly.

  CapSure. Another suction-cup shield, which has demonstrated good success for reducing stress leakage.

  Plugs and inserts. These devices fit into rather than over the urethra, and need to be fitted by a physician. They’re slightly more intrusive than a simple patch but may prove more stable during activity. They may provide a useful alternative to pads.

  Reliance urinary control device. A mini catheter that inserts into the urethra like a tampon and seals it shut like a cork. To urinate, a string is pulled to deflate the small balloon holding the device in place. The device is replaced around three times each day and removed before intercourse.

  FemSoft. A narrow silicone tube, surrounded by a soft sleeve containing mineral oil, which inserts into the urethra. Once inserted, the mineral oil pouches out the sleeve within the bladder, forming a tiny balloon that holds it in place. It’s intended for onetime use.

  COMMITTING TO SUCCESS

  Success with a device or physical therapy won’t come without a solid commitment. A 1999 study of more than a hundred stress-incontinent women compared pelvic-floor exercises (three daily sessions) with the use of electrical stimulation and vaginal cones. Surprisingly, pelvic muscle strength was most improved, and leakage most decreased, for the women doing regular Kegel exercises—but adherence to therapy was also greatest in this group. The lesson to be learned? Those women least likely to abandon their routine were the most likely to succeed. Whether you choose a low-tech or high-tech approach to finding relief, make it something you’re prepared to keep up with. Dedication is the key to your success with nonsurgical therapy.

  SURx: RADIO-FREQUENCY SHRINK THERAPY FOR THE BLADDER

  This new, minimally invasive procedure for stress incontinence involves a handheld penlike device used to heat and shrink the previously stretched tissues around the urethra and bladder, using low-power radio-frequency (RF) energy. The procedure is performed in an outpatient setting and involves no artificial or implantable materials. Although some modest short-term success has been shown, long-term results are not yet available.

  SURGERY FOR STRESS URINARY INCONTINENCE

  SURGERY FOR STRESS INCONTINENCE: ON THE RISE

  According to a recent report from Magee Womens Hospital at the University of Pittsburgh, the national rate of surgeries for stress urinary incontinence nearly doubled from 1979 to 1997. As stress incontinence procedures become less invasive, this rate continues to increase.

  Over the past hundred years, more than a hundred different operations have been performed for the treatment of stress urinary incontinence. Although there’s still no single best surgery, a few have risen to the top of the pack, with excellent odds of getting you dry.

  Almost all of today’s stress incontinence operations share a common goal: creating new support around the upper vaginal wall to stabilize and strengthen a floppy urethra. The operations fall into a few major categories designed to achieve this result.

  ABDOMINAL OPERATIONS

  Burch and MMK Procedures

  These two very similar operations, also known as retropubic bladder-neck suspensions, are the most common open abdominal operations for urinary stress incontinence. Through a small bikini incision, the upper wall of the vagina is strengthened and lifted in its most crucial area, beneath the neck of the bladder and urethra. Simple stitches (or, in some cases, surgical mesh or staples) are used to anchor the vaginal wall to specific ligaments or bones on the sides of the pelvis. The end result is to stabilize a floppy urethra.

  Advantages. The greatest advantage of these abdominal procedures is that they tend to work very well for long periods of time. Rates of cure at ten to twenty years have been estimated at around 70 percent; few other procedures have such a long track record and can claim such proven longevity. For some women, the operation’s history offers a sense of confidence. Moreover, when compared with other stress incontinence operations, the Burch and MMK have usually fared well. One 1994 analysis showed that among the major stress incontinence techniques used at that time, these retropubic procedures resulted in the highest rate of cure: 86 percent at two years. Another study comparing outcomes after five years found that retropubic procedures had fared better than the vaginal alternatives available at that time: an 80 percent chance of dryness, as compared with only 50 to 60 percent. However, newer and more effective vaginal operations for stress incontinence have been introduced since this comparison was performed (see “Tension-Free Operations,” below).

  Disadvantages. The most obvious disadvantage of open abdominal surgery is the need for a skin incision, general anesthesia, a hospital stay of one to two nights, and a longer convalescence. Cosmetically, there is a bikini scar, but in most cases, it becomes barely visible across the pubic hairline. Perhaps a more substantive limitation is that the procedures do not address all types of urinary stress incontinence. Specifically, if you have a thin-walled urethra, they may be more prone to failure over the long run, and a different operation (such as a sling procedure, described below) may be recommended.

  Laparoscopic Burch

  During laparoscopy, a small tube with a fiber-optic light and camera is inserted into the abdomen through a keyhole incision below the belly button. This technology is also used for performing tubal ligations or treating ovarian cysts. The laparoscopic Burch procedure shares the same basic goal as the Burch procedure—suturing to stabilize the upper vaginal wall and support a floppy urethra—but it is done through a laparoscope rather than an open abdominal incision.

  Advantages. Some surgeons feel that laparoscopy provides the clearest look at the sites of pelvic injury, and the closest restoration of this anatomy to its normal prechildbirth state. With the pelvis brightly lit, the defects in pelvic support leading to prolapse and incontinence can be directly seen and repaired. Laparoscopy involves relatively little postoperative pain, a quick return to activity, and is usually done as an outpatient procedure. Between three and four lower-abdominal keyhole incisions will be made and covered with Band-Aid dressings afterward.

  Disadvantages. Some early reports of the laparoscopic Burch raised concern over higher failure rates (up to 40 percent) and higher rates of complications, including injury to the urinary tract. But in the hands of surgeons performing these procedures regularly, very good results can be achieved.

  VAGINAL OPERATIONS

  Procedures performed through incisions in the vaginal skin, with only tiny incisions on the abdomen or none at all, are a popular alternative for fixing stress incontinence. Not unlike vaginal childbirth, operating through the vagina carries big advantages, including minimal pain, quick healing, and high patient satisfaction. The vagina perceives relatively little in the way of pain and has an outstanding ability to rapidly heal.

  The Bladder Sling

  Sling procedures place a band of tissue around the bladder’s neck, creating a floor for the urethra to compress against during a cough, strain, or any other moment of stress. Like most stress incontinence procedures, it transforms a floppy urethra into a stable one. If you have urinary stress incontinence caused by a urethra that’s both floppy and thin-walled, a sling procedure may be recommended, since it has traditionally achieved the best results for this somewhat challenging type of incontinence. Dozens of sling procedures are performed today, using a number of materials and a variety of techniques.

  Synthetic mesh, or strips of man-made material, comes in several types. Among the most common are Gore-Tex, Prolene, and Mersilene.


  The natural-tissue grafts include fascia and dermis. Fascia, a naturally strong tissue layer, is found all over the body. Taken from beneath the skin of the patient’s own leg or abdomen, it is particularly strong; during surgery, a small strip can be removed through a separate incision in one of these areas and inserted as a sling beneath the bladder and urethra. Prepared fascia can also be obtained from animal sources or human cadavers. Dermis is a skin graft, most often from a porcine (pig) source. As a natural substance, similar to fascia, it tends to be gentle on the body; the long-term durability remains to be seen.

  The two techniques are abdominal-anchored or pubovaginal, and transvaginal-anchored. Abdominal-anchored is the original sling technique. It involves a regular bikini incision on the abdomen. The vaginal sling arms are passed around the bladder neck and up to the incision, where they are anchored around or into the abdominal muscles. The middle section of the sling lies beneath the urethra and lower part of the bladder.

  In transvaginal-anchored, specialized devices enable the placement of slings through vaginal incisions, avoiding an abdominal incision altogether. Bone anchors (Vesica, In-Fast) are one such option, used to fix sling materials into the pubic bone with small metallic screws; however, concern has been raised over bone infections, which can occur in 1 to 2 percent of cases. Other devices (Capio CL) facilitate the anchoring of slings to ligaments, rather than bone.

  Advantages. In experienced hands, sling procedures can provide a cure for even severe types of stress incontinence. If you’re entering surgery with stress incontinence accompanied by a large cystocele, a sling may decrease your risk of a cystocele recurrence later on, a nice secondary benefit to the surgery. Finally, compared to other operations for stress incontinence, slings are viewed by some surgeons as especially durable for overweight women, or for those who participate in regular heavy exertion.

  Disadvantages. Urinary retention and voiding difficulties are more common after traditional sling procedures, as compared with other Burch-type incontinence operations. Erosion of sling material into the adjacent vaginal tissues, bladder, or urethra can occur; this is more common when slings are made of certain synthetic materials. Infection can also occur, due to the presence of foreign material in the body, but is rare.

  Tension-Free Operations

  It was once generally assumed that a less invasive operation meant a slimmer chance of success, and that the most complete and successful operations required a traditional open surgical incision. But several revolutionary stress incontinence procedures have emerged as real phenomena over the past several years, successfully combining minimally invasive and relatively pain-free techniques with outstanding results. The TVT—tension-free vaginal tape—was the original procedure and has become enormously popular across the developed world. It involves placing synthetic mesh tape loosely beneath the urethra, using only one small incision in the vagina. The arms of the tape are passed through the small vaginal incision and up through two tiny incisions on the lower abdominal skin, using a stainless-steel surgical needle. During a cough, a sneeze, or any other moment of physical stress, the tape allows the urethra to compress itself shut and hold back urine. If performed on its own, the procedure can be done under local or spinal anesthesia with no overnight hospital stay.

  The SPARC procedure entails placement of a similar synthetic mesh, using a slightly different technique but the same combination of small incisions. Even newer variations of this basic technique (for instance, the SABRE sling procedure) are now entering the medical marketplace. Based on the phenomenal success of this approach to date, the number of women choosing these operations will, by all predictions, continue to grow.

  Advantages. Despite the fact that the TVT doesn’t tighten the urethra like a traditional sling procedure—instead resting rather loosely beneath it—rates of cure for stress incontinence have been excellent. At least 86 percent of women treated for stress incontinence (of the floppy-urethra type) report being cured after five years, and rates of patient satisfaction approach 95 percent. Because of these outcomes, along with its low rate of complications and voiding problems afterward, the TVT continues to generate great enthusiasm. SPARC is a newer procedure, with few reported outcomes. Will long-term results prove these to be the ideal operations for stress incontinence? Only time will tell. But even before the outcomes are known, it’s safe to say that these procedures are revolutionizing the treatment of stress incontinence.

  Disadvantages. The most common complication during this type of surgery is that the operating needle may perforate the bladder, though this occurs in only 5 percent of cases. For most, it is simply pulled back out and replaced, with no long-term consequence for the bladder. More serious concerns involve injury to blood vessels or bowel, but these complications are exceedingly rare.

  Needle Suspensions

  Needle procedures were once a very popular approach, performed through a few tiny incisions inside the vagina and a few more along the lower pubic area. Through these incisions, stitches are placed that stabilize the bladder neck and floppy urethra, but unlike the TVT or SPARC, without mesh material. Unfortunately, the success rates for most needle procedures have not justified their continued use.

  Surgery for stress incontinence: Three common options and the way they work:

  • TVT/SPARC: Narrow “tape” rests loosely beneath the urethra

  • Burch/MMK: Stitches reinforce the vaginal “floor” supporting the urethra

  • Sling: “Hammock” of supportive material placed around the urethra and lower bladder

  TYPE #2: URGE INCONTINENCE AND THE OVERACTIVE BLADDER

  My husband was a principal, and I was a teacher. When he retired, there was a building and plaque dedicated to him. When I retired, my colleagues always joked that they would name the bathroom after me.

  —Janet, age sixty-two

  As you might have gathered from the multimillion-dollar ad campaigns for the latest overactive-bladder medications, urge incontinence (urine leakage when you feel a sudden urge to void) is an extraordinarily common condition. The National Overactive Bladder Evaluation (NOBLE) study, involving more than five thousand adults, found that nearly 17 percent of all women suffer from an overactive bladder—that’s over 33 million individuals, far higher than previous estimates. Among postreproductive women, the overactive bladder affects probably 30 percent. The NOBLE study found that in comparison to women who have never given birth, those with one to two previous births have 1.5 times the risk of an overactive bladder, and those with three or more births had 2.1 times the risk. Perhaps most surprising of all is the estimate that up to 80 percent of affected individuals are not receiving treatment.

  The same study confirmed a higher rate of depressive symptoms, poorer quality of sleep, and overall reduced quality-of-life survey scores among women with an overactive bladder. Moreover, a recent report from the University of Washington found that urge incontinence, even more than stress incontinence, appears to be strongly associated with depressive and panic disorders, perhaps a reflection of just how distressing unpredictable accidents, as opposed to those related to specific activities which can be avoided, can be.

  MAPPING

  Some women organize their lives around access to the bathroom. Those with an overactive bladder or incontinence are the most likely to map the nearest bathroom with each change of scenery. Every time they enter a room, they seek out a position that assures easy access to the toilet; for frequent flyers, these mental maps may eventually include toilets all over the world. According to the National Overactive Bladder Screening Initiative in 1999, 46 percent of women with overactive bladder symptoms admit to the habit of toilet mapping. In Australia, a National Public Toilet Map on the Department of Health website even has a search engine for finding the location and hours of public toilets along your driving route in the land Down Under (www.toiletmap.gov.au). If you’ve become an amateur cartographer of this sort, consider it a sign—it’s time to seek help.

 
Why should your bladder become overactive as you enter your postreproductive years? Aren’t your muscles supposed to become less active with age? In many areas of the body, the answer is yes. But the bladder muscle behaves very differently from your biceps or triceps. The bladder is surrounded by a bundle of nerves called autonomic nerves. The bladder contracts in response to a surge in the activity of these nerves. All over your body, autonomic nerves control the behavior of organs such as your heartbeat, breathing, and other autopilot functions—those that you don’t consciously control from minute to minute. But among all these organs, the bladder boasts a fairly unique distinction: it’s an autonomic organ that you learn to voluntarily control.

  As part of normal childhood development and toilet training, the bladder makes a transition from automatic emptying to controlled restraint. You learn to suppress the bladder’s natural tendency to contract by reflex, emptying itself when it first senses fullness, and teach it to tolerate this feeling, emptying on command after you’ve reached the toilet seat. A normal bladder should tolerate at least a pint of fluid (eight to sixteen ounces) for long periods of time without contracting.