Operations for Female Incontinence

Vaginal Sling (Tapes) operations for Stress Urinary Incontinence Information for patients

This section is intended to give information for women who are considering to have the tape operations for stress incontinence. You are advised to clarify any unanswered questions with your specialist. Though the information in this leaflet is applicable generally, your specialist may have his or her own way of advising the patients in a specific manner. Therefore we would recommend that you follow the advice given to you if that differs from that given in this leaflet.

What is the purpose of Vaginal Tape operation?

This operation is intended to support the urethra (water tube) and cure or improve stress incontinence. Stress incontinence means leakage of urine during coughing, sneezing, effort and exertion. This operation involves formation of a supporting hammock by placing a tape under the urethra for support. Your surgeon will tell you about the type of tape (synthetic or natural) and the type of procedure. Nowadays, mostly synthetic tapes are used for this operation. The synthetic tapes are made of Poly-propylene which is the same material as the meshes used for hernia repair operations.

What happens in stress incontinence and how does the tape helps to cure this condition?

Stress incontinence occurs due to weakness of the support to the urethra causing additional movement of the urethra (urethral hyper-mobility) during exertion. It can be also due to inability of the urethra to close (Urethral Incompetence). Either of these defects can cause leakage of urine during efforts and exertion.

female_incontThese defects are mostly caused by the damage to muscles and nerves to the pelvic floor during pregnancy and child birth. Vaginal tape operations involve placing a tape made of mesh under the urethra to support it and prevent the additional movements of the urethra and thereby preventing the leakage. Though the damage occurs earlier in life, usually the leakage starts to occur during menopause and also aggravated by longstanding cough, heavy lifting and being over-weight.

Do the Vaginal tape operations cure all women with stress incontinence?

It is suitable for those women who leak because of the mechanisms mentioned above. However, in a small proportion of women, the stress leak can happen due to over-activity of the bladder triggered by coughing. These women are unlikely to benefit from this operation. The likely cause of urine leakage can usually be diagnosed by a test called urodynamics. Most specialists would perform this test before considering surgical treatment for stress incontinence.

Types of Vaginal tapes used for Stress incontinence

The tapes could be inserted from the vagina towards the pubis behind the pubic bone (retro-pubic procedure) or towards the upper part of the inner thigh (Trans-obturator procedure).

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What are the other factors that would be considered before deciding for a Tape operation for incontinence?

A vaginal tape operation with synthetic tape is usually not recommended for a woman who may have intention to have further pregnancy. Pregnancy and childbirth after the tape operation can cause the women to become incontinent again.

Trans-Obturator Tape is preferred for women with over active bladder symptoms with Stress urinary incontinence. Any tape operation could make the Over-Active Bladder symptoms worse. The Trans-obturator tapes are less likely to aggravate these symptoms than retro-pubic tapes.

Retro-pubic tapes have slightly better success rates in curing stress incontinence caused by urethral incompetence though they are associated with slightly higher risk of difficulty passing urine (requiring self-catherisation) and overactive bladder symptoms like urgency and frequency.

Alternative Treatments for Stress Incontinence

Though the vaginal tapes are the most common surgical treatment for stress incontinence at present, we would strongly recommend that before resorting to surgery you try conservative non-surgical methods including pelvic floor muscle exercises that could be helpful for mild to moderate stress incontinence. Apart from this, the alternative options are to manage the leakage with lifestyle changes and use of pads. Other surgical methods like Injection therapy (for selected patients) or colposuspension (open operation to lift the front wall of vagina towards the pupis to support the urethra) are also available.

What is done during the operation? (per-operative)

The tape is introduced through a small cut in the vagina and passes out of the pelvis through a small cut in either side just above the pubis(Retro-pubic method) or in the inner thigh (Trans-obturator method) on each side.

This is usually done with a general anaesthetic (you will be asleep) or an injection in the back. Through the small cuts in the skin and vagina, the tape is threaded into place using two needles. After the introduction of the needles, the bladder will be checked by a camera to make sure the needles have not gone through the bladder. Absorbable (dissolving) stitches will be used to close the cuts. You may also have a vaginal pack to reduce the risk of bleeding from the vagina. This pack will come out when the catheter is removed.

What can you expect after the operation? (Post-operative)

We usually leave a catheter in the bladder when you leave the operating room.

Depending on the time of the day when you are operated the catheter may come out on the evening of the procedure or the next morning.

You may be able to go home on the same day as the operation if the catheter is removed on the same day. Patients who are uncomfortable or have difficulty passing urine stay over night.

You may experience pain or discomfort in your pubic area, vagina and the upper legs (trans-obturator) procedures. This is usually relieved by pain killers.

You may notice a bit of bleeding from the wound edge for 24 hours after the operation which usually settles without any treatment. But if there is a worrying amount of bleeding, you should seek medical help either by contacting your GP or the hospital you’ve been operated. All stitches used are dissolving stitches. You may feel the end of the stitches in your vagina or notice stitches falling over few weeks.

We would recommend you take time off from work for 2 to 4 week. You should avoid any activity or strenuous work that causes discomfort but otherwise no special restrictions are required. You may have a bath or shower after 24 hours as usual.

If you are sexually active, you would need to avoid intercourse for about 6 weeks to allow the cut in the vagina to heal.

With regards to driving, you may not drive for 24 hours after a general anaesthetic. You should refrain from driving until your movements are pain free and you are able to make an emergency stop without pain or discomfort. Usually this could be few days to a week.

When would you need to come for follow up?
We will see you in the clinic after about 3 months or sooner if you are having any problems.
What are the Success rates of this procedure?

Depending on the definition of success, the studies quote different figures. If the success is defined as the relief from the leakages during cough and exertion, the success rates are around 75% in most of the studies. If the success rates are defined as complete patient satisfaction and cure, the figures drop to about 55%- 60% though majority of the patients reported the symptoms were better.

There may be some improvement in associated urgency (a need to reach a toilet urgently.) The procedure is never successful for those with urgency but no stress incontinence.

What are the risks and complications associated with this procedure?

Common

As mentioned before there may be a need for temporary need for inserting a catheter for few days if you fail to pass urine and if you are not able to perform self catheterisation you may be fitted with an indwelling catheter.

Occasional

  • This procedure may fail to improve your incontinence or there may be only partial improvement.
  • The urinary incontinence may come back at a later time after initial improvement
  • If you are not emptying your bladder completely, this can predispose to recurring bladder infections.
  • Wound infection of the incisions that may need antibiotic treatment and in rare occasions operations to remove the pus and the tape.

Rare

  • Though this procedure helps the stress leaks, in about 10% of women, the symptoms like frequency and urgency may get worse. This is because of the bladder becoming over-active after the procedure.
  • If you develop retention of urine, you may require prolonged catheterisation or have to do Self-Catheterisation.
  • A small number of patients(1%) experience ongoing discomfort from the tape in the vagina or thigh.
  • If you are sexually active, you may experience pain or discomfort during sexual intercourse.
  • Some women develop reaction to the sling (tape) material and the tape may have to be removed.
  • During the operation there is a very small risk of injury to the bladder, urethra, bowel, blood vessels and nerves that may require a period of prolonged catheterisation and some times having to post-pone the insertion of the tape to a later date. If there is significant bleeding during or immediately after the operation, it may be necessary to perform an open operation to control the bleeding in the lower abdomen or pelvis.
  • The tape can erode into the bladder or urethra or into vagina in the early period or after few years and may require further operations to remove the tape.

 

Main Points

  • Most likely you will go home by latest the day after the operation. You may have some discomfort or minor bleeding, which usually settles in few days.
  • You will need to take time-off from work for 2-4 weeks and refrain from sexual intercourse for 6 weeks.
  • If you develop any complications mentioned above, you need to seek early attention from your GP or the specialist.
  • If you have any queries about this operation, you should clarify the queries with the surgeon prior to the procedure.