Procedures to stop incontinence
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: I've tried many things to treat my incontinence, including exercises and biofeedback. But I still leak urine when I exercise, cough, or sneeze. I'm ready to consider surgery. Can you tell me about the different options? I'm a woman in my late 50s.

A: For women, operations for stress incontinence aim to provide extra support for the urethra, the tube that carries urine from the bladder to outside the body. There are three main techniques: sling procedures, bladder neck suspensions, and a procedure that involves injecting a bulking agent to firm up tissues surrounding the urethra.

Sling surgery is the most common procedure. It creates a little hammock that supports the urethra (see illustration). The sling is usually made with an artificial tape similar to nylon that is placed under and around the urethra. Because your body creates scar tissue around and through the mesh, the tape stays in place without stitches. This operation can usually be performed under local anesthesia. Most women return to normal activities within about 10 days after the operation.

A newer, less invasive variation is called the transobturator tape procedure. The tape is inserted through a small incision in the vagina, and the ends are brought out through tiny incisions between the labia and the creases of the thighs. The sling supports the urethra in a gentler fashion, forming a curve that's shaped more like a smile than the letter U. This operation takes about half an hour. Most women can return to normal activities within a few days as long as they don't lift heavy objects. Because it doesn't require an incision in the abdomen, this procedure carries a lower risk of bowel or bladder injury during surgery. And it can be used in women who have scar tissue from previous operations. The most common complications are urinary infections, difficulty urinating and wearing down of the vaginal wall near the tape.

Bladder neck suspensions are less common but are still performed in some cases. For the main procedure, called a retropubic suspension, the surgeon cuts a 3- to 5-inch incision in your lower abdomen and lifts the tissue next to the bladder neck up, anchoring it near the pubic bone. The various procedures are usually named for the surgeons who developed them. In the Burch procedure, the surgeon uses strong stitches (sutures) to anchor the tissue to a ligament near your pubic bone. If the stitches are placed into the pubic bone itself, the operation is called the Marshall-Marchetti-Krantz (MMK) procedure.

Three distressing but uncommon problems may occur after any type of surgery for stress incontinence. In rare cases, women have undone the benefits of the surgery by lifting or other strenuous activity, even after the healing period is over. And up to 15 percent of women develop urge incontinence, which is characterized by a sudden, hard-to-control urge to urinate. Finally, some women have difficulty urinating, which in rare cases may require you to use a catheter (a tube inserted into the urethra) to empty your bladder. The risks vary with the different procedures.

The final option, injecting bulking agents, works best for women with a type of stress incontinence caused by a weakness in the muscles near the urethra. The bulking agent pushes against the urethra to make it narrower so that it closes off more readily.

The injections take less than half an hour and can be done in the physician's office or as an outpatient procedure in the hospital. You will be given either local or a light general anesthesia or sedation. The doctor places a needle into the urethra and injects the agent into the tissue alongside the urethra. A few injections may be given during one session. But since only a small amount of the bulking agent is injected at one time, you may need more than one treatment to get satisfactory results. Physicians must be cautious about injecting too much: If the urethra becomes blocked, they may need to remove the material surgically.

For the first day or two after an injection, you may feel irritation when you urinate. You might even need to use a catheter off and on until swelling goes down in the area of the injection. After a few days, you should be able to return to normal activities.

You may need to undergo testing to see which procedure would work best for you, and your physician can help you decide. Although not life-threatening, incontinence is a very frustrating and unpleasant problem. If simpler methods fail, surgery can be a good option.

Copyright 2007 the President and Fellows of Harvard College. Developed by Harvard Health Publications (www.health.harvard.edu). Distributed by UFS. Submit questions to harvard_ adviser@hms.harvard. edu.p