Incontinence, urinary - Surgery and procedures for urinary incontinence

If other treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended.

Before making a decision, discuss the risks and benefits with a specialist, as well as any possible alternative treatments.

If you are a woman and plan to have children, this will affect your decision, because the physical strain of pregnancy and childbirth can sometimes cause surgical treatments to fail. Therefore, you may wish to wait until you no longer want to have any more children before having surgery.

Read on to learn about the different treatments you may be offered. You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.

Surgery and procedures for stress incontinence

Tape procedures

Tape procedures can be used for women with stress incontinence.

A piece of plastic tape is inserted through an incision inside the vagina and threaded behind the urethra (the tube that carries urine out of the body). The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:

• tops of the inner thigh – this is called a transobturator tape procedure (TOT)
• abdomen (tummy) – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT)

By holding the urethra up in the correct position, the piece of tape can help reduce the leaking of urine associated with stress incontinence.

The effectiveness of these tape procedures is similar, with around two in every three women not experiencing any leaking afterwards. Even those who still have some leaking after surgery often find this is less severe than it was before the operation.

However, it is not uncommon for women to need to go to the toilet more frequently and urgently after this procedure, and some find they are unable to completely empty their bladder when they go to the toilet.

In some cases, the tape can wear away or move over time and further surgery may be needed at a later stage to adjust it (for example, to make it looser) or to remove it.

The British Association of Urological Surgeons (BAUS) has more information on synthetic vaginal tapes for stress incontinence (PDF, 255kb). You may also find it useful to read information from the Medicines and Healthcare products Regulatory Agency (MHRA) on vaginal tapes for stress urinary incontinence.

Colposuspension

Colposuspension involves making an incision in your lower abdomen, lifting up the neck of your bladder, and stitching it in this lifted position. This can help prevent involuntary leaks in women with stress incontinence.

There are two types of colposuspension:

• an open colposuspension – where surgery is carried out through a large incision
• a laparoscopic ('keyhole') colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments

Both types of colposuspension offer effective, long-term treatment for stress incontinence, although laparoscopic colposuspension needs to be carried out by an experienced laparoscopic surgeon.

Problems that can occur after colposuspension include difficulty emptying the bladder fully when going to the toilet, recurrent urinary tract infections (UTIs) and discomfort during sex.

BAUS has more information on bladder neck suspension (PDF, 240kb).

Sling procedures

Sling procedures involve making an incision in your lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. The sling can be made of:

• a synthetic material
• tissue taken from another part of your body (an autologous sling)
• tissue donated from another person (an allograft sling)
• tissue taken from an animal (a xenograft sling), such as cow or pig tissue

In many cases, an autologous sling will be used and will be made using part of the layer of tissue that covers the abdominal muscles (rectus fascia). These slings are generally preferred because more is known about their long-term safety and effectiveness.

The most commonly reported problem associated with the use of slings is difficulty emptying the bladder fully when going to the toilet. A small number of women who have the procedure also find that they develop urge incontinence afterwards.

Urethral bulking agents

An urethral bulking agent is a substance that can be injected into the walls of the urethra in women with stress incontinence. This increases the size of the urethral walls and allows the urethra to stay closed with more force.

A number of different bulking agents are available and there is no evidence that one is more beneficial than another.   

This is less invasive than other surgical treatments for stress incontinence in women as it does not usually require any incisions. Instead, the substances are normally injected through a cystoscope (thin viewing tube) inserted directly into the urethra.

However, this procedure is generally less effective than the other options available. The effectiveness of the bulking agents will also reduce with time and you may need repeated injections.

Many women experience a slight burning sensation or bleeding when they pass urine for a short period after the bulking agents are injected.

BAUS has more information on urethral bulking injections (PDF, 239kb).

Artificial urinary sphincter

The urinary sphincter is a ring of muscle that stays closed to prevent urine flowing from the bladder into your urethra. In some cases, it may be suggested that you have an artificial urinary sphincter fitted to relieve your incontinence.

This tends to be used more often as a treatment for men with stress incontinence and is only rarely used in women.

An artificial sphincter consists of three parts:

• a circular cuff that is placed around the urethra – this can be filled with fluid when necessary to compress the urethra and prevent urine passing through it
• a small pump placed in the scrotum (when used in men) that contains the mechanism for controlling the flow of fluid to and from the cuff
• a small fluid-filled reservoir in the abdomen – the fluid passes between this reservoir and the cuff as the device is activated and de-activated

The procedure to fit an artificial urinary sphincter often causes short-term bleeding and a burning sensation when you pass urine. In the long-term, it is not uncommon for the device to eventually stop working, in which case further surgery may be needed to remove it.

BAUS has more information on the insertion of an artificial urinary sphincter in men (PDF, 240kb).

Surgery and procedures for urge incontinence

Botulinum toxin A injections

Botulinum toxin A (Botox) can be injected into the sides of your bladder to treat urge incontinence and overactive bladder syndrome (OAB).

This medication can sometimes help relieve these problems by relaxing your bladder. This effect can last for several months and the injections can be repeated if they help.

Although the symptoms of incontinence may improve after the injections, you may find it difficult to fully empty your bladder. If this happens, you will need to be taught how to insert a catheter (a thin, flexible tube) into your urethra to drain the urine from your bladder.

Botulinum toxin A is not currently licensed to treat urge incontinence or OAB, so you should be made aware of any risks before deciding to have the treatment. The long-term effects of this treatment are not yet known.

Sacral nerve stimulation

The sacral nerves are located at the bottom of your back. They carry signals from your brain to some of the muscles used when you go to the toilet, such as the detrusor muscle that surrounds the bladder.

If your urge incontinence is the result of your detrusor muscles contracting too often, sacral nerve stimulation – also known as sacral neuromodulation – may be recommended.

During this operation, a device is inserted near one of your sacral nerves, usually in one of your buttocks. An electrical current is sent from this device into the sacral nerve. This should improve the way signals are sent between your brain and your detrusor muscles, and so reduce your urges to urinate.

Sacral nerve stimulation can be painful and uncomfortable, but some people report a substantial improvement in their symptoms or the end of their incontinence completely.

BAUS has more information on sacral nerve stimulation (PDF, 245kb).

Posterior tibial nerve stimulation

Your posterior tibial nerve runs down your leg to your ankle. It contains nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder symptoms, such as the urge to pass urine.

During the procedure, a very thin needle is inserted through the skin of your ankle and a mild electric current is sent through it, causing a tingling feeling and causing your foot to move. You may need 12 sessions of stimulation, each lasting around half an hour, one week apart.

Some studies have shown that this treatment can offer relief from OAB and urge incontinence for some people, although there is not yet enough evidence to recommend tibial nerve stimulation as a routine treatment.

Tibial nerve stimulation is only recommended in a few cases where urge incontinence has not improved with medication and you don't want to have botulinum toxin A injections or sacral nerve stimulation.

Augmentation cystoplasty

In rare cases, a procedure known as augmentation cystoplasty may be recommended to treat urge incontinence.

This procedure involves making your bladder bigger by adding a piece of tissue from your intestine (part of the digestive system) into the bladder wall.

After the procedure, you may not be able to pass urine normally and you may need to use a catheter. Due to this, augmentation cystoplasty will only be considered if you are willing to use a catheter.

The difficulties passing urine can also mean that people who have augmentation cystoplasty can experience recurrent urinary tract infections.

BAUS has more information on enlargement of the bladder using a segment of bowel (PDF, 260kb).

Urinary diversion

Urinary diversion is a procedure where the ureters (the tubes that lead from your kidneys to your bladder) are redirected to the outside of your body. The urine is then collected directly without it flowing into your bladder.

Urinary diversion should only be carried out if other treatments have been unsuccessful or are not suitable.

Urinary diversion can cause a number of complications, such as a bladder infection, and sometimes further surgery is needed to correct any problems that occur.

Catheterisation for overflow incontinence

Clean intermittent catheterisation

Clean intermittent catheterisation (CIC) is a technique that can be used to empty the bladder at regular intervals and so reduce overflow incontinence (also known as chronic urinary retention).

A continence adviser will teach you how to place a catheter through your urethra and into the bladder. Your urine will flow out of your bladder, through the catheter and into the toilet.

Using a catheter can feel a bit painful or uncomfortable at first, but any discomfort should subside over time.

How often CIC will need to be carried out will depend on your individual circumstances. For example, you may only need CIC once a day, or you may need to use the technique several times a day.

Regular use of a catheter increases the risk of developing UTIs.

Indwelling catheterisation

If using a catheter every now and then is not enough to treat your overflow incontinence, you can have an indwelling catheter fitted instead. This is a catheter inserted in the same way as for CIC, but left in place. A bag is attached to the end of the catheter to collect the urine.

Read more about urinary catheterisation.