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continued:

Urinary incontinence surgery: When other treatments aren't enough

Bulking agents

Bulking agents are materials, such as collagen, that are injected into tissue surrounding the urethra to help keep the urethra closed and reduce urine leakage.

A bulking agent procedure — usually done in a doctor's office — requires minimal anesthesia. The downside of the procedure is that bulking agents may lose their effectiveness over time and may require repeat injections.

The standard method of injecting a bulking agent is through a needle, which is inserted in different positions with the assistance of a cystoscope — a slender, tube-like instrument that allows the surgeon to view the urethral area.

Materials used as bulking agents include:

  • Collagen. Collagen is a natural fibrous protein found in connective tissue, bone and cartilage of humans and animals. Collagen can produce an allergic reaction in some people. For this reason, your doctor will apply a skin test before performing the procedure to see if you have a reaction.
  • Carbon-coated zirconium beads. Durasphere is a bulking agent that uses carbon-coated zirconium beads that consist of synthetic material to bulk up the tissue surrounding the urethra. Durasphere doesn't require allergy tests.
  • A component of bones and teeth. Coaptite is a bulking agent that's made from particles of calcium hydroxylapatite, which is a component of bones and teeth. Coaptite doesn't require allergy tests.
  • Silicone implant. Macroplastique is a bulking agent that's made from synthetic, rubber-like silicone. Macroplastique doesn't require allergy tests.

One material isn't necessarily better than another. If you try one and it doesn't seem to help, your doctor may suggest trying another material. New bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.

Surgery for overactive bladder

CLICK TO ENLARGE

Illustration showing sacral nerve stimulation device Sacral nerve stimulation

Surgery for overactive bladder may involve implanting a nerve stimulation device or increasing your bladder's capacity.

Sacral nerve stimulation
Sacral nerve stimulation inhibits messages sent by an overactive bladder to your brain, signaling a need to urinate. Sacral nerve stimulation works by continuously sending small, electrical impulses to the nerves that control urination. The impulses are generated by a small, pacemaker-like device surgically placed under the skin, usually in your buttock. Attached to the device — called a stimulator — is a thin, electrode-tipped wire that passes under your skin, carrying these impulses to the sacral nerve.

Because sacral nerve stimulation doesn't work for everyone, you can try it out first by wearing the stimulator externally, after the attached wire is placed under your skin in a minor surgical procedure. If the stimulator substantially improves your symptoms, then you can have it implanted.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia and mild sedation. You may be advised to limit activities for three or more weeks as your incisions heal. Your doctor can adjust the level of stimulation with a hand-held programmer, and you also have a control to use for adjustments. The stimulation doesn't cause pain and may improve or successfully treat people with urge incontinence who haven't had success with medications or lifestyle changes.

Tibial nerve stimulation
Tibial nerve stimulation is a procedure to stimulate a nerve in the leg (tibial nerve). The electrical stimulation travels along the tibial nerve to the spine, where it connects with the nerves that control the bladder.

Called percutaneous tibial nerve stimulation, the procedure involves placing a needle through the skin near the ankle to reach the tibial nerve. An electric impulse is sent through the needle. The procedure takes about 30 minutes and is initially done weekly for about 12 weeks.

Tibial nerve stimulation may be an option if you've tried other treatments without success and you don't want to undergo surgery. Tibial nerve stimulation is an alternative to sacral nerve stimulation.

Botox injection
Doctors are studying injections of OnabotulinumtoxinA (Botox) to see whether this medication, often used to relax muscles, may relax the bladder muscles. Botox injections for overactive bladder involve taking a medication to relax you. Your doctor then injects Botox into the bladder muscles using a needle. This usually needs to be repeated in six to nine months.

Bladder augmentation
Bladder augmentation is a procedure used to increase the size of your bladder. The operation is complex and involves major abdominal surgery. An incision is made in your abdomen and an opening is made at the top of your bladder. Your surgeon then takes a strip of tissue, usually from your intestine or stomach, and attaches it onto the bladder opening. This added tissue patch increases the size of your bladder.

Recovery generally requires staying in the hospital until you're able to start drinking and eating again. It usually takes six weeks after you leave the hospital for you to return to your normal schedule. Many people require lifelong use of a catheter after the procedure. Bladder augmentation doesn't always cure incontinence and can have complications such as infection. Bladder augmentation may be an option if other treatments haven't helped.

One step at a time

Finding an effective remedy for urinary incontinence may take time, with several steps along the way. If a particular treatment approach isn't working for you, ask your doctor if there's another solution to your problem.

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References
  1. Wein AJ, et al. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa.: Saunders Elsevier; 2007. http://www.mdconsult.com/das/book/body/208746819-6/0/1445/0.html. Accessed Feb. 15, 2011.
  2. Lentz GM. Urogynecology: Physiology of micturition, diagnosis of voiding dysfunction and incontinence: Surgical and non surgical treatment. In: Katz VL, et al. Comprehensive Gynecology. 5th ed. Philadelphia, Pa.: Mosby Elsevier; 2007. http://www.mdconsult.com/das/book/body/208746819-4/0/1524/0.html. Accessed Feb. 15, 2011.
  3. Jelovsek JE, et al. Stress urinary incontinence in women: Choosing a primary surgical procedure. http://www.uptodate.com/home/index.html. Accessed Feb. 16, 2011.
  4. Reyblat P, et al. Augmentation cystoplasty: What are the indications? Current Urology Reports. 2008;9:452.
  5. Smaldone MC, et al. Botulinum toxin therapy for neurogenic detrusor overactivity. Urologic Clinics of North America. 2010;37:567.
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  7. Flesh G. Midurethral slings for treatment of stress urinary incontinence in women. http://www.uptodate.com/home/index.html. Accessed Feb. 21, 2011.
  8. Surgery for stress urinary incontinence. American Congress of Obstetricians and Gynecologists. http://www.acog.org/publications/patient_education/bp166.cfm. Accessed Feb. 16, 2011.
  9. Surgical treatment for female stress urinary incontinence. National Association for Continence. http://www.nafc.org/bladder-bowel-health/types-of-incontinence/stress-incontinence/surgical-treatment-for-female-stress-urinary-incontinence/. Accessed Feb. 16, 2011.
  10. Bladder augmentation. UrologyHealth.org. http://www.urologyhealth.org/adult/index.cfm?cat=03&topic=170. Accessed Feb. 21, 2011.
  11. Urgency urinary incontinence/overactive bladder. National Association for Continence. http://www.nafc.org/bladder-bowel-health/types-of-incontinence/urge-incontinence/. Accessed Feb. 16, 2011.
  12. Pettit PD (expert review). Mayo Clinic, Jacksonville, Fla. March 11, 2011.
  13. Macroplastique (prescribing information). Minnetonka, Minn.: Uroplasty, Inc.; 2006. http://www.accessdata.fda.gov/cdrh_docs/pdf4/P040050c.pdf. Accessed March 11, 2011.
  14. Peters KM. Alternative approaches to sacral nerve stimulation. International Urogynecology Journal. 2010;21:1559.
WO00126 March 26, 2011

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