Note: Before any surgery, it is necessary to exclude the presence of urge symptoms. This is because they can worsen after surgery!This also means that in cases of mixed incontinence, the urge component must be treated first. 2nd order
Stress or strain incontinence
Ms.
- Colposuspension (elevation of the anterior vaginal wall )
- Burch surgery – through a lower abdominal incision, the vagina can be fixed via retaining sutures near the pubic branches, thus lifting the bladder neck.
- Laparoscopic colposuspension; most effective when using two paravaginal sutures; follow-up of 2 years postoperatively showed that the procedure could be as good as open colposuspension.
- Tension free vaginal tapes (TVT) – this is a plastic tape that is placed tension free over the vagina under the urethra, so that the urethra is stabilized during increased abdominal pressure.
- TOT (Trans-obturator technique ) – a plastic band is placed tension-free under the urethra and discharged via the thigh flexors. (Variant of TVT surgery) [TOT is currently hardly used; in contrast, retropubic TVT is favored again].
- Implacement therapy – injection of a gel (e.g., with silicone, polyacrylamide, Teflon, collagen or a hyaluronic acid derivative) via the urethra into the area of the urethral sphincter to stabilize it.
- Artificial sphincter (artificial sphincter) – insertion of a plastic sleeve, which is placed around the urethra and is connected to a pump and a reservoir of water in the abdomen; the fluid ensures urethral closure; to urinate, the pump is actuated, the fluid flows into the reservoir
Other notes
- Both the TVT procedure and the transobturator technique (TOT) are highly effective according to an evaluation by the Cochrane Institute. However, TOT results in significantly fewer complications.Further studies are needed to assess the long-term effectiveness of minimally invasive snare procedures.
- In a study of over 95,000 women with stress incontinence surgery (minimally invasive using sling insertion), the long-term effectiveness of implanted tapes was followed up; sling removal occurred:
- After one year: 1.4% of all women.
- After five and nine years: 2.7% and 3.3% of all women, respectively (retropubic loops: 3.6% and 2.7%, respectively)
Repeat incontinence-related surgery:
- After one year: 1.3% of all women.
- After five and nine years: 3.5% and 4.5% of all women, respectively (women with transobturator sling insertion were at a disadvantage: 9-year risk of 5.3% vs. 4.1% with retropubic technique
Consideration of both interventions together; outcome rates:
- After one year, 2.6% of all women
- After five and nine years: 5.5% and 6.9% of all women, respectively.
The type of technique used made no statistically significant difference!
Man
- Paraurethral injection therapy (sphincter suppression) – “bulbing agents”.
- Paraurethral balloon compression
- Suburethral slings – “male sling”.
- Autologous fascial strip
- Bone fixed sling system
- Transobturator ligaments (as in women).
- Artificial sphincter (artificial urinary bladder sphincter) – gold standard in the treatment of male stress incontinence.
Stress incontinence after radical prostatectomy has a favorable spontaneous course in most cases. Therefore, sufficiently long conservative therapy (pelvic floor training, biofeedback, electrostimulation, magnetic spring stimulation) should be used before surgical therapy is performed.
Urge Incontinence
It is the domain of conservative treatment methods:
- Combined stress urge incontinence [man + woman]After insufficient improvement of other therapeutic measures such as pelvic floor training, stimulation current therapy, biofeedback, etc., an appropriate operation is also considered if the stress component is clearly predominant.
Reflex incontinence
- Sacral nerve stimulation: this is an electrotherapy procedure. Similar to a pacemaker, electrical pulses are delivered by a generator that is implanted under the skin.The electrical impulses stimulate the nerves leading to the pelvic floor and the sphincter muscles of the bladder and anus, restoring control of these organs.
Overactive bladder (ÜAB; engl. “overactive bladder”, OAB)
- Bladder augmentation (bladder enlargement; usually performed as ileal augmentation) [last resort therapy; number of these procedures is declining overall].
Overflow incontinence
- Therapy of choice is surgical removal of the urinary outflow obstruction, such as a urinary stone or urethral stricture.
Extrauterine incontinence
- Therapy consists of surgical removal of the fistula
Chronic urinary retention with urinary incontinence
In a genesis of chronic urinary retention, surgical removal of the subvesical outflow obstruction is the primary goal.
- Male: The most common cause of subvesical outflow obstruction is benign prostatic hyperplasia (BPH) and prostatic carcinoma.
- Woman: meatusenge (extremely rare).
For surgical measures, see under the respective disease.
