SURGICAL TREATMENTS FOR INCONTINENCE

Treating incontinence can be incredibly difficult depending on the type.  Generally, treatment goals are to keep urinary tract and kidney damage to a minimum or eliminate it altogether, reduce or eliminate incontinence episodes (accidents), reduce (preferably eliminate) urinary tract infections (UTI) and maintain overall health.  As you saw in the “types of incontinence” section, there are a number of types of incontinence and a person can have more than one type.  The information below speaks in generalities and may or may not apply to your type of incontinence or the proper treatment for it.  Your first step is to talk with an Urologist for advice on where to start.  The following information should NOT be used for diagnosis or treatment or in place of the advice of a qualified physician.  it is for reference only to give you an idea of some of the options that may be available to treat your incontinence.  This information is in regard to surgical treatments for incontinence.  We have another section devoted specifically to non-surgical treatments for incontinence. 

Transurethral Resection of the Prostate (TURP):  This is a surgery that may be done when enlargement of the prostate is the cause of urinary retention, frequency, urgency and weak stream.  In this surgery, an instrument called a cystoscope is passed up the urethra to the prostate.  Then a cutting instrument is passed up the cystoscope and the section of the prostate that is causing blockage of urine flow is cut out (or resected).  This surgery is usually done under general anesthesia or using a spinal block anesthetic.  Following the surgery a catheter is placed in the urethra for a time to allow passage of blood clots that may form and to allow tissue to heal.  There may be a brief hospital stay after the surgery and strenuous activity must be avoided for a time after the surgery while the tissue heals.  For more on the TURP procedure, you can check out this WebMD link about BPH.

Sphincterotomy:  This is another surgery used to treat urinary retention or those who are unable/unwilling to perform intermittent catheterization as a means of urinary management or for those who other means of treatment have been ineffective at protecting the upper urinary tract (kidneys, etc...).  In this usrgery, as above, a cystoscope is passed up the urethra to the external urinary sphincter.  The sphincter is cut and then after the surgery a foley catheter is placed while the tissue heals.  Following the surgery, the bladder empties by reflex and the person must wear an external collection device such as an external catheter, diaper, etc...  The risks with sphincterotomy can include excessive bleeding during and after surgery necessitating blood transfusion and infertility.  Infertility is caused because sperm will now travel up into the bladder instead of out the penis after the surgery.  The sphincter muscle may grow back over time, requiring the surgery to be done again.

Chemical Sphincterotomy is the same idea as above, but not considered a permanent surgery.

In this surgery, botox (or botulinum toxin) is injected into the sphincter causing it to relax and open, allowing the free passage of urine any time the bladder (detruser) muscle contracts.  The result is the same as a surgical sphincterotomy, requiring an external collection device or diaper, but over a period of 6 to 9 months, the procedure must be done again, as the effects of botox wear off.  The benefits of chemical sphincterotomy is that it is temporary and will allow someone who may be considering permanent surgical sphincterotomy to see if it is something they can live with permanently.

Supra-Pubic Catheterization:  This is the same thing as foley catheterization with the key difference being that the catheter is passed through the abdominal wall into the bladder.  It is used for the same reasons as foley catheterization through the urethra (continuous urine drainage and/or bladder irrigation), and one of the benefits is it reduces or eliminates bladder spasms that are caused by the balloon resting on the floor of the bladder when the catheter is inserted through the urethra because the balloon from the supra-pubic catheter does not rest on the bladder floor.  This is a surgical intervention, as a supra-pubic passage is usually created in a surgical setting.  As with any invasive surgery, risks from infection, anesthetic exposure, etc... are present and should be carefully considered.

This picture shows the difference between urethral catheter placement and supra pubic catheter placement.  The supra pubic catheter is on the right.  Notice how the supra pubic catheter balloon does not rest on the badder floor as it does in a urethral catheterization.  Again, supra pubic catheterization is a surgical procedure and does have risks.

Vesicostomy:  The vesicostomy is a surgery that is usually done on babies or young children with neurological problems (spina bifida, spinal cord injury, etc....) as a way of continually draining urine so that pressure inside the bladder does not cause it to back up into the kidneys and damage them.  In a vesicostomy, a passage is made from the bladder to the outside of the body usually about two inches below the belly button.  The stoma allows urine to continuously drain into a diaper.  The vesicostomy is usually considered a temporary solution and can be reversed at a later time when another method of bladder management may be used.  

Urostomy:  The urostomy has some similarities to the vesicostomy in that it is a method to continuously drain urine from the body, but in this instance, the ureters (the tubes that run from the kidneys to the bladder are rerouted to a conduit that is made of a section of bowel that runs to the outside of the body.  Once this is is done, urine continuously drains from the ureters through the conduit to the outside of the body into a bag that is attached to the skin.  The bag is then emptied at appropriate times.  This surgery may be done when damage has occured to the urinary tract and urine can no longer pass or people who are incontinent may have this surgery done for “social continence” to eliminate diapers or pads.  The person would be dry after this procedure and no longer need diapers or pads for urinary incontinence.  This is an involved surgery and does involve a hospital stay and risks associated with any surgery.  It is meant as a more long term solution to urinary drainage.

Mitrofanoff (appendicovesicostomy):  In this surgery, the appendix is used to make a conduit from the bladder to a stoma on the outside of the abdomen (usually located inside the belly button) for the purpose of intermittent catheterization.  This is done when the urethra has sustained damage or has a defect or when regular catheterization is necessary to drain the bladder.  Many people with spinal cord injuries, spina bifida and other issues find this procedure makes them more independent as it eliminates the need to catheterize through the urethra, meaning they can cath while seated in a wheelchair.  The bladder neck is often tightened or stitched shut to prevent leakage from the urethra so pads, diapers or external catheters may no longer be necessary.  This is an involved surgery and a hospital stay and recovery are required.  this is usually considered a permanent solution.

Botox Injections into the Bladder:  This surgery is done to relax the bladder in an attempt to stop urine leakage and to lower pressure in the bladder to keep urine from backing up into the kidneys.  During the procedure (usually done under general anesthesia) a tube called a cystoscope is passed up through the urethra into the bladder.  Through that, a needle is passed and inserted into the wall of the bladder and botox is injected in several areas.  The botox paralyzes the bladder muscle keeping it from contracting.  Usually after this surgery, intermittent catheterization is necessary to empty the bladder and urinary leakage is either reduced or eliminated.  The surgery can usually be done on an outpatient basis and is considered temporary, as the effects of botox usually wear off over a period of 6 to 9 months and the surgery will have to be redone.  This surgery is done in cases of overactive and spastic bladder where medications have failed or the side effects are intolerable.

Bladder Suspension Surgery:  This is surgery that is performed on women who live with stress incontinence when other treatment options such as kegal exercises have failed.  Over time, the bladder and urethra sag due to things such as childbirth, age, pelvic floor muscle weakness and surgery.  The aim is to support the bladder and/or urethra in a more normal position.  The surgery is either done through an abdominal incision or laproscopically.  As with any surgery, there can be complications from anesthesia, infection and in rare cases, some women may experience urinary retention which requires intermittent catheterization.  Check out this WebMD write up on these surgeries.

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