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Incontinence treatments tailored to each patient

Many people think urinary incontinence is an uncommon and unusual problem that affects only a small number of elderly or disabled women. We recently found that about 35 percent of all women who came to our office for routine gynecological care have urinary incontinence.

Two out of every three affected women have not sought treatment for a number of reasons—because they were embarrassed, hoped their incontinence would improve by itself, were afraid they might need surgery or erroneously believed incontinence is a normal condition of aging.

Urinary incontinence is not a normal condition regardless of your age or health. It can be devastating psychologically as well as socially, emotionally and physically. Studies have found that up to 60 percent of women reported urinary incontinence affects their daily lives, 40 percent believed it interferes with their sexual function, 75 percent thought it affects their mental health and 20 percent concluded it makes their life intolerable.

Fortunately, there are treatments that can cure urinary incontinence and restore a woman’s quality of life. Stress urinary incontinence can be treated with nonsurgical and surgical methods.

Nonsurgical approaches
Muscle strengthening or Kegel exercises make a woman’s pelvic floor muscles stronger. The stronger pelvic floor muscles compress the urethra more effectively to prevent or lessen urine loss when the woman coughs or does anything strenuous. Several studies have found that approximately 50 percent of women treated with Kegel exercises either were cured or experienced significant improvement in their incontinence.

Kegel exercises
Kegel exercises are much more effective when they are taught by a trained physical therapist, reinforced weekly in a class for three to six months and practiced daily at home. Verbal or written instructions alone cause 30 percent of the women to contract the wrong muscles, which frequently makes incontinence more severe.

Kegel exercises are sometimes taught using some form of biofeedback. Biofeedback involves the use of visual or audio signals to let a woman know she is contracting the pelvic floor muscles. It may help a woman learn to contract the proper pelvic floor muscles; however, biofeedback probably does not increase the effectiveness of Kegel exercises in curing stress incontinence.

Vaginal cones
For women who are unable to master Kegel exercises, vaginal cones are an alternate approach. Vaginal cones are small cylinders of incremental weights that are placed in the vagina. The cones make a woman identify and exercise the proper muscles through trial and error since she can only retain the cone in her vagina by contracting her pelvic floor muscles. A Cochrane Library review concluded that vaginal cones seem to have similar efficacy as Kegel exercises in treating stress urinary incontinence.

Collagen injections
Collagen injections underneath the lining of the urethra are another option for women with stress incontinence due to a weak urethra. The injections narrow the lumen of the urethra, which allows a woman to close the urethral opening more easily and prevent or lessen urine loss. Injections may be performed in the office or operating room. The benefit usually lasts for several months and may last as long as one or two years. When incontinence recurs, collagen injections may be repeated, but each subsequent injection may become more difficult to perform.

Surgical approaches
Surgical procedures used to treat stress urinary incontinence include anterior repair, transvaginal needle suspension, suburethral sling, tension-free vaginal tape (TVT) and retropubic colposuspension.

Anterior repair
Anterior repair is performed vaginally through an incision in the anterior (upper) wall of the vagina. It tightens the vaginal wall and puts the bladder back in its normal position. It is easy to perform, does not require an abdominal incision, and has a short recovery time.

Transvaginal needle suspension
Transvaginal needle suspension is performed through a small vaginal and abdominal incision. It suspends the vaginal tissue adjacent to the urethra and bladder to the anterior abdominal wall. In two separate reviews, the Cochrane Library concluded that anterior repair and transvaginal needle suspension are probably not as effective as retropubic colposuspension in curing stress urinary incontinence.

Suburethral sling
Suburethral sling is performed through a small incision in the vagina and abdomen. In this procedure, a piece of synthetic or donor tissue is used to form a supportive hammock around the bladder neck (the area where the urethra enters the bladder) to prevent urine loss. Two ends of the tissue are then sutured to the anterior abdominal wall. A Cochrane Library review concluded that there are insufficient data to determine whether suburethral sling is more, less or just as effective as other surgical procedures in treating stress urinary incontinence.

Tension-free vaginal tape (TVT)
Approximately six years ago, a new surgical procedure, called tension-free vaginal tape (TVT), was introduced. This procedure is performed through a small vaginal and two small abdominal incisions. TVT involves placing a narrow strip of synthetic material around the middle of the urethra. A Cochrane Library review found that on a short-term basis, TVT seems to be just as effective as retropubic colposuspension in curing stress incontinence; however, its long-term cure rate is still unknown.

Individual choices determine treatment
We base our treatment for stress urinary incontinence on each woman’s individual preference. Some women prefer nonsurgical therapy; others request surgery; a few just want the reassurance that their incontinence is not caused by cancer. We make sure each woman is fully aware of all the available treatment options and understands the advantages and disadvantages of each. We then help her choose a treatment that matches her comfort level, which includes supporting a choice of no treatment.

If a woman does not have a treatment preference, we usually recommend undergoing nonsurgical therapy first. For women who do not respond to nonsurgical therapy or prefer surgical treatment, we usually recommend retropubic colposuspension performed through an abdominal incision because it has the highest long-term cure rate. This surgery, however, requires a two-day hospital stay and four to six weeks to recover.

For older women, a shorter operating time and quick recovery may be more important. In these cases, we frequently recommend TVT. We thoroughly discuss the advantages and disadvantages of this relatively new procedure—specifically the lack of data on long-term outcomes—with each patient before surgery. Most important, treatment of any kind should be tailored to each individual.

We encourage anyone whose daily activities and quality of life are being affected by urinary incontinence to talk to her health care providers about what treatment options might be most appropriate for her.

Dr. Sze is chief of Yale-New Haven Hospital’s section of urogynecology and reconstructive pelvic surgery. He is also an associate professor of obstetrics, gynecology, and reproductive sciences at the Yale University School of Medicine.