Bladder Health: What Every Woman Should Know About Stress Urinary Incontinence

Hi, I’m Dr. Amy Rosenman, this is Dr.
Tamara Grisales, and this is Dr. Ja-Hong Kim. And we are all here from the Center for
Women’s Pelvic Health at UCLA. We are urogynecologists, both from the
gynecology and urology divisions, all working together to give our patients
the best in care for incontinence, prolapse, and other bladder dysfunction
and pelvic floor dysfunctions. If you have any questions, please ask your
questions on Twitter at #UCLAMDChat. First, we’re going to talk about what is
stress urinary incontinence. It’s the involuntary urinary loss or
leakage with exertion, such as cough, laugh, sneeze, exercise, running–we could
go on and on–and in this picture here, you can see that with pressure in the
abdomen, urine leaks out of the bladder. Those of us who have it know exactly
what I’m talking about. Why does it occur? Well, this picture is extremely graphic,
and it shows you that the number one cause is childbirth, and you can see that
childbirth causes some damage to a lot of the pelvic structures that are easily
seen on this side of our screen. It causes crushing, nerve damage, and
actually tearing of some of the tissues. After childbirth does its deed, we have
gravity that takes its toll over the long term of our lives. Then we have the
additional benefit of menopause and a reduction in hormone support, and the
fact that we are bipeds. Quadrupeds– horses, dogs–don’t have quite as much
prolapse because the forces are in a different direction. This is an anatomic
view of the actual breakage that can occur in the ligaments that support the
urethra. So, here we have the disruption of the hammock mechanism and some
tearing that allows the urethra to move and urine to leak. When you have
weakening of the muscles that support the pelvic floor as well, this leads to urethral muscle insufficiency, and that
can cause leakage with minimal activity. So, here we see that with good support, we
have the urethra well-supported but if this isn’t, it can be open, and urine can
leak. And we’re dependent on the entire basket of muscles that we call the
pelvic floor that holds our bladder and keeps our urethra in place along with
our other pelvic structures. How do we diagnose it? Well, first you have to let
us know about it. You have to let your doctor know that you leak when you are
active or that you leak at all, and we’ll help you figure out what it is that’s
causing it. So if you’re having involuntary loss–involuntary means you
didn’t sit on the toilet and intend to pee–if you’re leaking urine with
exertion, coughs, laughs, sneeze, intercourse, jumping, running, lifting–if
you have a history of obstetric trauma, if you’ve had a difficult birth, forceps,
if you’ve had prior pelvic surgery or radiation, if you’re menopausal–we want
to know if you have plans for future pregnancies, we want to know what
medicines you’re on, we want to know how severe are your symptoms and how much
does it impact the quality of life, because this is a quality of life
problem. It’s not a dangerous disease, but it is one that is not normal, and it is
one that does impact the quality of life. We might ask you to do a voiding diary
or pad testing, which would mean that you would bring in wet pads that we would
then weigh, but more likely we’d be asking you to do a voiding diary and
measure how much you void and when you’re leaking. Just mark it all down for
1 or 2 days. It’s not an excessively onerous request. We’ll get a detailed
history, and we’ll ask you very specific questions. We will even ask you to cough
with your bladder somewhat full to actually see the leaking, and this is not
to embarrass you. It just really helps us know how to help you most, and I tell all
of our patients, we chose this field, we’re used to it, we don’t mind.
We look for the urethral movement that we described before that tells us you
have a lack of urethral support because that helps us also hone in and what’s
the best treatment. We’ll look for other conditions, such as vaginal prolapse,
dropping of your pelvic organs, or thinning of the vaginal tissues. That’s
going to help us add to your total treatment. We like to treat the total
patient. We do some office tests, we look at the urine, make sure you don’t have an
infection because that definitely impacts leakage, we’ll do a bladder scan
to make sure that you’re emptying your bladder properly, this is a painless way
to check how well you empty. Other office procedures that are occasionally
necessary are cystoscopy, where we take a little telescope that goes into the
bladder through the urethra in the office. It is painless, and it’s like a
little catheter, but we can have a telescope on it. We can see into the
bladder, see if there are any abnormalities. Urodynamics is
occasionally necessary, and this is a painless test where we will fill your
bladder with a liquid that shows up on an x-ray. Then we can see what’s
happening when you’re actually leaking and measure the pressures. This again
helps us decide how best to help you, and occasionally we’ll do a CAT scan to look
at your kidneys and your ureters, the upper parts of your renal system. Stress
incontinence is treated surgically or non-surgically. For non-surgical options,
there’s pelvic floor muscle physical therapy, there are little devices that
can be put in the vagina, like the Impressa or the incontinence pessaries,
and there are surgical options–bulking, urethropexy, and slings. We’re
going to talk in detail about all of these. Pelvic floor muscle strengthening/
pelvic floor physical therapy is usually a transvaginal approach where the
physical therapist will identify the muscles that are weak and help you focus
on strengthening them. It’s extremely effective, has no contraindications, and there are really no side effects, so it’s terrific.
Continence devices are little pessaries or diaphragm-like devices that can go in
the vagina and support the urethra like in this diagram, and these are some other
alternatives of what incontinence pessaries look like. They provide
additional support, and they increase the resistance to the leakage in this area.
They’re imperfect because very often we’ll find that this little device moves,
so now it’s not under here. So sometimes it’s effective part of the
time, but not all at a time, and they need to be fitted by your physician. This is
the Impressa intravaginal device. It’s over-the-counter, it’s available at the
market, the pharmacy, Walmart, Amazon, and in the picture on this side, we see the
urinary leakage, and here we see the Impressa device doing what the
continence devices in the previous slide do, increasing the resistance. Very
helpful for women who leak when they can predict, so you’re going to the gym, or
you’re going to play tennis, or you’re going on a hike. It’s difficult for women
who leak all the time with stress incontinence because it’s really
effective for about 8 hours. No one likes to wear them 24 hours, and it gets
pricey after a while, but for predictable leakage, if you go to the gym 3 times
a week, it’s terrific. We’re now gonna talk about surgery for stress
incontinence, and Dr. Tamara Grisales is going to start. Thank you, Dr Rosenman. So,
I’m Dr. Tamara Grisales, and Dr. Rosenman covered all of the conservative
strategies for dealing with stress incontinence, which are all important and
many times help, and there’s high success rates with those, but when they don’t, we
have several surgical options that can help with stress urinary incontinence,
and there are many things we can provide at our center. All of our physicians are
trained in all of these procedures, and it’s all about finding the right
procedure for you, so we’re going to go through each of these
individually, and just to highlight, we’re going to be talking about burch colposuspension,
we’ll talk about mesh urethral sling, also sometimes known as
tension-free vaginal tape, and we’ll talk about fascial sling, and then we’ll
also talk about urethral bulking at the end. So starting with a bulk
urethropexy, so this is a procedure in which the urethra is elevated, and recall
from Dr. Rosenman’s part of the talk, a lot of the issues here surrounding
incontinence really have to do with the support to the urethra, and all of these
procedures are really aimed at improving the support of the urethra and the
muscles surrounding it. So, a burch urethropexy allows the surgeon to
place some sutures, and these can be–are typically permanent sutures, but can also
be absorbable sutures, and they’re placed where you can see surround, kind of next
to the urethra and part of the bladder to give this area more support.
This was one of the first procedures that was performed or invented for
stress urinary incontinence. It previously was performed through a
larger abdominal incision, but more recently, it is now performed
laparoscopically, or robotically, so we can do this surgery without creating any
large incisions, and patients can go home the next day. Typically not the same day,
but usually less than a 24 hour day for this type of procedure. It is highly
effective, and it was, again, used very commonly in the past, and kind of went
away for a little while because of the invasiveness, but again, now that it’s
done minimally invasively, it is one of the options for surgery
for stress incontinence. Then we’re going to talk about slings.
So a sling is a little ribbon of mesh or a hammock that, again, is also aimed to
restore some of the support to the urethra. Mesh slings are actually the
gold standard surgical management for stress incontinence. So, they are highly
effective–greater than 80%-90% of patients are satisfied with this
procedure and notice improvement, and it again provides permanent support
to the urethra. So the mesh is a permanent implant, and it is intended to
provide permanent support to this urethral area. It is minimally invasive.
These are same-day surgeries. They take less than an hour when they are
performed out of mesh, and again, we’ll talk in a little bit about how a sling
itself can be made out of mesh or fascia, but we’ll continue kind of some
discussion here about the mesh sling. So in a mesh sling, we created a
very small incision in the vagina, and then the mesh is carried up through,
behind the pubic bone, and you can see where it emerges up here, just above the
pubic bone. Risks are similar between mesh and non-mesh slings, and
really, overall, the risk profile for these surgeries is very favorable. In
general, mesh slings have about a 3% risk of mesh complications, the
most common of which is a mesh erosion, or a mesh exposure, which essentially
means that mesh is visible through the vaginal wall. Most of the time, those
complications can be managed with either some hormonal cream or a very
small procedure, but again, this is a relatively low, relatively uncommon
risk. There are also–we can also create a sling out of non-mesh. We create
those out of fascia, and Dr. Kim is going to talk a little bit
more about that in a moment. In general, these surgeries are a little
bit longer. We have to harvest the fascia from another site, so there’s a little–
there’s an additional healing site, and there is a little bit higher risk of
what we call voiding dysfunction, which essentially means changes or potentially
difficulty in your actual urination, or voiding. I’m going to turn this over to
Dr. Kim. She’s going to talk a little more about fascial slings.
Thank you Dr. Grisales and Dr. Rosenman. I’m going to go over in detail some of
the alternatives to mesh sling. Just to reiterate, mesh slings are still
considered the gold standard by both urologists and gynecologists, but for those
patients who’ve had complications from mesh or those who may have wound healing
issues or simply do not want to have foreign body as a sling, this is a good
alternative. The autologous sling has been around, gosh, first described since
the 1950s, and it does involve harvesting fascia, which is essentially connective
tissue that’s made of durable and strong network of collagen and elastin, and we
have fascia in multiple parts of the body. They’re basically supposed to
separate compartments, and one of the most common places to harvest fascia
would be from the abdominal wall or the leg, and we’ll talk about that a little
bit more in detail. So, these are the 2 different common harvest sites for the
fascia. The most common ones, as I explained to you, is the anterior rectus
fascia, which requires a Pfannanstiel incision, also known as a C-section
incision. And there is definitely concern for cosmesis because it does require an
incision at the lower part of the body. It also means that there is increased
morbidity. Well, what does that mean? It means that there is longer recovery time
because there’s an incision through the skin and through the subcutaneous
tissues. That part needs to heal. And furthermore, some of the longer
complications could be that you could have a hernia because we are cutting
through the fascia, and that could cause a weakening of the abdominal wall. And
it’s important to note that it may not be readily available in some patients,
for example, somebody who’s had abdominoplasty that causes scarring in that
area. So, we are now looking at different sites for a harvest. So another common
area is the iliotibial band, also referred to as a fascia lata. It does
require a small incision over the lateral part of the knee, and some of the
side effects you can see are hematoma, which is a collection of blood that
could occur, or bruising, or seroma, which is a fluid collection. Sometimes patients
have complaints of temporary weakness, but it’s also a rare complication.
It does require change in positions during surgery, which means that we start
off with you, with your leg bent in this fashion, so that we could harvest a
fasscia from the left iliotibial band. Other treatment options for treating
incontinence would be, as Dr. Grisales and Dr. Rosenman mentioned, urethral
bulking. What is urethral bulking? It is also a minimally invasive procedure. It
can be done in the office, and it requires local anesthesia but does not require
any anesthesia that requires sedation. It can be done in the office, and it has
little to no downtime. It is temporary in the sense that the efficacy of the
treatment may not last as long as the slings. Therefore, you may require
multiple injections in order to have fuller or more durable efficacy. As you
can see in the diagram here, it requires a cystoscope, which is a procedure that
requires a special instrument that is inserted through the urethra. And through
the urethra, we inject bulking agents, and they are made of calcium hydroxyapatite,
and it is then injected near the bladder neck, or the proximal urethral area, to
give that area better closure pressure. Dr. Rosenman talked earlier about how
stress urinary incontinence is caused by opening of the urethra or muscles that
are not quite strong enough to have a closure mechanism, and by injecting
bulking agents, you could make that area tighter and therefore have better
closure pressure. And that concludes our talk. So, in summary, there are many
options for treatment of stress urinary incontinence, and we want to stress that
we, at the Center for Women’s Pelvic Health at UCLA, all of us are committed
to working with you to find the best option to fit your individual
preferences and situation. Thank you. We’re willing to–we’re happy to answer
any questions. So, I guess we’ll start off with a question. “Which treatment is right
for me? What is best for me?” Well, we have to consider how severe your symptoms are
and how it’s affecting your quality of life. Now, if it is a mild stress
incontinence, where you’re just leaking with some exercise or running, and you’re
not that bothered, perhaps a non-surgical option would be
best, such as pelvic floor physical therapy, and also some of the
continence devices. But if your treatment– I’m sorry, if your incontinence–is
moderate to severe, where now it’s affecting your quality of life and you
have to wear pads everyday, then some of the surgical options would be best. Some
things to consider would be, number one–are you planning to have more
children? Future pregnancy would mean that we’d ideally avoid operating on the
vaginal tissues. Some of the other things could be, have you had a prior surgery,
prior complication? Do you have wound healing issues, such as
history of diabetes or radiation, in which case a mesh sling may not be the
best one, and you may want to do fascia? But if you are otherwise healthy and you
want the most durable repair, a mesh sling would probably the best option,
and yeah, I think that’s–
-The only thing I would add is that it’s not–if you come
to see a doctor to discuss your stress incontinence, you are not compelled to
have surgery. This is a decision that’s made between you and your doctor.
The timing is what works for you. It’s a quality of life issue, and there’s no
pressure to have surgery, although it may turn out to be your best option.
“What is the long term outcome of slings, and will I have to get this repeated in
5 to 10 years?” So, in terms of slings, as slings have been around since the
late 90s–mesh slings have been around since the mid-late 90s–as we discussed,
fascial slings have been around even longer than that. Their efficacy, or success rates, are similar, and they’re quite high,
actually. They are about 80% to 90% in terms of significant
improvement or reduction in stress incontinence, and over 65% in terms
of complete cure. And this has been studied even as long as as long as 10, 14
years out from placement of a sling, so they are known to be–this is intended to
be a permanent implant that provides you with long-term support. Now, do they
always continue to work as well as they did at the very beginning, or could you
still have a bit of urine loss, more than what you wanted after a sling is placed?
Yes, that is possible, and in those situations, we, you know, your physician
will work with you to find an additional solution to that, whether that may be
bulking or whether that may be trying an additional sling, and those are very–
those can be very specific issues that sometimes require some additional
diagnostics, but that’s the exception and not the rule. And most of the time, these
slings work quite well, and people are highly satisfied, even when you look at
the responses in the 10 to 15 year range after surgery. You managed to cover
several questions there. Another question was “If my sling doesn’t make me
dry enough, what are my options?” Nicely done. “If I have bulking, how many sessions
of bulking injections will it take to get my best results, and will I need to
repeat this over time?” That’s a really good question, and for one, yes, you will
have to have a repeat injection. I found that to be variable. Some patients do
great with one injection, and some require another injection maybe 2 to
3 years. What’s important to note is that it is minimally invasive, meaning you
could drive to our office or surgery center, have the procedure, and drive
yourself home right after, so even though we may require
repeat treatments, it’s not as invasive. “What about burch suspension without a
sling? How long does this last?” Burch suspension without a sling also
has good long-term–similarly has good long-term results. Again, this is done
with permanent sutures. It’s a bit different because it’s not a hammock
wrapping completely around the urethra, but it does provide excellent support
and has also been studied long term and can provide great support in a long-term
fashion. Yeah. I think I’ll take another question. “Why have I heard so much
negative press about mesh?” And this is an issue that comes up with pretty much
every patient who we discuss any kind of mesh with. Mesh has been around for 50
years used for hernias, it’s been around for 50 years used abdominally for pelvic
organ prolapse with good results and low complication rates. The sling that Dr.
Grisales has been describing has been available in this country since
1997, so we have a 23 year history of safety and efficacy with it, but on the
basis of that safety, the same manufacturers said, “Well let’s use big
pieces of mesh in the vagina for prolapse,” and that was done without long
term studies, before it was approved, and it turned out not to have the same
safety profile and was eventually taken off the market. Instead of the 3%
complication rate of minor problems that Dr. Grisales mentioned, it
had a 15% to 20% risk of significant and serious complication, so
it’s no longer on the market, and we don’t place it, and we do remove
it on multiple occasions when it’s problematic from other placements, but
the mesh sling itself is on the market. It remains safe and it remains the gold
standard so I hope that’s reassuring. Any other clarifications or questions you’d like to ask? I guess I will add that, you know,
what’s great about coming to UCLA Center for Women’s Pelvic Health–that’s a
mouthful–is that we–all of us, three of us here–as well as Dr. Nitti and Dr.
Tarnay are well-trained to provide all the treatment options that we offer, and
therefore, we really are able to tailor your needs. Many patients do come here
because of the mesh scare, and it is important to make that distinction, that
mesh slings are considered low standard, whereas mesh for prolapse repair are not,
and so despite that, there are some concerns, which is understandable. We
are able to provide native tissue repairs, such as autologous fascia slings–
-Or abdominal mesh repairs, which are not the ones that are problematic.
It’s vaginal mesh for prolapse that’s a problem. Or burch procedures, which are
another non-mesh option, and I think the other thing I would add is that, you know,
I think when you come to see any of the 5 of us at the center, we all really
tailor our care to your preference. I think we all really see our role as
providing some education and providing you with all the options and
allowing you to be part of that decision-making process. That’s very
important to our care. I will put, because it’s a quality of life issue,
it’s not an issue where we need to put our–you know, we don’t have to make you
do anything, we’re gonna allow you to make the best decision for yourself, and
I think it’s important also that we have multiple options, so you’re not going to
get a one-size-fits-all like you might in a person who’s not trained and everything. We’re all board-certified in the subspecialty of
female pelvic medicine and reconstructive surgery. And the other
thing could be, if you’ve had treatment for stress incontinence elsewhere, and
you’re not satisfied, because we are a tertiary referral center, we do see patients who have had complications from other procedures, and
we’re able to assess with your dynamics and cystoscopy and then figure out a
secondary treatment that will hopefully be successful. In very complex cases, we
have more evaluation as well, like MRI or certain specialized ultrasounds, to look
for mesh, so we have a lot of diagnostic possibilities available because we are a
center focused on these problems.

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