Chapter
8: What
can be done? Treatments for urinary incontinence and pelvic
floor prolapse:
Surgical
procedures to treat overactive bladder
Surgery
is indicated only when other means to treat your overactive
bladder symptoms have failed to do so. The great majority of
women will be adequately treated with behavioral modification,
physiotherapy and medication. Once you have given these less
invasive treatment modalities a chance and they have not
improved your condition, it is time to consider surgery. Just as in the case of stress
urinary incontinence, the spectrum of surgery performed to
treat overactive bladder is wide and we will focus on just two
types of surgery: bladder
augmentation and sacral
neuromodulation.
Bladder
augmentation
Although
considered invasive surgery, this is the most successful
operation to treat overactive bladder symptoms. The idea
behind it is simple. The bladder is augmented
or enlarged with a patch made of your own intestine. A segment
of your intestine is isolated from the rest of the intestine.
The segment is, like the rest of the intestine, a tubular
structure. To convert it to a plate-like structure, the
intestine is opened and then configured to a plate form. The
bladder is then opened and the plate is sewed to its edges
like a patch. This surgery provides a larger bladder that will
accommodate larger volume of urine and allow longer lapses of
time between each time you urinate, decrease the sensation of
urge and may prevent urinary incontinence.
Success
rates are high with cure rates up to 90%. Bladder augmentation
increases bladder capacity and the ability of the bladder to
hold larger volumes of urine, and decreases the number of
unwanted bladder contractions.
This
surgery is performed under general anesthesia and takes 2-4
hours to complete. You may expect to stay in the hospital for
a few days and to carry a catheter to drain the bladder for a
period of 3 weeks. Except for the usual complications of
surgery discussed before, there are several complications
specific to this type of procedure that include reduced
ability to void requiring you to empty your bladder by
periodically inserting a catheter to your bladder and possible
imbalance in the salt concentration in your body. The patch of
bowel will still behave as a bowel segment and will secrete
some mucous into your urine and will make your urine look
cloudy.
Sacral
Neuromodulation
This
is a relatively new way to treat overactive bladder symptoms.
As you recall from the chapter on how your bladder works,
normal bladder function is regulated by the nervous system.
Nerve fibers from the bladder and from the brain meet at the
sacral region (at your lower back) to form a relay station
where signals are translated to the final commands given to
the bladder. Sacral neuromodulation is a surgical procedure in
which an electrode is implanted next to the nerve that leads
to the bladder. The electrode is connected to a generator that
produces tiny electrical signals. These signals are conveyed
to the nerve and from there to the bladder. The exact
mechanism is unknown but somehow electrical currents can
modulate the bladder and decrease the number of
urgency-frequency and urge incontinence episodes.
This
treatment is given in two separate stages. First, your
response to the electrode is tested with a temporary electrode
put at the sacral nerve. This is a minor procedure performed
under local anesthesia in an outpatient setting. Once the
electrode is in place its correct position is verified by
sending a few signals and looking for the response. Since the
nerve that simulates the bladder is also the one that
simulates certain muscles in your leg, a movement of your toe
and a pulling sensation in your rectum radiating to the
genitalia will signal that the electrode is in the right
position.
You
will have this temporary electrode for 3 days. You will have
to fill a voiding diary documenting the amount of fluid you
take in, the number of times you urinate, and the number of
accidents (incontinence episodes) you had. If there is a 50%
decrease in your symptoms then you will continue to the next
stage which is to implant a permanent electrode.
As
opposed to the temporary electrode, the implantation of the
permanent electrode is “real” surgery. It is performed
while under general anesthesia. A permanent electrode is
implanted next to the sacral nerve through an incision in your
lower back. A stimulator used to generate electrical pulses is
implanted on your flank through a separate incision and
connected to the electrode at the sacral nerve. All components
are implanted inside your body so that nothing is hanging out.
The electrical pulse can be up- or down- regulated and even
turned off using a remote control unit that you will receive
when you leave the hospital.
The
results of the procedure vary from one medical center
to another. The first stage where response to the temporary implant is
tested, is successful in 20-48% of the cases. As previously
mentioned only those women who respond to the first stage will
have the second permanent implant. In some medical
centers the match between the success of the first
stage and the second stage is almost perfect with almost all
patients having significant improvement or cure in response to
the permanent implantation. Other centers report 20-51% of
failure in the second stage.
Complications
of surgery include pain and discomfort, migration of the
electrode, wound infection and malfunction or failure of the
implanted device. Some complications require additional
operation.
