Incontinence Operation and Procedures

Incontinence Operation and Procedures

Introduction

Urinary incontinence is the unintentional passing of urine as an effect of the loss of bladder control. This could be the occasional leaking or the uncontrollable urge to urinate. The four main types of incontinence are:

  • Stress urinary incontinence (SUI)
    Involves urine leakage when events with increased intra-abdominal pressure are performed (e.g. coughing, sneezing, laughing, lifting etc.). SUI is caused by a loss of support of the urethra and pelvic floor muscle weakness. SUI is also strongly associated with vaginal childbirth and menopause. 
  • Urge incontinence
    It is associated with a strong desire to void and pathological contractions of the bladder. It is a neuromuscular dysfunction due to a pathological bladder over-activity and usually represents a symptom of an underlying problem (e.g. diabetes mellitus). 
  • Overflow Incontinence
    In overflow incontinence, the bladder is unable to empty itself fully, resulting in frequent or constant leaking of urine.
  • Mixed urinary incontinence (MUI)
    A combination of both the SUI and urge incontinence symptoms. 

 

It is a common problem among people, causing embarrassment, stigmatisation, and skin problems in bed-bound patients. Older people with urge incontinence face higher risks of falls and fractures. Incontinence operations and procedures aim to control urinary incontinence to enhance the quality of life in patients.

More conservative methods to treat and manage urinary incontinence are:

  • Bladder training
  • Double voiding
  • Pelvic floor exercises
  • Oral medications
  • Catheterisation

 

For more serious forms of urinary incontinence, other surgical or minimally-invasive methods are:

Transvaginal mid-urethral slings (MUS)

This procedure aims to control stress urinary incontinence. Surgical procedures are usually recommended if non-surgical treatments for urinary incontinence have not worked. 

During the procedure, a catheter (tube) is placed in your bladder to drain the urine. A “sling” is then created out of synthetic mesh or human tissue, lifting your urethra (the tube that urine passes through) and the neck of your bladder. This provides support and helps close your urethra and bladder neck and prevent leaks.

There are three main methods for this procedure:

  • Retropubic method (or the tension-free vaginal tape, or TVT, method)
    Three cuts are made – A 1 cm cut is made on either side of the lower abdomen (at the suprapubic region) and a 1 cm incision in the vagina to allow the sling to be put in place. The sling is located below the mid-urethra and lifts the urethra up to maintain closure.
  • Transobturator method (TVTO)
    This method is similar to the retropubic method, but a cut is made on each side of your inner thigh (just next to the folds of skin on either side of your vagina). The sling is then put under your urethra through the vagina, through the obturator foramen (opening in the pubic bone) and out from the inner thighs.
  • Single-incision mini method
    One small 1cm cut is made in your vagina and the sling is put through it. This method does not have any other external incisions at the skin.

 

FOTONA laser

The FOTONA laser is a technology that utilises thermal energy to affect the vaginal tissue. Collagen remodelling is stimulated and new collagen fibres are synthesised. The vaginal mucosa (inner lining of the vagina) and collagen-rich endopelvic fascia (connective tissue enveloping pelvic organs) shrinks and tightens, providing greater support to the bladder thus allowing the return of normal continence function. 

This procedure is non-invasive and ensures quick recovery without the need for the use of analgesics or antibiotics. 2-3 sessions are required at monthly intervals, and repeated sessions may be needed.

Electromagnetic Stimulation (HIFEM)

A HIFEM session triggers intense pelvic floor muscle contractions by targeting neuromuscular tissue and inducing electric currents. This directly modifies the muscle structure, inducing a more efficient growth of muscle fibres and the creation of new protein strands. Incontinent patients who were once unable to perform high-repetition rate patterns exercise due to pelvic floor muscle weakness can thus restore neuromuscular control after HIFEM. 

In this procedure, the patient sits on a chair/device that uses HIFEM to stimulate the pelvic floor muscles. This is especially useful for individuals who are unable to isolate their pelvic floor muscles during Kegels.

Comparison of patients’ condition before and after pelvic floor simulation

Neurotoxin Injections

Neurotoxins may be injected into the bladder muscles to relax them and prevent spasms for urinary incontinence. This powerful neurotoxin blocks the transmission of the electrical impulse from a nerve that causes uncontrolled muscle contraction.  This aids in the management of an overactive bladder in adult patients with urge incontinence. When the effects of the neurotoxin wear off, the injection can be repeated.

Tensi+

A non-medicinal and non-invasive device attached to the ankle to transmit electrical impulses to the posterior tibial nerve. Tensi+ utilises the  Transcutaneous Electrical Nerve Stimulation (TENS)  technology to control symptoms of overactive bladder.

This device has been proven to improve the central neurological control of urination by facilitating the messages transmitted between the bladder and the brain. Results are generally evident within 12 weeks of use. It is also recommended by international urological associations to be an alternative to PTNC (Percutaneous tibial nerve stimulation) which requires a thin needle for the procedure.

Summary

Urinary incontinence is a condition that can greatly affect the quality of life in patients. A variety of incontinence operations and procedures are available — surgical procedures like transvaginal mid-urethral slings, and minimally invasive procedures like FOTONA laser, electromagnetic stimulation and neurotoxin injections. These options offer much hope to improve bladder function and alleviate symptoms of urinary incontinence.

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Dr. Fiona Wu 2

Dr Fiona Wu
Consultant Urologist

MBBS (S'pore), MRCS (Edin), MMED (Surg),
MMED (Clinical Investigation),
FRCS (Urol) (RCPSG), FAMS (Urology)

Dr Fiona Wu is an experienced Consultant Urologist and is the Medical Director of Aare Urocare.

Prior to her private practice, Dr Fiona Wu spent 15 years in public service. She was a Consultant in the Department of Urology at National University Hospital (NUH), Alexandra Hospital and Ng Teng Fong General Hospital. She was also the Programme Director of Surgery-in-Training at NUH and a core faculty member of postgraduate junior doctors. 

Dr Wu’s clinical interests lie in Female Urology, Neuro-urology, Urinary Incontinence, Reconstructive Urology and Voiding Dysfunction. She believes in treating incontinence in a holistic way using minimally invasive methods. She worked closely with the gynaecology and colorectal departments to treat complex pelvic floor conditions and continues to do so in her own practice. 

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