Treating Female Stress Incontinence

by:  Gary Leach MD

Although there are a variety of options for treating female stress incontinence, the most effective surgical option is the sling procedure. Sling procedures were first performed in the early 1900’s. Since that time, there has been a continual evolution and improvement in sling techniques.

The sling is a surgical procedure indicated for women with urine loss during coughing, laughing, or sneezing (stress incontinence). In extreme cases of stress incontinence, urine loss can occur with walking or change of position.

-Single Incision Slings for “mild” stress incontinence: The single incision sling, or miniarc sling, is performed entirely through the vagina usually as an outpatient procedure. An incision is made in the top part of the vaginal wall and the miniarc sling is placed beneath the urethra with each end of the sling being fixed into the pelvic muscles (figure 1).
The procedure generally takes about 30 minutes with the patient being discharged home 2-3 hours after the procedure.

TOT Sling for “moderate” stress incontinence: The TOT sling is also performed mainly via the vagina with two small incisions in the groin on each side. The sling is longer than the miniarc sling which allows the TOT sling to be transferred from the vagina to the groin incision on each side by using special needles (figure 2). The sling restores bladder control by “compressing” the urethra and acting as a “backstop” for the urethra during coughing, thus allowing the valve muscle (sphincter) to close more effectively.

Fascia Lata Sling for “severe” stress incontinence: The fascia lata sling is considered a “salvage” procedure for women with very severe stress incontinence (usually after multiple previous procedures have failed).
The tissue used for the sling (called fascia) is removed from the outside of the thigh through two small incisions. This fascia is the very strong tissue present above the leg muscle and below the skin. This strip of fascia (usually about 10 inches long and about 1 inch wide) is then placed beneath the urethra like a “hammock” to help close the area of the valve muscle and eliminate leakage with stressful activities (figure 3). Potential postoperative problems include inability to empty the bladder (usually temporary) requiring the patient to empty the bladder by self-catheterization and postoperative leg pain (usually lasting about 3-4 weeks).

-Results and Complications:

In general, in well selected patients, sling procedures have a 85-95% success rate. The less invasive types of slings can be performed either as an outpatient or with a very short hospital stay. The fascia lata type sling usually requires 1-2 days in the hospital.

The main complication after sling surgery is not being able to empty the bladder (called urinary retention). For this reason, all patients are taught the technique of self-catheterization before the sling surgery. Most patients empty their bladder well immediately after the surgery. When the bladder is not able to empty completely, the patient is re-instructed in the technique of self-catheterization that they learned before the surgery. Rarely self-catheterization may be required on an ongoing basis. Postoperative discomfort is usually minimal, except for the leg pain from the site of fascia removal for the fascia lata sling. Other complications (bleeding, infection, anesthesia problems) are quite rare.

Recent advances in sling surgery have resulted in the correction of urine loss with less invasive surgical procedures. Sling surgery may be considered when non-surgical treatments for stress incontinence are not successful, when previous surgery has failed, or when the patient has a strong desire to correct her urinary leakage with one definitive procedure.