Sunday, May 20, 2012

Transvaginal Mesh and Stress Urinary Incontinence: Introduction and Surgical Options

What is Stress Urinary Incontinence?

Women who have accidental leaks when they cough, laugh or sneeze are likely suffering from SUI which occurs when the sphincter—the valve to the bladder—cannot stay closed when there is pressure exerted on the abdomen. This pressure causes small amounts of urine to leak out and can be both a challenging and embarrassing problem to deal with. In addition to coughing, laughing and sneezing, exercise, bending and lifting or having sexual intercourse can also cause urine to leak from the body and in severe cases even walking or getting up from a chair can lead to leakage. Overall, approximately one in every three women will develop SUI at some point in their life, making it a very common disorder.

SUI can lead to rashes and skin infections as well as chronic urinary tract infections. Women who suffer from SUI may stop participating in their normal activities such as exercise or social events. SUI can have a negative impact on a woman’s work life, particularly when she must constantly leave her work or a meeting to prevent accidental leaks. SUI can disrupt concentration at work and can even keep a woman awake at night, leading to fatigue and poor work performance. Changes in a woman’s personal life may be the most devastating; women may begin to avoid sexual intimacy, may be hesitant to discuss the issue with their family, and can even experience anxiety and depression because of their SUI.

There are a variety of risk factors which can determine whether a woman will develop SUI. Childbirth, chronic constipation, an extended period of coughing, obesity, pelvic organ prolapse or pelvic nerve surgery can damage the connective tissue and underlying structure of the urethra. Women who carry the increasing weight of a baby over 40 weeks into the pregnancy will experience extra pressure on the pelvic wall, and those who have vaginal deliveries may find the nerves in the pelvic floor have become stretched and bruised. Women who are going through menopause may also experience SUI due to lower estrogen levels, and in some cases medications for high blood pressure or depression can also lead to SUI.

What Surgical Options Are Available for SUI?

Some cases of SUI are managed through lifestyle changes, while others require surgery. Quitting smoking which leads to less coughing can be a good place to start for those who smoke. Women who are overweight or obese may find that losing the extra weight can greatly reduce their SUI symptoms, while others have had success with specific pelvic floor exercises to strengthen the pelvic muscles.

Vaginal Sling

The majority of SUI surgical procedures involve vaginal slings—pieces of material placed underneath the urethra as a kind of hammock support. The sling provides support for the urethra while also offering a degree of compression. Mid-urethral slings remain the gold standard for cases of relatively uncomplicated SUI without prolapse. The surgical procedure among women who suffer SUI and pelvic organ prolapse is dictated by the surgical route utilized to repair the prolapse. There are a variety of different slings used by surgeons, distinguished primarily by the type of material the sling is constructed of. Slings which rely on using the own body’s tissue—tissue to tissue suturing—do not implement synthetic mesh which has been implicated in medical complications such as infection, mesh exposure, mesh erosion and tissue breakdown and irritation. Vaginal sling procedures generally take place on an outpatient basis, although in some cases the woman may be required to stay in the hospital for a day or so. A small incision is required, and absorbable sutures are generally used which will dissolve on their own in several weeks.

Other Surgical Procedures

Other surgical procedures to correct SUI involve the injection of collagen around the urethra, implantation of an artificial urinary sphincter, or the use of tension-free vaginal tape. The use of urethral injections is generally limited to elderly or medically compromised women who are unable to tolerate surgery or in patients who have suffered a prior failed surgery. Women who receive tension-free vaginal treatment will have a tiny incision in the vagina made then a long-lasting mesh-like material will be placed under the urethra and attached to the muscles in the abdomen. This mesh is considered a permanent solution to stress urinary incontinence caused by straining, laughing or coughing. The tension-free vaginal tape is less invasive, causes less pain, has an 84-95% success rate, is performed under local anesthesia and allows the woman to return to work in two to three weeks.

Who Commonly Gets SUI and at What Age?

Many women suffer the effects of stress urinary incontinence or SUI, and while it is generally believed SUI is an older woman’s disorder, almost two out of five women between the ages of 35 and 54 experience symptoms of SUI—almost the same percentage as the over 55 age group. Further, a full quarter of young women between the ages of 18 and 44 also report symptoms of SUI. While ideally the nerves, ligaments and pelvic floor work together to support the bladder and ensure the urethra remains closed, pregnancy and childbirth often cause this system to stop working.

Many pregnant women suffer some degree of SUI and some of them will find it continues to plague them long after the baby is born. Vaginal birth is more likely to lead to SUI than Cesarean sections, and mothers who undergo assisted vaginal deliveries with the use of forceps are much more likely to develop SUI. Obesity raises the risk of SUI by as much as four times, while smoking doubles the risk. Kidney disease and diabetes also add to the likelihood of a woman developing SUI. Finally, some women simply are genetically predisposed to SUI and while they may have none of the risk factors otherwise they will develop the disorder. For a further explanation of non-surgical methods used in SUI as well as the differences in the surgical devices on the market used in the treatment of SUI, see part two of this article.

Author: Sullo & Sullo Attorneys

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