Patient Education
Stress Incontinence
Treatments
Mid-Urethral Slings:
National Average Success Rate (85-95%)
Zipper Urogynecology Success Rates (90-98%)
In or about the year 2002 mid-urethral slings became the gold standard in the surgical treatment of stress incontinence. As the name suggests, in this surgery, the surgeon places a sling under the urethra. The most common material used is a synthetic non-absorbable material called polypropylene mesh. Some surgeons use natural materials such as pig dermis. However, these natural slings seem to have a higher failure rate. Slings are named for the route the surgeon uses to put them in. Examples include Transobturator (TO) and Retropubic (RP). In the hands of an experienced and skilled surgeon, success rates are similar. Sling surgeries are completed in 15 to 30 minutes and patients are discharged home the same day. Zipper Urogynecology Associates recommends choosing a surgeon who performs at least 50 successful slings each year.
Burch and MMK Procedures:
National Average Success Rates (80-88%)
Zipper Urogynecology Success Rates
(We consider this an inferior procedure and do not offer it)
Prior to the introduction of mid-urethral slings, Burch and MMK procedures were considered the gold standard in the treatment of stress incontinence. However, lower success rates and higher complication rates associated with these procedures, caused these procedures to fall out of favor. Unlike sling procedures, which require no abdominal incisions, Burch and MMK procedures are typically performed through a small incision just over the pubic bone. Most patients are admitted to the hospital and do not go home the same day. These procedures are also associated with a higher rate of urinary retention and overactive bladder symptoms. Based on the lower success rates, higher complication rates, and more invasive nature of these procedures, Zipper Urogynecology Associates recommends choosing a surgeon who performs mid-urethral slings.
Urethral Injections:
National Average Success Rates (30-90%)
Zipper Urogynecology Success Rates (80-95%)
Material may be injected into the wall of the urethra in order to "tighten" or partially close it. The increase in bladder pressure associated with voluntary urination is sufficient to push open the urethra. However, when injected appropriately, activities such as exercise, coughing, sneezing, or laughing do not push open the urethra and cause incontinence. The trick to appropriate injection is not just in the technique. It involves choosing the correct patient. Most patients with stress incontinence have both a weak urethra (one that does not stay closed) and a poorly supported urethra (one that falls into the vagina). Urethral injections do not work well in patients who have a poorly supported urethra. However, subsets of patients with incontinence, 10-20%, have a urethra which is weak, but well supported. It is this group of patients that have the highest chance at cure via urethral injection. Urethral injections typically last six months to two years and can be repeated as needed.
There are many different materials which are used for urethral injection. The most common are Contigen® (collagen), Coaptite® (calcium hydroxylapatite), Macroplastique® (silicon), and Durasphere® (pyrolytic carbon-coated beads). Although the later three have been touted to last longer than Contigen®, this has not been our experience. We have found Contigen® to provide the highest cure rate from a single injection. It is also extremely well tolerated in the office setting. We perform approximately 500 urethral injections each year, the majority of which are done in the office. They average time to complete this procedure is just three minutes.
Pessaries:
National Average Success Rates (40-60%)
Zipper Urogynecology Success Rates (50-60%)
Pessaries are rubber or silicon rings, squares, or unique shapes which may be worn inside the vagina. Although they are most commonly used to treat women with pelvic organ prolapse who do not want surgery, they can also be used to treat stress incontinence. For those women whose stress incontinence is caused predominantly by movement of the urethra into the vagina, pessaries will sometimes decrease stress incontinence symptoms. Unfortunately, success rates are low and pessaries do cause substantial vaginal discharge.
Pelvic Floor Physiotherapy:
National Average Success Rates (30-70%)
Zipper Urogynecology Success Rates (60-80%)
Strengthening specific muscles of the pelvic floor, such as the pubococcygeus muscle, can decrease movement of the urethra. This may lead to a significant decrease in stress incontinence symptoms. Physical therapists with unique training in pelvic floor Biofeedback Therapy (using computers to help women strengthen their pelvic muscles) and other specialized methods offer the best chance at improvement. Special exercises such as Kegel exercises have low success rates when performed without the involvement of a physical therapist. More severe grades of stress incontinence do not benefit from physiotherapy. We utilize urodynamic testing to identify those patients most likely to improve with physiotherapy. We then pair those patients with the best physiotherapists.
Electrical Stimulation Therapy
National Average Success Rates (30-60%)
Zipper Urogynecology Success Rates (30-50%)
Gentle, painless levels of electrical stimulation applied to the muscles of the pelvis causes those muscles to contract. These contractions may lead to strengthening. The electrical stimulation is administered through a thumb-sized probe which is placed in the vagina for fifteen minutes twice each day. We, at Zipper Urogynecology, have one of the nation's largest experiences with E-Stim and believe that the success of such treatment has been exaggerated. However, as it has minimal to no side effects, we do continue to offer this treatment option.
Drug Therapy:
National Average Success Rates (10-30%)
Zipper Urogynecology Success Rates (80%)
Certain medications increase the tone of the urethral sphincter. Hence, these medications may decrease stress incontinence symptoms. Examples of such medicines include Pseudophed® and Imipramine. There is also some preliminary evidence that the antidepressant Cymbalta® may have an effect on the urethra. Unfortunately, these medications only help the mildest cases of stress incontinence and have associated side effects. Additionally, the patients that improve with drug therapy are the same patients that have the best chance of improvement with physiotherapy. Therefore, we rarely recommend medicine to treat stress incontinence. Our success rates with drug therapy are high only because we are very selective with regard to whom we offer it.
