Incontinence & Prolapse - Part 2: The Strengths and Limitations of Incontinence Surgery

Have you ever sneezed and felt a small amount of urine spurt out (or something worse?!) Do you ever feel the urge to urinate or defecate, and then suddenly can’t wait or control it? Beyond incontinence, you may be suffering from vaginal or pelvic organ prolapse. If you’re exploring medical solutions or have been considering surgery, this article is for you.

Scope of the Problem

Over half of women develop incontinence of urine, gas, or other symptoms of pelvic organ prolapse (POP) during their lifetime.

Pelvic organ prolapse is a general term used to describe the "falling" of the vagina, bladder, rectum, and uterus. Prolapse is when the bladder and rectum bulge into the vagina and fall downward toward the floor (if you’re standing).

You may first experience prolapse symptoms such as leaking gas or urine, as early as your twenties or thirties. Other symptoms include difficulty emptying a bowel movement, needing to press with a finger in the vagina to empty a bowel movement (also called digital defecation), low back pain, and a sensation of something falling out of the vagina.

Most of us start needing treatment for incontinence by our early to mid-fifties. Many women report experiencing symptoms for years or decades before seeking treatment.

Incontinence Surgery Statistics

• 400,000 = number of incontinence surgeries per year in the United States

• $26.9 billion (2005 dollars) = annual societal costs of incontinence (includes costs for treating, e.g. surgery, and managing, e.g. pads).

• 11.1% = your lifetime risk of undergoing incontinence surgery

• 29% = the re-operation rate for women with prior incontinence surgery (i.e. nearly 1/3 of incontinence surgeries fail to the extent women seek re-operation); some studies report as high as an 80% failure rate at three years of follow-up

• $751/year = annual cost (in 2006 dollars) for absorbent pads, laundry, related expenses

Prolapse (falling) of the uterus, bladder, vagina, and rectum is often the result of multiple factors:

• years of trauma (from pregnancy/birth),

• prior pelvic surgery (e.g. hysterectomy)*

• aging of the vaginal tissues, loss of estrogen to the tissues, weakening of the vaginal support structures

• weight gain (overweight/obesity quadruples the risk for incontinence)*

• smoking*

• chronic lung disease*

• failure to adequately exercise the pelvic support muscles*

*These conditions can be treated or modified to reduce prolapse.

Traditional Prolapse Surgery

Traditional prolapse surgery is a little like taking in a large pair of pants. It involves “plicating” or folding over stretched-out vaginal connective tissue and muscle to thicken and reinforce it; and to cinch in extra space.

Unfortunately, traditional prolapse surgeries often fail because the tissue is already damaged, stretched, weakened, thinned, or is no longer supplied with nerves (“de-innervated”) due to a previous pregnancy, advanced age, or weight gain.

Modern Surgery Using Mesh to Correct Incontinence

Because traditional prolapse surgery doesn’t work so well, medical researchers developed mesh in an attempt to apply the principles of hernia repair to female vaginal prolapse. It’s a good concept—except that the vagina is very different from the abdominal wall. The skin and underlying muscles of the vagina are much thinner than stomach muscles and are not made from tissue with the same strength and durability as the abdominal wall.

Most modern incontinence surgery involves placing a supportive mesh tape or “sling” under the urethra to help the urethra close during a cough or sneeze. The short-term success rate for this particular incontinence surgery is high — about 90% of women clear up their incontinence with this procedure. However, nearly one third of women who undergo incontinence surgery require re-operation for the problem within 10 years.

Some of this failure can be attributed to patient weight gain after the incontinence surgery. Weight gain contributes significantly to the problem of incontinence, and to the failure of incontinence surgeries. It makes sense: extra weight makes already weak muscles weaker – just the opposite of what we need to reduce incontinence!

Mesh does not solve the problem of weak tissue.

The hitch with mesh is that your vagina is a completely different environment than your abdominal wall, as we already saw. The vaginal skin is thin, is not buffered by fat tissue, is more fragile than external skin, and has to contend with more trauma and different bacteria than external skin (e.g. with intercourse, tampons, etc.). The vagina does not have the same type of skeletal muscle just beneath the skin, as does the abdominal wall. Over time, mesh can work its way through the vaginal skin, causing discharge, pain, and sexual dysfunction.

In October 2008 the FDA issued a "Public Health Notification" on "Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence.” This report placed a “black box” warning on mesh.

Mesh tape still has a place in correcting stress urinary incontinence: it is very effective with a lower risk of complications than the mesh sheets used for vaginal prolapse. You may be wondering what other solutions are available. Is surgery a sustainable solution or is there ? [link to Incontinence III post]?

What is your experience?

Have you had surgery for incontinence or prolapse?

If so what convinced you to have the surgery (i.e. doctor's recommendation, research on the Internet, scientific studies, etc.)

Were you satisfied with the surgery? Why or why not?