Incontinence Repair - Vaginal Sling Insertion
Urinary incontinence is a condition where women leak urine when coughing, sneezing, running or laughing. Any physically stressful event, even sexual intercourse, can cause the leakage. There is considerable stigma attached to the condition and it is seldom spoken about. Women sometimes feel embarrassed to mention it at a doctor's visit and many doctors do not ask about it during routine examinations.
The problem can be caused by childbirth or simply genetics. It is more commonly seen in certain ethnic groups. We have seen incontinence in women after having one child or after having several children. There are also many cases of incontinence in women after having cesarean sections.
The problem stems from a loss of the support surrounding the urethra, the organ that controls urination. The urethra is unstable, or the sphincter, which is the muscle that controls the opening, may be weak. This leads to loss of urine. When women lose the support they can no longer control the involuntary leakage of urine.
Tension-free slings (mesh material) are used to treat stress urinary incontinence caused by urethral hypermobility and intrinsic sphincter deficiency. With this approach, a synthetic transvaginal suburethral sling is placed through the retropubic space. The vaginal sling is held in place by the friction between the mesh and the tissue canals created during the surgery. Scar tissue later fixes the mesh in place, preventing movement. Because the sling is not anchored to the pubic bone, ligaments, or rectus fascia, it is considered to be free of tension. The result is urethral support that limits its mobility, improves the stabilization mechanism generated by other ligaments, and reinforces support of the backboard vaginal hammock. The procedure can be completed in under an hour via 3 small incisions, one in the vagina and one on each inner thigh.
Passage of the sling is through an anatomic space called the obturator canal in the inner thigh. The space that the needle passes through has been extensively studied via cadaveric dissections. It has been found to be a very safe space to work for the vaginal sling. There is almost no risk of major bleeding (no major blood vessels), bowel, and bladder or nerve injury from the procedure. If done correctly, the obturator nerve is not near the area of the surgical needle, and will not be injured.
The dotted arrows show the final position of the transobturator sling placement. The blue circles in the groin are where the small stab incisions are made to place the polypropylene mesh tape sling.
General anesthesia is required for these cases. We have found that a proper amount of relaxation cannot be achieved using local anesthesia.
Following the procedure, the wounds will be dressed with petroleum jelly gauze. The sutures will dissolve over a few weeks. You will return to the office in the morning to have the gauze removed. You should have light activity in the early post-operative period to minimize the potential to damage the healing wound or cause bleeding. Intercourse should be avoided for at least six weeks. In some cases you can receive oral sex in as little as 3 weeks. Avoiding trauma to the area allows for the best possible would healing. A small amount of patience during the post-operative period will pay off dramatically in the long run. There may initially be a small amount of leakage.
The repair tightens over time achieving maximal results in about 3 months. An effort is made to not "over" tighten the urethra in the operating room. This could result in urinary retention, the opposite of the original problem. This too, can be repaired if it occurs.
Recovery varies from person to person, and your recovery time and amount of pain will be different from other patients. After your surgery, you will be sent home with petroleum jelly gauze in your vagina. You will be instructed to return to our office for removal of the gauze. The purpose of the gauze is to absorb excess oozing of blood.
You will have none or very minimal pain that day. This is due to the injections that we place at the conclusion of the surgery. You will be drowsy when you arrive home due to the anesthesia.
For the next few days, you will take a prescribed pain medication (Vicodin or similar). We give you these prescriptions prior to your surgery for your convenience. You may shower on the second day and rinse the area, but no soap is allowed until the third day. You may be bruised, and swollen a bit on the inside. This is all normal.
The stitches used are almost always dissolvable and so will not need to be removed but it can take up to six weeks for them to dissolve completely. You will experience mild to severe discomfort with the sutures. You may experience itching during the healing process.
No exercise for at least two - four weeks, and again, no sex for at least six weeks.
Most people are able to go back to sedentary jobs after just 48 hours. In some cases, women may take a couple of days to sufficiently recover, so be prepared just in case you need to spend your time resting.
For women plagued with loss of urine and the inability to enjoy routine activities or sex, because of the involuntary loss of urine, this procedure may correct the problem. The correction can be life changing for women who suffer from urinary incontinence. Again you and your surgeon should know your expectations ahead of time. It is also important for you to find a surgeon whom you are confident in, and who is experienced in performing this procedure.
What if I am unhappy with the results? Will I be charged for a revision?
Though no surgeon can make a guarantee of 100% satisfaction, we will do everything possible to give you your desired results. We have a very low revision rate. Most patients just need a little adjustment of the sling by loosening. This is done in the office under local anesthesia. If another sling must be placed due to continuous leakage, this will require a return to the operating room. For incontinence surgery, there is a charge for a return to the operating room however incontinence surgery is always covered by insurance.