Stress urinary incontinence (SUI) is an involuntary spurt-like loss of urine provoked by a sudden increase in abdominal pressure such as sneezing, coughing, laughing, exercising, changing positions, etc. Underlying contributing factors include childbirth (in particular, traumatic vaginal deliveries of large babies), menopause, hysterectomy, aging and any condition causing a chronic increase in abdominal pressure such as cough, asthma, and constipation. SUI is usually due to urethral hyper-mobility, an acquired laxity in the tissue support of the urethra that allows urethral descent with increases in abdominal pressure.
The goal of surgical management of SUI is to provide support to the urethra in order to correct the hyper-mobility. The surgical treatment of SUI has evolved significantly over the past several years--the current procedure represents an evolution of surgical technique that has merit because of its effectiveness, durability, relative simplicity, and need for only tiny incisions.
The procedure for repair of SUI is called a sub-urethral sling. Its purpose is to cure SUI, but is also performed in conjunction with cystocele (bladder prolapse) repair to prevent the occurrence of SUI that may be unmasked as a result of the cystocele repair. The sling procedure works by providing support and a “backboard” to the urethra such that with “stress” maneuvers such as coughing, sneezing, and exercising, the urethra will be compressed.
The procedure is performed via a small vaginal incision and two tiny groin scratches. The sutures used to repair the vagina will dissolve on their own and do not require removal, and the groin scratches are closed with a surgical glue. The permanent synthetic material used for the sling is prolene mesh, the very same material as used by general surgeons to repair groin hernias. Sub-urethral refers to the placement of the sling beneath the urethra, the tubular channel that leads from the bladder to the urinary opening. The sling placed underneath the urethra recreates the “backboard effect”. Sling refers to the configuration created when the prolene mesh is firmly anchored to the soft tissues of the pelvis after being placed underneath the urethra. This creates a “hammock” to provide urethral support and to allow compression of the urethra with stress maneuvers.
The sling is an outpatient procedure that can often be performed in a surgicenter. On the day of surgery, prior to being transported to the operating room, certain preparations are necessary. The vagina and abdomen need to be gently cleansed with antiseptic solution, and the pubic region needs to be shaved. An intravenous is started so that appropriate fluids and antibiotics can be administered. The procedure is performed using general, regional, or local anesthesia. The anesthesiologist will discuss these options with you to help you determine the type of anesthesia that is best for you. The entire procedure is performed with your legs in padded stirrups. Most women are able to urinate adequately after the sling procedure, but some will have difficulty that generally lasts only a few days. If you are unable to urinate by several hours after the sling placement, a small catheter will be placed into the bladder. You will then need to go home with the catheter and it will be removed within 48 hours.
Your normal diet and medications can be resumed immediately. You can resume most of your normal activities very quickly. In fact, walking and stair climbing are desirable as rapid return to activities facilitates recovery. You may bathe or shower. Any non-strenuous activity is permissible as long as pain is not experienced. Avoid heavy lifting, strenuous exercise, straining at bowel movements, and sexual intercourse for about four to six weeks after the sling placement. The operative site may hurt more with excess activities---this should signal for you to ease up. Vaginal, pubic, groin, and pelvic soreness are normal for several weeks. Vaginal discharge (often bloody), is also typical for several weeks following surgery and it is therefore recommended that you wear a pad initially.
Prior to being sent home, you will be given a prescription for antibiotics and pain medication. It is imperative to complete the prescription for antibiotics to avoid a urinary tract infection. The pain medication can be used as needed.
BENEFITS AND POTENTIAL RISKS OF THE SUB-URETHRAL SLING
Potential Adverse Effects:
Andrew L. Siegel, M.D.
255 W. Spring Valley Ave.