Bladder weakness: how do operations help?

Stress incontinence is a taboo subject for many women. The chances of successful treatment for these bladder problems are good, but risks remain. What are the options

Enjoy life actively, climb stairs carefree: many incontinence patients only do this when their bladder is holding the urine again

© GettyImages / E + / PonyWang

She leaked a drop of urine on every step of the stairs. Just a few drops if she lifted a crate of water with one jerk. Since a failed intervertebral disc operation, Elke G. from Uslar (Lower Saxony) suffered for years from what is known as stress incontinence. When the spinal cord was anesthetized, the doctors paralyzed the nerves that control the emptying of the bladder.

Handle complaints openly

With every increase in pressure in the abdomen - be it due to coughing, laughing or jogging - her urethra leaked a little urine. Not only physically stressful, but above all for the soul. But to withdraw and limit yourself in your everyday life was out of the question for the secondary school teacher. "I was constantly using new templates and wearing dark fabrics so that you couldn't see anything. And I often thought: Hopefully there will be a break soon."

Help from the pharmacy

In many pharmacies you can get advice on suitable diaper briefs, disposable pants or templates for incontinence. An additional payment is necessary for products that are not reimbursed by health insurance companies.

For several years now, the 69-year-old has been working as a teacher in a geriatric nursing school, where she aggressively addressed the subject. "I said it could be anytime that a mishap would happen because of my incontinence."

Their openness was well received by their protégés, and they responded with understanding. "It's a disease like any other. Why shouldn't you talk about it?" Says Elke, who always dealt with it positively. Nevertheless, she suffered from the complaints.

Hammock under the urethra

Almost every fourth woman will suffer from a leaky bladder at some point in her life when it is stressed - more than from diabetes or migraines. Many struggle unnecessarily with the disease, which can be treated well. A small plastic band often improves the patient's life suddenly. As with Elke G. A little over a year ago, a doctor placed such a tape under her urethra within a few minutes.

Like a hammock: Professor Boris Gabriel shows an incontinence tape

© W & B / Lêmrich

"The ribbon lies like a hammock under the middle of the urethra and stabilizes it," explains Professor Boris Gabriel, chief physician of the gynecological clinic at St. Josefs Hospital in Wiesbaden. "It is not attached, but grows together with the body's own tissue over time."

Mostly it is located in a U-shape behind the pubic bone. In a variant, it is used flatter and around the hip bones. In recent years, shorter and less wide straps have also come into play, which are inserted into the tissue with plastic anchors, so-called mini-loops. However, these are not undisputed. It is also unclear whether they are effective for as long as their role models, for which there are already 20-year data.

Tension Free Vaginal Tape

The method, which the Swedish doctor Professor Ulf Ulmsten developed in the 1990s, revolutionized the standard surgical treatment for stress urinary incontinence. The very first product that a US company brought onto the market was called "tension free vaginal tape" (TVT).

Until then, a major operation was necessary, which resulted in a longer hospital stay. After an abdominal incision, the bladder neck was raised to relieve the urethra and relieve the pressure. Experts call this still recognized procedure colposuspension, which is performed today by laparoscopy - but only when a tape operation is not an option.

"This is the case, for example, if the anterior vaginal wall has subsided at the same time," explains Gabriel. The advantages of the ribbon: Only a local anesthetic is necessary. It is gentle on the tissue because it only requires mini-cuts. And it uses the vagina as a natural and minimally invasive access route.

Few of complications and lasting success

The success rate is 80 to 90 percent, which means that in most women, the bladder closes again after the procedure. The complication rate is low. In about five percent of patients, urination disorders occur because the ligament is too tight. Then it has to be loosened in a further procedure.

This will keep the bladder tight again

© W & B / Michelle Guenther

TO THE PICTURE GALLERY

© W & B / Michelle Guenther

This is how the urinary bladder lies in the pelvis

© W & B / Michelle Guenther

The U shape

is the most commonly used surgical procedure. The tape is passed under the middle of the urethra and lies loosely in a U-shape behind the pubic bone

© W & B / Michelle Guenther

The variant

Here, the tape made of the plastic polypropylene is guided a little flatter in the direction of the groin or the inside of the thigh

© W & B / Michelle Guenther

The mini sling

is shorter and less wide than traditional belts or slings. It is therefore equipped with plastic anchors on both sides that claw into the tissue

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If non-surgical treatment methods are unsuccessful, the surgeons stabilize the organ in the abdomen with a plastic band

Although bladder injuries and internal bruises are rare, side effects cannot be completely ruled out. These include wound healing disorders, groin and thigh pain, and pain during sex.

Overall, however, the long-term data are very good. A study recently published in the specialist journal Gynecology and Obstetrics with more than 17,000 participants showed that nine years after an operation, only 1.1 percent of the patients had to be operated again - experts see this as significant evidence of the long-term success of the method with few complications.

Textile implants under fire

The operation was also a blessing for Elke G. Immediately afterwards, she felt a significant improvement in her symptoms. If she goes to qigong or on the treadmill in the gym today, she no longer has to fear mishaps. "It's been quiet since I got the tape."

She only regrets that she did not take this step earlier and advises other women with stress incontinence not to wait unnecessarily long before an operation. In order to reach as many people affected as possible with this message, Elke G. got involved in the self-help incontinence association.

Internationally, textile implants made of plastic in gynecology have recently come under fire. The discussion sparked off about the nets that are used in cases of sagging genital organs. The US licensing authority FDA demanded that manufacturers should use long-term data to demonstrate that these nets actually provide the patient with additional benefits compared to conventional operating rooms.

Pelvic floor nets and incontinence bands

Because not all manufacturers were able to provide evidence on time, the FDA withdrew some products from the market for the time being. For Gabriel, however, comparing such nets with the plastic straps that are used in the surgical therapy of stress incontinence is like comparing apples and pears. "This discussion is about large-area nets as a tissue substitute, similar to how they are used for inguinal hernias."

The surgeon not only needs larger amounts of material than with a bladder band. "The surgical technique is also significantly more invasive and is associated with a higher risk of complications," says Dr. Christian Fünfgeld from the Interdisciplinary Continence and Pelvic Floor Center Tettnang.

Helpful measures before the operation

  • Change lifestyle: avoid heavy work and lose weight. This takes the pressure off the bladder
  • Physiotherapy with pelvic floor training: to strengthen the inner holding muscles, possibly combined with biofeedback and electrical stimulation
  • Medication: duloxetine
  • Tampons, pessaries, vaginal cones

Although, according to German experts, pelvic floor nets should not be confused with the small incontinence bands, band operations in England are now only permitted within the framework of studies. "This decision is politically motivated and scientifically not justifiable," says Gabriel. The larger nets and the small ribbons would be lumped together.

Laser therapy as a future alternative

That is why the medical profession in Germany is arming itself against possible restrictions - not least because of this, new and proven "old" therapy methods were discussed as alternatives at the annual meeting of the German Continence Society. However, some of these have not yet been very well investigated or have a higher rate of complications than the sling.

Doctors also achieve acceptable success with injections using gel-like substances that form cushion-like bumps in the urethra and thereby seal it off. The success rate is around 60 percent.

Laser therapy could also become interesting in the future. However, there are no long-term data for this method, which is still experimental. The discussion also provides an opportunity to focus more on conservative, non-surgical methods, primarily pelvic floor training, "which improves the pressure transmission to the urethra," says Gabriel.

Conservative method or bladder band?

In addition, local treatments with ointments containing estriol and pessaries that are used when necessary - for example when jogging or during fitness training. They are designed to support the pelvic organs from the inside in such a way that bladder problems are eliminated.

"These non-surgical methods must have been exhausted before each operation," says Fünfgeld. Not every woman who loses urine needs a tape. "Our motto is: as little as possible, as much as necessary," confirms Gabriel.

With Elke G. all attempts to alleviate her stress incontinence with conservative methods were unsuccessful. "I can't say that it really did me any good." Even after half a year of regular exercise, she did not get any improvement with the pelvic floor training. And the pessaries pressed unbearably. "It was not possible to run or walk with it." The tape made a lot of things easier and gave Elke G. new freedom.

You can find the addresses of advice centers on the Internet at www.kontinenz-gesellschaft.de