Midurethral sling surgery remains our mainstay treatment for stress incontinence. Excellent nonsurgical alternatives include pessaries and polyacrylamide hydrogel
For patients who want to be completely rid of stress incontinence, midurethral sling surgery remains our mainstay treatment. The data show a high success rate, great durability and a low risk profile.
With this procedure, a sling is placed underneath the urethra so when the patient coughs or strains in a way that normally results in incontinence, the urethra is compressed, preventing urine leakage.
I tell my patients that if their goal is to be cured of stress incontinence, this procedure remains the best option. Because it is surgery, the sling does come with risks. It also requires two to four weeks of recovery time.
There are a couple of excellent nonsurgical alternatives for stress incontinence for patients who do not want to undergo surgery, have had the sling surgery once and don’t to do it again, want to try a nonsurgical option first, or are too sick for surgery.
Pessaries — placed in the vagina to support the urethra — have been shown to work well in women with stress incontinence, giving them an average of 60% improvement with their symptoms. Pessaries can be fitted in the office by a nurse practitioner in 15 minutes and can be worn constantly or as needed for an exercise class or for physical work. There is also a similar, over-the-counter option that not only works for absorption but also for preventing stress incontinence — but it is only approved for eight-hour use.
Another option for women with stress incontinence is urethral injection with a polyacrylamide hydrogel, which is showing significantly longer durability than previous urethral injections. The polyacrylamide hydrogel results in complete dryness for about half my patients, and studies are showing the injection can last for up to seven years of significant improvement. This is a major improvement over previous injections, which tended to last only six to 12 months.
The injection does not require anesthesia, only light sedation, and takes only five minutes to administer. It also can be done with the patient fully awake, with only local numbing, so patients can drive themselves home after the procedure. As soon as patients urinate in recovery, they can go home. Twenty-four hours later they can exercise, can have sex and generally have no restrictions on their activities.
The polyacrylamide hydrogel is also an excellent option for patients with intrinsic sphincter deficiency (ISD), which is an inability to maintain coaptation either at rest or in the presence of stress. Women with ISD show a lower cure rate with midurethral sling surgery.
What the patient chooses for stress incontinence depends on the patient’s needs and lifestyle. I’ve had patients who are leaving on a trip the next day or the following week, who don’t have time to recover from surgery but don’t want to worry about stress incontinence. They will choose the injection and are usually very happy with the results. If patients aren’t satisfied with the results, they can choose another injection or move on to the midurethral sling.
Marjorie L. Pilkinton, M.D.
Marjorie L. Pilkinton, M.D., is board certified in obstetrics and gynecology and female pelvic medicine and reconstructive surgery. She practices at Norton Urogynecology Center offices in St. Matthews and Shelbyville in Kentucky; and in Clarksville, Indiana.