Peachtree Gynecology - Patient Education

PUBOVAGINAL SLING PREOP:

Stress incontinence is the most common kind of urinary incontinence in women. It is the term used for leakage of urine during exercise, coughing, sneezing, laughing, or lifting.

The pelvic floor muscles normally fit snugly around the neck of the bladder. They form a ring of muscle that prevents urine from escaping through the urethra, which is the tube that carries urine out of the bladder. However, the pelvic floor muscles can be stretched or torn during childbearing. There may also be further loss of muscle tone after menopause due to a thinning of tissues caused by a lack of estrogen. Sudden pressure on the bladder (for example, from coughing or sneezing) can overcome the weakened muscles and cause a little urine to escape. Diabetes, obesity, and urinary tract infections also contribute to stress incontinence.

For treatment of stress urinary incontinence, a pubovaginal sling is recommended.  The procedure will be performed through a small incision in the vagina and two small puncture incisions in the skin over the pubic bone that will be used to place a strap of synthetic mesh underneath the bladder neck like a hammock to prevent leakage with increases in abdominal pressure that occurs with cough, sneeze, and exercise.  Once the sling has been placed, a small scope is used to look into the bladder to make sure there has not been a bladder injury during the sling placement. The bladder is then filled and the tension on the sling is adjusted. The key to the surgery is having the sling snug enough to prevent leakage, but loose enough to not interfere with bladder emptying. The alternatives to surgery including using a pessary and pelvic floor physical therapy.  Urethral bulking is also an option if you have good urethral support and/or low urethral pressures.

The success rate of the sling surgery is 90-95% if this is your first surgery for stress incontinence. The success rate is slightly lower at 80-85% if you have had prior surgery and/or you have low urethral pressures which are suggestive of a weak sphincter mechanism. The general risks of surgery including bleeding, transfusion, damage to organs such as bowel and bladder, blood vessels and nerves, infection, formation of scar tissue, and bowel obstruction (<1 %).  The risks specific to this surgery including pain from the mesh arms, mesh erosion (failure of the vaginal to heal with mesh exposed in the vagina), post-operative voiding dysfunction, urinary retention, post-operative urinary incontinence, urinary tract infection and pain with intercourse (1-3%) .  The material used in the mesh has been used for more than 10 years in over a million cases worldwide.  The infection/complication rate associated with the sling material is very low. Occasionally we may injure one of the blood vessels behind the pubic bone which can result in a hematoma (blood clot) and significant bruising around the incisions. These usually require no intervention and resolve on their own after a few weeks. This surgery is meant to improve only stress incontinence and any symptoms of frequency, urgency or urge incontinence are unlikely to be improved by this procedure.

The surgery can be done under general or epidural anesthesia. The surgical data suggests that the type of anesthesia used has no effect on the success of the procedure; however, use of an epidural anesthesia allows the patient to undergo a “cough” test in the operating room with a full bladder to assist the surgeon in adjusting the tension on the sling. After the surgery is completed, the patient will have a catheter in the bladder and a packing in the vagina for about an hour, which will then be removed by the nurse. Often some fluid will be placed in the bladder before the catheter is removed. You are then allowed to void. Most people have no difficulty voiding after the procedure. However, sometimes with the effects of the anesthesia and the swelling after surgery, some patients may have difficulty emptying their bladder immediately after surgery. These patients are given a choice of going home without a catheter, but may have to do intermittent “in and out” catheterization to empty their bladder for few days. The other alternative is to go home with a catheter in the bladder and return to the office the day after surgery to have the catheter removed and attempt to void. You will be given the opportunity to view an instructional video on intermittent catheterization during your preoperative visit. Very rarely, patients are unable to void after surgery for a prolonged period (>1 week). If this occurs, we may need to return to the operating room to loosen the sling a little. This is a very quick procedure that is done as an outpatient.

There is no special preparation prior to surgery other than nothing to eat or drink after midnight the day prior to surgery.  No douches or enemas are required. You will need to register and complete hospital preadmission requirements.

Following the procedure, you will be asked to avoid heavy lifting, straining or intercourse for 3-4 weeks after surgery. As the sling is “tension free”, it is not attached to anything and relies on your own tissue to grow into the sling and hold it in place to provide long lasting support. However, you will be able to resume most normal activities such as walking, driving, bathing and routine daily activities that don’t require lifting > 25 pounds within a few days. Your bladder sensation may not be normal right after surgery, so it is recommended that you try to void every 2 hours while you are awake whether you feel the urge or not. If the bladder gets too full, it does not empty well. You may need to do “double voids” which involves leaning forward or changing position after you think you have finished voiding to completely empty your bladder. You urine stream may always be weaker and slower, and it may take longer to empty than you are used to. Some of these symptoms will improve over time, but they may persist indefinitely.

Although this may sound intimidating, this is a very successful procedure and most patients do extremely well with minimal down time. Please let us know if you have additional questions or concerns.