Treatment of incontinence using many different surgical techniques including the injection of the bladder neck did result in some unsatisfactory results like recurrence. The use of  the bladder neck suspension techniques has prove to be very satisfactory for many patients in particular if they are not treated before.

Incontinence is the loss of ability to control the bladder function in particular unremarkable loss of urine. This can be due to neurological hyperactivity of the bladder wall or more common the weakness of the mechanism of closure of the bladder.

The reason why many women suffer under this agonising social problem is weakness of the muscles of the pelvic floor, injury to the bladder sphincter, previous gynaecological operation or any disease of the urethra that results in a short urethra that is sagging so that it is not any more under the pressure initiated in the abdomen under certain strains.

The incontinence has three different grades:

1. the patient loses urine under  massive activity
2. the patient loses urine under some body activity like walking fast or sneezing and coughing
3. patients are wetting themselves under light activity like normally walking or even standing from the sitting  position.

This is the so called stress incontinence which may be combined with the more agonising urge incontinence. The stress incontinence can be treated by bladder neck suspension operations. This is done through elevation of the urethra at the region of the bladder neck. One of the methods of treatment is called the Burch operation where the anterior vagina wall is fixed with three stitches on each side to the coverings of the anterior bones of the pelvis to anchor the urethra into its normal anatomical position.Recently it is also possible to treat the different grades of incontinence through the injection of a collagen in the bladder neck to increase the resistance of this region when it is exposed to a high pressure thus preventing the leakage of urine. This goes right in particular in previously operated patients.

The urge incontinence is a sort of hypersensitivity to the normal sensation of the bladder or a hyperactivity of the muscle of the bladder itself. This later cause of incontinence can be treated medically. When the medical treatment does not work, it is mandatory to reduce the activity of the bladder through the injection of some anaesthetics at the root of the bladder nerves in the vertebral column.
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Anatomy of the woman
Please note the direct relationship between
Uterus, rectum and peritoneum.
B = bladder / U = urethra
Ut = ureter / M = outlet

During the pressure measurements are recorded the different values of bladder, stomach, urethra and muscles of the pelvic floor.
Pves = pressure in the bladder
Pabd = pressure in the abdomen
Pdet = pressure of the muscles of the bladder
Qura = pressure in the urethra
= EMG activity of the muscles of the pelvic floor

Who qualifies for the operation ?

Patients suffering from any grade of stress incontinence in particular the later two grades. The operation should be done after excluding or treating the urge component.

It is advised to reduce weight before the operation and to use some physical aids to increase the effect of the operation that may have to be repeated for 3-4 times before a satisfactory effect is reached.


How does the operation work ?

The patient lies in the gynaecological position on the back. The urethra and bladder should be inspected endoscopically. The vagina should be aseptically prepared and inspected. Two small incisions are done under anaesthesia lateral to the labia majora bilaterally. An other incision is done in the vagina immediately under the urethra. A tunnel is developed between the two incisions running under the urethra. The synthetic band in inserted and pulled through the tunnel. This results in pulling the urethra and bladder neck bringing them to the normal anatomical relationship again. Sometimes it is important to perform a bladder neck suspension  followed by the collagen injection in the bladder neck.


Healing:

The patients are treated on out patient basis and are dismissed after being sure that the urine is clear and pain is alleviated. Patients has to avoid strong activity for some days post operatively. Special vaginal plugs are inserted to support the urethra and aid in restoring the continence.

Incision

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Frequently Asked Questions (FAQ):

1. Is incontinence related to a certain age?
   
   No it can happen to young patients specially after pregnancy.
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2. Is incontinence related to certain diseases?
   
   No, It may increase after all diseases that increase the pressure of the abdomen like coughing and sneezing.
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3. Is surgery always indicated?
   
   No, It is only indicated in cases of late second stage and in third stage incontinence.
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4. What are the diagnostic measures of  incontinence?
   
   The good history taking is the best and first tool for diagnosis. This is followed by the clinical examination and the exclusion of bladder infection. The measurement of the different pressures of the bladder and abdomen (Urodynamic diagnosis) completes the picture and gives the indication for the right therapy.
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5. Why should you change the angle of the urethra at the bladder neck to treat incontinence?
   
   This is done to allow the functional part of the urethra be under the closure effect of the intra abdominal pressure which squeezes the urethra when increased.
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6. Is the operation painful?
   
   A good sedation and local anesthesia to the tunnel tracks are all what you need to have a painless operation which is done on out patient basis.
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7. Is there a guarantee for the operation?
   
   The suspension of the urethra is a good method for treatment and the success is guaranteed if the indication is critically selected.