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Urinary Incontinence Medications and Surgical Treatment
Stress incontinence results from a weak urinary sphincter. Medications that strengthen the urethral contraction include sympathomimetic drugs (such as Sudafed), estrogen (such as Premarin), and tricyclic antidepressant agents (such as Tofranil and Elavil), although none are overwhelmingly effective, and their use for treating stress incontinence are off-label indications.
Medical conditions that cause urge incontinence may be neurologic or non-neurologic. The urethra is healthy, but the bladder is hyperactive or overactive. Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen.
The three main categories of drugs used to treat urge incontinence include antispasmodic drugs (such as Bentyl, Levsin, Cystospaz, and Pro-Banthine), anticholinergic drugs (such as Enablex, VESIcare, Ditropan, Oxytrol, Detrol, and Sanctura), and tricyclic antidepressant agents (such as Tofranil and Elavil). Patients should not use anticholinergic drugs if they have narrow-angle glaucoma, urinary retention, bowel obstruction, ulcerative colitis, myasthenia gravis, or severe heart diseases. These medications can cause drowsiness. Anticholinergic drugs should not be taken with alcohol, sedatives, or hypnotic drugs.
In some cases, a medication called desmopressin (DDAVP) can be used to decrease nighttime urine production and help reduce nocturia.
Urinary Incontinence Surgical Treatment
Anterior Vaginal Repair
This procedure's primary purpose is to repair a cystocele in women (bladder descended into the vagina). A vaginal incision is used for vaginal repair; a vaginal or abdominal incision is used for the variation called paravaginal repair. The purpose of the procedure is to do two things: reduce the cystocele and reinforce the tissues that support the bladder and urethra.
This procedure was first described in 1913 and today is most commonly used when cystocele is an issue in addition to incontinence. Other procedures (see the following) have had better success rates at curing stress incontinence.
Bladder Neck Suspension
First described in 1959, this type of surgery stabilizes the bladder and urethra. Several different techniques are used and may be referred to as retropubic suspension, transvaginal suspension and Marshall-Marchetti-Krantz (MMK) and Burch procedures, for example. These techniques basically elevate the bladder and urethra and are used for stress incontinence.
Generally, the surgeon stitches into the ligaments and tendons that provide support to the pelvic organs and these stitches are tied to the pelvic bone, for example, to provide support to the bladder and urethra. This can be done either through the vagina with a long needle or with an incision into the abdomen.
The laparoscopic Burch procedure is a newer approach that accomplishes the suspension laparoscopically. Using an endoscope, which goes through the belly button, the abdomen is inflated and the tissue next to the bladder is lifted to reduce the pressure the bladder places on the urethra. The three to four small incisions require just a couple of stitches or surgical tape. The laparoscopic Burch procedure also offers a short hospital stay (one or two days), reduced recovery time and pain, lower cost, and smaller scars.
This procedure is most often performed for women with stress incontinence and is rarely used for men. The purpose of the procedure is to repair weakened urethral sphincter muscles by using a sling to compress the sphincter. This prevents urine from leaking when laughing, coughing, or doing other activities that can cause stress incontinence.
The sling is made out of abdominal tissue or synthetic tissue. The tissue is formed into a sort of hammock for the sphincter and is attached to pubic bone or the front of the abdomen (just above the pubic bone). The technique requires a small abdominal incision and (in women) a vaginal incision.
A recent advance is the Tension-Free Vaginal Tape Procedure. Also called TVT surgery for short, this variation on the sling procedure uses mesh-like tape under the urethra, which acts like a hammock to provide compression to the urethra sphincter. The TVT procedure requires no sutures and takes just 30 minutes under local or sedation anesthesia. The tape is inserted through small incisions in the abdomen and vaginal wall. The patient may be released the same day as surgery or stay overnight. People undergoing TVT typically have minimal pain and discomfort during and immediately after the procedure, but are instructed to avoid sex and strenuous activity for several weeks. Long-term success rates are very good and range from 80% to 90%.
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