If other treatments for urinary incontinence are unsuccessful, surgery or other procedures may be recommended.
Before making a decision, discuss the risks and benefits with a specialist, as well as any possible alternative treatments.
If you are a woman and plan to have children, this will affect your decision, because the physical strain of pregnancy and childbirth can sometimes cause surgical treatments to fail. Therefore, you may wish to wait until you no longer want to have any more children before having surgery.
Surgery and procedures for stress incontinence
Sling procedures involve making an incision in your lower abdomen and inserting a sling around the neck of the bladder to support it. The sling could be made of:
- a synthetic material
- tissue taken from another part of your body (an autologous fascial sling)
- tissue donated from another person (an allograft sling)
- tissue taken from an animal (a xenograft sling), such as cow or pig tissue
Autologous fascial slings are a long-term treatment for stress incontinence and may be the most effective.
Synthetic slings may carry long-term risks of causing difficulty urinating or urge incontinence.
Urethral bulking agents
A urethral bulking agent is a substance that is injected into the walls of your urethra (the tube that carries urine from the bladder to outside the body). This increases the size of the urethral walls and allows the urethra to stay closed with more force. A number of different bulking agents are available and there is no evidence that one is more beneficial than another.
This is less invasive than other surgical treatments as it does not require any incisions. However, it is less effective than the other options. The effectiveness of the bulking agents will reduce with time and you may need repeated injections.
Colposuspension involves making an incision in your lower abdomen and lifting up the neck of your bladder. Stitches through the walls of the bladder neck hold it in place.
There are two types of colposuspension:
- an open colposuspension – when surgery is carried out through a large incision
- a laparoscopic colposuspension – when surgery is carried out through a small incision using special, small surgical instruments (keyhole surgery)
Both types of colposuspension offer effective, long-term treatment for stress incontinence, although laparoscopic colposuspension needs to be carried out by an experienced laparoscopic surgeon.
For this reason, the National Institute for Health and Clinical Excellence (NICE) does not recommend laparoscopic colposuspension as a routine operation for women with stress incontinence.
Tape procedures for women
Tape procedures can be used for women with stress incontinence. A piece of tape is inserted through an incision inside the vagina and threaded behind the urethra. The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:
- tops of the inner thigh – this is called a transobturator tape procedure (TOT)
- abdomen – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT)
Some studies have suggested that TVT may be more effective than TOT in some cases. There is a higher risk of injury to the bladder during TOT, and a higher risk of injury to the urethra during TVT. TOT may also cause thigh pain.
Artificial urinary sphincter for men
The urinary sphincter is a ring of muscle that stays closed to prevent urine flowing from the bladder into your urethra. If another type of surgery has not been successful, it may be suggested that you have an artificial urinary sphincter fitted to treat your incontinence.
However, an artificial urinary sphincter can cause a number of side effects, such as the pump that controls the sphincter failing, or not being able to urinate. In such cases, the device commonly needs to be removed or fixed.
This treatment is rarely used in women.
Surgery and procedures for urge incontinence or overactive bladder syndrome
Botulinum toxin A injections
Botulinum toxin A (Botox) can be injected into the sides of your bladder to treat urge incontinence and overactive bladder syndrome (OAB).
Although the symptoms of incontinence may improve after the injections, you may not be able to pass urine normally, so you will need to insert a catheter (a thin, flexible tube) to drain the urine from your bladder.
Botulinum toxin A is not currently licensed to treat urge incontinence or OAB, so you should be made aware of any risks before deciding to have the treatment. The long-term effects of this treatment are not yet known, but it may be of benefit when other treatments have not worked.
Some limited evidence suggests that botulinum toxin A may cure incontinence or improve symptoms by 90%. The effects can last for up to 12 months.
Sacral nerve stimulation
The sacral nerves are located at the bottom of your back. They carry signals from your brain to some of the muscles that are used when you go to the toilet, such as the detrusor muscle that surrounds the bladder.
If your urge incontinence is the result of your detrusor muscles contracting too often (detrusor overactivity), sacral nerve stimulation, also known as sacral neuromodulation, may be recommended.
During the operation, a device is inserted near one of your sacral nerves, for example in one of your buttocks. An electrical current is sent to the device that stimulates the sacral nerve. This should improve the way signals are sent between your brain and your detrusor muscles, and so reduce your urges to urinate.
Sacral nerve stimulation can be painful and uncomfortable, but some people report a substantial improvement in their symptoms or the end of their incontinence completely.
Posterior tibial nerve stimulation
Your posterior tibial nerve runs down your leg and is found near your ankle. It contains some nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder symptoms, such as the urge to pass urine.
During the procedure, a very thin needle is inserted through the skin of your ankle and an electrode is attached to your foot. A mild electric current is sent though the needle and electrode, causing a tingling feeling and causing your foot to move. You may need 12 sessions of stimulation, each lasting around half an hour, one week apart.
In a number of different studies, at least half of people reported improvements in their symptoms, with some people being free from symptoms immediately after the 12 weeks of treatment. However, the results do not last long and you may need more stimulation sessions.
Posterior tibial nerve stimulation can also cause side effects, such as foot or toe pain, minor bleeding and headaches. Some people may also find the stimulation too uncomfortable to continue with.
In a procedure known as augmentation cystoplasty, your bladder is made larger by adding a piece of tissue from your intestine (part of the digestive system) into the bladder wall.
After the procedure, you may not be able to pass urine normally and you may need to use a catheter (a thin tube that is passed through your bladder and into your urethra). Because of this, augmentation cystoplasty will only be considered if you are willing to use a catheter.
Urinary tract infections are common among people who use a catheter. Read about urinary catheterisation for more information.
Urinary diversion is a procedure where the ureters (the tubes that lead from your kidneys to your bladder) are redirected to the outside of your body. The urine is collected directly without it flowing into your bladder. Urinary diversion should only be carried out if other treatments have been unsuccessful or are not suitable.
Urinary diversion can cause a number of complications, such as a bladder infection, and it is common to need further surgery to correct any problems that occur.
Surgery for other types of incontinence
Clean intermittent catherisation for overflow incontinence
Clean intermittent catherisation (CIC) is a technique that can be used to empty the bladder at regular intervals and so reduce overflow incontinence (also known as chronic urinary retention).
A continence adviser will teach you how to place a catheter through your urethra and into the bladder. Your urine will flow out of your bladder, through the catheter and into the toilet.
Using a catheter can feel a bit painful or uncomfortable at first, but any discomfort should subside over time.
How often CIC will need to be carried out will depend on your individual circumstances. For example, you may only need CIC once a day, or you may need to use the technique several times a day.
Regular use of a catheter increases the risk of developing urinary tract infections.
Indwelling catheterisation for overflow incontinence
If using a catheter every now and then is not enough to treat your overflow incontinence, you can have an indwelling catheter fitted instead. This is a catheter inserted in the same way as for CIC, but left in place. A bag is attached to the end of the catheter to collect the urine.
Surgery for LUTS in men
Lower urinary tract symptoms (LUTS) may be treated with surgery if it is thought that your symptoms are caused by an enlarged prostate gland. This is a small gland, found only in men, that surrounds the urethra and is located between the penis and bladder.
One possible type of surgery is a transurethral resection of the prostate (TURP). This involves cutting away a section of the prostate gland.
Another possible type of surgery is holmium laser enucleation of the prostate (HoLEP). This is a relatively new procedure and may only be available in some specialist centres. It involves using a laser to remove some of the prostate tissue.