Stress Urinary Incontinence and Pelvic Floor Prolapse

It is estimated that 13 million people, men and women, suffer from urinary incontinence.  Although incontinence of urine is common, it is by no means normal.  This condition is twice as common in women as it is in men.  This section concentrates on urinary leakage in women.

There are different types of female urinary incontinence as described in this other website provided by the National Kidney and Urologic Diseases Information Clearinghouse.  The two most common types incontinence are urge and stress incontinence.  Urge incontinence often can be significantly improved by the use of medications that help the bladder to relax and hold more urine.  There are also behavioral modifications that can be used alone or in concert with these medications.  Sometimes the cause of urge incontinence is a "dropped bladder", or cystocele, which can cause irritation of the bladder making it involuntarily empty itself of urine. 

Sometimes behavioral treatments or medications can improve this leakage.  If incontinence is associated with obesity (BMI or body mass index greater than 30), then a weight loss program alone can significantly improve the leakage.  If these conservative measures fail, then surgery may be recommended to restore the bladder back to its' normal position.  Dr. Hendricks has tremendous experience with newer minimally-invasive procedures which can restore normal female anatomy with minimal discomfort, as will be described later in this section. 

Stress Urinary Incontinence

Stress incontinence is the loss of urine with coughing, sneezing, or other forms of exertion.  This can be mild, where only a few drops of urine may come out at a time, or severe, where it just gushes out.  This is usually caused by weakness and stretching of the muscles of the pelvic floor, as shown in the images.  Kegel exercises will improve the leakage in about 20 percent of women, but they need to be consistently performed for at least three months for them to work.  These exercises are done by squeezing your anal sphincter like you were trying to prevent soiling your pants.  This squeeze needs to be held for a count of ten seconds.  One should do five sets of these ten second squeezes.  These fives sets should be done about five times per day, for a total of 25 sets of ten seconds.  These exercises help the pelvic floor muscles get stronger and bulkier, which can help compress the opening where the urine comes out, making one lose less urine.

In patients that are obese, a weight loss program is recommended. Recent studies have shown a 60 percent improvement in incontinence episodes in women who lost an average of 35 pounds! Dr. Hendricks can provide counseling on weight loss. He has experience in the weight loss field, having been trained in bariatrics (the medical weight loss field) by his father, Dr. Ed Hendricks, one of the innovative leaders of that specialty and Secretary of the American Board of Bariatric Medicine. Dr. James Hendricks regularly counsels patients on weight loss at his father's office.

If these conservative measures do not improve stress incontinence, then there are a variety of minimally-invasive procedures that can be done. If there is only mild incontinence, where one does not need to wear any absorbant pads or only wears 1-2 per day, then there are bulking agents that can be injected at the location of the urinary sphincter to help stop the leakage. Another new promising procedure involves radiofrequency ablation for stress incontinence. Both of these procedures can be done in the office with a local anesthetic with minimal discomfort. 

If the leakage is more severe, these office-based procedures are less likely to be successful. In these cases, surgical intervention is usually necessary to improve the situation.  There are a variety of procedures that can be done.  The most common is called a sling, where some sort of material is placed under the urethra (the tube from the bladder to the outside, which goes through the urinary sphincter) that is anchored somewhere above the urethra.  This helps to compress the urethra, stopping the leakage.  The anchoring points for the material can be the abdominal wall, the pubic bone, or a small opening in the bones of the pelvis called the obturator foramen.  The success rate for any of these procedures has been about 80 percent over 4-8 years. 

Dr. Hendricks has tremendous experience performing these procedures.  The majority of the slings he performs currently are done by anchoring the material through the obturator foramen in a procedure called placement of transobturator tape, or TOT.  This is an outpatient procedure that takes about 15 minutes to perform with little, if any, pain!  Dr. Hendricks has had excellent outcomes performing this procedure in hundreds of patients.  He is also a surgical proctor for the procedure and has instructed numerous other surgeons on the technique.   There are a few different systems that can be used to perform this procedure.  The ones most commonly used by Dr. Hendricks are the Monarc, made by American Medical Systems, and Aris, made by Mentor Corporation.

Pelvic Floor Prolapse

Sometimes stress incontinence is associated with different organs of the body herniating down into the vagina, which often cause symptoms of their own.  These herniations can also occur with the absence of stress incontinence.  For example, a herniation of the bladder down into the vagina, or a cystocele as described above, can often cause discomfort, a feeling of pressure, urinary frequency, and even urgency incontinence.  Herniation of bowel into the vagina can also cause significant discomfort and constipation.  This could be due to herniation of the rectum (a rectocele) or the small intestine (an enterocele).  If these herniations are present, then Dr. Hendricks has found that correcting this anatomy with other minimally invasive procedures often significantly improves these symptoms.  Sometimes these herniations are accompanied by prolapse of the uterus down into the vagina.  If that is present, then a gynecologist would evaluate this and treat it, if necessary, either by nonsurgical means or by performing a hysterctomy at the same time as the pelvic floor repair.

There are a variety of procedures that can be done to fix these herniations, restoring normal anatomy and improving symptoms.  These procedures involve strengthening the pelvic floor in some way.  The old-fashioned way of doing this was to place stitches to "pull" the muscles of the pelvic floor tighter, thus closing off the herniation.  The problem with doing that is that these muscles that are pulled together are already weak, which is why the herniation occurs in the first place, so that the muscles ultimately stretch out again, resulting in a recurrence of the problem. 

Dr. Hendricks is a national leader and surgical proctor in the performance of new techniques whereby the use of mesh is used to strengthen the pelvic floor.  This use of this mesh has the same principle as the use of mesh in abdominal wall hernia repairs.  In these repairs, mesh in placed over the herniation defect.  This mesh forms a scar that strengthens the abdominal wall better than the old procedures of pulling the abdominal muscles and fascia (the tough layer outside the muscles that holds the abdomen together) back together with stitches.  Since surgeons started using mesh to repair hernias, the recurrence of hernias has greatly decreased. 

If mesh works so well for abdominal wall hernias, then it seems to make sense that its' use could also help prevent recurrences of pelvic floor hernias.  The problem with using mesh in the vagina is that the vaginal skin is often much thinner than the tissue overlying the abdomen, particularly in postmenopausal women.  To solve this problem, surgeons use a much thinner mesh in the vagina to prevent too much scarring, and this mesh has worked extremely well!

Dr. Hendricks often will use this mesh to pull up the bladder (in the case of a cystocele) by placing the mesh as a hammock under the bladder and suspending it through the obturator foramen, an opening in the bones of the pelvis as described above.  He also uses this mesh to pull down or push up the rectum (for a rectocele) or small intestine (an enterocele) if it herniates through the vagina.  This hammock of mesh is suspended and fixated outside of the muscles of the pelvis.  Each of these procedures only take about 30 minutes to perform and involve minimal pain and an overnight stay in the hospital.  The system used to repair cystoceles is called Perigee, while rectoceles and enteroceles are repaired with the use of Apogee.  Both of these are made by American Medical Systems, a company that was created by a urologist.

Dr. Hendricks has one of the largest experiences in the country performing these new minimally invasive techniques with excellent outcomes and no recurrences to date.  There are a number of former patients of his that would be happy to discuss their experience to anyone interested in more information about what to expect.

Contact us at (707)224-7944 if you would like to arrange for a consultation to see if you would benefit from any of these techniques.