The Centre for
Gynaecological surgery

URINARY INCONTINENCE AND PELVIC FLOOR WEAKNESS

Incontinence and pelvic organ prolapse are relatively common and are unfortunately taboo subjects in our society. People who are affected often choose not to talk about it. Women in particular may feel very concerned about involuntary urine leakage. Various treatments are available that can help most people.

Stress incontinence is the involuntary leakage of urine when there is sudden pressure on the bladder, such as when coughing, sneezing, jumping or lifting heavy loads. Stress incontinence affects women in all age groups. However, middle-aged women are particularly affected. The ability to retain urine when there is sudden pressure depends on the muscles, nerves and ligaments in the pelvic floor working together in a coordinated way. These structures need to counteract the increased abdominal pressure on the bladder. The most common causes of stress incontinence are weakening of the urethra and damage to the structures that support the bladder as a result of childbirth and/or ageing. Damage to the pelvic floor, connective tissue weakness, nerve damage and localised hormone deficiencies can also play a role in stress incontinence.

Conservative therapy options

The pelvic floor muscles and pelvic connective tissue play an important role in securing continence. Tensing of the pelvic floor muscles works to support the urethra. If pelvic floor training is performed correctly, improvement of incontinence can be achieved in up to 40 to 80% of cases. Conservative measures include various special continence tampons and pessaries that can help improve continence in sports, for example.

The operation

If stress incontinence cannot be treated satisfactorily with conservative therapies, incontinence surgery can help.  A special kind of tape that was invented in the mid-90s has revolutionised incontinence surgery. The previous procedure, in which the bladder was “suspended” under general anaesthetic, has been replaced by the new tension-free vaginal tape (TVT) procedure and its variants. TVT has a net-like structure and is made of a non-absorbable synthetic material. It has been used in many millions of operations. The tape is not rejected by the body. It is fixed using a pointed guide needle and is placed on both sides of the urethra via the vagina and up behind the pubic bone with the aid of a guiding instrument, under local anaesthetic. The only visible scars are the two small puncture sites above the pubic hair. The TVT sling forms a U-shape under the urethra. When pressure is applied to the bladder and urethra from above, for example, when coughing, it “bends” the urethra, which prevents the release of urine. The patient is awake during the operation and must cough repeatedly with a full bladder. At the same time, the ends of the tape protruding above the pubic bone are tightened until there is almost no more escape of urine. The procedure is done in this way because, if the tape is applied too tightly, the patient can no longer empty their bladder well, and if the tape is too loose, the urine leakage will continue unchanged. Success rates depend on the experience of the surgeon and range from 80 to 95%.

IRRITABLE BLADDER, HYPERACTIVE BLADDER, URGE INCONTINENCE

What is commonly referred to as an irritable or sensitive bladder or urge incontinence is known in medical terms as an overactive or hyperactive bladder. The main symptom of an overactive bladder is the sudden, problematic, pathological urge to urinate. This results in increased frequency of urination during the day and sometimes also at night. In some cases there may be urinary incontinence before reaching the toilet. This is known as urge incontinence. At least one in six adults has an overactive bladder, making this one of the most common medical conditions.

Conservative therapy options

Pelvic floor training also helps with a hyperactive bladder. In addition, behavioural changes (abstaining from spicy food, nicotine, fizzy drinks, as well as losing weight), bladder training and medication are important elements of successful therapy. The goal of bladder and pelvic floor training is to increase the capacity of the bladder. The intervals between going to the toilet are gradually increased, sometimes with the help of medication that helps to calm and relax the bladder. The bladder learns to hold and retain more urine without releasing it. If symptoms of an irritable bladder occur following the menopause, locally applied hormonal cream or suppositories can also be helpful. Oestrogen can rebuild the mucous membrane in the urethra, the bladder and in the vagina. Initial improvement of symptoms of urge incontinence and burning, itching or pain during intercourse is noticeable after one to two months. The situation prior to menopause is restored by locally administered oestrogens. Because the oestrogens replace something that is missing, the same problems recur when the medication is stopped. This is why longer-term treatment is recommended. In some cases, bladder weakness then completely disappears.

The operation

Previously mentioned conservative, customisable treatment options can provide many individuals with satisfactory improvement in their quality of life. However, some people do not respond adequately to these treatments, or the side effects of the medications (e.g., dry mouth) may be intolerable. In this situation, botulinum toxin therapy should be discussed. Botulinum Toxin type A, also known as Botox, is injected into the bladder muscle at about 20 different sites during a cystoscopy.  This simple treatment often leads to very impressive improvement of the symptoms of urge incontinence. The effect on the bladder continues for a little under a year on average. However, in our experience, many women only need a second round of treatment after 18 months to two years.

PROLAPSE OF THE GENITAL ORGANS

The abdominal cavity and the lesser pelvis (or “true pelvis”) have the pelvic floor as their lower border. The bladder rests on the pelvic floor and the uterus is suspended by a system of muscles and connective tissue, as is the rectum, which is retained by the pelvic floor. Weakening or damage to the pelvic floor structures due to ageing or childbirth can lead to prolapse (sinking) of these organs. Symptoms of prolapse are typically reported in the pelvis, in the vaginal area and sometimes in the back or groin area. Gynaecological prolapse symptoms range from mild discomfort through to disability during movement and walking in the event of complete prolapse. With severe prolapse, a feeling of having a foreign body in the abdomen or a palpable finding (somewhat like a ping-pong ball) in front of the entrance to the vagina is often described. The symptoms typically vary through the day. Prolonged standing or physical work makes them worse. When lying down at night, the positions of the organs change, meaning that the symptoms can disappear. Sexual intercourse is often perceived by many patients as unpleasant or painful. However, the extent of the prolapse does not necessarily correspond to the intensity of the symptoms. These may include difficulty passing urine, increased urinary frequency or problems with defecation. Prolapse is not necessarily associated with urinary incontinence. On the contrary, some women experience urinary retention due to the pressure on the bladder.

Types of prolapse

The diagnosis is based on a gynaecological examination and ultrasound. Additional diagnostics such as a CT scan may be required in some cases. When the bladder sinks into the anterior vaginal wall, this is called a prolapsed bladder or cystocele. With a prolapsed uterus, the uterus, or more precisely, the cervix, slips downwards. A rectocele is when the rectum bulges into the posterior wall of the vagina. If the uterus has been removed in a hysterectomy, prolapse of the vaginal vault (top of the vagina) or an enterocele may occur. An enterocele is a small bowel prolapse, in which the small intestine drops into the lower pelvic cavity and pushes on the top of the vagina.

Conservative therapy options

With targeted pelvic floor training, it is possible to improve the prolapse findings, alleviate the symptoms and delay any progression of the symptoms. Vaginal pessaries can also be helpful. The pessaries are customised by the doctor and the patient can insert and remove them each day. They work by preventing the descent of the bladder or uterus (similar to a normal tampon).

The operation

Gynaecological prolapse can be treated surgically via the vagina, i.e. without an abdominal incision. The surgical restoration of anatomy and function in cases of prolapse has always been a demanding gynaecological procedure. The surgical procedures used today can be tailored to the needs of the patient and can be combined with additional procedures such as for urinary incontinence. If there is prolapse of the uterus, it is usually necessary to remove the uterus in order to restore the pelvic floor. For prolapse of the bladder, a surgical procedure known as a colporrhaphy  is performed via the anterior vaginal wall. The pelvic floor tissue between the vagina and urinary bladder is sutured to reconstruct the tissue layer that lifts the bladder and urethra into their original position. A similar approach is taken for a bowel prolapse. Prolapse of the vaginal vault (the top of the vagina in women who have had a hysterectomy) is particularly challenging. In this case, the top of the vagina is attached to the lower pelvis. The anterior and posterior vaginal walls (cystocele and rectocele) must be reconstructed at the same time, depending on the extent of the prolapse.

Endometriosis 

Endometriosis is one of the most common gynaecological conditions. It affects around 1 in 10 women. In endometriosis, cells from the uterine lining – the endometrium – spread outside the uterine cavity. They can settle on the pelvic peritoneum, ovaries, bladder or intestine, and even on the lungs or kidneys. Because endometriosis lesions are subject to cyclical changes in hormones, they grow and release neurotransmitters that cause pain in the lower abdomen during the menstrual period. In many women, the pain extends down to the leg or lower back. Sometimes it can feel like lumbago or irritation of the sciatic nerve. Endometriosis can occur at all stages of life and is a chronic but curable condition that may require repeated intervention. If it is not treated, endometriosis can lead to long-term infertility.

Laparoscopic surgery is the gentlest and most effective method of treating severe endometriosis. The endometriosis is completely removed in this procedure, while the pelvic organs and their functions are preserved. Removal of the uterus or ovaries is not usually necessary and also not desirable if the patient wants to have children at a later stage.

TREATMENT OF ENDOMETRIOSIS OF THE RECTUM, BLADDER OR URETER

When endometriosis occurs in the region between the intestine and the vagina, it is known as deep infiltrating endometriosis in the rectovaginal septum. In this case, endometriosis can affect the rectum, ureters, bladder and even the pelvic nerves that control the rectum, bladder and sexual function. Extensive endometriosis of the rectum can lead to intestinal obstruction, bleeding from the bladder, blockage of the ureters and irreversible kidney damage, and even destruction of the bladder wall. Surgical removal of the endometriosis is necessary in this severe form, along with removal of parts of the organs affected. This can be performed using laparoscopic or open surgery.

ENDOMETRIOSIS OF THE SCIATIC NERVE

Endometriosis can also affect the sciatic nerve and all pelvic nerves, including the obturator nerve (a lumbar nerve) and the femoral (thigh) nerves. Hormone therapy is not effective in endometriosis of the pelvic nerves – it even carries the risk of unnecessarily delaying surgical treatment of the disease. An operation is necessary to avoid irreversible damage to the nerves leading to motor deficits, particularly raising and lowering the foot. Removal of endometriosis on the sciatic nerve is the most demanding of all pelvic procedures. The use of tiny cameras provides for minimally invasive, highly precise treatment with the best possible protection of the nerves.

HYSTERECTOMY

Hysterectomy is one of the most common surgical procedures in the Western world. In about 90% of cases, a hysterectomy is performed due to benign conditions or changes in the uterus. These include benign tumours in the muscle cells called fibroids. A prolapsed uterus or treatment-resistant endometriosis are common indications. Although these changes are benign, they can lead to severe symptoms that significantly affect the woman’s daily life. Only 10% of women who have a hysterectomy have a malignancy, e.g., cervical or ovarian cancer. In rare cases, removal of the uterus may be required in an obstetric emergency (for example, due to severe, unmanageable bleeding).

The operation

Removal of the uterus can be carried out in various ways. Surgery is possible via the vagina, via an open abdominal incision or laparoscopically. These days the most commonly used method is laparoscopic hysterectomy, in which access is via 5 to 10 mm-long incisions in the abdominal cavity. The uterus may be either partially (supracervical) or totally removed (i.e. including the cervix). This is performed via the vagina and then sutured. In a partial hysterectomy, the remaining cervix and the rectum are fixed in place. Different surgeons use different techniques for this, which can also help prevent future problems with prolapse. If the ovaries and/or fallopian tubes also need to be removed – removal of the fallopian tubes is known as salpingectomy – this is performed in the same step. The technique used in each specific case depends on the underlying condition and the woman’s individual situation (for example, previous surgery, size of the uterus, desire to preserve the cervix, menopause, etc.). The desire for children will also influence the type of treatment and the choice of procedure.

Side effects and postsurgical care

The procedure is low-risk and is generally without complications. As with all surgery, however, infection, nerve injury or bleeding may occur in rare cases. Even with the greatest of care from the surgeon, injuries to the surrounding organs cannot be ruled out, especially if there are adhesions present. These problems can usually be detected and corrected during surgery, and rarely require a second operation. As a result of the laparoscopy, there may be slight abdominal cramping and flatulence for a few days after surgery. A hysterectomy takes between one and two hours and requires a stay of two to three nights at the clinic. Strenuous physical activity and lifting heavy loads must be avoided for some time after the operation. Sexual intercourse should also be avoided for some time.

Neuropelveology

Neuropelveology is a specialist field within gynaecological surgery. This is an interdisciplinary field focusing on neurological, gynaecological and urological issues, and diagnosis and treatment of diseases of the pelvic nerves in particular. The LION procedure developed by Professor Possover has revolutionised many treatments in gynaecological surgery, including treatment for hyperactive bladder, incontinence and sexual disorders. The Laparoscopic Implantation Of Neuroprosthesis (LION) procedure is based on nerve stimulation or the application of electricity to the nerves to control pelvic nerve dysfunction by laparoscopic implantation of a microstimulator system. Applied to the pudendal nerve, the LION procedure is suitable for the treatment of a hyperactive or irritable bladder as well as urinary and faecal incontinence, especially if both are present. The pudendal nerve is also one of the most important genital nerves, controlling sexual function and erection of the clitoris or penis. The LION procedure is therefore also used to treat sexual disorders and erectile dysfunction. 

AN EXPERIENCED TEAM OF EXPERTS

Prof. Dr. Possover is a board certified gynaecologist and professor of neuropelveology. He’s specialized in operative gynaecology and neuropelveology, laparascopic pelvic surgery and tumour surgery.

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