Urinary Problems after Surgery

Frederick R. Jelovsek MD

• Frequency and urgency after laparoscopy for fibroids
  
• Urgency after hysterectomy
• Incontinence after bladder repair
• Risk of stress incontinence following prolapse repair
• Incontinence after hysterectomy
• Incontinence after hysterectomy and cystocele repairr
• Loss of bladder sensation following unsuccessful prolapse repairs
• Incontinence after a fall/disc injury
• Unable to void after vaginal hysterectomy

Frequency and urgency after laparoscopy for fibroids

I had a laparoscopy and my gyn removed endometriosis off the ovaries and left the fibroid tumors. Ever since then, I've been urinating non-stop.

I have pain right before urination but not during urination. I can sleep during the night, through the night, but when I get up it's head for the bathroom all day long for me. My gyn stated that the fibroid was small back in Aug 2 years ago. An 1/8 of an inch. Please tell me what size do they have to be in order to cause bladder problems?

I don't know that there is a critical size, but most anterior wall fibroids less than 2 cm. (about one inch) that I have seen, don't give symptoms. They usually have to be at least about 2 cm. or more to be indenting a normal bladder enough to cause urgency or decrease bladder volume and cause frequency.

A fibroid on the posterior wall of the uterus would not give any bladder symptoms. Keep in mind that endometriosis can often give bladder symptoms such as pain on initiation of voiding or urgency symptoms from causing bladder contractions.

It is most likely that you either have a bladder infection from the catheterization at the time of surgery or you are having bladder irritation from one of the laparoscopic puncture sites just above the bladder. You will need a urinalysis to see if there is infection. Be sure to see your doctor right away to see if you need any antibiotic or if you should just wait to see if this gets better on its own.

Urgency following hysterectomy

I had a hysterectomy about six months ago and have recently had a problem with bladder control. If I wait too long and hold my urine, I must run and hope to get to a restroom ASAP or I have leakage. Is this a common problem after hysterectomy?

It sounds like you may have a bladder urgency problem which, if it just recently started, is not related to the hysterectomy. Rather it is the new development of "overactive" or urge incontinence or a plain old urinary tract infection. Assuming you do not have a urinary tract infection, the cause of the bladder muscle showing urgency is unknown. This is not a common problem at all this far out from surgery. You need to be checked first for a urine infection.

Incontinence after bladder repair

I have had 2 bladder repair surgeries, the first was with a vaginal hysterectomy in 1984 in which the bladder was tacked. The second was an incision from hip to hip in 1991, which was terrible. Now 8 years later I still leak constantly, have a lot of pressure, and have frequent urination - 3 to 4 times nightly and many times during day the day. I swore that the last surgery would be my last as it was horrible, but I am only 51 years old and feel I am too young to live like this and I am told it will only get worse with aging. I am tired of wearing pads constantly. Last spring I had the incontinence testing and a scope to make sure there were no cysts or tumors, and another surgery was suggested, the sling procedure. It was explained that the sling was used originally for years before the hip to hip incision and doctors are now returning to the sling. I now understand there is a new procedure using a mesh webbing that attaches the bladder to muscle. Is this the same procedure or a different procedure from the sling? What would you recommend? I am overweight and do have a disc degeneration problem in my back.

There are several different procedures to treat your problem, some of which use mesh. Some sling procedures use mesh while others use your own natural tendons. I cannot recommend one over the other because the choice of procedure depends on your particular anatomy as well as the surgeon's experience. In some cases a procedure using mesh would be appropriate while in others there might be better results with another technique. My best advice is to see a urologic or gynecologic surgeon who specializes in this type of surgery doing at least 2-4 cases a month.

Risk of stress incontinence following prolapse repair

Will surgical repair of bladder prolapse cause incontinence? Is the Burch procedure used in cases like this on occasion?

There is not good data on the risk of stress incontinence following repair of bladder prolapse. Estimates range from 25%-75% incontinence after a cystocele repair (bladder suspension) alone if no extra precautions such as a Burch retropubic bladder suspension are taken. Some doctors believe by checking a "Q-tip" test you can decide which patients need bladder neck suspension in addition to the prolapse suspension. You can even make a case for adding the retropubic bladder suspension part routinely to all prolapse surgery.

Incontinence after hysterectomy

I had a hysterectomy with bladder repair following which I had some incontinence. It occurs when I bend over or sit down (whenever I put pressure on my bladder) and still a little with coughing, etc. It appears to be getting worse rather than better. I had the stress incontinence with coughing prior to surgery but not the leakage just from bending or sitting. What is going on? I will be going back to work soon and need to do something about this.

You may be having urge incontinence or even overflow incontinence rather than recurrence of stress incontinence. You need to see your doctor about this and probably have urodynamic studies done.

Incontinence after hysterectomy and cystocele repair

I am 52 yrs old. Five weeks ago I had a total hysterectomy with uterine prolapse and cystocele repairs. A benign grape sized cyst was found under and entwined around the urethra and was removed. Since the surgery I have had virtually no control of my bladder. I spill urine excessively and must go to the bathroom every 20 minutes or so to keep urine from running down my leg. I have limited, if any sensation that I am releasing urine and I cannot hold anything. My doctor has had me on Detrol 2MG twice daily 4 weeks ago and says this will restart the bladder's nervous system but I have had no improvement to date. I cannot return to work in this condition and am becoming depressed. My doctor suggests that an additional surgery may be required. What is causing this and what can be done?

If the cystocoele repair work has resulted in a stress incontinence, further surgery may be needed but at this time, it is very important to diagnose correctly what is going on. Since you had some sort of cyst near the urethra removed, there may be some weakness of the urethra or even a fistula in the urethra or bladder. Those are the serious problems that need to be ruled out. Your doctor may want to do urodynamic studies and even put dye in the bladder to see if there is any injury or poor healing where the cyst was removed.

From your side, you need to ask for complete explanations so you understand all the possibilities and what needs to be done to get you over this. There is no way to tell the success of what treatment needs to be done until it is clear what that treatment is. In general, this sounds like something that can be fixed. Keep us posted as you find out more about what is going on exactly.

The urodynamic study showed that I can retain only 30cm of water. I understand the norm is 90 to 100cm. The doctor prescribed RONDEC-TR8-120. I received the generic CARBINOX/PSE8-120 taking one pill twice a day. In one week I cannot really see any improvement with this medication and it makes me drowsy.

I have returned to work half time now and am managing the problem by restricting my fluid intake to 8 oz water 1-1/2 hr before leaving to work which allows it to get through before departing to work. I then limit my additional intake to small sips to keep my mouth moist and changing pads twice in 4 hours. I then consume water when I get home and handle the leakage then.

I had kidney stones 1-1/2 years ago that plugged the ureter and gave me a serious blood infection so I am very sensitive to trying to keep my kidneys purged.

It appears to me that I am faced with some sort of surgical solution.

The urologist suggested a collagen implant and I started a 4 week allergy test for it. What are the negative side affects of collagen? I have been all over the Net trying to find information on this but find very little. It appears that the collagen is not as permanent as a sling but also not as invasive and perhaps not as risky. Apparently the collagen can be allowed to be absorbed if I decide to try a sling later which, depending upon how it is obtained and installed, can be significant surgery in itself.

Please advise about the collagen success and side effects compared to a sling. Thanks in advance.

Collagen injections (Contigen) range in efficacy from about 50% to 80% success rate. Slings are probably more effective overall but in the range of 75-85%. Both of the procedures depend upon the experience of the doctor doing the procedure so be sure to find someone who has done more than a dozen or so. I have included the following abstracts that might be helpful.

Transurethral collagen injection for female stress incontinence.

Elsergany R, Elgamasy AN, Ghoniem GM
Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.

Int Urogynecol J Pelvic Floor Dysfunct 1998;9(1):13-8

Periurethral collagen injections have been used to treat female urinary incontinence secondary to intrinsic sphincteric deficiency (ISD). As an alternative, a transurethral submucosal collagen injection was used in 33 consecutive women suffering from stress incontinence secondary to ISD at Tulane University Medical Center. Prior to the procedure, careful clinical examination with a videofluorourodynamic study was performed for each case. The procedure was carried out under local anesthesia assisted with monitored anesthesia care (MAC). The collagen was injected transurethrally by the long collagen needle (C. R. Bard). In the first 11 cases the average cumulative collagen injected per patient was 6.1 ml, whereas in the last 22 cases the average was 3.5 ml. As a result of the injection 16 patients were dry (48.5%) and 11 were improved (33.3%), with an overall success rate of 81.8%. The injection failed in 6 patients (18.1%). The mean follow-up was 18.8 months, with a range of 2-33 months. In the successful group there was a significant decrease in pretreatment frequency, from an average of 8 to 4.9 (P = 0.005) and in nocturia from an average of 2.14 to 0.76 (P = 0.001). Also, there was a significant decrease in the number of pads, from an average of 3.7 to 1.1 (P = 0.001). The stress leak-point pressure showed a significant increase, from an average of 68.1 to 93.5 cm H2O (P = 0.03). There was no relation between grade of incontinence and the success of the injection. Two cases suffered from temporary urinary retention. This study revealed that the transurethral submucosal collagen injection is an effective method for treating cases of intrinsic sphincteric deficiency. The volume of collagen required to produce the seal effect is small and it may decrease the reinjection rate. As experience is gained, the procedure time is typically 15 minutes. This makes it a reliable, cost-effective and well-controlled method. However, it has a learning curve and the cystoscope instruments require minor adaptation for its use.

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Endoscopic injection of glutaraldehyde cross-linked collagen for the treatment of intrinsic sphincter deficiency in women.

Richardson TD, Kennelly MJ, Faerber GJ
University of Michigan Medical Center, Department of Surgery, Ann Arbor, USA.

Urology 1995 Sep;46(3):378-81

OBJECTIVES. To determine the clinical efficacy, safety, and durability of endoscopically injected glutaraldehyde cross-linked (GAX) collagen for the treatment of intrinsic sphincter deficiency (ISD) in women. METHODS. Forty-two women with a mean age of 64 years (range, 28 to 88) underwent injection of GAX collagen for ISD. Collagen was injected via a transurethral or periurethral approach. Treatment outcome was based on the change in stress leak point pressures (SLPP) and individual incontinence grades before and after collagen injection. RESULTS. With a mean follow-up of 46 months (range, 10 to 66), 83% were cured (n = 17), greatly improved (n = 5), or improved (n = 13), and 17% were unchanged (n = 3) or worse (n = 4). The median number of treatments was 2 (range, 1 to 8). The 22 women greatly improved or cured required a mean of 2.4 collagen injection treatments, whereas the 20 women who were improved, unchanged, or worse had a mean of 4.1 treatments (P = 0.009). The mean amount of collagen injected per patient was 28.3 cc (range, 2.5 to 85). The group of women who were greatly improved or cured had a mean of 17.5 cc of collagen injected, whereas those who were improved, unchanged, or worse had a mean of 39.5 cc injected (P = 0.002). Mean pretreatment SLPPs of women improved, greatly improved, or cured versus the women unchanged or worse were not significantly different (P = 0.015). The 35 women who were improved or cured had a significant increase in mean SLPP of 65.4 cm H2O (P = 0.001) compared to a mean change in SLPP of 14.7 cm H2O in those women who were unchanged or worse (P = 0.038). CONCLUSIONS. GAX collagen injection for the treatment of stress urinary incontinence secondary to ISD appears to be safe, effective, and durable; hence, it should be considered the treatment of choice in appropriately selected female patients.

I have now seen both my general OBGYN and my surgical specialist after insisting that time was not the solution. A dye test was done to look for a fistula with negative results. My specialist is convinced that the surgical reconstruction was very successful but that the cyst which was removed may have been providing critically needed pressure on the urethra to provide back pressure to the bladder. A urodynamic study is now recommended. Depending upon the findings, a "sling", collagen injections, or a diaphragm may be required under the urethra to replace the lost restriction.

It turns out that the Detrol® may have been a totally wrong medication because its function is to reduce the "urge" sensation. I had little or no urge sensation thus the Detrol® made me lose whatever sensation I had. I am now waiting to see if stopping the Detrol® will improve things while I wait in queue for the urodynamic study.

Thanks to your prompt response I insisted on something further evaluation and I think my doctors are now getting on the right track. I now feel much more positive and expect that there is a satisfactory solution ahead.

You might have them try the medications Hytrin® or Ornade® after your uroflow study. Those are alpha-adrenergic stimulators which may help whatever urethral muscle is there to contract. If you get some response from that you might still put off further surgery for awhile to see how it improves with continued medications.

I am somewhat concerned about your small bladder capacity. I assume you meant 30 ccs or ml as a volume and not 30 cm as a pressure. If it is only 30 ml capacity, you may need a hydrodilatation of the bladder before any surgery.

Loss of bladder sensation to void following prolapse repairs

I am 51 and have 3 children ages 25, 19 and 8. All of my children were forceps babies. The labors were horrendous, even in the case of the youngest who weighed just 4 pounds 11. In 1990 I had repair surgery of uterine prolapse, cystocele, rectocele, and enterocoele. Unfortunately it failed and was so botched that I am full of adhesions and scar tissue.

Now I have more trouble. I have lost bladder function. In other words, I have no urge to empty the bladder and I have to express urine manually every 4 hours. However, without the feeling of having to go to the bathroom, I am not sure if I am emptying it. I drive out of state to the gynecologist who I searched for quite some time in hopes of avoiding a hysterectomy. We tried the use of a pessary to see if lifting the pressure in the pelvic floor would help my bladder condition but the pelvic muscles are so weak that I can't retain the pessary. I am being scheduled for diagnostic tests for my bladder, as the doctor needs to know the cause of the dysfunction before doing more surgery. I don't think I could bear to go through the original repair surgery again only to have it fail. Can you give me any more positive input?

Do you have strong feelings or reasons for avoiding hysterectomy? At the point you are at now, I do not think that saving the uterus will be beneficial. It can be done, but most doctors have more and better experience with removing the uterus (hysterectomy) and then suspending the vaginal vault to the sacrum using mesh and culdoplasty. You will then need anterior compartment repair with Burch retropubic urethropexy and paravaginal repair. After that, any further cystocoele and/or rectocoele repair can be done vaginally.

This is quite a bit of surgery but it will give you the best chance for success. If you find a doctor who wants to try all this repair work vaginally, you may want to keep looking for someone else. Doctors who are members of the Society for Gynecologic Surgeons are usually, as a group, skilled in these types of repair.

Incontinence after fall/disc injury

I fell down a flight of stairs about 4 months ago. I went to the emergency room and they took regular back X-Rays and did not find anything wrong. After the fall I started to leak urine and have occasionally noticed blood in my stools. I also have pain in my lower waist down my left and right legs and have been experiencing numbing and tingling throughout my arms and legs. What are the symptoms of a Slipped/Prolapsed Disk of the spine/back, and how is it diagnosed? Is it possible that I need another type of test such as an MRI? Could this be connected to the urine leakage?

MRI is the best way to detect a disk problem which can cause numbness, tingling, and/or pain in one or both legs. Arms should not be affected unless there is a high injury. From your description of symptoms, you should see an orthopedist or neurosurgeon for a full diagnosis. If you are having weakness of the legs at all, it is urgent that you see someone right away.

Sometimes nerve root irritation from a disc problem can cause uninhibited bladder contractions (bladder spasms) which in turn can cause leakage. You should first be evaluated and diagnosed for disc injury. Then if any treatment does not quickly help the bladder leakage, see you gynecologist or urologist for treatment for the bladder.

Unable to void after vaginal hysterectomy

Immediately after a vaginal hysterectomy a catheter was put in and when I went back for my first week check up to measure urine and to see if I could come off the catheter, I wanted to urinate but my bladder would not function. I returned at the end of the second week and the same thing happened. Next week will be the third week and I am afraid that my bladder will still be nonfunctioning. Any information on this condition or advice?

By not functioning I assume you mean you cannot void at all, even if the bladder is quite full. That is different than being able to void but not completely emptying the bladder.

If you are unable to void at all, it is usually due to swelling around the urethra (opening from bladder to outside), spasm of the urethra due to irritation of the catheter, swelling around the bladder contraction muscle (detrusor), medications that affect the urethra or detrusor, and finally, if you had extra repair work to correct urinary incontinence, the stitches near the urethra may be too tight (usually due to swelling).

Usually voiding difficulty after surgery clears within a month. Rarely it will last out to 3 months if you had any continence surgery performed. After 3 months, voiding difficulties are much less likely to get better on their own.