How Incontinence Can Be Affected by Surgery

Frederick R. Jelovsek MD, MS

"Thirteen weeks ago I had a laparoscopic assisted vaginal hysterectomy and a bladder suspension using a sling. I have not been able to urinate since; I've been doing clean intermittent catheterization (CIC) to empty my bladder. The doctors say to wait six months to see if I will eventually urinate on my own. They believe my bladder is weak from years of drinking too much fluid and not urinating often enough. Are they being realistic that six months will cure this? Or should I save myself the trouble and have the sutures removed now?"

"I am 43 years old and in good general health." Diane

The muscle of the bladder which does the contracting to void urine is called the detrusor muscle. Voiding function requires not only this muscle to contract, but also the intrinsic sphincter muscle of the urethra to relax and open the urethra. If that sphincter muscle does not relax or if the urethra is externally compressed from the surgical sling procedure, then it does not matter whether the bladder detrusor is strong or weak. You will not be able to void when obstruction is present.

If you have not been able to void for 3 months already, I assume the doctor has given you a trial of medication (alpha-blocker) to try to relax the urethra. This would be something like Minipres ®, Hytrin ®, or Cardura ®. If you did take it and it did not allow you to void, there is a very good chance that the problem is urethral obstruction from the sling rather than a "weak bladder" muscle.

Urodynamic studies, especially a cystometrogram, can diagnose a weak detrusor muscle post operatively. In this case you would not have the urge to void until huge amounts of urine (over 800 ml or about 27 oz) are in the bladder. If you are getting a normal urge to void at about 300-500 ml of urine in the bladder as indicated on a cystometrogram, then the detrusor muscle is not the problem. The reason it is important to know the difference is because surgery to take down the urethral sling has less of a chance to be successful if the detrusor muscle is really "weak" as they say. In that case you would wait longer before having a surgical take-down (urethrolysis).

There is no data that I could find in the literature to answer the question of how likely it is for you to gain spontaneous voiding function by 6 months if you do not have it at 3 months. I would guess that there is about a 10-20% chance that by 6 months (3 months from now) you will be voiding on your own.

How common is it for a woman to having urinary voiding problems after surgery for incontinence?

It is more the rule than an exception to have some sort of voiding problems after a surgical procedure for stress urinary incontinence. These problems can be divided into several areas:

• a temporary voiding difficulty right after the surgery for several days to several weeks usually due to urethral spasm (7-50%) 
• a prolonged voiding difficulty lasting weeks to months due to partial or total urethral obstruction (5-20%) 
• a permanent or extremely prolonged inability to voluntarily void urine due to urethral obstruction (under 5%)
• the new occurrence of bladder spasms or irritative voiding symptoms 5-25%, (lower with Burch colposuspension and higher with a sling procedure)
• the new inability to completely empty the bladder
• persistent stress urinary incontinence (mild 1-2 pads 20%, moderate 3-5 pads 3-8%)

It is important to note that some of the irritative voiding symptoms and difficulty in emptying the bladder completely can also occur after hysterectomy alone and are not necessarily be related to the incontinence part of the procedure.

Voiding problems after a sling procedure for urinary incontinence that last long enough to require a repeat surgical procedure to relieve any urethral obstruction vary from about 2-3%.

What are the causes of voiding problems post operatively?

Initially after incontinence surgery, there is a significant degree of swelling around the bladder and urethra. The swelling disrupts the nerve supply to the bladder which in turn makes it difficult to relax the urethral and initiate voiding. It may take anywhere from several days to several weeks for this swelling to clear.

An inability to void after 2 or 3 weeks is most often due to external compression of the urethra. In other words, the tissue or material used to support the urethra is compressing the urethra at rest or with minimal straining. Sometimes the surgical tissues stretch over time and this compression relaxes.

Another postoperative cause of voiding dysfunction is due to the inability to feel the need to void. There may not be a bladder sensation of fullness or the urge to void. Such a loss of feeling can be due to denervation of the bladder when tissues are dissected during surgery. If the nerve tissue is interrupted to the bladder, it may not be able to sense fullness or contract when it is full. It may take 6-18 months for that nerve tissue to regenerate. It is more common to have innervation problems after radical surgery for cancer but it can occur with any surgery.

How long should I go before deciding to have surgery to release any obstruction?

Most postoperative voiding difficulty resolves within the first week or two after surgery but up to 20% of women can have an extended period (up to 6 months) before being able to void without a self-cath or having to have an indwelling urinary catheter. The incidence of voiding dysfunctions goes up with age, being 12% under age 50 and as high as 50% over age 65. Six months is usually the cutoff that many doctors use because there can be a natural loosening that takes place up until then. After six months it is unlikely that the obstructive symptoms will improve on their own, but in several series, the average time elapsed between the initial surgery and subsequent surgical takedown of the compressed urethra is as much as 14-18 months).

Some physicians feel that if a woman is unable to void spontaneously by 8 weeks that there is urethral obstruction present and surgical revision should be considered. Other physicians will not consider surgical revision (urethrolysis) until at least 6 months have passed. Even if a woman can void on her own but with some difficulty, there can often be irritative bladder symptoms in which the detrusor muscle has spasms when it senses fullness. With high bladder volumes and bladder spasms, a woman may still need surgery to relieve urethral obstruction even though she can void without self cath.

How successful is the surgery to release urethral obstruction?

In general, the surgery to release urethral obstruction is about 85-90% successful to the point that a woman does not need to self-catheterize or have an indwelling Foley catheter, but there is a new or recurrence of stress incontinence rate of about 10-20%. Thus the total success of the procedure is about 65-80%.

The surgical approach for releasing the obstruction may be vaginal or abdominal although it is slightly more successful if the approach is abdominal (retropubic). The main question that surgeons have is whether to perform any sort of milder suspension surgery at the time of taking down the previous suspension, because there is always the risk that the second suspension would also obstruct the urethra. There appears to be about a 10% difference in reversion to stress incontinence depending upon whether an anti-incontinence procedure is done (10%) or not done (20%) at the time of urethrolysis.

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