Surgical management/invasive procedures for urinary incontinence in women

• surgical treatment/invasive procedures
  • for overactive bladder
    • augmentation cystoplasty restricted for the management of idiopathic detrusor overactivity to women whose condition has not responded to non-surgical management and who are willing and able to self-catheterise
      • counselling should include common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention
        
        • small risk of malignancy occurring in the augmented bladder should also be discussed
    • bladder wall injection with botulinum toxin type A1 to women with OAB caused by detrusor overactivity that has not responded to non-surgical management, including pharmacological treatments
      • risk of adverse effects, including an increased risk of urinary tract infection
      • start treatment only if the woman is willing, in the event of developing significant voiding dysfunction: to perform clean intermittent catheterisation on a regular basis for as long as needed or to accept a temporary indwelling catheter if she is unable to perform clean intermittent catheterisation.
        
        
    • percutaneous posterior tibial nerve stimulation
      • non-surgical management including OAB medicine treatment has not worked adequately and the woman does not want botulinum toxin type A1 or percutaneous sacral nerve stimulation
        
        
    • percutaneous sacral nerve stimulation
      
      
    • urinary diversion
      • considered for a woman with OAB only when non-surgical management has failed, and if botulinum toxin A1, percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her
        
        
  • procedures for stress UI
    
    
    • there is public concern about the use of mesh procedures. For all of the procedures mentioned below there is evidence of benefit, but limited evidence on long-term adverse effects. In particular, the true prevalence of long-term complications is unknown
    • if non-surgical management for SUI has failed, then surgical options include:
      • colposuspension - bladder neck is lifted up and stitched in this position(open or laparoscopic) or
      • an autologous rectus fascial sling - made out of tissue from the woman's abdomen; the sling supports the urethra
      • mid-urethral mesh sling procedures are also a treatment option - if offering a retropubic mid-urethral mesh sling, advise the woman that it is a permanent implant and complete removal might not be possible
        
        
    • intramural bulking agents (glutaraldehyde cross-linked collagen, silicone, carbon-coated zirconium beads, or hyaluronic acid/dextran co-polymer) should be considered for the management of stress UI if conservative management has failed. Women should be made aware that:
      • repeat injections may be required to achieve efficacy
      • efficacy diminishes with time
      • efficacy is inferior to that of retropubic suspension or sling
        
        
    • use of an artificial urinary sphincter should be considered for the management of stress UI in women only if previous surgery has failed. Life-long follow-up is recommended

Notes:

• bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections, or renal dysfunction, and in whom this cannot otherwise be corrected
• intermittent urethral catheterisation should be used for women with urinary retention who can be taught to self-catheterise or who have a carer who can perform the technique

Reference:

1. NICE (April 2019). Urinary incontinence - The management of urinary incontinence in women