Women's struggle with stress incontinence

Research examines which surgery is most effective

May 25, 2007|By Frank D. Roylance | Frank D. Roylance,sun reporter

Stress incontinence — It's an embarrassing problem. Not painful or life-threatening. Just embarrassing and upsetting. And expensive.

Stress incontinence - the tendency to leak urine when you sneeze, cough or lift a heavy object - affects as many as 3 million women in the United States, about a third of all those who experience any sort of urinary incontinence.

The cause isn't clear. It could be a consequence of childbearing, hormonal changes at menopause or simple aging. But something weakens the muscles that support the bladder and control the flow of urine through the urethra below it. And under the mechanical stress of a cough, a laugh or just walking, urine slips out.

Incontinence of all types becomes more and more common as we age, and sufferers spend $20 billion a year, by one estimate, on absorbent pads, drugs and surgery in an effort to cope.

"Everywhere I go, I run into women who are having this problem, and they are normally too embarrassed to talk about it," said Gevaul Smith, 50, of Randallstown.

Doctors say many don't seek help because they don't realize there are treatments available.

Smith, a mother of four, said her struggle with stress incontinence began in 1989. She began wearing pads and carrying spares, just in case. But "it gradually got worse. ... I kept telling myself, `You cannot stop doing the things you enjoy doing,'" she said.

Smith was one of 655 women across the country who enrolled in the first major effort to compare the effectiveness of the two primary surgical solutions to stress incontinence.

The research, reported this week in The New England Journal of Medicine, was the first designed to resolve a decades-long dispute among urologists and gynecologists over which procedure works better. In the end, the results were mixed.

While the "pubovaginal sling" surgery preferred by urologists had a higher success rate than the "Burch colposuspension" procedure favored by gynecologists, it also produces higher rates of complications, including urinary infections.

"The doctors practicing in this field never really knew which was better. ... They never had the strength of evidence we have now," said Dr. Toby C. Chai, a urologist at the University of Maryland School of Medicine and principal investigator for the UM portion of the multicenter study.

In one sense, it may not matter. Patient satisfaction was high for both, said Dr. Harry W. Johnson Jr., director of urogynecology at Maryland and co-principal investigator in the study. "They're both still good operations."

And both camps have already moved on to more advanced, less invasive techniques with quicker recovery times.

Chai and Johnson agreed the study's most important contribution may be as a point of comparison for evaluating the effectiveness of the new procedures. "Now we have something that is well-described as far as the outcomes," Chai said. And that should mean better information and better solutions for patients.

The outcome for Gevaul Smith could not have been better. After she enrolled in the study, she was among the 326 women randomly selected to have the "sling" procedure.

"Sling" surgeons first open the abdomen with a 4-inch incision and remove a 4-inch-by-half-inch strip of connective tissue.

Then, working through an incision in the vagina, they use the tissue to construct a sling to support the bladder's "neck" and the urethra. The two ends of the sling are attached to the abdominal muscles above the pubic bone.

"It was one of the best things I could have done," Smith said. "I have not had any problems, not any whatsoever. I feel like before I had kids."

Cate Teague, 51, of White Marsh, was among the 329 women selected for the Burch procedure.

After years of gradually worsening leaks, she said, "it got totally out of control." She worried about leaving home and fretted over the availability of bathrooms. "A lot of anxiety built up from it," she said.

Finally, one day at work, her adult diaper filled, and she began to leak. Worse, she couldn't even feel it. "I had urine running down my leg," she said. "I told the boss, `I have to go home.'"

Since her surgery, all that is past. She has no more leaks, and she can feel when urine is on the move. "From [my surgery] on, I have never had a problem. It's a huge success," she said.

The Burch procedure is subtly different from the sling. Instead of harvesting connective tissue to make a sling, surgeons enter through a belly incision and suspend the outer wall of the patient's vagina with sutures attached to a ligament on the pubic bone. Like suspension cables, the permanent sutures also add support for the urethra.

Although Teague was happy with the Burch procedure, the study found that the sling operation was significantly better at "curing" stress incontinence - 66 percent compared with 49 percent. Sling patients also experienced fewer re-treatments for stress incontinence.

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