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Vol. 1 No.1 November 2000 wmfurology.com
Female Incontinence Update Stephan L. Werner, MD , FACS Many women suffer, usually silently and unnecessarily from urinary leakage or incontinence. There are several types of incontinence: Stress Incontinence (SI), leakage with coughing, sneezing, laughing; Urge incontinence, (UI), "I gotta go right NOW!!"; Mixed incontinence, (MI), both SI and UI; and total incontinence. Over the years there have been many treatments for female stress incontinence (SI). The major cause of SI is the progressive weakness of the supporting vaginal tissues due to age and trauma, allowing the urethra and/or bladder to "fall". Milder cases of SI may be treated with Kegel exercises or biofeedback, however significant SI usually requires surgical treatment. The surgical approaches have included trans-abdominal, trans-vaginal and recently, laparoscopic. Many procedures have early success, but late failure due to the ongoing progressive weakening of the vaginal supporting tissues. In an effort to bolster the weak tissues various "sling" procedures have been developed. The original procedures involved harvesting a strip of fascia from the abdomen or leg, passing it under the urethra and fixing it to either the abdominal wall or pubic bone, forming a sling or hammock of new tissue under the urethra and bladder neck, restoring normal anatomy with strong new tissue that was unlikely to weaken with time. Slings could be placed by the abdominal, vaginal or laparoscopic approach. The harvesting of the fascia resulted in significant increase in operative time and patient discomfort. Several artificial materials were tried as a replacement for autologous, (the patient's), fascia with significant failure and complications. Recently slings made from allografts, (donor); or hetero-grafts, (porcine); of fascia, dermis (deep skin), or dura, (covering of brain), have been used with much success. The grafts are biologically inactive, so there are no rejection phenomena. When the bladder has fallen as well, a larger patch is added to the sling to support the bladder. We usually perform the operation transvaginally. The tissues over the bladder and urethra are dissected free, and anchor screws are placed into the back of the pubic bone. A sling is fashioned from the donor tissue and sutured snugly in place. If the bladder has fallen as well, (cystocoel), a supporting patch is sutured to the sling and the pelvic muscles, reconstituting the pelvic floor. The vaginal tissues are then closed over the graft. The surgery usually takes less than an hour and is done on an in-and-out basis or with an overnight stay. With trans-vaginal surgery, muscles and skin are not cut so there is relatively little pain. A catheter is usually left in place for a day or two and then removed. Most patients have good to excellent results that appear to be durable, although long term results are still pending. Some patients may have difficulty urinating and may need a catheter or intermittent catheterization for a while. A few patients will continue to leak and may require collagen injections to improve the results. A rare patient will have chronic pain. Other forms of incontinence will be addressed in future issues. For more information: incontinence.htm
============================================================================================== Where are we all rushing to…and what's with this handbasket? George Carlin
Healthcare is in turmoil. Why? No one wants to pay for it. Not the employers, "it cuts into our bottom line"; not the government, "medicare is going broke"; not the patients, "paid for healthcare is a right". So America invented Mangled, (oops, Managed) Care. Let's review the results. Hospitals are going broke: Leland closed, Georgetown, G.W. University Hospital, Washington Hosp. Center, Prince Georges, Greater Southeast and DC General are all in the red. Doctors are now "Providers",. Denigrate and discount. At least one big pediatric group in the area has gone belly up, and there are a few other practices near the rocks. Service has deteriorated. When physicians are required to add staff to do referrals, get authorizations, fight over payment denials, and deal with overwhelming paperwork, while reimbursements are one third of what they were 5 years ago for the same services, waits are going to be longer, visits shorter, and the services reduced. For example: most patients now have to go to a lab to get blood tests drawn. Why? It takes about 15 minutes to draw a specimen, prepare it, fill out the lab slip. About $3-$8 per specimen in staff time. With some insurers paying only $3.65 a month to provide ALL care to a patient… you do the math. Fortunately most physicians are still practicing good medicine when the insurers allow. But service has deteriorated. What is the answer? Apply a little common sense America: you get what you pay for! Insurers are taking 20 to 28 percent of the health care dollar. Costs for new drugs are unconscionable. Is single payor insurance the answer? Medicare only costs 8%. Regulate the drug companies profits? It's un-American. I don't have any easy answers, besides I gotta get back and make my quota for today. SLW, MD Patient friendly information on urologic problems.
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