If you have severe symptoms of stress urinary incontinence or overactive bladder, surgery may provide a permanent solution to your problems. But surgery isn't for everyone. Find out what procedures may help in treating urinary incontinence.

By Mayo Clinic Staff

For some women, symptoms of stress incontinence or overactive bladder don't respond to conservative treatment. When urinary incontinence markedly disrupts your life, surgery may be an option.

Urinary incontinence surgery is more invasive and has a higher risk of complications than do many other therapies, but it can also provide a long-term solution in severe cases.

The surgical options available to you depend on the type of urinary incontinence you have. Most options for urinary incontinence surgery treat stress incontinence. However, low-risk surgical alternatives are available for other bladder problems, including overactive bladder — also called urge incontinence or urgency-frequency syndrome.

Before you choose urinary incontinence surgery:

  • Get an accurate diagnosis. Different types of incontinence require different surgical approaches. Your doctor may refer you to an incontinence specialist, urologist or urogynecologist for further diagnostic testing.
  • Think about your plans for having children. Your doctor may recommend waiting for surgery until you're finished with childbearing. The strain of pregnancy and delivery on your bladder, urethra and supportive tissues may undo the benefits of a surgical fix.
  • Understand that surgery only corrects the problem it's designed to treat. In some cases, surgery may not cure urinary incontinence. For instance, if you have mixed incontinence — a combination of stress incontinence and overactive bladder — surgery may improve your stress incontinence but not your overactive bladder. You may still need medication and physical therapy after surgery to treat overactive bladder.

Like any surgical procedure, urinary incontinence surgery comes with risks. Although uncommon, potential complications may include:

  • Temporary difficulty urinating and incomplete bladder emptying (urinary retention)
  • Development of overactive bladder, which could include urge incontinence
  • Urinary tract infection
  • Difficult or painful intercourse

Talk with your doctor to understand possible risks and benefits of surgery.

Most surgical procedures to treat stress incontinence fall into two main categories: sling procedures and bladder neck suspension procedures.

During a sling procedure, your surgeon uses strips of synthetic mesh, your own tissue or sometimes animal or donor tissue to create a sling or "hammock" under your urethra or bladder neck. The bladder neck is the area of thickened muscle where the bladder connects to the urethra — the tube that carries urine from the bladder. The sling supports the urethra and helps keep it closed — especially when you cough or sneeze — so that you don't leak urine.

The sling procedure that's best for you depends on your individual situation. Discussing the risks and benefits of each type of sling procedure with your doctor can help you make the right choice.

Tension-free sling

No stitches are used to attach the tension-free sling, which is made from a strip of synthetic mesh tape. Instead, body tissue holds the sling in place. Eventually scar tissue forms in and around the mesh to keep it from moving.

For a tension-free sling procedure, your surgeon may use one of three approaches:

  • Retropubic. With the retropubic approach, your surgeon makes a small cut (incision) inside your vagina just under your urethra. Your surgeon also makes two small openings above your pubic bone just large enough for a needle to pass through. Your surgeon then uses a needle to pass the sling under the urethra and up behind the pubic bone. A few absorbable stitches close the vaginal incision, and the needle sites may be sealed with skin glue or stitches.
  • Transobturator. With the transobturator approach, your surgeon makes a similar vaginal incision as in the retropubic approach and also creates a small opening on each side of your labia for the needle to pass through. The sling passes in a different pathway from the retropubic approach, but it's still placed under the urethra. Your surgeon closes the vaginal incision with absorbable stitches and the needle site with skin glue or stitches.
  • Single-incision mini. With this approach, your surgeon makes only one small incision in your vagina to perform the procedure. Through this single incision, your surgeon places the sling in a manner similar to the retropubic and transobturator approaches. No other incisions or needle sites are needed.

Recovery time for tension-free sling surgery varies. Your doctor may recommend two to four weeks of healing before returning to activities that include heavy lifting or strenuous exercise. It may be up to six weeks before you're able to resume sexual activity.

Using surgical mesh is a safe and effective way to treat stress urinary incontinence. However, complications can occur in some women, including erosion of the material, infection and pain.

Conventional sling

With a conventional approach, your surgeon makes an incision in your vagina and places a sling made of synthetic mesh tape — or possibly your own tissue or tissue from an animal or deceased donor — under the neck of your bladder. Through another incision in your abdomen, your surgeon pulls the sling to achieve the right amount of tension and attaches each end of the sling to pelvic tissue (fascia) or your abdominal wall using stitches.

A conventional sling sometimes requires a larger incision than does a tension-free sling. You may need an overnight stay in a hospital and usually a longer recovery period. You may also need a temporary catheter after surgery while you heal.

A bladder neck suspension reinforces your urethra and bladder neck so that they won't sag and provides something for the urethra to compress against to help prevent leakage.

To perform the procedure, your surgeon makes an incision in your lower abdomen. Through this incision, your surgeon places stitches (sutures) in the tissue near the bladder neck and secures the sutures to one of two places:

  • A ligament near your pubic bone (Burch procedure) or
  • Cartilage of the pubic bone (Marshall-Marchetti-Krantz procedure)

Your surgeon may recommend this surgical approach if you're also having another abdominal surgery at the same time, for instance to repair prolapse of other pelvic organs.

The downside of bladder neck suspension is that the procedure requires an abdominal incision, and you need general or spinal anesthesia. Recovery takes several weeks, and you may need to use a urinary catheter until you can urinate normally.

Certain procedures to treat overactive bladder involve stimulation — using small, electrical impulses — of the nerves that signal the need to urinate. Nerve stimulation may help with urge incontinence, but these procedures aren't effective for treating stress urinary incontinence.

Sacral nerve stimulation

In this procedure, your surgeon implants a small, pacemaker-like device under your skin, usually in your buttock. Attached to the device — called a stimulator — is a thin, electrode-tipped wire that carries electrical impulses to the sacral nerve. These electrical impulses block messages sent by an overactive bladder to your brain, telling it that you need to urinate.

Sacral nerve stimulation doesn't work for everyone. You can try it out first by wearing the stimulator externally, after the attached wire is placed under your skin in a minor surgical procedure. If the stimulator substantially improves your symptoms, then you can have it implanted.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia and mild sedation. Your doctor can adjust the level of stimulation with a hand-held programmer, and you also have a control to use for adjustments. The stimulation doesn't cause pain and may improve or successfully treat urge incontinence and urgency frequency syndrome in people who haven't had success with medications or lifestyle changes.

Tibial nerve stimulation

An alternative to sacral nerve stimulation, tibial nerve stimulation is a procedure to stimulate a nerve in your leg (tibial nerve). The electrical stimulation travels along the tibial nerve to the spine, where it connects with the nerves that control the bladder.

Called percutaneous tibial nerve stimulation, the procedure involves placing a needle through the skin near the ankle to reach the tibial nerve. An electric impulse flows through the needle. The procedure takes about 30 minutes, and you start by having it done weekly for 12 weeks. Based on your response to the treatment, your doctor may recommend follow-up sessions at regular intervals to maintain the results.

Tibial nerve stimulation may be an option if you've tried other treatments without success and you don't want to have surgery.

Finding an effective remedy for urinary incontinence may take time, with several steps along the way. If a particular treatment approach isn't working for you, ask your doctor if there's another solution to your problem.

April 18, 2014