By: Jean Johnson for MedTech1
Plastics have had a bad rap ever since “The Graduate” linked the slick new substance with corporate greed and consumer madness back in the ‘60s. Admittedly, some observers of contemporary pop culture might find the sight of half the adults in the nation drinking from plastic water bottles a bit bizarre.
Still, most would agree that plastics have their place. Certainly we at Medtech1 think that’s the case when it comes to the tiny blue tapes of Prolene mesh urogynecologists are using in surgeries designed to treat urinary stress incontinence.
Technology Straight from Sweden
While the synthetic mesh isn’t new and has been used in hernia repairs for some 30 years now, only in the past decade has the technology been applied to treating bladder problems. We can thank the Swedes for the innovation. In 1995 they developed what’s known as the TVT procedure, by taking a thin strip of Prolene mesh and surgically implanting it so that it held a weakened urethra and bladder in place.
|Are you at risk for urinary incontinence? Risk factors include:|
Chronic smoking and the often accompanying chronic cough
In 1998 Connecticut urogynecologists including Paul Tulikangas, M.D. and Christine Lasala, M.D. brought the technique to the United States. Since that time, they’ve had such success that in December 2005 the colleagues staged a broadcast at Hartford Hospital in which they demonstrated and commented on the surgery. The following remarks are taken from that broadcast.
Urinary Incontinence, A Highly Treatable and Historically Ignored Condition
The sub-urethral sling surgery using Prolene mesh is one among several medical advances over the past 10 to 15 years that has enabled women to age without enduring a loss of control over their urinary function that their mothers and grandmothers considered inevitable.
Urinary incontinence is very common with 15 to 20 percent of women who are child-bearing age reporting significant problems, said Tulikangas. He added that about one out of three women who are postmenopausal report urinary incontinence which can lead to problems related to independence.
“Over half of women in nursing homes report significant urinary incontinence, and urinary or fecal incontinence is the fourth most common reason why women are admitted to nursing homes,” Tulikangas said.
“The economic impact is very impressive. Over $21 billion is spent on urinary incontinence, but interestingly, only 4 percent of that is spent on diagnosis and treatment. The majority of that money is spent on pads and other devices to help absorb the urine loss. More sanitary napkins are purchased for urine protection than are purchased for menses.”
Now that Tulikangas has our attention, he goes on to point out that “urinary incontinence is more common that hypertension, more common than depression and more common than diabetes.”
Clearly the urogynecologist has a handle on the extent and severity of the problem. On the up side, he also has a solution – at least for urine incontinence caused by stress.
These days with technology like Prolene mesh, Tulikangas underscores, women do not have to accept leaking and loss of bladder function as a part of the aging process. That’s why, he calls on the “one in four women who don’t tell, and the one in four doctors who don’t ask,” to come out of the closet and address the issue squarely.
Indeed, Tulikangas is quite blunt about myths that have grown up around older women and bladder control. “Urinary incontinence is the uncontrolled loss of urine that is socially or hygienically a problem to the woman. It is not a normal part of aging or getting older,” said Tulikangas. “Some patients have been pushed aside by family members or even practitioners who said, ‘well, everybody leaks a little bit as they get older.’
“In some cases, though, that type of urine loss can restrict people from going out. They become socially isolated. In many cases, it keeps people from doing exercise and other activities which should be a healthy part of their lives and would help with other cardiac health and their overall benefit in terms of bone density,” Tulikangas explained.
“So we’ve really tried to change how people think about incontinence. Really, when people are candidates for treatment for incontinence, it can make a profound impact on their lives.”
Sub-Urethral Sling Surgery for Stress Incontinence – How it Works
As urogynecologist and expert in the Prolene mesh procedure, Christine Lasala, M.D. who is Tulikangas’ partner in practice notes, the surgery uses a tension-free device that’s comparable to a “little mini-sling.”
Lasala explains how it works. “This tape goes underneath the urethra and behind the pubic bone, so it’s minimally invasive. In years past, we used to have to do these incontinence procedures oftentimes through a big incision on the abdomen. That’s the real nice thing about this procedure.”
Tulikangas adds that since stress incontinence is usually due to loss of support at the bladder or the urethra, the sling which is essentially a blue piece of nylon mesh adds additional support and “is very effective in preventing stress urine incontinence.” He also states that because “the procedure is done through a significantly smaller incision, it speeds up recovery” and hopefully circumvents the need to use a catheter after the surgery.
Lasala, who has had the procedure done herself, agrees wholeheartedly. “Many times women would have to go home with their catheters for a week or so. Now most women are able to void very simply after this procedure, so it’s much easier for the patient.”
More, since the surgery is minimally invasive, patients do not have to go under general anesthesia and can have the procedure done on an outpatient basis. They return home the same day, with little more than some mild pain medication for the first three days. The only challenge Tulikangas has had he said, “is trying to get patients to go slow after surgery. We don’t want them to get back into their regular activities too quickly because we want this to be a permanent solution.”
That said, he said that after six to eight weeks, he and Lasala “don’t limit patients at all in their physical activities particularly if it’s a primary procedure, where the patient hasn’t undergone a prior surgical procedure for urine incontinence.”
The Prolene mesh sling has an 80 to 82 percent “curative” rate with data based on seven years of following patients. “If you take 100 patients who undergo a procedure like this, about 80 of them will say ‘I really don’t leak any urine at all,’ and that will be confirmed by their testing,” said Tulikangas. “About 15 or so will say, ‘Boy, I’m much improved,’ and are happy they had the procedure but still might leak a little bit, but consider themselves a success. About 5 percent or so won’t have much improvement with the procedure.”
Tulikangas also points out that the body does not have problem in accepting the presence of the Prolene sling. “This is an inert mesh. It’s very similar to hernia mesh that’s used in inguinal hernia repairs. It’s been around for 20 to 30 years, and the rate of having a reaction or abnormality with this mesh in the vagina is about 1 percent.
“In cases where we’ve seen that, it’s been a fairly small procedure to go and excise the area where there’s been a problem and re-close the area of the vagina over the mesh, so the actual rates of problems with the mesh have been very low in this procedure.”
As both urogynecologists know, urinary incontinence can be exceedingly difficult to manage. They offer the following accounts of patients whose lives have been put back on track with the TVT surgery.
“The great thing is that one of my patients had been a former marathon runner and her running partner, a man, was very impressed at how much she perspired,” said Lasala. “It turned out she was not perspiring. She had tons of urine running down her legs as she would run. So anyway, we did the TVT procedure. She is back to running marathons again, and she doesn’t even wear a panty liner. She is most delighted about that.
“Your story about the marathon runner reminded me that I had a patient who was a dance instructor,” said Tulikangas. “Halfway through her classes, she always had to leave and change her pants. She used to kid the people in her dance class that she was doing it to change her dance routines, but she was actually doing it because she was leaking so much urine. She was so happy when she could just wear one outfit to her class. It’s really made a big difference for her, although she says a lot of people that she teaches dance to miss her great variety of clothes.”
Types of Urine Continence Differ and Have Different Treatments
Stress incontinence is urine loss caused by anything that increases intra-abdominal pressure. Coughing, laughing, sneezing, running, dancing – anything that puts pressure on a bladder and urethra that through the course of life have grown a little worse for the wear. This condition is what the sub-urethral sling procedure can help.
Tulikangas, however, is careful to point out that urge urinary incontinence is also very common (and often called overactive bladder). This type of incontinence is treated by different modalities, not the surgery.
“We often call this the ‘key in the door’ incontinence. When you come home from a busy afternoon shopping at the mall and you get out of the care and you can’t find your key to get in the door or you just get your key out and all of a sudden there’s a sudden urge to urinate, he said. “Other triggers for urge incontinence can be the sound of running water, the sound of a shower, or even the suggestion or talking about fluid.
“Most people feel that it’s an abnormality of the nerves that enervate the bladder. The bladder has a very complex nervous enervation, some signals telling the bladder to relax and some telling it to contract. It’s probably, in part, an imbalance in that situation that leads to overactive bladder.”
That’s why overactive bladders have different treatment modalities and can benefit from various medications and avoiding substances that are known irritants to the bladder like caffeine, nicotine and synthetic sweeteners including NutraSweet and saccharin. Fluid management is also proving to be a useful tool for helping people manage overactive bladders as is using the rest room on a regular schedule instead of waiting for an urge signal.
Either way, people who are having problems with urine incontinence are smart to discuss their situations with their physicians. There are various interventions that can help overactive bladders, and if the patient has stress incontinence, they just might be a candidate for the sub-urethral sling that uses the Prolene nylon mesh. Indeed, it’s in ways like this that plastic truly has improved lives in contemporary society.