Dr. Joshua Cohn, Fox Chase-Temple Urologic Institute Provider, discusses urinary incontinence in women, focusing on the etiology, prevalence and diagnostic evaluation. He also discusses the various treatment options that may be most helpful for each patient.
So my name is Joshua Cohen. I'm an associate professor of urology at Fox Chase Cancer Center in Temple Health. Um I wanted to give a talk today about urinary incontinence in women, particularly focused on stress urinary incontinence and the various types of issues that may arise in the language that you may see in charts as it relates to the treatment of stress or hearing comments. Because there's a lot of language out there, it can be a little bit confusing and hopefully this helps with this very, very common problem in terms of getting a better sense of what to what to do to help these patients and first steps and when to send them on to specialists who can hopefully help them out. So uh the scope of the problem is very significant for urinary incontinence if you just look at all your comments, not just stress urinary incontinence. Um in general it varies depending on the patient population. You're looking at anywhere between 5% and our youngest patients and we're talking about even teenagers in that population all the way up to 70%. Of course institutionalized adults would be an example where incontinence is almost a role. Um as opposed to an exception. Risk factors for urinary incontinence include increasing age, increasing body mass index, family history of incontinence plays a role. Um parody plays a role. And then unfortunately um cognitive decline as you get older also plays a role. So I think it's an independent risk factor of just getting older. Uh immobility and frailty, there can be a functional components that not being able to get to the restroom in time. Certain medications and and certainly neurologic disease as well, challenges of an aging population in this country again, speaks to that that is we are getting older and there's a greater degree of life, maybe not quality of life, a greater degree of life in the later years. And there's a greater degree of patients living into older age. But cognitive impairment. It's extremely common to see uh, urinary incontinence and then also as patients come into the hospital and then leave after admission, um, it's uh, particularly unfortunate how many we're coming continent not leaking and then we'll leave leaking. So about a third of patients, older adults who get admitted to the hospital just because of that frailty will wind up incontinent by the time they're discharged. So very common. But again, the young are not spared. Uh, so when you look at a population survey, this is probably the best, you know, epidemiologic data we have is the epic study for laurier track symptoms. And we find that even amongst those under 40 years old, 7% suffer from any type of overactive bladder urinary incontinence. And then in the 40 to 59 year old range 14% suffer from urinary incontinence. And then unique risk factors That we have to consider a younger population. So you're seeing a 60 year old woman with stress urinary incontinence. You may think about certain things that that you you um need to consider more in 40 year olds who come in. Um potentially they may have uh plans for future pregnancy than they have to be considered younger patients. Menopausal status should be considered. Is there some longstanding voiding dysfunction in a patient who has new onset urinary incontinence? Or it occurred after sort of childbirth? Or this is somebody who's had issues with urination their entire life and whether they're being newly diagnosed with a neurologic disease or illness to explain their new onset urinary incontinence, such as multiple sclerosis. So, these are all things to consider when you see a younger patient who has urinary incontinence versus somebody who's maybe in their fifties or sixties. So in the initial evaluation, I think for anyone, but I also talked to a urologist about this uh and I will talk to the kind of college of residents about this and certainly for primary care physicians as well, You know, what's complicated. Um, So we are happy to see anybody who has urinary incontinence who needs help. But there may be certain steps that uh or certain steps you can take as an initial management of patients who are less complicated in certain patients for whom there should be a little bit more of a red flag that this is somebody who should be seen by a specialist earlier. Um, So patients who have complicated urinary incontinence might be those who have associated pain, they have blood in their urine that you can see or microscopic blood in the urine. They may have what's called voiding dysfunction. Where it's very difficult for them to empty their bladder. Um They have uh what's difficulty sort of in that peeing phase as opposed to just sort of holding onto the urine. There may be a component of pelvic organ. Prolapse may be diagnosed by the gynecologist or reported on exam as feeling like there's a vaginal bulge or pressure. They may have been treated for urinary leakage before and have persistent issues. They may have received a radiation in the past in the pelvis or they may have a suspected fish from prior surgery. Those are all patients who should get fairly urgent evaluation. We're talking about uncomplicated. Now, getting into specifically stressing and comments and the rest of the talk is primarily going to focus you know, on stress urinary incontinence. But talking about uncomplicated stress urinary incontinence. Again, this is because of urethral incompetence for patients often have um coughing, sneezing, leakage, bending to pick things up. Uh They may leak. Um running crossfit high impact exercises. Those tend to be the circumstances but we'll talk again about why it may not always be the case. Um So what what defined sort of uncomplicated stress urinary incontinence patients who may benefit um from, say a physical therapy. And we'll get into that physical therapy early and then referral of its persistent or considering some of the other uh less complicated management options for them. So we define it based on what's called the value trial. The value trial looked at which patients need additional testing before surgical treatment. Um And so the testing that we perform is called Euro dynamics. And it's fairly invasive, but it's it can be highly informative for us and complicated circumstances. And patients get catheters and we essentially measure their bladder function as far as filling and empty and the pressures under which the bladder fills and the bladder empties. And we get a sense of what's actually going on in the bladder at the time of leakage. It's sort of like taking this, you know, on a journey through bladder filling and emptying. And those patients with sort of uncomplicated comments, they've had long lasting symptoms, they empty their bladder well um they have no signs of infection. Um And then there's some other, you know, assessments of the mobility that I would um expect a specialist to be evaluating for more than than a primary care setting. Um And then when we look at our guidelines for uncomplicated comments, it's more or less follows along the same lines. They don't have other conditions like pelvic organ, prolapse prior stress incontinence surgery or um have a predominantly overactive bladder component where it's the urgency and the frequency and they're running to the bathroom, that's the primary issue for them. We talk about stress incontinence as a fair number of patients who may fall into that uncomplicated category. Fair number. Not as many as you might think, at least in a tertiary care setting. But certainly a fair number. Uncomplicated urgency urinary incontinence. I like to think of it as like, you know, when we get the loch ness monster and Bigfoot or the tooth fairy, it's probably not um something that really exists. Uncomplicated urgency urinary comments. There's so many factors that go into urgency leakage age vascular factors. Um uh whether they've had a neurologic injury or not that we know about something very, you know, very calm create like a spinal cord injury, whether they have a neurologic injury that's sort of not as concrete like chronic spine disease. Um maybe an example. It could be an early sign of Parkinson's disease or as we spoke about before, multiple sources. So I think the uncomplicated urgency urinary incontinence doesn't really exist, but that in and of itself, I think would be a great topic for another discussion of what to do about those patients with overactive bladder for sugar common. We talked about how even the patients who are uncomplicated uh may may not be as uncomplicated as they seem and the reason we can talk about this, there's an old saying in neurology that the bladder is an unreliable witness. So we talk about who's uncomplicated. It's really actually only gonna be about one third of women to meet the definition for uncomplicated structure and contents. But what that means for us as specialists treating stressing the incumbents is about a third of them are gonna require that Euro dynamics testing or would potentially benefit from that Euro dynamics testing that we spoke about to determine. Is this really a problem of you know the urethra not working well enough to to stop leakage or is this a misbehaving bladder phenomenon? The good news is the initial management of these patients um is reversible For most of what we do is initial management. We don't have a patient come in and then immediately recommend that they have an irreversible sort of therapy or treatment. Um when appropriate. Or your dynamics testing can help us sort out what's going on and then it's not a life threatening condition. So that's the good news, you know for this. And the general principles for us managing this is that we take a look at whether they need an advanced evaluation by that. I mean your dynamics testing or sta Skopje where we take a look in the bladder of the light scope. Try to choose the predominant symptom first if they have really bad urgency, really bad feeling like they can't make the bathroom in time and focus on that coughing sneezing is the major issue. I try to focus on that as well. Um And then we try to look at non or minimally invasive therapy. So that might be um physical therapy or a pill for overactive bladder. Did you see if those work pretty well, that might be an indicator that yeah, sure. It was probably overactive bladder that's their main issue and not stressing comments. And it can be telling even if it's not adequate in treating them. So we do the best that we can and with with some degree of uncertainty. Um treatment options for stress urinary incontinence uh involve a non operative approaches as well as operative approaches. I say, for for every patient, we try to match up what is needed, what they need in order to get the relief that they're seeking versus what is wanted. So, I I say that every patient, if you offer them, you know, a pill, no side effects, they could take it once and it would fix their problem forever. And it was very inexpensive. Um every single patient would sign up for that in a heartbeat, but that's not, unfortunately, that's not the reality. And so there are certain things that they may need if they want to get better, that they don't want to do and they'd rather live with their symptoms. And that's okay. I think that every approach that we take to every single patient has to be individualized with what they're comfortable going through and frankly risking on the side effects side in order to achieve the outcome that they're looking for. Um but I'm not operative approaches, I think are great because they really have very little downside. But even these we'll talk about do have downsides to where it's not, you know, there's not nothing you know, to to consider doing them for our patients and and we do the best we can to counsel them and help them make a decision about the value of those particular approaches for them. On the operative side, there are urethral bulking agents will discuss those will discuss synthetic media rifle slings, also known as mesh slings, pupil vaginal or fashion slings where we take tissue from the patient and use that as a sling rather than using mesh. And then uh more historic procedure. Although it has been to come back with some of the concerns about mesh, which is a retro pubic suspension. So public floor exercises are the absolute, you know, um forefront of noninvasive therapies. Uh these are a structured program. Typically uh the patients will go to public for therapy. There are so many public for therapists who are out there and I would say for stress urinary incontinence, especially the vast majority of them are very good and our patients are happy with them and They're glad that they do it. Um so what's the, you know, what's the deal with this? I would say about 40% of patients will have an adequate response to physical therapy. About 40% of patients with stress and comments will have an adequate response to physical therapist. That's a pretty good chance of success for something that has fairly little downside. But here's the downside. Um, it does require a time commitment that not all patients can commit to depending on the insurance coverage and may be very expensive for some patients. Most insurances do pretty well. But if you start getting into some of the insurances that maybe don't have such good coverage for physical therapy, of course of pt for them, If it's coming out of pocket even can approach $1,000 or more. So it's not insignificant to think about that. We really don't think they're gonna do well with it. But if someone is very open to physical therapy, they'd like to try to avoid a surgical procedure or they think they might like to try to avoid it. And they think that they can commit to the home exercises. Absolutely. I encourage them every time to think about physical therapy. And I think as primary care physicians or gynecologist who are not looking to necessarily treat um treat these conditions surgically in your practice, but would refer them for surgical treatment, you can refer them first for public for therapy. And then if they fail to benefit adequately from that, can see a specialist at that point to um certainly though we see them earlier, we're happy to do that for many patients, probably from every clinic to physical therapy in that context, mechanical devices can be effective as well. These are, you know, I guess a little bit more invasive, I would say. But they're not certainly not surgical. Uh, this device up here on the top left is something called the, that doesn't exist anymore. But actually the original plug. So it's possible this could come back on the market at some point. And then these are incontinence. Pastors, this is being inserted into the vagina. Here's the uterus and the black and this has a little knob. You can see where the cursor is right here. The mouse cursor. Um, it's pressing on the urethra and actually blocking it off. These are poised, impressive devices, probably most common commercial device that our patients used for incontinence and they can buy these off the shelf and the walmart target are there in the fifties, like the special tampons essentially that compress the urethra just like these continents batteries do. And they work okay. They're probably pretty decent for situational leakage and certain patients leaking only with crossfit only with really high impact exercises. These may be beneficial, but for the most part, they don't provide long lasting, um, really significant relief for the vast majority of patients. Um, we talked about your dynamics a little bit. I don't want to spend too much time on this because I think that starts getting into probably the nitty gritty of of what what we think about is a urologist and probably all over and, and, and sort of nerd out about a little bit, but, but the idea is that we bring your dynamics into the fold to help us sort out what's going on. We do a lot of your dynamics in our practice uh for us to try to develop that individualized treatment to really match up what patients need with what they want. Um And so that helps us put some things into what they need category with more confidence. This is what I think you need, you know, in order to get better and there it is. That's how we develop an individualized tailored approach to meet the unique needs of the patient. That's our approach in neurology too. So that's why we may wind up performing that study and do it fairly often. So moving beyond our our noninvasive therapies, we get into what's called urethral bulking agents. Uh The idea of urethral bulking agent. If you look down here on the left, this is a wide open your retail related to what's called intrinsic sphincter deficiency. So the actual sort of tissue itself is deficient. The sphincter muscle is deficient. And so it doesn't co opt or come together very well. And once you inject the bulking agent collapse much better. Here's a schematic view of that sort of a cartoon representative drawing, it's a sista scope is inserted, A needle is inserted through the system scope and is used to inject some new coastal uh injection of the bulking agent. And that helps bring this tissue together. This is an example of a particularly popular uh bulking agent because of how effective it was. It's called micro plastic that's very small, but it's called micro plastic. But there are many bulking agents as we come here, we can see that there are many bulking ages. There have been many over the years um that have come and gone and all the ones that are now grayed out are ones that no longer exist on the market and have 100 and a few more that don't exist on the market anymore either. Just because the minute a new one comes around that seems to be better than the old ones it becomes. Uh this incentive to continue to use the old one goes down. So I'll tell you that the the ones that are most highly used in today's day and age would be micro plastic in bulk. Um and I think macro plastic also is is probably going to continue to fade as well because it has become so popular. Not too many are using person porcine, dermal implants, uh calcium, hydroxide, appetite, also known as co appetite or carbon beads. Doris fear at this point because of the preference for those other agents that seem to be more consistent. So um when we look at uh the efficacy of bulking agents, macro plastic, I like looking at macro plastic studies because I think it's a very good bulking agent. Um and you're going to do about as well with macro plastic as you will with any any of the bulking agents, if not better. The improvement rates at six months for about 75% 73% of 68 18 months and 64% grade at 18 months. That's pretty good. Long term data as far as how many patients are expected to improve. And the cure dry rates are about 40% and that seems to be consistent in the long term. It's like, well, you know, you can do better in the entrance. Yes, you absolutely can do better with slings. But when you're talking about bulking agents, that's a procedure that's administered in an outpatient setting. And patients, you know, go home the same day, Sometimes we can even do it in the office depending on the circumstance with the little local anesthesia. And patients don't need any anesthetic, you know, general anesthetic whatsoever. And they go home the same day and very few have any problems or complications, you know, immediately after surgery. And it's great, you know, so it's a good reason, you know why we like that so much. But but you can do better as far as efficacy. And oftentimes need to this is comparing a sling a particular type of so called vaginal made from the patient's own tissue that's compared to micro plastic. And you can see the long term cure rates with this. In this particular study, we're talking about 9% for the for the bulking agent versus 80% for the sling and that's Probably a distortion. I think that the folks getting bulking agents do better than that. Um but patients getting slings, that's about how well they do. It's about 80-90%, you know, success rates. So clearly patients choosing bulking agents are balancing the risks of the procedure with the benefits and choosing to go that route. I mentioned the newest kid on the block is probably acrylamide, hydrogel. Uh This is the most common bulking agent that's going to be done in the United States and you know, in the in the coming, I would say five years certainly. Um, it's much easier to inject I found than prior bulking agents. Um more and as a result it's easier to get a consistent injection and you can see here from an actual ball committee procedure um That you have a nice open open urethra insufficient, you know, co optation of that. You're reachable tissue from the system's coptic view. And then after ball command injection was excellent. We talk about these cushions that come together and co opt and patients still similar to the macro ballistic, about 40% of them will be dry in about 60% or so will be significantly improved and the ones that tend to do well initially tend to continue to do well long term. So adverse events with bulking agents. We talked about this. I tell patients this is a one or two day recovery patients can get urinary tract infection. They can get a little bit of, you know, problems with frequency or burning with urination. Almost always use resolved within two days and some patients will have difficulty peeing. We say sometimes that's a good sign because it means it's gonna work really well. Uh And usually that's managed with one catheterization or a catheter that's left overnight. Um but quite nice. Um So when we look at um our management, you know why bulking agents again sort of are not always preferred. Although they are becoming increasingly popular. This is an old bulking agent from our old from a from a fairly old you know review of of uh multiple options for management of incontinence. You can see the collagen which is no longer used but as a bulking agent. But you can see that it's probability of cure or dry is significantly lower than just about every other potential treatment for stress and comment. So again this is really a this is really a balance act between risks and benefits from patients choose that approach. But because of that risk benefit balance. Many will still choose bulking agents. So we're talking about surgery for stress urinary incontinence moving into the sling and and other types of procedures that are more invasive. Just go over the nomenclature. There's a synthetic media Rachel sling. This is also known as a mesh a mesh sling. Uh There's a retro pubic sling which is passed, you know behind the pubic bone And we'll show the anatomy for that briefly. It's what's called a trans operator sling. And there's also something called a single incision sling or a mini sling. And that's passed in the trans operator direction typically. So it's passing its past in that direction, but does not pass all the way through the membrane. It actually just pierces into it. And and that fixes it in place. There's a pubic vaginal and or black internet slang and this is typically refers to a sling that is made of some sort of bio synthetic or more commonly, actually the patient's own fashion their own tissue. And then there's a retro pubic suspension, which is a again, increasingly popular because of concern over the synthetic mesh. So some uh your gynecologists and move back towards doing retro pubic suspensions in patients who are good candidates for them is a retro pubic. Many original sling. Here's the anatomy of the uh of where that song has passed. Here's the here's the pubic bone here, bladder. And then this thing goes from behind that pubic bone And underneath the urethra and back up. So on the other side of the vaginal dissection allows you to get access to this area and it can be passed either from the bottom up in the classic approach developed in in the 1990s in the mid-1990s or top down so many urologists prefer, you know, a top down approach, but many of us also prefer the retro pubic approach because we're very comfortable in that awkward space. The trans operator major regional sling is passed through the device that looks like this, this Stroker for the for the trans operator swing passage. Um and this gets passed through the operator canal and that could be from inside the vagina is out or outside the vagina outside the vagina in either way. Um the sling winds up getting passed in this uh this direction where you can see it goes through the operator canal um on it goes through the operator remembering rather on the other side. Uh there was a trial which looked at which of these types of slings was better than the other. Uh And the only real conclusion that you can make from that is that they're pretty similar as far as their objective success. Um They're pretty similar as far as their subject of success, a little bit better as far as retro pubic sling. However, um patients with retro pubic sling, One passed behind the pubic bone tend to have more dysfunctional voiding or difficulty urinating. Whereas patients with a trans actor to sling had a higher likelihood of developing symptoms that were bothersome in terms of pain or uh neurologic symptoms as well as described in the paper. Um five years success rates, we're looking at about 50%. So they drop in this trial, you know, very good randomized trial data. Um Five years success rates are about 50% despite being pretty successful early on by a very, very high standards of definition as many of these randomized trials. So I think real world you'll see more about satisfaction with treatment that really reflects it. Um um What what reality is and you'll see 80-90% of patients are very satisfied with sling treatment at the five years time point. Now, if you look at it, I would say through I guess finish color, you know, finished colored glasses. Um The fins in 19 in the mid nineties, you know, put these put these things in a number of patients and they were able to follow up with 55 of them at 17 years either by phone calls or actually getting them in the office, it was quite impressive. Um and so um what they found is that in terms of patient reported success at 17 years, 87% of them were actually still reported being cured or significantly better. And they actually look to see if they had stress urinary incontinence on exam with a full bladder. From those that were able to get into the office. It really worked. So I tell patients that, who asked me, you know, is this sling gonna continue to work for me forever? I'm gonna have to have it replaced. And I say not necessarily, But the patient that the sling is going in may change because you know, we know our patients, if we put a sling in at age 50, they're not gonna be the same patient, you know at age 65 or 70 they may have new medical issues. Um their weight may fluctuate, uh they may become more debilitated or frail. So they made change but the sling stays and so um as long as they stay healthy and they stay fairly, you know fairly consistent um in terms of their overall medical condition and their pelvic anatomy, the sling ought to continue to work just as well as it has. But unfortunately that changes for the worse and many patients as they get older and that's what they found in this study to that when patients did fail, it wasn't because the sling failed, it was because the patient changed and they developed overactive bladder. So complications of mesh slings, major regional slings. There are a number of them to discuss, but mostly they relate to urinate tract infection. These tend to be transient and easily treated with antibiotics, urgency of urination, again fairly similar between the two groups, bladder preparation a little bit higher. Again in the retro pubic sling, When you look at trans activator slings, they tend to have more growing pain and more like pain. So if you ask if you ask me and you ask many urologists, I think we can deal with, you know the urgency and the U. T. I. Or the bladder preparation. This is this is something we almost always recognize at the time of surgery. Almost almost always always, you know recognize the time of surgery. So it's actually really fairly insignificant to the patient because we just re pass re pass our troll card with with really no consequence to the patient. But the growing pain in the leg pain if that's persistent, that can be very tough to manage. So for me, I'd rather find myself dealing with voiding dysfunction that that I feel like I can, you know, stand up pretty well against versus managing growing pain which may or may not resolved with certain treatments. Um We look at specific complications I think you're talking about, you know, as we say, six and 1.5 dozen in the other between the retro pubic sling and the trans operative sling. Um mesh erosion rates are somewhere around 2 to 3%. Um That means finding it in the urethra, we're finding it in the bladder erosion versus exposure would be finding it in the vagina. Um By definition and that would be somewhere under 1.5 to 2% rate. So I tell patients is about a 2 to 5% chance of a mesh specific complication. Most of the time those are, you know, exposures, those are fairly, you know, straightforward to manage and and not terribly morbid. But we do see the erosions do take a little bit more to manage and it can be more challenging for patients. So there's a lot of mixed information out there about mesh slings. Uh Maybe your patients have asked you and put you in a position where you're trying to, you know, give them what the what the sort of right answer is and how to help people and what to do. But the truth is it's it is still in the United States um or organization that that I belong to what's called su fu um the international continent society, also the american, your gynecologic society still, we believe that mesh sling should be available to patients because they're so highly effective. And the morbidity of placing the sling is absolutely acceptable based on how effective they are, that it should be available. And for many patients is absolutely the right treatment. So um that is balanced against certain countries where in England they've decided it shouldn't be used in Australia. They've decided that it shouldn't be used. And um certainly still a source of controversy. What I tell patients is that they've got about a 3 to 5% chance of a mesh specific issue, some of which may not be, you know, a massive deal or a big deal. They've got an 80 to 90% chance of being pretty happy with their results. You know, I'm not extremely happy with the results of their sling surgery if they have a mesh sling place. Uh and they'll have a recovery time period of somewhere in the order of 1 to 2 weeks and they typically go home on the same day of surgery. So p patients tend to look at that and they weigh that against the risk of the mesh related complications and may decide based off of that whether they want to have a mesh sling or not. And I leave it up to them and try to sway them one way or another, I try to give them the the facts of what we know about it. It is such a well studied surgery that's been performed in hundreds of thousands of patients. You've got great data on it. But you and I and I think that most of the patients who've had, you know, a lot of, you know, issue after these slings. And there are many out there. It's because also the number of slings that have been done is so high that even a small percentage of a very large number is is a pretty big group and they are suffering for sure. So I just think it's important that we provide informed consent. Um And um patients don't don't really want patients to make the wrong decision to avoid a mesh sling because they're worried about something that has a relatively low likelihood of happening. But if they're concerned about it. Uh and they have every right to be then um which absolutely avoid it. And that's great whatever they're comfortable with this is what I want them to do. Um So one of the reasons we absolutely cannot do a mesh link basically, I just want to do the I don't want you to take my own tissue and I don't want to do a bulking agent doesn't work well enough. And physical therapy didn't work for me or I can't do it because I don't have the time or the money to be able to dedicate to physical therapy. Um So there are lots of reasons, you know that we I can't do a mesh sling but primarily it relates to really really severe what's called intrinsic sphincter deficiency where the tissue doesn't come together as well. Or patients with risk of significant wound healing issues that takes the mesh complication rate from what I would say it sort of goes from acceptable to too high. And then it becomes something that you probably don't want to do. The other reason would be if you're doing can accommodate your regional surgery. This right here is an M. R. I have something original that particular and it's like almost like a gland around the urethra that gets inflamed and filled with with fluid and can infect chronically. And these patients needed your ritual repair at the time that this is removed. And so you know, definitely don't want to put mission around the urethra any time that you had to prepare it. Um Same thing would be said for a in here. So when you can't do a mesh sling or a patient doesn't want a mesh sling, our option for them is something called a vaginal sling or autologous fashion. So this exposure of the rectus fashion here, the rectus muscles on the left, on the patient's right side and left side. A strip of fashion has taken off as seen here. And uh it's measured out somewhere around eight centimeters, you know by about a centimeter and a half. And that gets used as a sling instead. So that section is all still through the vagina with the counter incision, through the in the retro pubic space. Uh the sutures that are placed on the sling our past Through that small retro pubic incision that's used to harvest the fashion and tied in the mid life. And so those patients have a 0% chance of mesh related complications because they have no mesh. And the futures that we use are absorbable in at least as we do it. Um So there's no foreign body left in the patient's long term at all. It relies really on scarring. And if you go back in and look years later, you just sort of see scar. But that wind up supporting that region and bladder neck area very well. And it's just as effective as the mesh link. So patients who choose this may do it because they don't wanna mesh. They may choose it because they have to because they're having a urinal repair at the same time. But what I tell patients, if they're, you know, all things equal, they're able to choose a mesh sling or a vaginal sling or bulking. I say for bulking, talking about 1 to 2 days of recovery for um a mesh sling. You're talking about 1 to 2 weeks of recovery home, same day for a pupil vaginal sling. You're talking about somewhere in the order of 4 to 6 weeks of recovery. So there's a greater sort of initial investment. The potential upside is that you don't have to worry about long term risk of mesh specific complications. So, and there are others, there are some who will advocate for doing, you know, this procedure exclusively and no foreign bodies, no foreign mesh, etcetera in every patient. Um my eye and society would, you know, our governing societies would agree with us here in the United States that that's probably overkill to not. Do you know, any mesh slings ever or not offer that to any women anywhere in the country. But um there are others, you know, like in in the UK in Australia, for example, who would advocate for second approach? How effective these pubic vaginal slings versus what's called a retro pubic suspension. So this is an old procedure that has come back as there's been more concerned about mesh. Um Here's the sling procedure, a schematic view of that versus uh culpa suspension where there's a permanent sutures thrown in lateral to the to the urethra and vagina. And that actually sort of helps to lift and support, you know that whole urethral complex and and and restore the pelvic floor support responsible for leakage in many cases. And the idea is that the slings and the birds procedures both help slings work better and they tend to last, you know, tend to last longer. Um As a consequence though, unfortunately despite higher sort of patient satisfaction with the sling procedure, um voiding dysfunction is more common in slings and purchase. But again, when you look at the sort of long term outcomes, I think generally speaking are going to find that the pupil vaginal things are gonna last longer. And we're looking at these numbers and you look very similar to the mesh slings. Uh 90% satisfied. And follow about 2 51 months, 92% character improved to a follow up of, you know, 1 to 15 years. And so again, these are patients who were, once they get this procedure, they attempted to, you know very well after this. But they may change. Patient may change and as a result their benefit may change as well. Just briefly touching on urgency urinary incontinence and why this is probably a a procedure for a maybe a different time. You know, sorry, I talk for a different different time. Different topic. This is from our organization. I think it's a little confusing but the idea is that when we we're seeing patients for urge incontinence or overactive bladder, we really take them on a pathway. So stress urinary incontinence is do you need to have it treated if you do you want you know to try non operative approaches or operative approaches and then which one? An overactive bladder? It's let's try the non operative approaches, then let's go to medicine, dietary modification, fluid management etcetera. Um uh let's try sort of you know um those approaches. Then we may try medications and then we may go into office based procedures and then if you still really you know are struggling um and we haven't been successful. We may even talking major surgery, you know that's as an option for that's uh so um that's all I have today. I would certainly encourage anyone to reach out or contact us with any questions that you have were uh certainly grateful for your support and happy to to be involved in um care for your patients, you know in uh in real time in person or in consultation over over email. Thanks so much
