Surgery For Stress Incontinence

Table of Contents
Royal College of Obstetricians and Gynaecologists

Published February 2005

Key Points

  • When you have Surgery For Stress Incontinence, you accidentally leak urine during normal everyday activities (for instance if you cough, sneeze, laugh, exercise or change position).
  • What you do about stress incontinence will depend on how far it affects you and what you feel you can cope with. Physiotherapy and/or practical advice from a continence nurse specialist on managing your daily life may help.
  • Not everyone with stress incontinence needs surgery, but if your problems persist, your doctor may suggest it.
  • Surgery for stress incontinence aims to give you more control over your bladder. It cannot always cure the problem completely.
  • There are a number of possible operations; what is suitable for you will depend on your circumstances.
  • Surgical procedures for stress incontinence are not usually suitable if you still plan to have children, or think you might want to in the future.

About this information

This information is intended to help women who have stress incontinence and are considering whether to have surgical treatment for it. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Surgical Treatment of Urodynamic Stress Incontinence (published by the RCOG in October 2003).

It tells you:

  • what stress incontinence is
  • the recommendations the guideline makes for the UK about the most effective surgical treatments for stress incontinence.

It aims to help you and your health care team to make the best decisions about your care. It is not meant to replace advice from a doctor, nurse or continence adviser about your own situation. It does not look at treatments for stress incontinence that do not involve surgery.

  • Some of the recommendations here may not apply to you; this could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor or with someone else in your healthcare team.

What is stress incontinence?

The muscles of the pelvic floor (see diagram on page 3) support the bladder and usually help keep it closed or open as necessary. Surgery For Stress Incontinence usually happens when these muscles become weak. So when there is sudden extra pressure (‘stress’) on your bladder, it cannot stay closed as it should and some urine leaks out.

This leakage happens during normal everyday activities, and most often when you cough, sneeze, laugh, exercise or change position. Whether you leak a small or large amount of urine, stress incontinence can be embarrassing and distressing.

Stress incontinence can be triggered by pregnancy, childbirth or the menopause. If the problem develops while you are pregnant or after you have a baby, it usually improves with time for most women. Sometimes it happens again later on and a few women may need to consider surgery.

Surgery For Stress Incontinence
Side view of a woman’s bladder, pelvic floor muscles and nearby organs

Do I need an operation?

Many treatments for stress incontinence do not involve surgery. Not everyone with stress incontinence needs an operation. Whether you choose to have surgery will depend on how far stress incontinence affects your daily life and what you feel you can cope with. You may want to consider surgical options if other things (such as exercises to help strengthen the muscles in the pelvic floor) have not helped.

Surgical procedures for stress incontinence are not usually suitable if you still plan to have children, or think you might want to in the future.

Your doctor or nurse should already have asked you about the problems you have been having. You may have had a urine test to check for infection. You may also have had special bladder tests (known as urodynamics).

You should already have had advice from your doctor or a continence nurse specialist about:

  • adjusting your daily routines to help you cope better
  • how you can help yourself by losing weight if you are overweight
  • managing a chronic cough if you have one
  • special physiotherapy exercises to make your pelvic floor muscles stronger and improve control of your bladder
  • giving up smoking.

These things will also help to improve the results of surgery, if you have it.

If you have seen no improvement after doing pelvic floor exercises, your doctors may suggest you consider surgery. If you are offered the choice of surgery, it is up to you to decide if and when you should have it.

What operation will I be offered?

Surgical procedures for stress incontinence aim to improve support for the muscles around the bladder entrance, in order to help the outlet (known as the urethra) to stay closed when it should and prevent it leaking.

No operation can be guaranteed to cure your stress incontinence, but most offer a good chance of making an improvement. The benefits of some last longer than others. The risk of developing extra problems (known as complications) also varies depending on the procedure.

You can find more information about the main operations used to help stress incontinence in the tables on the following pages. They are:

  • Burch colposuspension
  • Tension-free vaginal tape (TVT).

You can also find out about procedures that are used less often. They are:

  • Bulking agents
  • Sling procedures
  • Artificial sphincters
  • Anterior vaginal repair.

Your surgeon may offer you a choice of one or two methods, depending on your circumstances and his or her own expertise. He or she will take into account such things as your general health, age, weight and previous operations and should explain the reasons for recommending a particular operation to you. Some operations are very specialised and are only offered in special centres.

If your surgeon is not able to offer the operation that best meets your individual needs, you may be able to find another who can. You should discuss this with your GP.

With some operations you may need to have a temporary catheter. This is a tube which is put into your urethra (the tube leading out of the bladder) or your lower abdomen, in order to empty your bladder when necessary. The length of time you need to spend in hospital after the operation will vary depending on the type of operation and how quickly you recover.

What might happen if I don’t have an operation?

Your problems may remain the same, or get worse, or improve over time. There is no sure way of predicting this.

What does the operation involve?

NameWhat it involvesBenefitsDisadvantagesSuitable …
Creates a cradle of
threads, like a
hammock, from back
to front of the pelvic
area to provide
support for the
urethra, the entrance
of the bladder. Can
be done through a
‘bikini line’ cut just
below the line of the
pubic hair or through
‘keyhole’ surgery
colposuspension); this
takes a little longer,
but you recover more
The most effective
treatment, although
it is a major
operation. Restores
continence in 85-90
women out of 100 for
the first year, and in
around 70 out of 100
for the first five
years. More
effective in the long
term than other
Less effective if you
have had surgery
before. Some women
get extra problems:
about 10 in every 100
have trouble
emptying their
bladder properly;
about 17 out of 100
pass water very
often, or get little
warning of needing to
do so, or have trouble
getting to the toilet
in time. About 13 in
every 100 women
have a prolapse
(where part of the
rectum or small bowel
pushes through the
wall of the vagina)
within five years.
Extra problems more
likely with
laparoscopic method.
for most women
vaginal tape
A special kind of
synthetic sling (see
next section). The
surgeon makes small
cuts just above the
pubic area and passes
synthetic tape through
them. The tape
supports the bladder
entrance (urethra) and
remains permanently
in place. Body tissue
soon grows around it
(this is normal and
not harmful).
Simpler than
colposuspension; you
may not need a
general anaesthetic
or overnight stay.
Restores continence
in about 80 women
out of 100. 94 out of
100 see some
improvement in
bladder control. We
need to know more
about long-term
About 4 out of every
100 women initially
have problems with
fully emptying the
bladder, but does not
seem to be a longterm problem. 3 to 15
in every 100 women
pass water very
often, or get little
warning of needing to
go to the toilet or
have trouble getting
to the toilet in time.
for most women

Other procedures

NameWhat it involvesBenefitsDisadvantagesSuitable …
Takes just a few
minutes. Natural or
synthetic materials
(such as collagen, fat, silicone or Teflon) are
injected around the
bladder entrance to
help keep it closed
when necessary
Few side effects. Up
to two years
afterwards 48 out of 100 women are
completely dry, and 76 out of 100 are dry or
have improved bladder
control. More research
Less successful than
other operations.
Benefits do not usually
last. The material may
be gradually absorbed
or broken up inside the
body, and so becomes
less effective; you may
need to have the
operation done again.
when other methods
have failed, or you
want to avoid or are
not fit enough for
more invasive surgery
tissue sling
Uses a wide sling to support the bladder,
make the urethra
narrower and so
prevent leaking. The
sling is usually made of your own tissue (taken from muscles in your
abdomen) or other
human or animal tissue
Slings usually give good bladder control in the long term, but more
research is needed.
Slings made from a
woman’s own body
tissue are generally
more effective and
cause fewer problems
than synthetic ones.
Slings using other
human or animal tissue
fail eventually for 20
out of every 100
women. Some risk of
sling material moving
into the vagina, of
problems in fully
emptying the bladder
or of needing a longterm catheter, though
less than for synthetic
when other surgery
has failed to help
As for natural tissue
slings, except that the
material used is
Good long-term
bladder control. More
research is needed.
More risk of extra
problems than natural
tissue slings. For up to 16 in every 100 women the sling material
moves into the vagina.
Up to 11 in every 100
women may have
problems in fully
emptying the bladder.
About 2 in every 100
women need a longterm catheter. May
reduce quality of life.
when other surgery
has failed to help.
A circular sac is placed
around the bladder
entrance (the
urethra). You open and
close it manually to
control the flow of
urine. Only done in
specialist centres.
Cures 80 women out of
100 and improves
bladder control for 92
out of 100.
Major operation with a high risk of further
problems. You may
need more check-ups
afterwards or a
further operation (or
when other surgery
has failed to help.

Are there any alternatives?

There is often no need to rush into having surgery. Some people prefer not to have an operation and find ways of adapting. Your continence adviser can tell you more about this.

New surgical techniques are being developed all the time. You should talk to your continence adviser and/or your consultant to find out if there is anything new that might be more suitable for you.

There is not yet enough evidence about a procedure called paravaginal repair to show how effective it is. More research is needed.

Women who have a prolapse, where part of the bladder pushes through the vaginal wall, may be offered a procedure known as anterior repair. The surgeon makes a cut inside the front of the vaginal wall, to remove the extra tissue from the prolapse and restore the muscle support. If you also have stress incontinence, however, sling procedures are more effective than this operation.

Some operations are no longer recommended:

  • Marshall-Marchetti-Krantz (MMK) colposuspension used to be common but has been replaced by other methods.
  • Needle suspension has been replaced by safer, more effective procedures.

Is there anything else I should know?

As you can probably tell from previous sections, all operations carry some risks. Your doctors should discuss with you the risks of any operation they offer you.

  • You have a right to say whether there are any procedures you do not want the surgeon to carry out.
  • You have the right to be fully informed about your health care and to share in making decisions about it. Your health care team should respect and take your wishes into account.
  • No treatment can be guaranteed to work all the time for everyone.

© Royal College of Obstetricians and Gynaecologists