Andrew Siegel MD 8/6/2016
Illustration of bulking agent being injected into urethral tissues to plump up and compress the urethra
Stress Urinary Incontinence (SUI)
SUI is a common condition that affects one in three women during their lifetimes, most often young or middle-aged women, although it can happen at any age. An involuntary spurt of urine occurs at times of sudden increases in abdominal pressure. This can happen with coughing, sneezing, laughing, jumping or exercise. It can even happen with walking, changing position from sitting to standing or during sex.
SUI most often occurs because the tissues that support the urethra (the channel that conducts urine from the bladder) have weakened and no longer provide an adequate “backboard.” This allows the urethra to be pushed down and out of position at times of sudden increases in abdominal pressure, a condition known as urethral hyper-mobility. The key inciting factors are pregnancy, labor and delivery, particularly traumatic vaginal deliveries of large babies.
Although the predominant cause of SUI is inadequate urethral support, it may also be caused by a weakened or damaged urethra itself, a condition known as sphincter dysfunction. Risk factors for this are menopause, prior pelvic surgery, nerve damage, radiation and pelvic trauma. A severely compromised urethral sphincter causes significant urinary leakage with minimal activities and typically results in “gravitational” incontinence, a profound urinary leakage that accompanies positional change. In this situation the sphincter does not provide sufficient closure to pinch the urethra closed.
Useful analogy: Sphincter dysfunction is similar to a situation in which a sink faucet is leaky because of a brittle washer that has lost the suppleness to provide closure.
First-line Treatment For SUI: Pelvic Floor Muscle (PFM) Training (Kegels)
It is important to know that you can tap into the powers of your PFM and harness the natural reflex that inhibits stress urinary incontinence. Combatting SUI demands that the PFM contract strongly, rapidly and ultimately, reflexively. The goal of Kegels is to increase PFM strength, power, endurance and coordination to improve the urethral support and closure mechanism. This has the potential to improve or cure SUI in those who suffer with the problem and prevent it in those who do not have it.
Kegel exercises are most effective in women with mild or mild-moderate SUI. Kegels increase PFM bulk and thickness, including the sphincter mechanism, reducing the number of SUI episodes. Additionally, Kegels improve urethral support at rest and with straining, diminishing the urethral hyper-mobility that is characteristic of SUI. It also permits earlier activation of the PFM when coughing, more rapid repeated PFM contractions and more durable PFM contractions between coughs. PFM training can cure or considerably improve 60-70% of women who suffer with SUI. The benefits persist for many years, as long as the exercises are adhered to on an ongoing basis.
Urethral Bulking Agents
The “gold standard” treatment of SUI that does not respond to conservative measures is a mid-urethral sling, a surgical procedure that provides support and a “backboard” to the urethra. Cure or significant improvement is in the 85-90% range with sling surgery. An alternative to the sling surgery is the injection of a urethral bulking agent.
Urethral bulking agents are typically used for SUI due to weakened or poorly functional sphincter muscles. A special material—a bulking agent—is injected into the tissues around the urethra in an effort to “plump” up the urethra to help provide closure to it, with the goal of improving urinary control. The material works by bulking up the layer of the urethra immediately under the inner urethral lining, providing closure of the urethra via compression. This outpatient procedure is simple to perform and generally takes only a few minutes. In theory, it is similar to the lip injections that are used by plastic surgeon in order to plump up the lips and make them appear fuller, suppler and more sensuous.
The urethral bulking agent procedure is done under direct visual control using a small, lighted scope (cystoscope) that is inserted into the urethra. The bulking material is injected into the tissue immediately under the urethral lining while the plumping and closure of the urethra is observed. Several treatments may be necessary for lasting results.
There are three materials that are FDA-approved bulking agents: carbon-coated beads suspended in a water gel (Durasphere); calcium hydroxylapatite (Coaptite); and silicone microparticles (Macroplastique).
For whom are bulking agents appropriate?
- Women with SUI primarily due to sphincter dysfunction
- Women who are too elderly or frail or have too many medical issues to undergo anesthesia and standard mid-urethral sling surgery
- Women who have had unsuccessful or incompletely successful sling surgery
- Women who wish to avoid surgery for SUI
- Women who have SUI and wish to have more children
- Women with mild SUI
- Women with SUI who are anti-coagulated with “blood thinners” and whose anti-coagulation status cannot safely be reversed
How effective are bulking agents?
Generally, bulking agents result in a 75% improved or cure rate, including about 30% who are cured and 25% who fail to improve. It is important to understand that the effectiveness of urethral bulking agents is inferior to that of sling surgery, the duration is limited and multiple repeat injections may be required. Improvement rather than cure is the goal.
Can urethral bulking agents be used for men as well as women?
Yes, they have been used in men with SUI after prostatectomy, but the results are less favorable than the results in women.
Bottom Line: Injection of urethral bulking agents is a reasonable alternative to mid-urethral sling surgery in certain populations of women who either are not medically fit for sling surgery, have failed sling surgery, or wish to defer or avoid sling surgery.
Wishing you the best of health,
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Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com
Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48
Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc
Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon. In the works is the female PelvicRx pelvic floor muscle training DVD.
Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount.
Tags: Andrew Siegel MD, Arnold Kegel MD, Kegel exercises, Macroplastique, mid-urethral sling, pelvic floor muscle exercises, pelvic floor muscles, sphincter dysfunction, stress urinary incontinence, urethral bulking agents, urethral hypermobility