Philippe Zimmern, M.D. Answers Questions On: Urology

The top causes of incontinence are pregnancies and deliveries, but aging and hormone changes also can cause it. It affects about 30 percent to 40 percent of women, so it’s very common at every stage of life.

Incontinence has varying degrees. It’s a quality of life issue – how much it bothers people. Sometimes people just lose a drop when they cough or sneeze, but the condition can also involve people having to wear 20 pads a day.

If you’re a soccer player and every time you run on the field you lose urine, you’re miserable. If you’re 80 years old and you lose a drop from time to time, you wear a pad and can live with it.

That’s why we always ask, “Can you live with it, or are you bothered by it?” If people are bothered, then we can evaluate the source of it and see how bad it is. We see how the sphincter muscle works and how the bladder works and make a decision on how to treat them after that.

We start with training the pelvic floor muscles to make them stronger. Medication doesn’t work because it is a gravity disease: when you stand up, things drop.

Surgery is the next option. With surgery, we can inject an agent into the sphincter muscle to make it stronger. That’s done as an outpatient procedure through a telescope that we place in the urethra tube. The injection allows us to narrow the passageway so that people hold their urine better.

After that, we have surgeries to the vagina to provide support to the bladder and urethra, like sling procedures that use a synthetic mesh.

We can create a sling with your own tissue, too, which is called fascia. This is what I primarily do. The procedure has been around for decades, and it is very safe.

The last option ­– which is not used commonly – is an artificial sphincter, the same device we use for men who leak after prostate surgery. It circles the urethra and can be activated with a remote pump that we place in the labia.

Prolapse is a herniation of an organ – the bladder, uterus, or rectum – through the vagina.

These vaginal herniations bother people. They have trouble urinating. Often they have constipation. With uterine prolapse, they feel pressure and a mass or bulge coming out that they have to push back.

It limits what you can do. You can’t exercise easily. People try to lose weight and they can’t. Many stop being sexually active because it bothers them.

Those organs are not where they belong, so we have to either remove them (for example, in the case of the uterus) or place them where they used to be. We can do that with a patient’s own tissues – which is my specialty. At times, for recurrences in particular, we may use a mesh placed abdominally, possibly via a robotic procedure.

People who use mesh can experience complications. We spend a lot of time removing transvaginal mesh from people because of pelvic pain, pain with intercourse, vaginal exposure, or infection. In some cases, the mesh has retracted and the vagina is really scarred and cannot function for sexual activity.

A sacrocolpopexy is when you fix the vault of the vagina (the top part) to the promontory, in the area of the sacrum. This allows a holding point so that the vaginal apex remains in place. Otherwise, it would drop back down.

We use this procedure when people have had prior prolapse repairs and the tissues are too weak to hold things in place, which happens typically with age, having children, and/or hormone changes.