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Mesh Sling for Stress Urinary Incontinence • PreOp Patient Education

August 28, 2019

Your doctor has recommended a mesh sling to
treat your stress urinary incontinence. Before we talk about this surgical option,
let’s review some information about the female body and this medical condition. The female bladder is behind the pubic bone
and on top of the vagina. It is in the pelvis, the lowest part of the
body between the hips. The bladder muscle squeezes to empty urine
through a short tube called the urethra. This tube lies under the pubic bone and in
front of the vagina. The urethral sphincter is a muscle at the
opening to the bladder. You control urination by relaxing and squeezing
this muscle. Stress urinary incontinence , SUI (say S-U-I)
is uncontrolled urine leaking from pressure on the bladder and urethra. This pressure happens with sneezing, coughing,
laughing and exercise. SUI is a problem when the pelvic muscles that
support the bladder and urethra, or the urethral sphincter are weak. Support problems can start from pressure on
these muscles with pregnancy and childbirth, chronic constipation, extra body weight, smoking,
coughing and certain activities like heavy lifting that are repeated often. Other risks for female SUI include low estrogen and menopause genetics, meaning a woman can be born at risk
for weak tissue and it can be an occasional side effect of
pelvic surgery Some changes can make leaking better without
surgery, drink smaller amounts at a time, quit smoking if you smoke and work to get
to a healthy weight if you are overweight. Another way to help stop leaking without surgery
is to make pelvic muscles stronger with Kegels, also called pelvic floor exercise. These exercises can help before and after
incontinence surgery. Physical therapists can help with these exercises. They will sometimes use biofeedback therapy
to test if you are exercising the right muscles. Other tools for this therapy are electrical
stimulation and vaginal weights. If exercise and other changes have not helped
stop the leaking then bulking agents may be an option. Silicone microbeads or another material is
injected into the urethra to make the wall thicker so that it closes more tightly. Many patients are better after this but the
leaking eventually returns for most. The injection may be repeated. Bulking agents are most helpful for people
with mild SUI, for patients not ready for surgery and patients that cannot or should
not have surgery. The sling procedure is a permanent surgical
treatment option for women with problem leaking from SUI. A sling is a ribbon which can be made of human
tissue or plastic fabric called mesh. The ribbon is looped under the urethra during
surgery, to create a sling or hammock. This adds support for the weak tissues and
urethral sphincter and helps stop leaking for most patients. Your surgeon has recommended a mesh sling
for you. This means that your sling will be made of
a ribbon of plastic fabric called polypropylene (say “poly-pro-pa-leen”). The main benefits to using mesh instead of
human tissue are mesh slings are faster and easier to place less time is spent in surgery incisions are smaller so healing is faster than if the sling was
made from your own tissue. Mesh slings have been used to treat SUI for
over 15 years. About 8 out of 10 women have no leaking or
are drier after this procedure. As with any surgery there can be problems
or complications for some patients. Mesh exposure in the vagina is one problem
that can affect about 3 percent or 3 in 100 women after a mesh sling. This is when a piece of the mesh is not completely
covered by the vaginal wall after healing. A small edge of the mesh can be felt by the
patient or their partner as a screen or gritty patch in the vagina. This can usually be fixed with a minor procedure
to trim and cover the mesh. If the exposed mesh is not causing the patient
any problems, it can be safe to leave untreated, and repair if new problems develop. Mesh exposure is more common in patients that
have thin delicate vaginal tissue from low estrogen. You may be advised to use estrogen vaginal
cream before or after surgery. Rarely, the mesh causes painful scar tissue,
erosion or damage to the bladder or urethra. Some problems, especially pain are not able
to be fixed with surgery. There are three main types of mesh sling procedure:
mini sling, retropubic and transobturator (say trans-ob-tur-A-tor) . Each way of placing
the mesh has its own risks and benefits. Mini Slings are the newest procedure. They use the smallest size mesh and only need
one small vaginal incision to place. But we are still learning about how well these
work and the problems that patients may have. The retropubic sling procedure guides the
mesh using the pubic bone in front of the bladder. This has the highest risk of a small hole
being poked in the bladder. These injuries usually heal quickly if seen
and treated at the time of surgery. This type of sling is the best-studied with
proven long-term benefits. The transobturator procedure guides the mesh
in from the side and bottom of the pubic bone. This is away from the bladder so there is
less risk of bladder damage. Two small incisions are needed in the groin
or leg crease to place this mesh. A risk of this procedure is pain from these
groin incisions for some patients. Mesh is permanent. During healing your tissues grow into the
mesh. Surgery to remove it can be difficult or impossible
to do. Experts haven’t agreed that any one sling
procedure is the best. The procedure recommended for you depends
on your surgeon’s experience and training and your individual situation. Be sure you understand which procedure and
sling material is planned for you. Let’s talk about what happens during a Mesh
sling procedure. To start, you are given anesthesia to keep
you free of pain during the procedure. You are positioned carefully. A thin soft tube, called a Foley may be placed
in your bladder. A tool called a retractor is gently used to
enable the surgeon to reach and operate on the front wall of the vagina. Here an incision is made. If you are having a mini mesh procedure, this
will be the only incision. The small piece of mesh is gently positioned
under the urethra and the incision is closed. If you are having a retropubic mesh procedure,
the vaginal incision is made followed by 2 small skin incisions above the pubic bone. If a trans-obturator procedure is done, the
vaginal incision is made, followed by 2 small skin incisions in the groin-crease of the
upper-thighs. For the retropubic and trans-obturator procedures
special tools are used to guide the sling into position under the urethra. The tools and the way they are used vary for
the different procedures and kits. The mesh is gently positioned to support the
urethra without crushing or pressing on it. This is called tension free. The ends of the mesh are cut to the needed
length. The mesh holds itself in position. A cystoscope is gently placed thru the urethra
to the bladder and the bladder is filled with water or saline (pronounced say-leen) This scope has a light and a camera, and is
used to help the surgeon see the inside of the urethra and bladder during the procedure
and after the sling is placed. The surgeon checks for bleeding, holes in
the bladder and for mesh or tools where they should not be. At the end of the procedure a foley may be
placed. The vaginal incision and skin incisions are
closed. After surgery “speak-up” and tell your
care-team if you have more than expected pain or problems. You may be able to go home the same day, but
many patients stay overnight. You may have a foley to drain your bladder. This is usually taken out before you leave
the hospital. Sometimes the foley needs to stay in a while
longer. You may have vaginal packing. This soft ribbon of gauze is pulled before
you go home. You will have some pain and soreness but this
is usually very mild. When you are home from surgery, follow your
doctor’s instructions to have the best results. The first week rest as much as possible and
do not lift anything heavy. Use Tylenol, Motrin, Aleve or any other pain
medication as recommended by your physician. The first 4 to 6 weeks you must not have sex. Showering to stay clean is important but don’t
swim or use a hot tub unless your surgeon says that it is safe for you to do. You should not exercise or do any heavy lifting. There is a very small risk of serious problems. These can include internal bleeding, injury
to the bladder, bowel, urethra or ureter. More surgery is sometimes needed to correct
some problems. Call your doctor if you: cannot urinate, have
a fever, worsening pain or bright red bleeding that doesn’t stop. Hospital admission, medication or surgery
may be needed to fix some problems. Signs of mesh exposure can be, vaginal discharge
that doesn’t go away, bladder pain, bleeding or pain with intercourse. Be sure to tell your surgeon if you have these
symptoms. Some patients may have bladder side effects
early after surgery. There can be a problem called retention, if
you can’t urinate or empty your bladder on own. If this happens, a catheter is needed for
longer than originally planned. A procedure to loosen the sling is sometimes
needed. Other possible bladder side effects include
a new or worse feelings of urgency, or feeling like you have to urinate because of bladder
muscle spasm. Or you may still have leaking. You should not have a sling if you have bladder
spasm causing overflow or urge incontinence unless it is treated first because it can
be made worse with a sling. To help your body heal eat healthy foods. Avoid junk food and sugary drinks and snacks. If you are a smoker, don’t smoke. And if you have diabetes, keep your blood
sugar under control. Both smoking and high blood sugar slow healing. To avoid cancellation or complications from
anesthesia or your procedure, your Job as the Patient is to not eat or drink anything after midnight,
the night before surgery, not even a stick of gum take only medications you were told to on
the morning of surgery with a sip of water stop your aspirin or blood thinners before
surgery as you are instructed and arrive on time You should be ready to verify or confirm your
list of medical problems and surgeries, all of your medications, including vitamins and
supplements, your current smoking, alcohol and drug use and all allergies, especially
to medications, latex and tape All surgery and anesthesia have a small but
possible risk of serious injury, even some problems very rarely leading to death. It is your job to speak up and ask your surgeon
if you still have questions about why this surgery is being recommended for you, the
risks and alternatives. This video is intended as a tool to help you
better understand the procedure that you are scheduled to have or are considering. It is not intended to replace any discussion,
decision making or advice of your surgeon.

1 Comment

  • Reply Patient Engagement - Patient Education February 14, 2019 at 9:37 pm

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