New Surgical Option for Treating Stress Urinary Incontinence (SUI) Postpartum

If you are reading this article, chances are you already know all about stress urinary incontinence (SUI). SUI is that unwelcome gush or drip of accidental urine wetting your underwear when you least expect it – with a cough, a sneeze, a jump, or even when laughing at your friend’s really stupid joke. Maybe it started during pregnancy for you or just started happening postpartum – regardless, you are probably wondering what you can do to make it stop ASAP. So keep reading to learn more about urethral bulking, a newer, non-invasive, effective treatment for SUI that more postpartum moms choose to stay dry.

Stress urinary incontinence (SUI) is the unintentional leakage of urine in response to increased stress or pressure in the pelvis. The reason it’s called stress incontinence does not relate to your emotional state (although contemplating wearing adult diapers will cause stress for anyone). Instead, SUI describes how your body – mainly your bladder and pelvic floor– becomes stressed by increased pressure during pregnancy and childbirth. According to a 2019 study, approximately one-third of people experience urinary incontinence between the second trimester of pregnancy through the first three months after delivery.

Usually, your nerves, ligaments, and pelvic floor muscles work together to support your bladder like a sling. They also keep your urethra (the straw-like tube connecting your bladder to the outside of your body) closed and upright, so urine doesn’t leak. However, during pregnancy and after birth, hormonal and anatomical changes can weaken the strength of your pelvic floor muscles.

Even though delivery relieves some of the pressure on your pelvic floor, weakened pelvic floor muscles frequently cause continued postpartum leakage after pregnancy and childbirth. This is especially true if you needed an episiotomy (which cuts through pelvic floor muscles) or if your delivery damaged the nerves controlling your pelvic floor or bladder.

You are probably all too familiar with what causes that unwelcome wetness between your legs, but here is a comprehensive list of some of the activities that cause increased pressure (and leaking):

As you’ve probably figured out, the intensity of the activity determines how much you leak (jumping jacks versus just standing up). What makes stress incontinence so troubling is the unpredictability of it – the unexpected sneeze that leaves you standing cross-legged, madly doing Kegel exercises, and hoping you remembered to wear a pad that day.

Other causes of SUI are obesity, menopause, chronic cough, chronic constipation, and working in a job setting requiring frequent heavy lifting. Women often have multiple risk factors for SUI. For example, women who are overweight or obese are much more likely to develop stress incontinence after childbearing.

If you had pregnancy incontinence, you probably hoped that your leaking would stop postpartum. Or, if your leaking has persisted postpartum, maybe your healthcare provider referred you for some postpartum pelvic floor therapy. Three out of every four women show an improvement in their leakage after pelvic floor exercise training (aka Kegels and biofeedback). But unfortunately, pelvic floor therapy is not always covered by health insurance, can be time-consuming and inconvenient, and only works as long as you do the exercises regularly. And we all know how low Kegel exercises fall on new moms’ lengthy to-do lists.

As a result, many women look beyond pelvic floor physical therapy for easier, more affordable, or longer-lasting solutions to their SUI. There are now several over-the-counter urinary incontinence gadgets, such as at-home biofeedback kits (like Elitone) and disposable internal urethral supports (like Poise Impressa). Still, they generally are most effective for people with mild SUI only.

Surgery is the remaining option for women with more severe SUI which has not improved with pelvic floor physical therapy or incontinence devices, or for female athletes requiring more significant urinary support. Many people have concerns about the invasive nature of surgeries to repair the supports of the bladder neck (called sling procedures or bladder surgeries). The surgical technique and type of materials used (mesh or your own tissue) to repair bladder supports have evolved significantly in the past decades. According to the International Urogynecological Association, bladder or sling surgeries are safe and effective procedures with a low risk of complications. Possible (but rare) complications of bladder surgery include infection, development of overactive bladder, urinary tract infection, painful sex, and movement or slipping of the surgical mesh out of the correct position.

Aside from worries about bladder surgery, timing, and family-building can also prevent women from seeking surgery. Many surgeons counsel women to avoid bladder surgery until they finish building their families because a future pregnancy could compromise the initial bladder repair surgery.

This is where urethral bulking comes to the rescue. This newer, less-invasive option may be the solution for women needing more than pelvic floor therapy but who are not ready for bladder surgery. In urethral bulking, urologists or urogynecologists (specialized bladder surgeons or OBGYNs) inject a bulking agent around the urethra. Picture one of those silicone straws that is so flexible and bendy that it can’t stand upright or straight on its own. Your doctor can inject small bean-shaped bumpers around 4-5 sides of your urethra (the silicone straw), which narrow it, hold it upright, and in place.

There are several key advantages that urethra bulking offers over bladder sling procedures. Urethral bulking:

  1. Can be performed in women still wanting future pregnancies.
  2. Is injected around your urethra using a specialized syringe or cystoscope (it is minimally invasive)
  3. Does not require surgery, wounds, or stitches in the vagina or abdomen (belly).
  4. Either cures or improves SUI symptoms in 60-70 percent of women who have the procedure. According to the International Urogynecological Association, this is a lower cure rate than bladder surgery, which allows 80 to 90 percent of women with SUI a complete cure or improvement in symptoms.
  5. Does not require any downtime. You can return to regular activities, including exercise, sexual activity, and lifting your child within 24 hours after your procedure.

In contrast, recovery from bladder sling surgeries can take two to four weeks, and some women will have an aching discomfort in their groin for several weeks after surgery. The downsides of urethral bulking, when compared to bladder surgery, are that:

  1. Its effects can decrease with time. The newest bulking agent (called Bulkamide) has been shown to last for up to seven years (as long as it has been in existence). Doctors don’t yet know the compound’s effective lifespan beyond seven years.
  2. One out of every three women who have a urethral bulking injection requires a second injection to stay dry with less leaking.
  3. Urethral bulking does not work for treating urge incontinence or overactive bladder.

The other good news about urethral bulking is that it does not impact your ability to have bladder surgery at a later date (or after subsequent pregnancies). So, in some ways, urethral bulking offers women with SUI who are mid-childbearing a more effective option for treating their leaking.

Knowing there are multiple ways to tackle your urinary incontinence can be reassuring. First, remind yourself that it is nothing to be ashamed of and that there is help for treating your SUI. If you are still pregnant and experiencing incontinence, talk to your provider and consider starting prenatal pelvic floor therapy to help better prepare your pelvic floor for childbirth and minimize damage.

If you are in the first six weeks after your delivery, still discuss your incontinence with your provider. They may want to check you for a urinary tract infection, another common (and easily-treated cause of incontinence). At the same time, be patient  – it can take up to six to eight weeks for damaged pelvic floor muscles and nerves to heal and regain strength.

If your urinary incontinence continues longer than six weeks, follow up with your childbirth provider to discuss treatment options. Unfortunately, for some people, the pelvic floor never fully recovers. According to a 2016 longitudinal study involving 3,763 people, in three-quarters of females, urinary incontinence persisted for 12 years after birth. Kegels can help, but if it’s affecting your quality of life, consider urethral bulking  – a less-invasive, longer-lasting, and more effective treatment for stress urinary incontinence.

Amy Harris
Amy Harris is a certified nurse-midwife with a Master's Degree in Maternal and Child Health from Harvard Chan School of Public Health. Her passions are health literacy and women's reproductive health. A recent two-year sabbatical with her family in Spain was the impetus for becoming a freelance women's health writer. An exercise nut, she is happiest outdoors and on adventures abroad.

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