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What causes urinary incontinence?
There are several causes of urinary incontinence which may occur alone or in combination. Stress incontinence occurs when straining (e.g. coughing, laughing, sneezing) puts pressure on the bladder causing leakage of urine. Urge incontinence occurs when one is not able to control an overwhelming desire to urinate, with resulting leakage of urine. Neurogenic incontinence occurs as a result of some disease (e.g. diabetes) which affects the nerves controlling the bladder. Overflow incontinence occurs when the bladder is full, due to a partial obstruction, resulting in a constant steady leakage of urine.

Why does prolapse occur?
A description of the reason for vaginal vault prolapse demands that a short explanation of the normal support of the floor of the pelvis be explored. In a general way the pelvic contents are maintained in their position in a number of ways. Although we talk about individual ligaments and organs, there is one single body of connective tissue that attaches the apical part of the vagina to the sacral area and to the pelvic side wall down to the vaginal outlet. Contained in this body of tissue is the uterus and vagina. The bladder is located in front of the vagina and the rectum is located posteriorly or behind the vagina. At the very floor of the pelvis there is a series of muscles called the levator ani muscles which form a diaphragm with a genital opening that allows the rectum, vagina, and urethra to exit to the outside. These muscles form a shelf on which all of the pelvic organs sit. They are in constant states of contraction providing a firm, strong floor. These muscles have the ability to close the genital opening. They originate in front of the pelvis and attach at the back of the pelvis to the sacrum, coccyx, and pelvic side wall. They have the same type of constant contractions seen in the sphincter of the bladder and of the anus and relax only during defecation, parturition, and urination. Damage to these muscles creates marked weakening of these muscles and loss of strength is intricately involved in vaginal prolapse. A third aspect of support concerns the position of the vagina over the pelvic musculature. In a normal women the vagina is positioned, in the standing position, almost parallel to the floor, creating a valve overlying the muscular support of the pelvic opening. Loss of the support of the muscles or the ligamentous support of the uterus and vagina causes the vaginal position to be lost and subsequent movement of the uterus, vagina, and pelvic contents through the genital opening and progressive pelvic organ prolapse occurs.

Support of the pelvic structures can be described in three levels. Level 1 is the suspension of the apex of the vagina from the sides of the sacrum. This level prevents uterine or upper vaginal prolapse. Level 2, concerns the lateral attachment of the vagina to the pelvic side wall. This level prevents prolapse of the bladder and the rectum into the vagina. Clinically we call this a cystocele or a rectocele. Level 3 is near the opening of the vagina where the muscles of the levator sling and the distal portion of the vagina fused to the perineal body. This area can be felt between the vagina and the rectum.

What are the significant physical findings in vaginal vaultprolapse?
Examination of the external genitalia reveal a gaping, wide, and enlarged vaginal opening. There is loss of the body of tissue between the vagina and anal opening. If one looks inside the vaginal opening, the cervix or vaginal tissue can be seen near the vaginal opening and with straining it will descend to or past the opening.

How should vaginal vault prolapse be evaluated?
There are five major goals to be achieved in the evaluation of a woman with pelvic support defect. 1. Critical to any evaluation is an accurate history of the patient's complaints. 2. Documentation of the patient's specific pelvic support defect. 3. There should be a correlation of the complaints and the physical findings. 4. There should be development of a management plan. 5. There should be a long-term follow-up to evaluate the success or failure of the treatment plan that has been designed. There must be strict attention applied to each area of pelvic defect and repair of each defect.

What questions should be asked of each patient?
Usually these questions should fall in relation to three areas. Can the patient initiate a urine stream to void and empty her bladder to completion? Must she push the bladder into the vaginal canal before being able to initiate a stream? Does she leak urine by accident with increases in intra-abdominal pressure such as coughing or sneezing? Does she have recurrent urinary tract infections? Can she evacuate her bowel adequately without placing her finger into the vagina to facilitate defecation? Does she have fecal incontinence? Is she sexually active? Does she have pain with sexual intercourse? Is there obstruction to penetration because of tissue protruding outside of the vaginal opening? Has the frequency of intercourse been diminished because of the psychological revulsion of the appearance of her genitalia? Are her complaints less in the morning and progressively increase the longer that she is erect and active? Are her symptoms stable or are they progressively increasing in severity? What specific complaint does the patient hope to have relieved by therapeutic intervention?

Is incontinence a problem with vaginal vault prolapse?
The problem of failure to store urine may be simplified by considering the cause. There may be a problem with the bladder or a problem with the urethra which drains the bladder to the outside or to the support of the bladder and the urethra and junction between the bladder and urethra. Incontinence may be caused by a defect in the anatomic support that is associated with vaginal vault prolapse, but it also may be related to a problem in the inability of the urethra to close itself in a normal way. It can be due to neurologic dysfunction of the bladder itself. When a person has incontinence in conjunction with vaginal vault prolapse it is important to determine the cause of the incontinence or the treatment program may be ineffective. If the problem is due to excessive neurogenic activity of the bladder then medications are an appropriate therapy. If the incontinence is due to an anatomic defect with loss of support of the bladder neck, then the corrective procedure is to support the bladder neck. If the urethra itself is deficient then it is important that a urethral sling be considered. Sometimes identification of the cause can be a very difficult decision to make. Many times it may not be apparent until repair of the prolapse has been done.

In some instances anal incontinence is a component associated with the neurologic defect that also causes urinary incontinence and if they occur in conjunction with each other, almost always it represents a neurologic injury in the past. Recent studies have implicated injury to the nerve supply during delivery as the main cause of this syndrome.

What can be done about incontinence?
Incontinence operations fall into four broad groups. Abdominal incision with support procedures, vaginal procedures to support the urethra and bladder support, urethrovesical sling procedures, and peri-urethral injection procedures. Success rates with each of these are always somewhat subjective. In general, it is stated that there is about an 85% cure rate of stress urinary incontinence. It is imperative that the correct diagnosis be made in the preoperative period for the correct surgical procedure to be chosen. In general, if a person has a defect in the function of the urethra, a urethrovesical sling procedure is very appropriate. A less permanent procedure is to inject collagen in the urethra. If a person has stress incontinence secondary to an anatomical defect in the support of the bladder and urethra, a procedure such as a paravaginal suspension or Burch procedure will usually be effective. In general, the abdominal procedures are effective longer than procedures done through the vagina.

How can vaginal vault prolapse be repaired?
In general, vaginal vault prolapse can be repaired either through an abdominal incision or through the vagina. It is imperative that the entire vaginal prolapse be assessed and document the areas that are prolapsed and in need of repair. The site of prolapse can be specific. The area under the bladder and urethra can be independently prolapsed. The very top portion of the vagina can prolapse downward alone and sparing the support underneath the bladder and over the rectum. The side walls of the vagina can collapse inwardly and the wall between the vagina and rectum can independently prolapse and form a rectocele and all of these things can concur in conjunction with each other with total eversion of the vagina with a mass extending completely to the outside. In addition to these, the abdominal contents can slide down either in front or behind the vagina and be associated with the prolapsed mass. This is called an enterocele.

There are two general approaches to repair these defects. It is essential that all of the defects be repaired or there will be recurrent problems. The experience of the surgeon has significant bearing on the procedure that is chosen. Both avenues of approach have good outcomes. If the surgeon is highly skilled in vaginal procedures and has a good record or results with that procedure, then he should chose that procedure. If the surgeon is more comfortable with an abdominal approach to the prolapse this will be the better procedure for him to recommend. In general, the more severe the prolapse, the more appropriate the need to repair through an abdominal incision, anchoring the vagina to the bony structure of the sacrum, and the muscular structure of the pelvic wall. There is a significant amount of individualization of the surgical approach that should be applied to each person in chosing the extent and the different procedures that should be applied.

What Is laparoscopic surgery for stress incontinence?
Laparoscopic surgery for stress incontinence is called bladderneck suspension. In one procedure, two to four stitches are placed between the vaginal wall and pubic bone. This stabilizes the vaginal wall and bladderneck causing slight compression of the urethra at the bladderneck which prevents leakage of urine when straining (e.g. coughing, laughing, sneezing).

What can I expect during the procedure?
The procedure is performed under general anaesthetic (asleep). Three small incisions (5mrn) are made in the abdomen. The laparoscope (telescope), inserted through an incision in the bellybutton allows the surgeon to precisely view the area and perform the procedure which takes approximately 30-60 minutes.
No stitches are used to close the skin incisions, butterfly paper strips are used. A catheter is left in the bladder overnight and removed the next morning. After passing urine a small "in-out" catheter is inserted to drain any residual urine in the bladder. When this is less than 150mls on two consecutive occasions you can be discharged. Most patients are discharged the day after surgery, provided no other simultaneous surgery was performed.

Does it hurt?
There is minimal pain involved with laparoscopic bladderneck suspension as the incisions are very small. Most patients require only tablets for pain relief. Stronger pain relief is always available if required.

How long will it take me to recover?
Recovery is usually very fast (2-3 days). Gradually increase the amount of exercise and stop if it hurts. Patients must refrain from high impact sports f and heavy lifting or at least 3 months.

Is there any special preparation before the procedure?
We ask that you go on a liquid diet 48 hours before the procedure and that you have nothing to eat or drink on the day of surgery.

Is laparoscopic bladderneck suspension surgery as safe and effective as the traditional "open" procedure?
The laparoscopic procedure is less painful than the open procedure. You will see immediate results, in approximately 85% of women incontinence is eliminated, 5 years after surgery 65% of women remain completely dry. These figures are the same as for the open procedure.
Laparoscopic bladderneck suspension carries different risks as opposed to open procedures. Overall the risk is estimated at less than 5%. The risks are: bleeding requiring transfusion, infection requiring treatment with antibiotics, injury to bladder or bowel requiring repair sometimes by laparotomy (larger incision in the abdominal wall).

What is Laparoscopic Bladder Suspension? (Modified Burch Procedure)
This surgical procedure is used in the management of urinary stress incontinence, which is the involuntary loss of urine , usually during some physical activity such as lifting sneezing, laughing, jogging, bending or stooping. Childbirth and loss of estrogen associated with menopause conditions that can weaken muscles supporting the bladder- are common causes for the condition.

Surgical therapy is indicated after conservative therapies have been proven ineffective, or if the condition is interfering with daily activities. Initial management of the problem can include weight reduction to help lessen intraabdominal pressure, behavior modification (i.e. changing posture), estrogen replacement therapy in menopausal and postmenopausal women, Kegel exercises, and electrostimulation to strengthen the pelvic floor. Medication to help constrict the muscles in the. bladder may also be prescribed. The procedure takes one to two hours based on the patient's anatomy, and has an excellent success rate.