Posterior Tibial Nerve Stimulation
Your posterior tibial nerve runs down your leg to your ankle. It contains nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor.
It’s thought that stimulating the tibial nerve will affect these other nerves and help control the urge to pee.
A very thin needle is inserted through the skin of your ankle and a mild electric current is sent through it, causing a tingling feeling and your foot to move.
You may need 12 sessions of stimulation, each lasting around 30 minutes, 1 week apart.
Some studies have shown that this treatment can offer relief from urge incontinence and overactive bladder syndrome for some people, although there’s not enough evidence yet to recommend tibial nerve stimulation as a routine treatment.
Tibial nerve stimulation is only recommended in a few cases where urge incontinence has not improved with medicine and you do not want to have botulinum toxin A injections or sacral nerve stimulation.
Risks Of A Urethral Bulking Injection
Complications associated with a urethral bulking injection are rare but may include:
- Worsening of a patients stress incontinence
- Bladder infection or urinary tract infection
- Discomfort at the injection site
- Urinary retention – difficulty urinating
- Allergic reactions to anesthesia or bulking agent used during the procedure
What To Do To Prepare For Surgery
You will receive detailed instructions from the surgical schedulers regarding any necessary testing or appointments prior to surgery. In general, you should temporarily stop blood-thinning medications prior to surgery . Prescription blood-thinning medications should be stopped following clearance from the doctors that prescribed them though other medications that thin the blood including fish oil and pain relievers such as ibuprofen should be stopped as well.
On the day before surgery, you will receive a phone call alerting you to the time that you should arrive.
You should not eat or drink anything after midnight on the day of surgery, but you may take approved home medications in the morning before surgery with a small sip of water.
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What Is A Urethral Bulking Injection
A urethral bulking injection is a procedure that is used to treat urinary incontinence in women. During the procedure, bulking agents are injected into the walls of the urethra to help close the sphincter. The goal of a urethral bulking injection is to help patients gain control over their urine flow.
Possible Complications Of The Procedure
ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to: Urinary Retention : As previously mentioned, it is possible to have too much closure and actually be unable to void. Usually this is corrected by one or afew catheterizations. A permanent problem is extremely rare.
- Urinary Tract Infection or Urosepsis : Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections . It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.
If you have high temperatures or any symptoms of severe illness let your doctor know immediately and proceed to the nearest emergency room.
- Bleeding: There is usually a tiny degree of blood in the urine for a day or so. Prolonged bleeding is very rare and almost always responds to observation alone.
Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation.
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Injection Of Bulking Agents
Injection of bulking agents may offer short-term relief but does not cure stress urinary incontinence. Bulking agents can consist of synthetic materials or bovine collagen. The substance is injected into the urethral wall to aid urethral closure. The effect wears off over time. There is a risk that the injection will lead to temporary problems emptying the bladder.
Why The Procedure Is Performed
Implants can help both men and women.
Men who have urine leakage after prostate surgery may choose to have implants.
Women who have urine leakage and want a simple procedure to control the problem may choose to have an implant procedure. These women may not want to have surgery that requires general anesthesia or a long recovery surgery.
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Patient Selection And Counselling
As with other interventions for SUI, careful selection of patients for urethral bulking is the key to optimizing treatment outcomes and patient satisfaction. The efficacy and durability of bulking agents is inferior to surgical treatment for SUI and repeat injections may be required.1 The lower efficacy and durability of bulking agents is balanced by low treatment morbidity and a favourable adverse event profile when compared to surgical management.
Treatment is indicated for patients who desire to undergo minimally invasive treatment at the potential cost of decreased efficacy and durability . Bulking is more suited to low- to moderate-volume SUI and persistent SUI after prior anti-incontinence procedures. Patients with advanced age, high anesthetic risk, or inability to interrupt anticoagulation may benefit from bulking if other interventions are not feasible. Other indications include young patients who may desire future pregnancy or patients with a combination of SUI and poor bladder-emptying.15 Contraindications to urethral bulking agents include a history of hypersensitivity to the bulking agent and active urinary tract infection.
What Can I Expect After The Operation
If you have the operation under anaesthesia, you may experience episodes of nausea, as you come round. Please let the nursing staff know and they will assess you and take appropriate action. The doctor will explain the findings and the next step in the management of your condition. You will be able to go home shortly after the operation.
You will be asked to pass urine in a jug and will have a scan to measure how much urine is left in the bladder.
Most patients go home on the day. As you physically recover from your operation, the nursing team will discuss your convalescence.
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Are There Any Alternatives To Urethral Bulking Agents
Alternative forms of surgery include:
Autologus sling: this operation supports the urethra using a strip from the abdominal wall. This is a more invasive operation that requires stay in hospital for a day or two.
Colposuspension: this operation supports the bladder neck to the back of the bone in the lower abdomen. This is a more invasive operation that requires stay in hospital for a day or two.
All these operations are more effective and durable than urethral bulking agents. These can be discussed with your doctor.
The use of Tension free vaginal tape sling was paused in 2017, following safety concerns.
What Can I Expect During The Procedure
This procedure is done under light sedation at our office in Austin, Texas. Your provider will insert a tiny camera into the urethra, allowing us to see the bladder. The bulking implant will be passed through the scope and injected into the urethral walls on both sides. The implant will cause the urethral walls to close together more effectively. The entire procedure takes 15-30 minutes.
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How Does Urethral Bulking Work
A substance is injected into the wall of your urethra using a special device called a cystoscope. This is a lit scope that looks into the bladder and urethra).
The substance bulks up the urethral tissue, causing it to tighten. This helps limit urine leaking if your leaking is the result of a weak urinary sphincter.
Cystoscopy With Urethral Bulking Agent Injections
cystoscopy = placing a small telescope into the urethra and urinary bladder
urethra = tube from the bladder through which you urinate
bulking agent = a substance used to thicken or bulk-up tissue
There are different types of bulking agents currently in use. The type used in you will depend on your surgeons preference as well as on your full understanding of the pros and cons of each type. If collagen is going to be used, you will undergo a small-dose test injection to ensure that you have no allergic reaction to the substance.
The indication for this procedure is to correct urinary incontinence . The procedure is performed in both females and males. Although there are different types of urinary incontinence, urethral bulking injections are primarily used to correct Type III incontinence . Essentially, this type of incontinence is when the inner walls of the urethra lack adequate closure . Patients with ISD typically leak urine easily and often continuously. In the most severe of circumstances, a patient would never actually feel the need to urinate because their bladder is always empty from the constant leakage. While there are many causes, most patients with ISD have a history of radiation treatments to the pelvis or a prior history of prior surgery to correct stress urinary incontinence.
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What Can I Expect Before The Operation
At your pre op assessment and on your admission day the nurse will go through your hospital stay and explain your operation. Please do let us know about any concerns you have or if there is any information you think we should know about that will make your stay with us more comfortable.
You will need to make arrangements for your family, children or any other commitments that you have prior to coming in to hospital and to cover the length of your recovery.
You will see the doctor performing the surgery before you go to theatre. You will also see the anaesthetist, if you are having the operation under general or spinal anaesthesia. It is not unusual to feel anxious the nursing staff will gladly discuss how you are feeling and talk you through your emotions.
If you have not already signed the consent form on booking, the doctor will go through it with you before you go to theatre. You will be asked for permission to enter your data on the national database for continence and prolapse surgery. This is a quality control measure to compare the safety and effectiveness of such procedures at the hospital against other units in the country.
Completing a frequency volume chart and quality of life questionnaire at follow up will enable assessing the benefit of surgery for you.
What Are The Risks
There are risks with any operation but these are small. The main risks associated with urethral bulking agent injection are:
- Blood stained urine. This results from passing the camera into the bladder as well as making the injection and usually settles within days.
- Initial difficulty in passing urine. This is usually managed by leaving a catheter for few days and you can go home with a leg bag.
- Urinary tract infection. This may happen as a result of passing the camera into the bladder and is treated with antibiotics.
- Venous thrombosis and pulmonary embolism . This is extremely rare, given the minimally invasive nature of the operation, especially if carried out under local anaesthesia.
In order for you to make an informed choice about your surgery please ask one of the doctors or nurses if you have any questions about the operation before signing the consent form.
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What Are The Features To Look Out For
You should contact your doctor or the hospital if you notice increased temperature, discomfort when passing urine or offensive smell of urine. A specimen of urine will be taken and sent to the laboratory for confirmation of infection. You may be provided with an antibiotic prescription.
If you are passing small volumes of urine repeatedly or not passing enough urine you should contact the hospital. You will have a scan to check if your bladder is full and may have it emptied with a catheter. If this persists, a nurse will teach you how to perform clean intermittent self catheterisation, this is usually for a short duration.
What Are The Advantages Of Bulkamid Injections
- This is the least invasive surgical procedure to treat stress urinary incontinence.
- It can be performed under local anaesthesia or general anaesthesia/ sedation if preferred.
- The side-effects and complication rate from Bulkamid® injections are minimal.
- This procedure may be more acceptable to women who wish to avoid the potential complications associated with more invasive surgery or a general anaesthetic.
- Having a Bulkamid® injection does not prevent an individual from having more invasive surgery such as a sling procedure in the future.
It may suit:
- Some women who have only a mild degree of incontinence even after performing pelvic floor physiotherapy.
- Women who already have difficulty emptying their bladder and who are therefore at risk of emptying their bladder poorly after stress incontinence surgery, as Bulkamid® injections have an extremely low rate of problems with long-term urinary retention.
- Women who want a procedure that allows them to return rapidly to work and their normal level of activity.
- Women who are willing to accept the lower cure or significant improvement rate in stress urinary incontinence after treatment with Bulkamid® compared to sling surgery success rates.
What Are The Main Indications For Bulkamid Injections
This procedure is most suitable for people with stress urinary incontinence due to intrinsic sphincter deficiency where the urethral tissues close poorly and which is generally associated with more severe urine leakage with minimal exertion.
It might also be effective in patients with urethral hypermobility where excessive movement of the urethra predisposes to stress urinary incontinence.
Dr. McKertich will advise patients regarding suitability for Bulkamid® injection depending on the results of investigations including Urodynamic study.
How Long Will It Take Me To Get Back To My Daily Activities
If you are unable to urinate without any problems and there is not much residual urine in the bladder, you will be discharged from the clinic.
For 3-4 weeks your doctor may recommend to:
- Consume enough liquid, especially water, to provide at least 2 litres of urine output
- Not lift anything heavier than 5 kilograms
- Not do any heavy exercise
- Take showers instead of baths
- Avoid thermal baths, or going to the sauna
- Prevent constipation by adapting your diet
- Avoid sexual activity
- Avoid activities which can traumatise the operation such as cycling and horseback riding.
- Have a fever
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Who Is A Candidate For A Urethral Bulking Injection
A urethral bulking injection is an option for women who have the following conditions:
- Stress urinary incontinence after a urethral sling
- Stress urinary incontinence in women who cannot have surgery due to other medical conditions
- Urinary sphincter dysfunction
- Difficulty emptying the bladder
- Have an obstruction in the urethra
If you are undergoing cancer treatments that have impacted the pelvic muscles, a urethral bulking injection may not be an appropriate option either.
Injections Of Urethral Bulking Agents Helps To Reduce Urine Leakage In Individuals With Stress Incontinence
Intraurethral injections of bulking agents is generally proposed as a stress incontinence treatment for older women who cannot or do not want to undergo surgery. Its also used in cases in which perineal rehabilitation has not been effective. Bulking agents can also be used to treat chronic urinary incontinence in younger women.
The intraurethral injections of bulking agents has the effect of swelling the urethral wall. This, in turn, provides resistance against urine leakage and facilitates closure of the striated sphincter.
While this treatment provides only short-term results, it can be repeated and has the advantage of being non-invasive. When tested in clinical trials,injections of bulking agents have had positive results, with 66% of patients self-reporting that their condition improved or was resolved after a year of treatment.
- Urinalysis and urine culture are required about 10 days before the injection. If the culture shows the presence of bacteria, antibiotic treatment will then be started. You will receive a notice from the secretary, along with a prescription.
- If you are taking anticoagulant medicines you will be asked to stop taking them and in some cases, they will be replaced by other medicines before the injection. You can start taking your medicine again after the injection.
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Why Do I Need A Urethral Bulking Agent Injection
Injections increase the bulk of the bladder neck. This will resists any increase in pressure on coughing and sneezing, to stop leakage of urine .
As with other forms of surgery, an injection is offered after failure of conservative measures, including pelvic floor muscle training. Injections are less effective than other procedures such as autologous sling and colposuspension. The effect may ware off with time, so the procedure may need repeating.
Urethral bulking agents may be more suitable for patients who can not have other forms of surgery, for example due to anaesthetic reasons.
Injectable Bulking Agent To Treat Postprostatectomy Urinary Incontinence: A Safety And Effectiveness Pilot Study
1Department of Urology, Leiden University Medical Center, 2 Albinusdreef, P.O. Box 9600, Leiden 2300 RC, Netherlands
2Ziekenhuisgroep Twente, 141 Geerdinksweg, P.O. Box 546, Hengelo 7550 AM, Netherlands
3Amstelland Ziekenhuis, 8 Laan van de Helende Meesters, P.O. Box 328, Amstelveen 1180 AH, Netherlands
4Catharina Ziekenhuis, 2 Michelangelolaan, P.O. Box 1350, Eindhoven 5602 ZA, Netherlands
2. Materials and Methods
2.1. Inclusion and Exclusion Criteria
All patients gave their written informed consent before inclusion in the study. The study was approved by the local ethics committee and registered in the Dutch Trial registration as number NL.57054.044.15. Patients were included in this pilot study and treated with Opsys® bulking agent between October and December 2016. Inclusion criteria were minimal SUI , at least 12 months after radical prostatectomy, and being refractory to conservative treatment, such as pelvic floor muscle training. Patients remained dry at night and could voluntarily stop micturition. Patients with a history of radiation treatment for prostate carcinoma, bladder neck sclerosis, urethral stricture, urgency urinary incontinence, detrusor overactivity during urodynamic evaluation, and/or urinary tract infection were excluded from the study.
2.2. Bulking Agent
2.3. Injection Procedure
Uroflowmetry and postvoid residual volume was measured each post treatment visit.
2.5. Statistical Analysis
2.5.1. Power Calculation
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