So Sometimes Surgery is the Best Option

National Health Blog Post Month Day 23 – Friday, Nov. 23 What’s something your doctor taught you or you taught your doctor? 

Well…that sometimes surgery is truly the best option.  And it technically wasn’t my doctor, but it was a doctor I know well and with whom I have worked closely for years.

I have been reviewing several articles lately on the pelvic floor, pregnancy, childbirth, incontinence and pelvic organ prolapse and a section of one article had me stuck. It made me think about what could be done when someone is leaking urine because their pelvic floor muscle tissue is damaged from tolerating extreme pressure. You see, the basics behind remaining continent (ie. no urine leaks) are that the pressure from below (within the pelvis) has to be the same as or higher than the pressure above (in the bladder and abdomen).  The point of this section of the article was that sometimes there is irreparable damage to the pelvic components (muscles, connective tissues, nerves) such that no amount of pelvic floor retraining would be sufficient to make up the gap between pressure above and pressure below (pressure below being lower due to the damage and this leading to incontinence).

Since this doctor colleague and I recently attended the same conference, I grabbed this opportunity to ask his thoughts.  “Wouldn’t it be possible to train the accessory muscles enough to potentially make up this difference?” I asked.

“Or you could just do a sling,” he said.

“Ok, I get it.  But if you have 100 units* of pressure from above and can only generate 80 units from below, due to muscle tears, loss of nerve supply, or other permanent injury, what if you do some combination of interventions to essentially cobble together the 20 units of pressure that are needed,” I said.  “Perhaps with pelvic floor retraining alone you get 5 units better, with combined training of the abdominals and breathing you can get another 10 units, and then you train the heck out of their glutes for another 5 units (because a strong, powerful group of buttock muscles will provide better support of the pelvic for alignment and both active and passive support for the pelvic floor).”

With a nod to all the wheels turning inside my head, he still smiled and said, “Or you could just do a sling.”

And the truth is, though we both have a point, he is right.  From a surgical perspective, a sub-urethral sling – the classic surgical intervention for stress urinary incontinence – is low risk, highly successful, and has a very quick recovery time.  I can somewhat sheepishly admit that yes, Dr. R, there are times when giving it the old PT-try, you “could just do a sling” and get rapid resolution of incontinence.  Can you still throw me a bone, though, and toss a little PT in the post-op mix?

Visit the American Urogynecologic Society‘s site for more information on pelvic floor disorders, treatments and more. *Numerical values of the units are made up to illustrate the point, not to be precisely reflective of the pressure amounts in real life situations.