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Surgical treatment of stress incontinence

Mesh use in gynaecology for incontinence and/or prolapse has become highly contentious. Many practitioners may have been faced by women and their families with a high degree of anxiety about their options for treatment, either that which has been proposed, or potentially already undertaken.

It is my feeling that in the last 2 years in particular, women have become a lot ‘warier’ of surgical approaches such as the retropubic or transobturator mid-urethral slings, even though they are some of the most studied and well-validated surgical techniques available. So, what is the current situation around mesh use for incontinence, and what are the other options?

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Fibroids – the easy culprit

On face value fibroids may seem an obvious and measurable abnormality to account for the patient’s problems, however in many cases they may be an ‘incidentaloma’. As many as one in four women may have a uterine fibroid. They are even more common in woman of African ancestry. In many cases no treatment will be required, while in others they may be the cause of a number of symptoms. Management of fibroids must be individualised and treatment selective.

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Why does endometriosis occur?

Throughout my early specialist gynaecology training I compared the pathogenesis of endometriosis to one of my Otago University Dunedin flats. My bedroom in this flat had a serious case of ‘mouldy roof’. If I neglected to ‘mop the roof’ every few months, things got way out of control. At the time this seemed a fitting analogy to the pathogenesis of endometriosis. With experience, further training, and a more complex understanding of endometriosis, I began to appreciate that the theory of ‘retrograde menstruation’ could not be the only pathogenic mechanism.