Review emphasises the importance of informed choice for women undergoing surgery for stress urinary incontinence

Posted: 02/07/2015

Over the last few years concerns and questions have been raised over the safety of surgical procedures carried out to improve stress incontinence but recent evidence published has caused experts to reassure patients that the surgery is relatively safe and effective.

Stress urinary incontinence (SUI) typically involves the involuntary loss of urine upon activities such as coughing, sneezing, laughing or exercise. It is a common problem, particularly for women after childbirth and it is said to affect 9 million people in the UK and millions worldwide.

SUI can occur when the pelvic floor muscles which support the bladder become weak and fail to stop urine leaking when the bladder comes under stress.

The main non-surgical option for treating stress incontinence is pelvic floor exercises. However, for some women this does not prove effective and surgery can be a potential solution to improve bladder control. This surgery involves one of two common operations to support the bladder. One approach is the insertion of a sling, made of an artificial mesh, behind the pubic bone coming out via the abdomen known as the 'retropubic' route or, alternatively, from side-to-side coming out through the groin known as the 'transobturator' route.

Unfortunately, over the years a number of women have criticised the procedure stating that it has led to excruciating pain and discomfort; with some women even saying that the procedure has destroyed their quality of life. Others have confirmed that the procedure has been successful in that it has stopped their incontinence but it has left them in constant pain.

Figures from the UK regulator, the MHRA (Medicines and Healthcare Products Regulatory Agency), show that there have been 124 adverse reactions reported from mesh implants since the beginning of this year.

Last year the Scottish Government suggested that hospitals in Scotland consider a temporary suspension of the use of these medical devices until more evidence became available. This led to an independent review being set up in Scotland in 2014 to examine the safety of these operations. As part of this review, a group of Cochrane Collaboration scientists looked at 81 trials involving over 12,000 women and found that such problems were rare. They also found that 80% of women with SUI were either cured or experienced relief of their symptoms. They said the procedure was generally safe in the short to medium term but admitted there was a lack of long-term data.

This review, which was published on 1 July 2015, highlights the importance of helping women to make informed choices about their treatment. It will be important for women to balance the cure rates of the procedures against the different risks and complications when choosing an operation.

At a time when the recent Supreme Court decision in Montgomery v Lanarkshire Health Board [2015] UKSC 11 has highlighted the importance of patient autonomy in assessing consent to a procedure, it is now clear that women should be well informed of the risks and benefits before undergoing this type of surgical intervention.

Lead author Abigail Ford from Bradford Teaching Hospitals has said: "[Women] need to be aware of less invasive alternatives such as pelvic floor exercises, which should be tried first before contemplating any type of surgery.

"As all surgery carries some risk, women must weigh up carefully how much they are troubled by their urine leakage against taking a small chance that things may go wrong as a result of surgery."

The report from the independent review set up in Scotland last year about the safety of these operations is due to be published later this year.

The Penningtons Manches clinical negligence team is currently dealing with a number of cases against Frimley Health NHS Foundation Trust for the care provided by Miss Jayne Cockburn, a consultant obstetrician and gynaecologist. One of the issues that has become apparent in the team's investigations into these claims is that there has been a tendency to undertake surgery such as the use of this type of mesh surgery for incontinence when the patient was not fully informed of the risks of the procedure and such surgery was neither indicated nor required. Therefore, many clients were never given the opportunity to balance the risks of the procedure against the benefits and make an informed choice. 

If anyone is concerned about the treatment they have received for stress incontinence, please either email Elise Bevan or Emma Beeson or call free on 0800 328 9545 for an initial chat.

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