Urethral bulking agent (Bulkamid®) for the treatment of stress incontinence

What is stress incontinence?

Stress incontinence is one of the types of urinary leakage (urinary incontinence) which happens when the bladder is put under any pressure (such as coughing, lifting or exercise). It is caused when the opening of the bladder is weak or unsupported.

What is urethral bulking?

Urethral bulking is only suitable for stress incontinence and involves an injection of a jelly like substance, at 3 or 4 different sites, into the walls of the urethra (tube from your bladder) to improve the seal and prevent leakage of urine. This is a permanent procedure.

There are several varieties of bulking agents available. At Gloucestershire Hospitals NHS Foundation Trust we use Bulkamid® which is a polymer gel that is easily accepted by the body. There have been no reports of allergic reactions to Bulkamid®.

Enzymes within the body do not break the gel down and it is not reabsorbed by the body. The gel is soft and does not induce scarring around it. It acts to bulk out the urethra and make it more difficult for urine to leak.

The success rate of this procedure is about 60% meaning that 6 out of 10 women will stop leaking or notice a significant improvement in their bladder control with less wetting.

What needs to be considered before the procedure?

• It is recommended that you should have tried pelvic floor exercises for at least 3 months, supervised by a trained women’s health physiotherapist.
• You have had urodynamic tests - these are tests on your bladder, often carried out to confirm that you do have stress urinary incontinence.
• Discussion at a Multidisciplinary Team (MDT) meeting is considered good practice before carrying out surgery for your stress urinary incontinence. Your medical notes and the results of any tests are reviewed at the MDT meeting which is attended by urogynaecologists, specialist nurses and physiotherapists. The team will take into account any preferences you have expressed before a decision is made as to whether the proposed treatment is appropriate for you.

How is urethral bulking carried out?

• Currently the procedure is usually carried out in an operating theatre under a short general anaesthetic (while you are asleep). Alternatively, the procedure may be offered at an outpatient clinic under a local anaesthetic.
• A telescopic camera examination of your bladder and urethra is carried out before the procedure.
• The bulking agent is then injected into the tissues around the urethra either through the telescope or alongside the telescope.

Stress urinary incontinence is the result of weakening of the closing mechanism.

Under local anaesthesia 3 to 4 deposits of Bulkamid® gel are injected into the wall of the urethra.

This bulking effect stops urine from passing.

Within the PDF below, see the images on page 2

What are the benefits of urethral bulking?

• Cure or improvement in stress incontinence.
• A minor procedure without making a cut.
• Suitable for women who are not medically fit for a general anaesthetic.

What are the risks and possible complications of urethral bulking agent?

• Less successful compared to other larger surgical procedures.
• First treatment may not provide sufficient bulking and further bulking is required a few weeks later.
• Pain at the time of injection if done under local anaesthesia. It is likely that you will feel a small scratch as each injection is placed.
• Small amounts of bleeding when you pass urine for a few days.
• Temporary discomfort around the bladder which may last for a few days.
• Urine infection immediately after the procedure. Your urine will be tested before the procedure to rule out any infection. You may require antibiotics if an infection develops. A chest infection may also develop if the procedure is performed under a general anaesthetic.
• Difficulty in emptying the bladder can happen. This usually settles quickly without any intervention but can sometimes require a catheter to help the bladder empty. This would only be for a few days.
• Urinary urgency symptoms have been reported in 1 or 2 people out of every 100 patients following the bulking procedure.
• Rarely, infection at the bulking site causing an abscess.
• General anaesthetic risk - this is very small unless you have specific medical conditions, such as a problem with your heart or breathing. Smoking and being overweight also increase any risks.

What are the alternative options?

Non-surgical

Do nothing

If the stress incontinence is not bothersome, treatment is not necessarily needed. It is not easy to predict if incontinence will get worse over time.

Devices

There are a number of devices which can be inserted to block the urethra. The devices are inserted into the vagina. Devices inserted into the urethra are not recommended. These devices are not a cure but are used with the aim to keep you dry while in use, such as during exercise. Some women find inserting a tampon useful, although care should be taken not to leave the tampon in place for too long as this can be harmful, leading to infection.

Weight loss

Losing weight has been shown to reduce leakage of urine.

Pelvic floor exercises (PFE)

The pelvic floor muscles support the pelvic organs. Strong muscles can help to prevent or reduce leakage of urine. A women’s health physiotherapist can explain how to perform these exercises using the correct technique. It is important that you try these exercises to help to manage the symptoms of your urinary incontinence and to prevent it becoming worse.

It is also very important to continue with pelvic floor exercises even if you have opted for other treatment options. These exercises have little or no risk.

Duloxetine

This is a medication that can help reduce incontinence. It needs to be taken every day. Stopping the medication will result in the leakage returning. Some women find that the medication causes unacceptable side effects such as nausea and abdominal pain. Duloxetine is not usually recommended as a first line treatment but is an option to consider if you do not want to have a surgical procedure or are unfit to do so.

Surgical

The type of surgery and the particular risks of procedures vary in each person, with some procedures not being suitable for all patients.

On the following pages there is a list of the different surgical procedures considered to treat stress incontinence. Not all of the procedures are available in the Gloucestershire Hospitals NHS Foundation Trust.

Further information about the procedures is available in our on ward leaflets.

Please seek the advice of your consultant before the operation if you wish to discuss any of these procedures in more detail.

Contact information

If you have any problems or concerns after going home, please contact your GP for advice. If your GP is not available contact the:

Urogynaecology Nurse Practitioner

Women’s Centre, Gloucestershire Royal Hospital

Tel: 0300 422 6246

Monday to Friday, 8:00am to 4:00pm

In an emergency (out of hours only), please contact:

Ward 9a

Gloucestershire Royal Hospital

Tel: 0300 422 6780

Further information

National Institute for Health and Clinical Excellence (NICE)

Website: www.nice.org.uk

Guideline

Website: http://guidance.nice.org.uk/CG171

Patient decision aid

Website: https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress-urinary-incontinence-patient-decision-aid-pdf-6725286110

Bladder & Bowel Community

General enquiries: 01926 357 220

Email: help@bladderandbowel.org

Website: www.bladderandbowel.org

British Society of Urogynaecology

Email: bsug@rcog.org.uk

Website: https://bsug.org.uk/pages/information-for-patients/111

International Urogynecological Association (IUGA)

Your Pelvic Floor

Website: https://www.yourpelvicfloor.org/conditions/urethral-bulking/