Abstract
This report describes two cases of urinary stress incontinence secondary to mesh repair of large abdominal hernias. Both patients had never experienced urinary incontinence before their hernia repair. In both cases, polypropylene nets were inserted to stabilise the abdominal wall. Immediately after the intervention, both patients became stress incontinent. Probably pressure transmission to the pelvic floor was increased due to stabilisation of the abdominal wall, which worked as a “windpipe” before surgery. After the insertion of suburethral tapes the incontinence resolved.
BACKGROUND
Abdominal wall hernias are a common problem and are treated surgically.
Urinary stress incontinence may occur postoperatively if a large abdominal hernia is repaired.
CASE PRESENTATION
Case 1
In 1984, a 72-year-old woman underwent median laparotomy due to an intra-abdominal abscess. In the past, she had delivered eight children vaginally; one child weighed more than 5 kg and the other six were each more than 4 kg at delivery; one child was stillborn at 20 weeks of gestation. After the third delivery she developed stool incontinence but never urinary incontinence.
After laparotomy the patient gained 65 kg of weight during the following 10 years. She had a cholecystectomy in 1986 and was diagnosed with diabetes, hypertension and was hypothyroid. As weight loss was recommended for her diabetes and hypertension, she went on a low calorie diet and lost 70 kg between 2000 and 2002. After this weight loss she noticed a large swelling next to her median abdominal scar which increasingly caused abdominal discomfort.
After being referred to the surgeon, an abdominal hernia was diagnosed and surgery was recommended including mesh insertion. Hernia repair was performed and a Vipro net was fixed using stapler and PDS sutures. Postoperatively, the patient complained of involuntarily urinary loss on coughing and sneezing, which made her use up to four incontinence pads per day. The patient was referred to the department of urogynaecology.
Gynaecological examination revealed moderate atrophy, no marked prolapse and a mobile uterus with normal adnexae. Her pelvic floor muscle function was poor with a pelvic floor testing of 1 (Oxford grading). Multichannel urodynamics confirmed urinary stress incontinence with a normal maximum urethral closure pressure (MUCP) and normal bladder contractility. She voided with a maximum flow rate of 24 ml/s and with residual urine of 20 ml. Initially the patient was referred to physiotherapy for pelvic floor exercises including electrical stimulation.
At 3 months follow up, she was still suffering notably from incontinence and desired surgical intervention.
Case 2
An 83-year-old woman (gravida 4 para 4) with no history of urinary incontinence underwent a repair of a large umbilical hernia. She had no history of abdominal operations in the past. A Prolene net was inserted and fixed with Prolene sutures after hernia repair. On the first postoperative day she complained of urinary stress incontinence, but therapy was delayed until follow-up 3 months after hernia repair. She was referred to physiotherapy for pelvic floor exercises.
After 3 months she was followed up in the department of urogynaecology and reported some improvement of the stress incontinence, but still complained of involuntary urinary leakage. Gynaecological examination was uneventful with a moderate pelvic floor muscle testing of 3. Multichannel urodynamics confirmed stress urinary incontinence with an MUCP of 12 cm H2O and a normocontractile bladder, residual urine of 40 ml, and a maximum flow rate of 24 ml/s. The patient refused further conservative therapy.
TREATMENT
We discussed options of a Burch colposuspension, insertion of a tension-free vaginal tape (TVT) or transurethral bladder neck injection. Both patients opted for a retropubic TVT and received a suburethral sling.
OUTCOME AND FOLLOW-UP
Case 1
The operation was uneventful and on follow-up 12 months postoperatively she was subjectively and objectively continent, voided with a maximum flow rate of 17 ml/s, and had no residual urine.
Case 2
The operation was uneventful; on follow-up 14 months postoperatively she was subjectively and objectively continent, voided with a maximum flow rate of 32 ml/s, and had a residual urine of 30 ml.
DISCUSSION
To our knowledge, these are the only two reported cases demonstrating de novo stress urinary incontinence after the repair of large abdominal wall hernias.
De novo stress incontinence after hernia repair can be explained as follows. The hernia works as a windpipe mechanism, which prevents incontinence during increasing intra-abdominal pressure such as occurs during coughing, sneezing and laughing. Possibly urethral function is already weak but this does not show because the pelvic floor is not exposed to increased intra-abdominal pressure. After having stabilised the anterior abdominal wall using hernia repair and mesh insertion, the abdominal pressure is applied to the pelvic floor directly resulting in urinary stress incontinence. If stress incontinence is shown to occur from the repair of small abdominal hernias it is less likely to be secondary to the “windpipe” effect described.
Our two cases demonstrate that de novo stress incontinence is a possible postoperative consequence after large abdominal wall hernia repair; however, no larger studies are available to clarify the incidence of this distressing consequence. The hernia masks the stress incontinence.
If this complication occurs, further investigations such as urodynamics should be undertaken, and treatment should be commenced without delay. Prospective studies are needed to determine the incidence of de novo stress incontinence after large abdominal wall hernia repair.
LEARNING POINTS
De novo stress incontinence may occur in patients after large abdominal hernia repair.
The true incidence of de novo incontinence after hernia repair is unclear; prospective studies are needed to determine frequency and severity of incontinence after hernia repair.
In case of de novo stress incontinence, urodynamics are a helpful investigation and conservative treatment, such as pelvic floor exercises, can be started.
Surgeons should be aware of the occurrence of stress incontinence after abdominal hernia repair so they are able to inform their patients preoperatively about this rare but possible consequence.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
