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The TVT operation - a guide for patients
This leaflet was written for women who are considering having a TVT operation. If you have any questions that aren't answered by this leaflet then please ask me and I will do my best to answer them.
What does TVT stand for?
It can stand for either Tension-free Vaginal Tape or Trans-Vaginal Tape. These are identical operations
Who might benefit from a TVT operation?
It is performed to treat stress incontinence, a condition where women leak urine from their bladder with certain activities eg. coughing, sneezing, laughing, lifting, walking or with sport.
What causes stress incontinence?
Urine is stored in the bladder and empties through the urethra. Stress incontinence happens when the urethra is weak. Such weakness may be caused by damage to the muscles and nerves of the pelvic floor, and this is rare in women who have not had children. This weakness may be aggravated by the menopause, a chronic cough, heavy lifting and being overweight.
Is a TVT operation suitable for all women with stress incontinence?
It is suitable for those women who leak because the mechanism for holding urine at the base of the bladder is weak. Occasionally women have stress incontinence that is caused by an overactive bladder (see below) and these women are unlikely to benefit from an operation. The cause of urine leakage can usually be diagnosed by performing urodynamics, a test that is carried out on all women before a TVT operation is performed.
A TVT operation is usually not recommended for a woman who may want to have a further pregnancy, as this may cause the woman to become incontinent again.
How is urodynamics performed?
This is a simple outpatient test where the pressure inside the bladder is measured whilst filling the bladder through a small tube. A separate information leaflet is available for this test.
Are other treatments available for stress incontinence?
Yes. Many women will find that they leak less often if they perform pelvic floor exercises. You may not be sure that you are performing these exercises correctly, and your doctor or nurse can check to make sure you are. Some women find to difficult to contract the correct muscles and can benefit from seeing a physiotherapist. For most women it is simply a matter of remembering to do enough exercises every day. A separate information leaflet is available about pelvic floor exercises. Some women find that putting a tampon in the vagina can help prevent leakage during sport, and this must be changed frequently like any tampon.
Women whose body mass index is greater than 30 kg/m2 should be advised to lose weight according to national guidance. Weight loss can improve leakage and make any surgery more safe.
There are some women, particularly those with severe leakage and/or a large vaginal prolapse, who are unlikely to benefit from pelvic floor exercises. Your doctor/ nurse will advise you if this applies to you.
A drug (Duloxetine) may be used to treat stress incontinence. Approximately 20% of women who take this will experience a moderate/great improvement in their leakage. Side-effects are fairly common with this drug and commonly include nausea and sleep disturbance. This drug may have a valuable role in women who are not keen on having surgery, or who are not fit for surgery.
Are there any other operations for stress incontinence?
Yes. A peri-urethral injection involves injecting bulking agents into the urethra (the tube along which urine flows, from the bladder to the outside). Although this is a simpler operation and has fewer risks that a TVT, the success rate is lower and the procedure often needs repeating to maintain the benefit. This procedure is sometimes advised in frail women or women who want more children, for whom the risks of a TVT are more significant.
How is a TVT operation performed?
The TVT operation works by supporting the middle of the urethra with a tape. The tape is made of Prolene and has a long needle at either end. A 3cm incision is made in the vagina underneath the urethra and two 1cm incisions are made at the bottom of the abdomen beneath the pubic hair line. The needles are passed upwards from the vagina so that the tape comes to lie underneath the urethra.
A telescope (cystoscope) is inserted through the urethra into the bladder to make sure that there is no bladder injury. The tape is then placed in the correct position and the needles are removed. Dissolving stitches are placed in the incisions – the abdominal stitches dissolve in around 2 weeks, the vaginal stitches takes around 6 weeks.
Diagram showing the tape in position.
What type of anaesthetic is used?
The operation can be performed using either a general anaesthetic, a spinal anaesthetic or local anaesthetic (you would be awake with these latter two types of anaesthetic). Your surgeon may have a preference, based on his/her experience and your general medical condition. You may have a preference and, where feasible, we will try and accommodate your wishes.
Will a cough test be used?
A cough test can be used to judge how to position the tape when a woman is awake during the operation. It has not been shown to improve the success of the operation and many surgeons prefer to use their own experience to position the tape.
How successful is the TVT operation?
The answer to this question is not that simple because there many different ways to measure success. Doctors cannot agree which is the best way to measure success but a good method is to ask a woman whether she is satisfied with the operation and whether she would recommend it to a friend. This is known as Patient Satisfaction and the best scientific study to date has shown a satisfaction rate of 85%, measured 6 months after surgery. However, the satisfaction rate will be lower in women who have had previous surgery for stress incontinence or who have other bladder problems such as an overactive bladder or difficulty emptying their bladder.
When will I go home after the operation?
Many women can go home on the day of the operation, especially if it is done in the morning. You will be able to go home when the nurses are happy that you are emptying your bladder well, any vaginal bleeding is not heavy, and any discomfort is controlled.
How will I be monitored after the operation?
You will receive general nursing care. The nurses will follow a protocol to determine whether you are emptying your bladder well enough to go home. If you are not, a catheter may be inserted into your bladder overnight and removed in the morning.
How will I feel after the operation?
The effects of the anaesthetic have usually worn off after 24 hours. You will have discomfort at the operation site and will need to take painkillers for several days. Paracetamol and/or Ibuprofen (Nurofen) are usually sufficient.
When can I return to my usual routine / work?
Most people need 2 weeks off work. If your job is strenuous, then you may need 4 weeks. You should avoid heavy lifting for 6 weeks.
When will I able to drive?
Most women stop driving for 1-2 weeks.
When can I play sport?
After 6 weeks.
When can I resume sexual intercourse?
After 6 weeks.
How long will the operation work for?
As the tape is permanent, it is likely that the operation will remain successful in the long term.
Is it a safe operation?
All operations have risks and the TVT operation is no exception. It is not the intention of this leaflet to make you afraid of surgery but it is important nowadays that you are fully informed about possible risks of operations. The following list is fairly complete but if you have anything that you wish explaining in greater detail, please speak to your doctor or nurse.
Risks from the anaesthetic. Modern general anaesthesia is fairly safe. If you have a spinal anaesthetic, the anaesthetist will explain about its risks.
Bleeding during / after the operation. Some vaginal bleeding is common afterwards and may take a day to settle. More significant bleeding is rare, affecting only about 1% of women and an operation through the abdomen to stop this bleeding may need to be performed in this situation.
Injury to the bladder. A needle is passed through the bladder wall in about 2% of operations. As long as this is recognised during the operation, this is not a serious problem as the bladder heals very well. A catheter would usually be left in the bladder for a few hours and you can normally go home the same day. On rare occasions a catheter may need to be left in for 1-2 weeks.
Bladder infection (cystitis). This is not uncommon and treatment with a course of antibiotics is usually effective. Rarely, women may get recurrent cystitis after the operation and the cause of this would need to be investigated.
Infection at the site of the incisions. Some soreness or discharge from the site of the incisions is fairly common and is often not due to an infection. It may need treatment with antibiotics.
Inability to empty the bladder properly (voiding difficulty). This is fairly common in the first few days after the operation but usually settles as any bruising and swelling around the tape subsides. Some women have a higher than usual risk of voiding difficulty eg. if they have had previous surgery for stress incontinence or if the urodynamics test shows that they do not empty their bladder quickly, completely or with good pressure before the operation. You will be told if this applies to you.
If the bladder is still not emptying properly after one week then it is possible to stretch the tape under a general anaesthetic and this is usually effective. Despite this, about 1-2% of women will have a long-term voiding difficulty and this can be troublesome, causing frequent cystitis and urine leakage. This situation can usually be improved by either dividing the tape or by passing a catheter into your own bladder 2-3 times per day.
Overactive bladder. Approximately 10% of women who have not been found to have an overactive bladder before the operation will develop it afterwards. This can cause urgency (a strong desire to empty the bladder) and urge incontinence (where leakage occurs before getting to the toilet). These symptoms can usually be improved with tablets.
Women who are known to have an overactive bladder before the operation may find that their urgency and urge incontinence get better or worse after surgery. Such women often need to take tablets for their overactive bladder after surgery.
Tape erosion. On rare occasions, a portion of the tape in the vagina may become exposed. This can be treated by a small operation to remove the visible portion tape. Very rarely the tape can erode into the bladder or urethra and the treatment of this problem is more complicated.
Chronic pain. A small proportion of women develop chronic pain in the region of the tape after surgery. In my personal experience, the incidence of troublesome chronic pain is around 1 in 200. I do not use the "transobturator" technique which is associated with a greater likelihood of pain. Women who have chronic pain in the pelvic region before surgery and those with chronic pain syndromes elsewhere are more likely to develop chronic pain after a TVT. These women should be very cautious before having a TVT.
Should you develop chronic pain then it can be treated with steroid injections, physiotherapy or removal of the tape. Although removal of small portions of the tape is quite easy, removal of the whole tape is very difficult and does not always result in complete relief of pain.
What will happen if I still leak urine after the operation?
Small amounts of urine leakage are not uncommon in the weeks after the operation, especially when lifting. This usually settles down, but if the leakage is heavier or more persistent, you may have a urinary infection or an overactive bladder. If a urine sample does not show any infection and an ultrasound scan shows that you are emptying your bladder completely, you may be given a course of tablets that treat overactive bladder. Alternatively, the urodynamics test may be repeated to get more information about the cause of any leakage. If the cause is still weakness at the bladder base, then treatment options include a Peri-urethral injection (see above) or repeating the TVT operation.
Where can I get further information?
Information of a general nature about continence issues can be found at:
www.incontact.org or Tel. 0870 770 3246
www.continence-foundation.org.uk or Tel. 0845 345 0165
Author – Robert MacDermott, Consultant Gynaecologist, April 2004