Comprehensive Urology

Diseases and Conditions

Procedures

Imaging Services

The daVinci System

Cystoscopy with Urethral Bulking Agent Injections

Definition

cystoscopy = placing a small telescope into the urethra and urinary bladder

urethra = tube from the bladder through which you urinate

bulking agent = a substance used to thicken or bulk-up tissue

There are different types of bulking agents currently in use. The type used in you will depend on your surgeon's preference as well as on your full understanding of the pros and cons of each type. If collagen (protein substance derived from an animal) is going to be used, you will undergo a small-dose test injection (under the skin on your arm) to ensure that you have no allergic reaction to the substance.

The indication for this procedure is to correct urinary incontinence (the involuntary loss of urine). The procedure is performed in both females and males. Although there are different types of urinary incontinence, urethral bulking injections are primarily used to correct Type III incontinence (commonly referred to as intrinsic sphincter deficiency or ISD). Essentially, this type of incontinence is when the inner walls of the urethra lack adequate closure (the "pressing-together" of the walls to obstruct the flow of urine). Patients with ISD typically leak urine easily and often continuously. In the most severe of circumstances, a patient would never actually feel the need to urinate because their bladder is always empty from the constant leakage. While there are many causes, most patients with ISD have a history of radiation treatments to the pelvis or a prior history of prior surgery to correct stress urinary incontinence.

Other risk factors include a post-menopausal state (loss of estrogen causes the tissue to atrophy or "thin-out") and perhaps a history of smoking. In men, there may have been a history of prostate surgery for either benign enlargement (BPH) or for cancer. Urethral collagen injections may also be appropriately used in patients with mixed incontinence (different types of incontinence contributing to the overall leakage) if it is thought that ISD is one of the contributing factors. In other words, if one aspect is corrected, the other types of incontinence may not be severe enough to cause significant leakage.

In almost every instance, a patient will have undergone a urodynamic test (special computerized test on the bladder and urethra) to determine the presence of ISD. By the time this injection procedure is recommended, medications or special exercise therapies may have been tried and have failed or been poorly tolerated. Urethral injections are very minimally invasive and can be done in a hospital or even office-procedure setting. The level of anesthesia used will depend on the physician's and patient's preferences. It can be done with just some local numbing medicine and/or with some sedation. If heavy sedation is going to be used, the procedure would have to be done in a hospital setting.

Preparation

If for some reason you are having your procedure done under sedation (as opposed to just local anesthesia), you will be asked not to eat or drink anything after midnight on the evening prior to your procedure. You may brush your teeth in the morning but not swallow the water.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

Urethral bulking injection(s) usually take less than half an hour depending on how many injections will be administered. Your position on the table will be lithotomy (flat on your back with your legs gently elevated in holsters called stirrups).

A cystoscope (small telescope used to look in the urethra) is placed into the urethra and the urethra and bladder are once again examined. The scope is then positioned at the point where the injection(s) is/are going to be administered. If local anesthesia is going to be used, a small needle will be used to inject numbing medicine into the areas that are going to receive the bulking agents. In some instance, the numbing medicine may be injected through the skin of the perineum (area outside of the urethra in front of the anal region) prior to putting the scope in.

The needle for the bulking agent injection(s) can be passed directly through the scope or alongside the scope depending on the surgeon's preference. The material is injected into the inner walls of the urethra under direct vision until the surgeon is satisfied with the degree of thickening of the wall. The location of each injection, the number of actual injections, and the total amount of bulking agent used will vary with each patient's anatomy and degree of incontinence.

Once the surgeon is satisfied that there is proper closure of the tissue, the procedure is over.

Post Procedure

After the procedure, you will be observed for a short time prior to going home. If you had sedation in the hospital, you may need to be observed for a longer period than if you only had local anesthesia.

We will let you go home when we believe you are ready from an anesthesia standpoint; or, we may observe you until we see you urinate on your own. Sometimes the bulking agent (possibly combined with some swelling from the scope itself) may cause urinary retention (the inability to urinate). If you are still under our supervision, we will catheterize you to empty your bladder. If you have already gone home, you will need to return to the office or hospital in which the procedure was performed. If you require catheterization, we will usually remove the catheter after your bladder is emptied so that you can try again.

*If you return to an emergency room with complaints of urinary retention, please do not allow a catheter to be placed until the emergency room physician speaks with your urologist first.

You have no real restrictions after the procedure. If you received sedation, you should stay at home and rest for the remainder of the day. Certainly, you should not drive or operate any machinery. You may shower, bathe, or swim. It may burn or sting the first few times that you urinate.

You may also see a blood-tinge or discoloration of your urine for 1-2 days. This is not uncommon. Your stream may be a bit slow or intermittent (start and stop) the first few times that you urinate as well.

Expectations of Outcome

Most patients are quite satisfied with the results of the procedure in that they are significantly or completely improved.

There are many possible outcomes, however, and they are as follows:

  • The first treatment may be a complete success in that you urinate well and do not leak at all.
  • It may be a partial success in that you urinate well but still leak a little.
  • It may be that you don't leak at all but have difficulty passing your urine (slow or obstructed stream).
  • It may not have worked at all in that your leakage is not improved.
  • It may be a complete or partial success for a while and then the leakage recurs in the future.

In other words, results are not always predictable. In cases of severe incontinence, more than one treatment is often necessary. Repeat future treatments may also be needed.

Permanent urinary retention is extremely rare.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:l Urinary Retention (Inability to Void): As previously mentioned, it is possible to have
too much closure and actually be unable to void. Usually this is corrected by one or a
few catheterizations. A permanent problem is extremely rare.

  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.

This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.

If you have high temperatures or any symptoms of severe illness (fevers, shaking chills, weakness or dizziness, nauseaand vomiting, confusion) let your doctor know immediately and proceed to the nearest emergency room.

  • Bleeding: There is usually a tiny degree of blood in the urine for a day or so. Prolonged bleeding is very rare and almost always responds to observation alone.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.

Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional.

While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

Delta Medix, P.C.