Female Urinary and Bowel Incontinence

How to Choose a Doctor and Hospital for Your Treatment

Hospitals and doctors are not all alike…

…they vary in quality due to differences in their training, experience and service. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.

A surgeon who performs a complex procedure often, for example, has better success with it than a surgeon who does the same procedure only occasionally. The complication rate, death rate and effectiveness of the same procedure may be many times higher at one hospital than another.

Clearly, the doctor and hospital that you choose have a direct impact on how well you do, especially when you need treatment for a condition as serious as incontinence.

Urinary incontinence — the loss of bladder control — affects an estimated 15 to 20 million adults, and the vast majority are women. Despite its prevalence, many women do not seek treatment, either because they are embarrassed to ask for help or just don’t realize that it can be effectively treated. Many women resort to altering their social and physical activities, even their employment, to cope with the problem.

Bowel or fecal incontinence — the loss of bowel control — affects up to 10 percent of the population, and the majority are women. Like those who suffer from urinary incontinence, many people with bowel incontinence often do not seek treatment.

Although these are sobering statistics, the total picture is far more positive. With appropriate treatment, most patients with urinary or bowel incontinence can be cured or significantly improved and can return to a better quality of life.

You may be reading this brochure because you suspect you or a family member may have incontinence. Or, you have been diagnosed with it and are looking for guidance on how to get the most appropriate treatment. Selecting a doctor and hospital for treatment of incontinence involves making some difficult and important decisions. Carefully consider where to go and what physicians and surgeons are the most qualified to treat incontinence. Doing comparisons of hospitals and doctors early will better prepare you to make your decision.

Treatment of incontinence can often involve more than one type of medical specialty, such as urology, gynecology and colorectal surgery, as well as physical therapy. And, there are many different and new types of surgical treatments. For these reasons, finding a medical center with a multidisciplinary team of physicians who treat incontinence is important. In a multidisciplinary environment, team members consult, discuss and agree upon the diagnosis, and together determine the most appropriate treatment for each patient.



A Step-by-Step Guide

This guide helps you choose a doctor and hospital by:

• describing the different types of incontinence;

• explaining how incontinence is diagnosed;

• discussing how incontinence is treated, including nonsurgical therapies and surgical procedures;

• explaining six points that indicate quality; and

• providing questions and answers from the Cleveland Clinic that you can use to compare hospitals and doctors.


How Do You Judge Quality?

Most of us do more research when we buy a car or major household appliance than when we choose a doctor or hospital. That may be because we don’t know what questions to ask or on what to base our evaluation.

Quality of care can be measured in many different ways, and no universal agreement exists on which way should be used. At The Cleveland Clinic Foundation, however, we believe that you can use the following six points, or quality indicators, to compare health care providers:

• Credentials

• Experience

• Range of services

• Participation in research and education

• Patient satisfaction

• Outcome

Choosing a doctor or hospital is often influenced by values. You may want to go to a hospital that is close to home. You may want a hospital with a specific religious affiliation. But when you need specialized care for incontinence, you should also consider a doctor’s qualifications and credentials, and a hospital’s experience and outcome record. These quality indicators will help you make that kind of evaluation.


Female Incontinence

Urinary incontinence is the involuntary loss of urine that occurs frequently enough to become a problem. Although it is more common among older women, it is not an inevitable part of aging and can occur at any age.

Urinary incontinence is caused by various problems with the bladder, where urine is stored, and the urethra, the canal that carries urine from the bladder to outside the body. Problems with the bladder include weakness of the muscles and hypersensitive or overactive bladder muscles. Urethral problems include weakness of the urethral sphincter (band of muscles that close off the bladder opening to the urethra) or a blocked urethra. Sometimes, urinary incontinence is temporary, appearing as a side effect to a medication or a symptom of an underlying condition, such as infection or hormonal imbalance. This temporary condition will disappear once the causal condition is identified and treated.

There are three main types of urinary incontinence.

Stress incontinence, the most common type, is often caused by poor bladder support, a damaged sphincter muscle or a problem within the urethra. Stress incontinence causes urine to leak out with activities, such as sneezing, laughing and coughing, or with any effort that increases pressure on the bladder, such as bending or exercise.

Urge incontinence occurs when an "overactive" bladder contracts unexpectedly. It usually comes with little warning and causes an abrupt and uncontrollable need to urinate.

Overflow incontinence is caused by a weakened bladder or a blocked urethra, making it impossible for the bladder to empty completely. This eventually causes the urine to overflow and leak out. Diabetes, heavy alcohol use and certain neurologic problems can cause overflow incontinence.

Evaluation and Diagnosis

A careful and thorough physical examination by an experienced physician can determine the type of incontinence. This includes the patient’s history, urinalysis and measurement of the volume of urine remaining after trying to fully empty the bladder. Further procedures or tests that may be necessary to confirm a diagnosis include:

• Ultrasound, which uses sound waves to produce shadow-like images of the bladder

• Cystoscopy, which uses a small viewing telescope through the urethra to visually check for bladder abnormalities

• Stress test, which checks for leakage from the bladder on exertion

• Video urodynamic testing, which graphically and anatomically shows how the bladder works, and determines how well it fills and empties urine. This advanced technique is available at only a few centers nationwide.


Incontinence and Prolapse

Both urinary and bowel incontinence can frequently coexist with prolapse.

Uterine or vaginal prolapse occurs when the uterus or pelvic organs drop or become displaced because of weakened pelvic muscles. Rectal prolapse occurs when the mucous membrane of the lower portion of the rectum protrudes through the opening of the anus. Both conditions can be effectively treated with surgery.


Incontinence can almost always be treated successfully, and treatment does not always mean surgery. Depending on the severity and type of incontinence, treatment options can range from conservative, nonsurgical treatments to specialized surgery. Matching the treatment to the underlying cause of incontinence is the key to a successful outcome.

Nonsurgical therapy. Some women may be poor surgical candidates or may not be affected enough to require surgery. Nonsurgical treatment options include physical therapy and exercise, biofeedback, behavioral therapy, medication and bladder support devices called pessaries. Exercises, such as the Kegel exercise, can strengthen pelvic and urethral muscles that help control urinary flow. Biofeedback teaches ways to control the bladder and sphincter muscles by recording muscle action onto a screen so that you can see and, therefore, learn to strengthen these muscles. Behavioral therapy teaches ways to retrain the bladder, such as being on a routine urinating schedule. The type of medication used depends on the problem. Some drugs act as bladder relaxants, while others work to strengthen muscle contraction. Pessaries are temporary devices that are placed in the vagina to reduce leakage and must be changed often. Pessaries can relieve symptoms, but they do not cure incontinence.

Collagen implant therapy is a newer, highly effective technique performed on an outpatient basis. It helps many women with stress incontinence avoid major surgery. Collagen is injected into the urethral tissues and acts as a bulking agent by bringing the walls of the urethra closer together or by sealing off the base of the bladder.

Surgical options. When surgery is recommended, be sure to find out your full range of options. There are several different surgical procedures for treating incontinence, as well as several variations and new modifications. In general, surgery is performed to correct poor bladder support and/or to help the urethra close properly. Surgery can be performed using vaginal or abdominal procedures. The type of procedure performed and the approach used will depend upon the patient’s specific condition and the physician’s expertise.

Minimally invasive surgery is a new approach being used to perform a growing number of incontinence surgeries that once required traditional open surgery. Much smaller incisions are used, so patients have less postoperative pain, less scarring, a shorter hospital stay and a quicker return to normal activities. Laparoscopic bladder neck suspension, sling procedures and percutaneous bladder neck stabilization (PBNS) are types of less invasive or minimally invasive surgery. Newer, more technically complex surgeries require an experienced team of physicians and, therefore, are performed at few medical centers.

A more complex urinary incontinence procedure, cystoplasty, is reserved for patients with other serious disorders, including multiple sclerosis or spinal cord injuries. It involves enlarging the bladder with the patient’s intestine or removing some of the bladder muscle.


Minimally Invasive Procedures

Laparoscopic bladder neck suspension: a thin telescope-like instrument, called a laparoscope, is inserted through a small abdominal incision, instead of a larger incision needed for traditional surgery. Tiny instruments are used to elevate the upper vaginal wall to raise and stabilize the bladder neck.

Sling procedure: part of the fascia (the strong tissue that covers the muscles) or some kind of synthetic material is placed underneath the urethra, like a hammock, to support and compress it.

Percutaneous bladder neck stabilization: a modification to the sling procedure in which the suspension sutures are anchored in the pubic bone for stability.

Laparoscopic rectopexy: treats rectal prolapse by elevating the rectum and securing it to the lower part of the back bone.

Bowel incontinence can range from occasional leakage to complete loss of bowel control. Normal control of bowel movements depends on proper functioning of the colon, rectum, anal muscles and entire nervous system. It can result from damage or injury to the anal sphincter muscles or the nerves of these muscles. The number-one cause of bowel incontinence in otherwise healthy women is injury to the anal muscles or nerves during childbirth. Most of these women recover bowel control, but a small percentage will develop fecal incontinence. Certain medications, trauma, improper diet, diabetes, stroke, chronic constipation and other factors can contribute to loss of bowel control.

There are two main types of bowel incontinence. Passive fecal incontinence is related to a poorly functioning sphincter muscle, and the person is unaware that stool is being passed. Urge incontinence is often caused by disease in the rectum, and results in involuntary passage of stool through normal sphincter muscles.

Evaluation and Diagnosis

Thorough evaluation and accurate diagnosis is critical to receiving the most appropriate treatment. Advanced, sophisticated diagnostic techniques have led to improved treatment. Endosonography, also called rectal ultrasound, is a new diagnostic tool that makes it possible to visualize the sphincter muscles by using sound waves to produce images and precisely identify abnormalities. Other diagnostic procedures include flexible sigmoidoscopy to view the lining of the lower gastrointestinal tract, manometry to measure the pressure of the anal muscles and nerve studies to check for nerve damage.


Nonsurgical therapy. Medication, diet and exercise are often successful in helping patients regain bowel control and avoid surgery. Patients who experience bowel incontinence despite medical management will most likely require surgery to regain control.

Surgical options. Rectal sphincter repair, called sphincteroplasty, is the most common procedure used to correct a defect in the sphincter muscles. An innovative procedure, called gluteal muscle transposition, may be an option for the very small percentage of patients whose condition cannot be successfully treated with sphincteroplasty. It involves using the gluteal (buttock) muscles to encircle the anal canal. Until very recently, the only alternative for such patients was a colostomy: a surgically created opening in the abdomen wall through which the colon passes, and where a bag is fitted to collect stool. Gluteal muscle transposition is performed at only a few large medical centers nationwide.


Where Do You Begin?

Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, it may not be possible to get complete information for each of these quality indicators. But the willingness of providers to give you as much information as possible is a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capabilities.

If you are told by your family doctor that you have incontinence, ask your doctor for a referral to a physician who specializes in treating incontinence. Get the names of several doctors and hospitals that offer the newest, most effective treatments and have the most experience in treating incontinence. Ask the questions we suggest on the following pages. Make comparisons. Then make your decision. Be an informed consumer for yourself and your family.


How to Use Quality Indicators

How can you use these indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to a report, "The Quality of Medical Care: Information for Consumers," produced by the U.S. Congress, Office of Technical Assessment.

According to the report, patients about to have surgery can be confident if the hospital performs a high number of surgeries, has a low mortality (death) rate, and if the surgeon has extensive training and experience in the procedure.

On the other hand, the report states "...if a hospital has a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals require longer travel."


1. Credentials

Do the doctor and hospital measure up?


Board certification, or the international equivalent, is a sign that doctors are highly trained in their fields. Doctors who specialize should be board certified in the specialty in which they are practicing. Each specialty has a national board that is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialties have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty and have passed a difficult examination in their specialty area. Some excellent doctors are not board certified. Board certification, however, is generally a good indicator of competence and experience.


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps or loses accreditation based on meeting certain criteria for staffing, equipment and facility safety requirements. Although accreditation is voluntary, most hospitals go through the process. If the hospital that you are considering is not accredited, it is important to know why.

Some of the best hospitals are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital’s reputation is widely available through the mass media, listings, the government, consumer groups, books and magazines such as U.S. News & World Report.


For information about a hospital’s status, call the Joint Commission on Accreditation of Healthcare Organizations at 630/916-5800 or visit their website at http://www.jcaho.org

Are the physicians who treat incontinence board certified in their specialty?

Yes. All Cleveland Clinic physicians who treat urinary and bowel incontinence are board certified* in their specialty.

Is the hospital accredited by the JCAHO?


Have the doctors been recognized for excellence?

Yes. Eight Cleveland Clinic urologic surgeons, two gynecologists and three colorectal surgeons are recognized in the book "The Best Doctors in America: Midwest Edition" (1996-1997). The Midwest edition is a subset of the ratings listing in "The Best Doctors in America." All Cleveland Clinic physicians in these departments work together to improve treatment through research and clinical practice.

Many Cleveland Clinic physicians and surgeons who treat incontinence serve as officers or members of professional organizations related to their specialty. Physicians in the Department of Urology are represented in every major urologic society, and several are active members of the American Board of Urology. Physicians in the Department of Gynecology and Obstetrics are represented in the American Urogynecology Society and the Society of Gynecologic Surgeons, among others. Physicians in the Department of Colorectal Surgery are members of the American Society of Colon and Rectal Surgeons and the American College of Surgeons.

Has the hospital been positively and consistently recognized for medical excellence and leadership?

Yes. The Cleveland Clinic is consistently rated among the top medical centers in the country. Some of the recognition that the Clinic has received is noted in the box at left.

*Board certification or its international equivalent became a requirement at the Cleveland Clinic in 1989 for doctors being appointed to the medical full staff.


Among America’s Best

The Cleveland Clinic has been named one of America’s ten best hospitals by U.S. News & World Report, every year since 1990.

The specialties of urology; gynecology; and colorectal surgery (recognized within the specialty of gastroenterology by U.S. News) at the Clinic have consistently been ranked among the top 10 in their field in the country. All of these specialties also are consistently ranked the best in Ohio.

The Cleveland Clinic was named among the "Top 100" best-performing hospitals for the last three years in a study published by Modern Healthcare magazine.


2. Experience

Does practice make perfect?

In the case of specialized medical and surgical care for incontinence, the more experience the doctors and hospital have, the better the results usually will be. Experienced physicians who have handled many cases are prepared for the most difficult situations and complications that may arise.

Physicians who dedicate much of their practice to incontinence have the experience and professional judgement needed to make an accurate diagnosis, appropriate treatment recommendations and careful decisions. An experienced surgeon who performs many procedures and treats many patients with incontinence generally has a higher level of surgical skill than a physician who performs incontinence surgery occasionally. This is particularly important for incontinence problems requiring more complex procedures.

Physicians who spend much of their time treating incontinence also pursue innovative therapies that advance the treatment of incontinence. Knowing whether the physician you are considering for your care has this type of expertise and surgical experience is vital to getting the most appropriate care.

How many women are seen for urinary incontinence at this facility each year?

More than 1,100 women are seen for urinary incontinence as outpatients in the Women’s Center for Pelvic Disorders at the Cleveland Clinic each year.

How many surgeries for urinary incontinence are performed at the hospital each year?

More than 400 surgeries for urinary incontinence are performed at the Cleveland Clinic each year.

How many collagen implants for urinary incontinence are performed at this facility?

More than 280 collagen implant procedures for stress urinary incontinence are performed at the Cleveland Clinic each year.

How many uterine and vaginal prolapse surgeries are performed at this facility?

More than 300 uterine and vaginal prolapse surgeries are performed at the Cleveland Clinic each year.

How many outpatients are seen for bowel incontinence at this facility each year?

Approximately 200 outpatients are seen for bowel incontinence in the Women’s Center for Pelvic Disorders at the Cleveland Clinic each year.

How many surgeries for bowel incontinence are performed at this facility each year?

More than 47 surgeries for bowel incontinence are performed at the Cleveland Clinic each year.

In addition, nine gluteal muscle transposition surgeries were done within an 18-month period. This new procedure can offer some patients with complicated cases of bowel incontinence an alternative to colostomy.

How many surgeries for rectal prolapse are performed at this facility each year?

Approximately 20 surgeries for rectal prolapse are performed at the Cleveland Clinic each year.


In a study of 243 patients who underwent both prolapse and urinary incontinence surgery (vaginal suspension and pelvic reconstruction) from 1978 to 1990 at the Cleveland Clinic, only 4 percent underwent repeat procedures for prolapse or incontinence.


3.Range of Services

What services are available?

Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur. If complications arise, you want the best care available, and you want it immediately.

Range of specialty departments

There are several types and causes of incontinence. This means treatment may involve care from different types of specialty departments, including urology, gynecology, colorectal surgery and physical therapy. Having a variety of specialists available is also important because incontinence can overlap or coexist with other problems.
Therefore, direct access to a full range of specialty and subspecialty departments is critical when seeking treatment for incontinence.

Range of diagnostic and treatment options

Choosing a facility that can treat incontinence in a variety of ways allows you to get the most effective, appropriate treatment available. With incontinence, this means the availability of the latest standard treatments as well as promising new ones. Many surgeries for incontinence can now be performed using minimally invasive techniques, allowing patients a shorter hospital stay and quicker return to normal activities.

Ideally, the physician you choose should dedicate much of his or her practice to treating incontinence, thus ensuring you experience and availability of all treatment options.

Is help available from a full range of specialty departments?

Yes. 850 physicians and scientists at the Cleveland Clinic provide care and conduct research in more than 100 specialties and subspecialties, including urology, gynecology and colorectal surgery. All specialties are present in one facility, so prompt consultation, diagnosis and treatment are readily available.

Does the hospital offer a variety of options for diagnosing and treating incontinence?

The Cleveland Clinic offers the complete range of options for the diagnosis and treatment of incontinence, including:


• Urinalysis

• Post-void residual urine measurement

• Voiding cystourethrogram

• Ultrasound

• Cystoscopy

• Stress test

• Video urodynamic testing

• Manometry and anal physiology testing

• Endosonography

• Flexible sigmoidoscopy


• Collagen implants

• Laparoscopic bladder neck suspension

• Sling procedures, including innovative treatment with bone anchoring and percutaneous bladder neck stabilization

• Physical therapy, including biofeedback

• Augmentation cystoplasty

• Sphincteroplasty

• Gluteal muscle transposition surgery

• Pessaries (bladder neck support devices), including a new FDA-approved prosthesis

• Laparoscopic and abdominal surgery for rectal prolapse


Women’s Center for Pelvic Disorders

The Cleveland Clinic Women’s Center for Pelvic Disorders treats the complete patient. This is important because incontinence does not exist in isolation, but often involves other factors that may require care from more than one type of specialist. The center’s multispecialty team approach combines the knowledge and expertise of different specialists to ensure patients the utmost in diagnostic and treatment capabilities, including participation in important clinical trials.

Physicians at the center are dedicated to treating incontinence and related disorders. They have expertise in the very latest treatments — some still investigational — and have contributed to advancing many existing procedures.


4. Participation in Research and Education

What type of hospital is it?

There are many advantages to selecting a hospital that combines patient care with research and education.

Ideally, the individuals engaged in patient care, research and teaching are organized around a given disease or class of patients, facilitating the sharing of knowledge, research and clinical findings. This approach results in the most rapid transfer of basic scientific knowledge from the laboratory to care delivered at the patient’s bedside.

Those individuals on the staff of such a hospital are exposed to an important interchange of ideas. They are also exposed to the newest treatment and forms of technology. At teaching hospitals, physicians are available 24 hours a day.

There may be other advantages to choosing a teaching hospital. Major teaching hospitals in the Cleveland area had lower mortality rates and shorter hospital stays than other types of hospitals, according to a study published in the August 13, 1997 issue of the Journal of the American Medical Association.

Choosing a large, multispecialty center to diagnose and treat incontinence can improve your quality of life. For example, these centers are the first to offer the latest techniques and be involved in important clinical trials. Minimally invasive techniques, such as laparoscopy, are less traumatic, allowing patients to heal and return to their daily activities in less time than traditional open surgeries.

Is the hospital associated with a teaching program?

Yes. Incorporated in 1935, The Cleveland Clinic Educational Foundation sponsors one of the nation’s largest physician post-graduate training programs and is affiliated with The Ohio State University College of Medicine.

Does the hospital have advanced training programs in specialty areas that treat incontinence?

Yes. For physicians who complete their residencies, the Cleveland Clinic offers fully accredited advanced fellowship training in incontinence and related disorders in the departments of Gynecology and Obstetrics (a three-year fellowship in urogynecology/reconstructive pelvic surgery, one of only six such fellowships in the country); Urology; and Colorectal Surgery.

The Cleveland Clinic recently initiated fellowships in minimally invasive surgery, which includes laparoscopic surgery for urinary and bowel incontinence.

Does the hospital conduct basic research and clinical trials related to incontinence?

The Department of Gynecology and Obstetrics is conducting a clinical trial comparing three different surgical procedures for cystocele repair, a condition that commonly coexists with stress incontinence. This study is funded through a research award from the American College of Obstetricians and Gynecologists. The department is conducting seven other studies for incontinence.

The Department of Urology is participating in 55 clinical research studies and 20 laboratory projects, eight of which target urinary incontinence. Cleveland Clinic urologists were pioneers in developing collagen implant therapy as an alternative to major surgery for certain types of urinary incontinence.

The Department of Colorectal Surgery is currently participating in a number of studies, several of which are related to bowel incontinence. One recent study aims at demonstrating and defining the forms of anal sphincter and pelvic floor dysfunctions associated with childbirth for earlier and more successful intervention.


Research into Quality of Life Outcomes

The Cleveland Clinic is beginning to measure and determine the health status and quality of life patients experience following their treatment here. Returning to work, being able to perform the usual activities of daily living and being free from pain are some of these important indicators of successful care.

So far, the study has asked approximately 250 patients with a variety of medical conditions to report about their health status before, during and after treatment. More than 80% responded. All of those who responded thought their ability to function and quality of life generally improved following their care at the Cleveland Clinic. Approximately 70% experienced substantial improvement in physical function, pain relief and energy.


5. Patient Satisfaction

Is everybody happy?

If you ask one person about his or her experience with a doctor or hospital, you get one person’s point of view. Patient satisfaction surveys allow you to judge quality based on the experience of many previous patients. This provides you with a more objective measure to use.

Most hospitals routinely use surveys to learn if patients are satisfied with their medical experiences. The hospital can use these results to improve its services.

Patient satisfaction often reflects the personal side of care. Surveys ask questions such as, How willing are the doctors and nurses to listen? Do they answer questions and explain treatments? How much time does the doctor spend with the patient? Is the hospital clean? Is the food good?

Patient satisfaction information can predict what your experience in a particular hospital is likely to be.

How satisfied are outpatients with their experience at this facility?

96% of outpatients seen in the departments of Urology, Gynecology and Colorectal Surgery said they were either very satisfied or satisfied with their experiences; 98% say they would return; and 98% say they would recommend the Cleveland Clinic to family or friends.

How satisfied are hospitalized patients with their experience at this facility?

89% of patients who are hospitalized at the Cleveland Clinic for treatment of urologic, gynecologic and colorectal problems are either very satisfied or satisfied with their experience; 93% said they would return; and 97% would recommend the Cleveland Clinic to family or friends.

Is there a program to help patients and their families with difficulties that may arise during a hospital stay?

Cleveland Clinic patients may call an ombudsman, another name for a patient-relations representative, if they have concerns about their care.

Patients in the Cleveland Clinic hospital may dial a help line from their hospital rooms if they have any problems, questions, suggestions or concerns related to service. Representatives from Cleveland Clinic’s Patient Access Services respond to all calls to help patients resolve their difficulties.


6. Outcome Indicators

What is the prognosis?

Many outcome indicators can be used to measure the success of treatment and the risks associated with it. The appropriate indicators to use depend on the treatment or procedure. All potential risks and complications associated with a procedure cannot be eliminated. However, your risk can be reduced by choosing a hospital with a low complication rate and high success rate. These rates at a hospital typically correlate with the volume of procedures performed.

When comparing hospitals and providers, be sure you’re comparing apples with apples. Sometimes, cure or success rates at one hospital that appear better than that of another institution can be misleading. This is especially true when a hospital that performs complex procedures on high-risk patients is compared with hospitals that perform more routine procedures on patients not at high risk. Surgical outcomes at a more specialized hospital will not accurately reflect how well it compares to others. Because of the level of expertise required, few centers in the country offer the more complex, sophisticated procedures required to treat high-risk patients with complicated cases of urinary or bowel incontinence.

Quality of Life

The major goal of treatment is to control incontinence so that a person achieves a normal or close-to-normal quality of life. This means not missing out on social or physical activities for fear of losing continence control. Even though one person’s definition of quality of life differs from another, making it difficult to measure, it’s important to discuss this with your doctor. Ask about the quality of life you can expect after surgery.

Urinary and bowel incontinence can be a serious disorder and many personal factors can contribute to your outcome, including your age, type of incontinence, general health and the stage at which the disease is diagnosed.

Taking everything into consideration, you can help ensure your best outcome by making sure the hospital and doctor you are considering provide the most up-to-date, comprehensive treatment for incontinence.

On the following page are success rates for surgical treatment and length of stay information for patients treated at the Cleveland Clinic for urinary and bowel incontinence.

What is the success rate for patients undergoing surgery for urinary incontinence at this facility?

The success rate for patients undergoing surgery, including minimally invasive surgery and open surgery, for urinary incontinence at the Cleveland Clinic is 85% to 90%.

What is the success rate for patients treated with collagen therapy at this facility?

The success rate for patients treated with collagen injection therapy for urinary incontinence at the Cleveland Clinic has been 87% since this therapy was introduced in 1993. The Clinic pioneered collagen therapy for urinary incontinence and has established the nationwide standard for its success rates.

What is the success rate for patients undergoing percutaneous bladder neck stabilization surgery at this facility?

The success rate for percutaneous bladder neck stabilization surgery at the Cleveland Clinic is 94% at 18 months after the procedure. (See box at left.)

What is the average length of stay for patients having minimally invasive surgery?

The average length of stay for patients having minimally invasive surgery is less than 10 hours, compared to two or more days for open surgery.

What is the improvement rate for patients undergoing surgery for bowel incontinence at this facility?

72% of patients undergoing sphincteroplasty at the Cleveland Clinic achieved moderate to significant improvement. 87% of patients undergoing gluteal muscle transpostion surgery achieved improvement.

It’s important to note that these rates are primarily based on high-risk patients who have undergone complex procedures. Many of these patients were unable to be treated at other less specialized centers, or their only alternative was a colostomy.


PBNS Improves Outcomes

Percutaneous bladder neck stabilization (PBNS) is a new technique that combines aspects of several surgical procedures used to treat stress incontinence. Cleveland Clinic urological surgeons have developed this minimally invasive surgical technique with a demonstrated cure rate of 94% at 18 months; other procedures are associated with 12- to 24-month continence rates of 80% to 90%. PBNS can be performed on an outpatient basis under local anesthesia or as an inpatient procedure with a one-night stay. In nearly all cases, women can return to office or nonphysical work within one week.


Pioneering Work in Incontinence

Medical innovations have earned the Cleveland Clinic a national and international reputation for excellence in both patient care and advancement of knowledge and treatment of urologic, gynecologic and colorectal disorders. Contributions in these areas include:


• Pioneered the use of collagen injection therapy for intrinsic sphincter deficiency, a type of stress incontinence, as an effective alternative to surgery

• Advanced minimally invasive techniques, including laparoscopy, enabling more patients a less invasive alternative to open abdominal surgery

• Pioneered bone anchoring, a technique that secures suspension sutures in the pubic bone to decrease the risk of long-term suture pull-through

• Pioneered percutaneous bladder neck stabilization (see pages 7 and 21)

• Advanced urinary diversion techniques that avoid the need for an external pouch in patients whose bladder must be removed

• Performing surgery to correct severe urinary incontinence through the use of prostheses

• Developing catheters with a valve that will eliminate the need for a bag after urinary incontinence surgery

• Investigating management with electrical stimulation for both bladder and urethral dysfunctions using implantable (spinal neuroprostheses) and nonimplantable devices


• Pioneered laparoscopic bowel surgery, including laparoscopic rectopexy, a procedure that treats rectal prolapse (see page 7)

• Pioneered use of rectal ultrasound to diagnose sphincter abnormalities

• Refined manometry, a technique to measure muscle function of the rectum

• At the forefront of developing procedures to reduce the likelihood of the need for a colostomy


For an Appointment or More Information

To make an appointment with a Cleveland Clinic physician specializing in urinary or bowel incontinence, please call the Women’s Center for Pelvic Disorders at 216/445-8774 or 800/223-2273, ext. 58774.

If you would like to receive any other guides in our series "How to Choose a Doctor and Hospital for Your Treatment," please call 216/444-8919 or 800/545-7718, or visit the Cleveland Clinic online at http://www.ccf.org


Cleveland Clinic Florida

Cleveland Clinic Florida provides state-of-the-art treatment for urinary and bowel incontinence with the support of The Cleveland Clinic Foundation.

For more information or to make an appointment at Cleveland Clinic Florida, call 800/359-5101.