A person’s body is not held together by skin. The human body depends on supporting tissues called Fascia. Fascia is in the back, in the abdominal wall, between the organs, and supporting tissues are interconnected. Fascia is the scaffolding that holds you together. Fascia works together with skeleton, muscles, ligaments. For example, an abdominal wall hernia forms when there is a defect in the fascia.
There is an interconnecting system of Pelvic Supports (see more information on Pelvic Pain). Pelvic Support Defects are when supports are broken and tissues start to fall down, called Pelvic Prolapse. With prolapse, the bladder, rectum, cervix-uterus, and/or upper vagina can drop down. All areas can be affected, or only specific areas can be affected, referred to as Site-Specific Defects.
There is a shelf of supporting tissue, from side to side, between the bladder and vagina, from pubis to cervix. This is the Pubocervical Fascia, and this holds the urethra, bladder, and anterior vaginal wall in place. There is a shelf of supporting tissue, from side to side, between the rectum and vagina, from perineum to cervix. This is the Rectovaginal Septum, and this holds the rectum and posterior vaginal wall in place. There are other supporting tissues that hold the vaginal apex up and in place.
Coughing, laughing, sneezing, lifting, and heavy exertion all have in common an Increase in Abdominal Pressure. When the pressure in the abdomen goes up, this pressure is equally and instantaneously felt by all abdominal organs. When pelvic supports are intact, the bladder, bladder neck (where urine funnels to go into the urethra), and the proximal urethra (first part of the tube through which urine leaves the body), are all intra-abdominal organs. When pelvic supports are intact and a person coughs or sneezes, and pressure in the abdomen rises, and the elevated pressure is felt in the bladder, bladder, neck, and proximal urethra. All pressures are elevated the same, there is no gradient, and no leakage of urine.
When pelvic supports have been weakened, for example by childbirth, there are Pelvic Support Defects, and the bladder and anterior vaginal wall will start to fall down. While some individuals have a dropped bladder, other individuals the bladder is sitting in fairly normal position, but the bladder will bounce downward whenever there is an increase in abdominal pressure. At the moment of a cough or sneeze, the bladder and bladder neck drop down, and at that moment the bladder is still mostly intra-abdominal, but the bladder neck and proximal urethra are Not intra-abdominal. Therefore, at the moment of a cough and sneeze, in a person with Pelvic Prolapse, the bladder is still mostly intra-abdominal, but the bladder neck and proximal urethra are not intra-abdominal. Pressure in the abdomen and bladder are elevated, but the bladder neck and urethra remain at lower pressure, Urine follows the Gradient from high to low pressure, and urine leakage occurs. This is known as Stress Incontinence, where the “stress” is the increased intra-abdominal pressure.
WHAT IS THE BURCH PROCEDURE?
The Burch procedure is simply a hammock to support the bladder neck and urethra so that when there is an increase in intra-abdominal pressure, the bladder, bladder neck, and urethra are supported so they do not bounce downward and they remain intra-abdominal. This surgery can be done by open laparotomy or laparoscopy. I prefer laparoscopy for better visualization, less blood loss, less pain and faster recovery for the patient. Laparoscopy is preformed. The space between the bladder and pubic bone is opened, 4 permanent sutures are placed, 2 sutures on each side, one alongside the bladder neck and one alongside the middle of the urethra. The sutures are purposely placed loosely so there is no difficulty with urination, since the intention is to just support the tissues and keep the bladder neck and urethra from bouncing down during a cough, sneeze, or any other increase in intra-abdominal pressure.
With the Laparoscopic Burch colpo-suspension, no dissection is done under the urethra, so there is less risk of hurting the blood supply to the urethra. With no vaginal incision and no swelling under the urethra, the catheter comes out the morning after surgery, which is done Outpatient overnight.