This is a question often asked by my patients. It is a legitimate question but the answer is often difficult to provide.
Fortunately, incontinence is not a life-threatening issue. This is not to say that it does not cause a large amount of suffering. Incontinence can be debilitating for severely affected patients. But the level of suffering or distress is a matter of personal tolerance. Some patients will have years of severe leakage requiring adult diapers considering the incontinence to be a minor bother. Other patients will become distraught over one or two minor leakage episodes.
So when is surgery appropriate? My first question to a patient is regarding level of bother. If the leakage is causing a patient to alter their lifestyle and is becoming a focus of their attention surgery certainly seems reasonable. If a patient has ceased activities they enjoy, like tennis or dancing, for fear of leakage this certainly argues for intervention. The second question is whether the patient is willing to accept the possible risks (although minimal) for complications with the incontinence surgery. Most patients who answer affirmatively to both questions often go on for surgery.
But what if the leakage is minor and the patient is having other surgery in the vagina? Should a patient undergo surgery in this setting? Again the patient has to understand both sides of the decision to accept or decline surgery. Certainly incontinence surgery is not indicated for every woman undergoing hysterectomy but if there is a small amount of leakage present prior to surgery it is unlikely that this will improve without incontinence surgery. If the patient understands that another surgical procedure and another anesthetic would be necessary in the future if surgery is declined, the patient should hold on surgery if the bother is insignificant. If the patient favors moving to surgery for incontinence in this setting, the risks of surgery should be considered for a problem that causes little bother.
The decision a patient makes can be further complicated by the surgery offered. If the surgical technique is minimally invasive and requires little recuperative time it is easier to recommend in patients with minimal symptoms. Certainly if incontinence surgery recovery is worse that the problem it attempting to correct, the decision about surgery is easy to make. I have chosen the surgical procedures I use for stress incontinence based on efficacy, safety and ease of recovery. Consequentially, I can usually recommend these procedures to patients who have minimal symptoms and are undergoing other vaginal procedures.
As surgeons, we function as counselors, advisors and also technicians for our chosen craft. We can provide the information and assess whether surgery is appropriate. In the final analysis, however, the patient has the only vote about whether surgery is right for them.