TOT is used to treat urinary stress incontinence or USI (see Urinary Incontinence in Patient Health Information). USI is the uncontrollable loss of urine when you cough, sneeze, jump or run. The TOT is especially suited to treat a specific type of USI called intrinsic sphincter deficiency or ISD. ISD is a result of an anatomic problem where the urethra comes into the bladder. The urethra is the tube that leads out from the bladder. Normally the urethra is shaped like a tube or pipe. Patients with ISD have a urethra shaped like a funnel. Again, the TOT is ideally suited for this situation.

There are other types of urine loss that are not USI and will not improve if treated with a surgical bladder-neck suspension. One of the types of incontinence that falls into this category includes urge incontinence or UI. UI is loss of urine when you feel the need to urinate but cannot make it to the bathroom. It is possible to have more than one type of urinary incontinence at the same time. If you have both types of urinary incontinence, both urge and stress, you may benefit from surgical repair. But, you must be aware the urge-incontinence component of your problem will not be improved by the surgery and may possibly be made worse.

Factors that increase the likelihood of developing urinary stress incontinence include:

• previous pregnancy with vaginal delivery
• obesity
• chronic coughing
• heavy lifting
• frequent straining
• increased urine output with excess fluid intake or taking "water pills"
• primary urinary tract problems including infection and tumor (bladder tumors are unusual)
• certain medications you may be taking
• estrogen (hormonal) deficiency
• immobility such as with arthritis

The TOT suburethral sling may be performed under spinal, epidural, general, or sometimes under local anesthesia. You will be placed in a position similar to that for a pelvic examination, and a small (3/4") incision is made in the anterior vaginal wall just below the mid-urethra (the urethra is the tube leading out from the bladder). Two additional small (1/4") incisions are made lateral to the clitoral hood on either side where your legs attach to your bottom. A special tape (prolene mesh) is looped under the urethra. The two ends of the tape are brought to the surface through the incisions on your bottom where the ends of the tape are cut just under the surface of the skin. The tape is now "U"-shaped, supporting the urethra. The small incisions are closed. Other surgical procedures, if appropriate, may be performed at the same time as the TOT.

The advantages of the TOT suburethral sling over some other procedures in treating urinary incontinence may include shorter operating time, quicker recovery time, and better long-term results.

The likelihood of success of the TOT support procedure is reported to be 80-90% in most cases.

As with other surgical procedures to treat urinary incontinence, non-surgical alternatives may include:

• lifestyle modification: quit smoking, lose weight, allergy treatment
• Kegel’s exercise: regular contraction of the muscles that allow you to stop urine in mid-stream may reduce or eliminate incontinence
• pessary use: usually a donut-shaped rubber or plastic device inserted into the vagina to support the bladder
• hormonal (estrogen) replacement therapy
• treatment with medication helps certain types of incontinence

Other surgical procedures such as the laparoscopic Burch procedure may better treat urinary incontinence depending on the specific situation. Many times using a combination of several forms of treatment results in the best treatment for incontinence. These might include the non-surgical alternatives, plus the TOT, plus an anterior repair (see Vaginal Repair of Pelvic Prolapse under Surgical Procedures).