Evaluation and Management of Urinary Retention and Voiding Dysfunction After Sling Surgery for Female Stress Urinary Incontinence

Management of urinary incontinence in postmenopausal women: An EMAS clinical guide

INTRODUCTION

The prevalence of urinary incontinence and of other lower urinary tract symptoms increases after the menopause and affects between 38 % and 55 % of women aged over 60 years. While urinary incontinence has a profound impact on quality of life, few affected women seek care.

AIM

The aim of this clinical guide is to provide an evidence-based approach to the management of urinary incontinence in postmenopausal women.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

Healthcare professionals should consider urinary incontinence a clinical priority and develop appropriate diagnostic skills. They should be able to identify and manage any relevant modifiable factors that could alleviate the condition. A wide range of treatment options is available. First-line management includes lifestyle and behavioral modification, pelvic floor exercises and bladder training. Estrogens and other pharmacological interventions are helpful in the treatment of urgency incontinence that does not respond to conservative measures. Third-line therapies (e.g. sacral neuromodulation, intravesical onabotulinum toxin-A injections and posterior tibial nerve stimulation) are useful in selected patients with refractory urge incontinence. Surgery should be considered in postmenopausal women with stress incontinence. Midurethral slings, including retropubic and transobturator approaches, are safe and effective and should be offered.

Urodynamics are necessary for patients with asymptomatic pelvic organ prolapse

AIM

To evaluate the role of pre-operative urodynamics in women with pelvic organ prolapse, who are asymptomatic for urinary symptoms. Correlate urodynamics findings with King's Health Questionnaire (KHQ) responses.

MATERIALS AND METHODS

Retrospective review of prospectively collected data on routine pre-operative urodynamics investigations in women with urogenital prolapse requiring surgery. Patients who were reported to be asymptomatic of urinary symptoms at the urogynaecological clinical consultation, were included for analysis. KHQ and urodynamics data were reviewed.

RESULTS

A 800 records of women having routine pre-operative urodynamics were collected over a 10-year period, were reviewed. 98/800 (12%) were aymptomatic of urinary symptoms and underwent urodynamics. 82/98 (84%) completed the KHQ. 48/98 (49%) had normal urodynamics. 30/98 (31%) had detrusor overactivity (DO). 17/98 (17%) showed occult urodynamic stress incontinence (USI). 3/98 (3%) both DO and USI. 28/98 (29%) had peak flow rate less than 15 mL/s. Forty-five percent of women reporting nocturia had DO. Nine percent had over 100 mL residuals after the free flow study. Routine pre-operative urodynamics changed management in 25/98 (25%) of asymptomatic prolapse patients. TVT was performed in 12 patients. One patient who declined TVT for moderate occult USI, developed new-onset stress urinary incontinence post-operatively.

CONCLUSION

This data show, that an accurate pre-surgical evaluation of patients with prolapse is incomplete without a structured validated questionnaire and urodynamics, due to the high proportion of abnormal KHQ and UDS findings in presumably "asymptomatic" patients.

Transobturator midurethral sling: What should patients expect after surgery?

INTRODUCTION AND HYPOTHESIS

Midurethral sling (MUS) surgeries are minimally invasive procedures; however, they are not free of postoperative complications. The aim of the study was to assess the occurrence of lower urinary tract symptoms (LUTS) (urgency, nocturia, frequency, splitting/spraying, hesitancy, terminal dribbling, and subjective feeling of postvoid residual) in patients suffering from stress (SUI) or mixed (MUI) urinary incontinence with a predominant SUI component before and after transobturator MUS placement.

METHODS

The study group consisted of 88 women with SUI and 18 with MUI who underwent transobturator MUS. All participants were questioned with a self-developed questionnaire before and after surgery regarding the presence of LUTS.

RESULTS

Seven days after surgery, 62 patients (58.5%) noted voiding and postmicturition symptoms, whereas 67 (63.2%) reported problems in storage. The more commonly reported LUTS at week 1 after surgery were urgency (52.8%), splitting/spraying (41.5%), and feeling of incomplete bladder emptying (34.0%). Patients perceived that splitting/spraying was the most bothersome. After 6 months, the most common LUTS reported were hesitancy (14.1%), terminal dribbling (10.4%), and splitting/spraying (9.4%). We noticed a decrease in the number of urgency episodes >2.7 times (p < 0.001) compared with baseline. After 6 months, 97 (91.5%) patients reported the lack of incontinence episodes.

CONCLUSIONS

A vast majority of patients after MUS suffer from LUTS in the early postoperative period; however, the majority of undesired symptoms resolve spontaneously within the first 6 months postsurgery.

Urinary retention

Urinary retention, defined as the inability to void, is a common medical problem. If unidentified and/or untreated, it may become a serious condition that can lead to kidney damage or urosepsis, compromising the patient's life.
Acute urinary retention (AUR) is usually easy to identify and to treat as patients usually complain of hypogastric pain and anuria. Proper bladder drainage with urethral or suprapubic catheter is the first line of treatment, with posterior studies to determine the cause of retention.
Chronic urinary retention (CUR) is often much more difficult to identify. It is invariably linked to increased post-void residual urine (PVR), but its asymptomatic nature makes it often a hidden condition.
There is a wide range of intrinsic and extrinsic, obstructive and non-obstructive causes affecting the lower urinary tract, which can lead to urinary retention. Due to the differences in urinary physiology and in order to simplify diagnosis and management, these are usually studied separately in men and in women. Management consists of a variety of options depending on the cause of retention, including conservative treatment, drug therapy and several forms of surgery. 
In this review, we make an overview of the main causes of acute and chronic urinary retention in men and women, focusing on the main aspects of diagnosis and management.


Management of complications after tension-free midurethral slings

Since their introduction in 1996, tension-free midurethral slings (MUS) have been proven to have long-term efficacy and safety. They are considered the gold standard treatment of female stress urinary incontinence, especially in cases that are associated with urethral hypermobility. However, they are not free of complications and, although rare, some of these complications can be challenging for both patients and physicians. Some complications occur intraoperatively, whereas others appear in the early or late postoperative period. There is less controversy in the diagnosis and treatment of complications such as vaginal extrusion or urinary system erosion, whereas de novo voiding problems are at best not completely understood. Voiding dysfunction after MUS placement may vary in a wide range from urinary frequency or urgency to retention and is usually attributed to the obstructive or irritative effect of the sling. However, present urodynamic criteria for the diagnosis of female infravesical obstruction are not satisfactory, and the best management policy for de novo voiding dysfunction remains controversial. In the majority of cases, the diagnosis of obstruction leading to a urethral release surgery depends on a combination of several clinical findings. The timing of urethral release surgery varies depending on the preferences of the surgeon, and the outcome of this surgery is not always predictable. The purpose of this review was to assess the diagnosis and management of the immediate, short-term, and long-term complications of MUS in light of the current literature in an attempt to determine the best management policy.