Mixed incontinence: Stressing about urge

Adjustable mini-sling compared with conventional mid-urethral slings in women with urinary incontinence: a 3-year follow-up of a randomized controlled trial

Introduction and hypothesis

The aim of this study was to compare the long-term subjective outcomes of an adjustable single-incision sling (Ajust®) vs standard mid-urethral slings (SMUS) for the treatment of women with stress urinary incontinence.

Methods

This study was designed as a multicenter prospective randomized trial. Women under 60 years old with objectively verified stress urinary incontinence were included from seven centers in three countries. Women with mixed urinary incontinence were also included. Randomization was held in blocks for operation with either Ajust® or SMUS. Women analyzed at 1-year follow-up received the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF), International Consultation on Incontinence Questionnaire Overactive Bladder, Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Questionnaire-12, Patient Global Impression of Severity, and Patient Global Impression of Improvement questionnaires, together with a bladder diary to fill out at least 3 years after the procedure. The main outcome evaluated was the subjective cure rate as reported through the ICIQ-UI-SF questionnaire at 3 years.

Results

In total, 205 women participated in the 3-year follow-up: 107 in the Ajust® and 98 in the SMUS group. No significant difference was observed between the groups regarding subjective cure rate (50.9% vs 51.5%, p = 0.909) or dyspareunia. Both groups demonstrated similar postoperative perception of improvement in addition to reduced urgency and urge urinary incontinence. The postoperative improvement remained at the same level after 3 years as it was at 1-year follow-up for both Ajust® and SMUS.

Conclusions

Ajust® appears to be equally effective and safe as SMUS with regard to long-term follow-up of patient-reported outcomes.

Relationship between Proximal Urethrovaginal Space Thickness and Detrusor Overactivity in Women with Stress Urinary Incontinence

Purpose

Detrusor overactivity (DO) cannot be predicted by clinical symptoms. Although it is possible that DO could be related to anatomical structures, scanty data exist about the relations between DO and anatomical structures. The aim of this study was to investigate anatomical differences in DO by measuring the thickness of the urethrovaginal space (UVS) and the urethral length (UL) in women with stress urinary incontinence (SUI).

Materials and Methods

Prospective data were collected from 72 women with SUI who underwent the midurethral sling operation. The subjects were divided into 2 groups according to the presence of DO by preoperative urodynamic study (UDS). UVS thickness was measured by trans-vaginal ultrasound. UL was measured by using a urethral catheter and a ruler. UVS thickness, UL, Q-tip, and urodynamic parameters, such as maximal urethral closure pressure (MUCP) and Valsalva leak point pressure, were compared between the two groups.

Results

Of 72 women, 23 patients had DO (31.9%). The proximal UVS was significantly thinner (p<0.001) and the MUCP was significantly lower (p=0.008) in women with DO. According to the receiver operating characteristic (ROC) curve based DO prediction, the best cutoff value for UVS thickness was 0.84 cm (area under the ROC curve 0.763).

Conclusions

In this study, the proximal UVS was significantly thinner and the MUCP was significantly lower in patients with DO. A proximal UVS thickness of less than 0.84 cm was shown to be a predictive parameter for the development of DO on preoperative UDS. A large-scale prospective study is needed to validate these results.

Prevalence of urinary urgency symptoms decreases by mid-urethral sling procedures for treatment of stress incontinence

INTRODUCTION AND HYPOTHESIS

Conflicting opinions on the effect of incontinence surgery on the prevalence of postoperative urgency symptoms exists. Our aim was to evaluate the prevalence of urgency symptoms preoperatively and during 3-year of follow-up in women undergoing mid-urethral sling procedures for stress incontinence.

METHODS

Two hundred and sixty-seven women were randomly assigned to a retropubic or a transobturator operation. Detrusor instability score (DIS) and Urogenital Distress Inventory-6 (UDI-6) questionnaires were used to assess prevalence of urgency symptoms. The Incontinence Impact Questionnaire-7, visual analog scale, urinary incontinence severity score, and the EuroQol-5D assessed overall quality of life changes.

RESULTS

A significant decrease in the DIS and UDI-6 score was seen postoperatively. Signs of de novo urgency symptoms were low.

CONCLUSIONS

Mid-urethral sling procedures can be recommended in cases of mixed incontinence, and the procedures seems to decrease prevalence of urgency symptoms.

Update of AUA guideline on the surgical management of female stress urinary incontinence

PURPOSE

We updated the 1997 American Urological Association guideline on female stress incontinence.

MATERIALS AND METHODS

MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions.

RESULTS

A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category.

CONCLUSIONS

The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently 50%of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.

Mixed incontinence: definitions, outcomes, and interventions

PURPOSE OF REVIEW

Mixed incontinence remains a problematic issue in clinical practice. Interventions designed to benefit one of the contributory symptoms often do no benefit the other constituent symptom. Recent evolution in the taxonomy of mixed incontinence as well as the increased reporting of standardized results has produced a better understanding of the response of this entity to clinical interventions.

RECENT FINDINGS

Three main areas of development have occurred in the analysis of mixed incontinence. The advancements in definitional and taxonomic changes have clarified the concept and presentation of mixed incontinence. In light of these changes, results reported from pharmacologic or surgical interventions have improved. Several new studies have demonstrated the efficacy of these interventions in selected groups of patients using either pharmacologic or operative modalities.

SUMMARY

In well selected and symptomatically characterized patients, therapy directed at mixed incontinence can provide efficacious results. The implications of these positive outcomes suggest that therapy founded on appropriate symptomatic appraisal can produce generally salubrious outcomes. These outcomes must, however, be assessed with tools that allow adequate differentiation of symptomatic changes including methods that delineate not only cure but also symptom improvement.