Urgency After a Sling: Review of the Management

Pilot Study of a Novel At-Home Posterior Tibial Nerve System for Overactive Bladder Syndrome

IMPORTANCE

Urgency urinary incontinence and overactive bladder are common conditions. Third-line therapies are often underutilized because of either being too invasive or being burdensome for the patient.

OBJECTIVE

We aimed to determine the efficacy and acceptability of a noninvasive, home-based posterior tibial nerve treatment system for the treatment of overactive bladder syndrome.

STUDY DESIGN

In this pilot study, 10 postmenopausal women with urgency urinary incontinence were given the SoleStim System for home-based posterior tibial nerve stimulation. Symptoms at baseline and completion of the 8-week study were determined by 3-day voiding diary and quality-of-life questionnaire (Overactive Bladder Questionnaire) to assess for reduction in incontinence episodes.

RESULTS

All patients were 100% adherent to the SoleStim System application over the 8-week period and reported statistically significant reductions in the mean number of voids (-16.3%, P = 0.022), urgency episodes (-31.2%, P = 0.02), and urgency urinary incontinence episodes (-31.4%, P = 0.045). Forty percent of participants reported a decrease of ≥50% in their urgency urinary incontinence episodes. SoleStim was scored a value of 1.8 ± 2.0 (mean ± SD) on a 10-point usability scale, indicating that it was highly acceptable from an ease-of-use perspective. No adverse events were reported.

CONCLUSIONS

The SoleStim System improved key overactive bladder (frequency, urgency, and urgency urinary incontinence episodes) and quality-of-life metrics. The results from this pilot study suggest that the SoleStim System may be a safe, effective, and highly acceptable at-home overactive bladder therapy.

Surgical Effect Observation and Treatment Strategy Analysis of Pseudo Urgency Syndrome

Background and Objectives: pseudo urgency syndrome among patients with mixed incontinence (MUI) causes and the corresponding treatment strategies is explored. Materials and Methods: A total of 40 patients with MUI are treated with transobturator tape (TOT) and/or solifenacin succinate. Further, 30 patients with simple stress urinary incontinence (SUI) that were treated with transobturator tape (TOT) from the period of December 2018 to August 2020 are retrospectively analyzed; then, their clinical characteristics and therapeutic effects were summarized and analyzed. Results: The effective rates of SUI symptoms in MUI and simple SUI groups were 85% and 90%, respectively; further, the difference was noted as not statistically significant (P > 0.05). Among the 40 patients with MUI, 12 patients had unstable bladder contraction, and the other 28 patients showed normal bladder compliance. The treatment effectiveness rates of SUI symptoms in patients with unstable bladder contraction and normal bladder compliance were 83.3% and 85.7%, respectively; further, no significant difference was noted (P > 0.05). However, the effective rates of urge urinary incontinence (UUI) were 50% and 85.7%, respectively, however the difference was noted as statistically significant (P < 0.05). Conclusions: Most of the UUI symptoms in MUI patients may be “pseudo urgency syndrome” caused by the worry about the leakage of urine, rather than a real sense of UUI that is caused by excessive bladder excitement. Direct surgical treatment in patients with MUI can improve the symptoms of urinary incontinence, and the effect is more obvious in patients with urinary frequency who have normal bladder compliance according to urodynamics.

Efficacy of combination therapy of mid-urethral sling and low-dose Abobotulinumtoxin-A injection in mixed urinary incontinence

OBJECTIVES

To determine the outcome of combined transobturator tape sling (TOT) and low dose intradetrusor injection of Abobotulinumtoxin-A (Abobot-A, Dysport®) in women with mixed urinary incontinence (MUI).

METHODS

This randomized, active comparator-controlled, parallel-group, two-part clinical trial was conducted on women who had positive Valsalva leak point pressure (VLPP) + detrusor overactivity (DO), cough-associated DO. In Part 1, 20 women with MUI who had a failure of medical and behavioral therapies to cure MUI, randomized in two groups receiving TOT surgery alone, or in combination with Dysport® injection (n = 10 in each group), and then Part 2 was initiated as a prospective open-label on 40 more patients. We performed cystoscopy and injected 300 U of Dysport®in 20-30 intradetrusor injection sites in each patient.

RESULTS

The patient's symptoms in both groups decreased significantly after treatment. The symptoms were improved significantly in the combination therapy group according to the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB) questionnaire (p < .001), and International Consultation on Incontinence Questionnaire-urinary Incontinence-short form (ICIQ-UI-SF) (p = .041) in comparing with the TOT group. In Part 2, the mean score was 17.10 (4.75) for ICIQ-UI-SF and 9.22 (2.89) for ICIQ-OAB before the treatment. Twelve weeks after the intervention, the median (interquartile range: IQR) of ICIQ-OAB symptoms (2.0 [3.0]; p < .001) and ICIQ-UI-SF decreased, too (1. 0 [2.0]; p < .001). Considering improvement using Patient Global Impression of Improvement scale, 46 (92.0%) stated that they had significant subjective improvement of their symptoms.

CONCLUSIONS

Combination therapy was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.

Risk Factor of De Novo Urgency and Urge Incontinence After Autologous Fascia Pubovaginal Sling

Introduction

Pubovaginal sling is an efficient and safe procedure for stress urinary incontinence without the complications of synthetic sling. Urine retention and de novo urgency are bothersome aftermath of this procedure. We aim to identify potential risk factors for de novo urgency after autologous pubovaginal sling.

Methods

From 2013 to 2016, 347 patients underwent autologous pubovaginal sling. Age, BMI, pelvic irradiation, use of anticholinergic medication, previous vaginal related surgical histories, “over-tight” technique, and concomitant surgeries were examined for potential risk factors. De novo urgency/urge incontinence was defined as treatment (medication, botulinum toxin injection, sacral neuromodulation) for urge postoperatively and was not noted before surgery. Chi-square and fisher’s exact tests were used as statistical analysis.

Results

A total of 109 patients underwent autologous rectus fascia pubovaginal sling, after excluding status post urethral diverticulectomy, concomitant diverticulectomy, and concomitant abdominal surgery. Twenty-three (21.1%) patients were treated for de novo urge/urge incontinence, 18 (78.2%) with anticholinergic, 4 (17.3%) with botox injection and 2 (8.69%) with sacral neuromodulation. None but prior pelvic organ prolapse surgery was associated with developing de novo urge/urge incontinence (p=0.026).

Discussion

Patients with prior pelvic organ prolapse surgery were more likely to be at risk of de novo urgency after autologous pubovaginal sling. This study provided more information for preoperative consultation for patients undergoing incontinence surgery.

The evolution of incontinence into resolved, refractory and de novo urgency urinary incontinence following sling placement at time of prolapse repair in a large urodynamic cohort

PURPOSE

To improve counseling in women at risk of refractory and/or de novo urgency urinary incontinence (UUI) following sling placement at time of prolapse repair, we created an outcome model to characterize changes in storage dysfunction.

MATERIALS AND METHODS

We identified 139 women who underwent urodynamics followed by sling or no sling placement at the time of prolapse repair over a 6-year period. Our primary outcome was the presence of UUI following sling placement. Data were analyzed in SAS using chi-square, Fisher's exact, Student's t-test, and Kaplan-Meier methods.

RESULTS

At baseline, the sling group had significantly higher subjective (62/81 [76.5%] vs. 18/58 [31.0%]; p<0.001), objective (62/81 [76.5%] vs. 6/58 [10.3%]; p<0.001), and occult (41/81 [50.6%] vs. 6/58 [10.3%]; p<0.001) stress urinary incontinence (SUI); and rates of subjective and objective UUI were similar to the no sling group prior to surgery. After surgery (mean follow-up 859 days) there was no difference with or without sling, in the rate of SUI (subjective, objective) and further SUI treatments (bulking agent, repeat sling). Higher rates of de novo (13/81 [16.0%] vs. 6/58 [10.3%]; p=0.454) and refractory (31/81 [38.3%] vs. 14/58 [24.1%]; p=0.048) UUI were noted in the sling group following surgery. On Kaplan-Meier analysis, a greater proportion of women in the no sling group did not report UUI at longest follow-up (hazard ratio 0.63; 95% confidence interval 0.37-1.06; p=0.081).

CONCLUSIONS

Women should be counseled on the risk of de novo and refractory UUI following sling placement at time of prolapse repair.

De novo OAB After ATOMS: An Underestimated Problem or a Rare Side Effect?

Background: The urinary incontinence system ATOMS (A.M.I., Austria) generates suburethral compression through its sphincter cushion. To what extent the ATOMS may lead to overactive bladder (OAB) symptoms or which risk factors for these symptoms exist remain unknown to date. We report on our multicentre evaluation on the prevalence, status, and therapy of OAB after ATOMS.

Methods: Between 10/09 and 01/17, a total of 361 patients received an ATOMS device in Vienna and Halle. A prerequisite for surgery was persistent male stress urinary incontinence lasting at least 6 months after the primary intervention, as well as the failure of conservative treatment. Patients with a preoperative untreated anastomotic stricture or detrusor overactivity were excluded. In addition to continence and voiding parameters, patient's age, BMI, comorbidities, and pre-treatment strategies of the underlying disease and urinary incontinence were examined. If de novo OAB was present, urodynamics were used for further clarification. Statistical analysis was performed with GraphPad Prism 7® (GraphPad Software, Inc., La Jolla, USA), p < 0.05 considered significant.

Results: OAB presented 18 patients (4.9%). Regarding the degree of urinary incontinence as well as uroflowmetry, residual volume and comorbidities, patients with an OAB showed no differences compared to patients without an OAB (p < 0.05). Only previous radiotherapy or urinary incontinence surgery and urethral stricture interventions resulted in statistically significant differences based on the bivariate analysis (p = 0.030, p = 0.006, p = 0.007). The consecutive postoperative urodynamics revealed a sensory OAB in 17 patients and a low-compliance bladder in a patient with newly diagnosed insulin-dependent type II diabetes mellitus. OAB was treated with a standard dose of antimuscarinic drugs and for the low-compliance bladder with botulinum toxin type A.

Conclusion: OAB symptoms can occur after ATOMS implantation, but are rare and have no clear correlation to the incontinence device but rather are due to urinary incontinence-related underlying diseases and previous treatments.

Usefulness of Ospemifene in the treatment of urgency in menopausal patients affected by mixed urinary incontinence underwent mid-urethral slings surgery

The aim of this study was to assess the effectiveness and safety of Ospemifene in the improvement of urgency component in women affected by mixed urinary incontinence (MUI) who underwent surgery with mid-urethral sling (MUS). Eighty-one patients with MUI underwent surgical intervention with MUS were enrolled. After surgical intervention 38 patients received Ospemifene 60 mg one tablet daily per os for 12 weeks. Physical examination, 3-day voiding diary, urodynamic testing were performed at the start and the follow-up after 12 weeks in the Trans-Obturator-Tape (TOT)-Alone group and TOT-Ospemifene. Patients completed the Overactive Bladder Symptom and Health-Related Quality of Life Short-Form (OAB-Q SF), International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), and King' s Health Questionnaire (KHQ). A significant difference between the two groups was observed in peak flow (ml/s), in first voiding desire (ml), in maximum cystometric capacity (ml), and in detrusor pressure at peak flow (cmH₂O) at urodynamic evaluation. A significative difference between the two groups at voiding diary was observed in the mean number of voids, urgent micturition episodes/24 h, urge urinary incontinence, and in nocturia events. The OAB-Q symptoms and OAB-Q (HRQL) scores after 12 weeks showed a significative difference between the two groups. Ospemifene is an effective potential therapy after MUSs in women with MUI improving urgency symptoms and quality of life.

Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder

INTRODUCTION

The mid-urethral sling (MUS) procedure is the gold-standard for the surgical treatment of stress urinary incontinence (SUI). Urethro-vesical sling exposure is one of the most serious complications of this procedure. We describe the treatment and follow-up of 18 patients with bladder or urethral sling exposure.

PATIENTS AND METHODS

This single-center, retrospective study assessed the diagnosis and management of MUS penetrating the lower urinary tract in 18 women. The lesions included were classed as 4B, T3-4, S3 according to the international classification of complications related to the insertion of prostheses. Diagnosis was confirmed by flexible urethro-cystoscopy. The patients were treated surgically. In all cases, the aim was to remove all synthetic materials eroding the bladder or urethra. The patients were reassessed 6 weeks after the procedure, and functional urologic sequelae were treated. Urologic symptoms were evaluated using the USP questionnaire and urologic comfort was assessed using the Contilife questionnaire.

RESULTS

Seven MUSs were retro-pubic and 11 were trans-obturators. The material was 11 polypropylene macroporous monofilament, four polypropylene silicone coated and three non-available. There were six cases of urethral sling exposure, nine cases of bladder sling exposure, and three cases of urethral and bladder sling exposure, including five complicated cases of lithiasis and one urethra-vaginal fistula. Thirteen patients underwent one surgical procedure, four underwent two, and one underwent five procedures. Seven patients received a Martius flap. Three surgical approaches were necessary: (i) vaginal approach; (ii) urologic (urethral and suprapubic) cystoscopy approach; and (iii) laparoscopy approach. Median follow-up time was 34.5 months. At the end of follow-up, 17/18 patients had no sling exposure from the MUS, and 12/13 patients were considered comfortable from a functional urologic viewpoint.

CONCLUSION

Our study showed that surgery could treat urethro-vesical sling exposure. Three surgical approaches may be necessary. Controlled cystoscopy is vital to confirm healing due to the recurrences of sling exposure in our study.

Overactive Bladder Symptoms after Transobturator Sling Surgery for Pure Stress Urinary Incontinence: A Cross-Sectional Comparative Study

INTRODUCTION

Transobturator tape (TOT) surgery has been associated with increased overactive bladder (OAB) although much controversy exists.

METHODS

In a cross-sectional study, women who underwent TOT surgery for pure stress incontinence (MonarcTM) answered the 6 questions of the symptom bother (SB) subscale of the OAB questionnaire - short form (OABq-SF) and an additional question regarding whether symptoms began after surgery. Women with SB score over the 4th quartile (≥30/100) were reassessed after a longer follow-up. Patients from primary care were recruited as controls.

RESULTS

We recruited 213 patients (135 in the TOT group and 78 age-adjusted controls). The mean age of operated patients was 58.7 ± 10.1 years with a mean follow-up of 25.9 ± 13.2 months. OABq-SF SB scores did not differ between the TOT group and controls (respectively, 18.5 ± 30 and 15.5 ± 6.7, p = 0.202). A total of 48% patients reported no relationship between symptoms and surgery. Highly symptomatic operated patients were reassessed after a longer follow-up (46.3 ± 10.6 months). The mean score in the second follow-up (n = 25) was not statistically different from the first assessment (46.4 ± 22.7 and 58.1 ± 19.8, p = 0.059).

CONCLUSIONS

Women who underwent TOT surgery did not show increased OAB SB scores when compared to controls. Our study suggests that OAB symptoms may thus be present but overlooked during initial clinical assessment.

Effectiveness and quality of life 10 years after transobturator suburethral tape surgery for stress urinary incontinence

AIM

We aimed to measure the effectiveness and quality of life (QoL) 10 years after transobturator suburethral tape surgery.

METHODS

We carried out a prospective observational study of 42 women assessed 10 years after surgical intervention with the transobturator technique. The main outcome measures were subjective and objective cure or improvement, complications, and changes in QoL.

RESULTS

The median abdominal leak point pressure had been 92 (82-113) mL H₂ O prior to surgery. Thirty-six women (85.7%) remained cured (negative cough test) and 13 (31%) reported urine leakage during physical activity, percentages which were similar to those at a previous assessment at the 5th year. Urgency urinary incontinence was reported by 18 women (42.9%), 16 of whom required the use of anticholinergic drugs. Nineteen women had undergone some form of surgical pelvic reconstruction concomitantly with the TOT procedure, four of whom presented with relapse. The QoL tests indicated that cure and improvement persisted in 85.7% (n = 36, Urogenital Distress Inventory-6) and 92.9% (n = 39, Incontinence Impact Questionnaire-7) of the 42 evaluable women, respectively.

CONCLUSION

Rates of objective and subjective effectiveness remained stable after 10 years of surgery and QoL did not deteriorate significantly during that interval. The increase in urgency incontinence needs to be further investigated.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Current Treatment Concepts for Stress Urinary Incontinence

Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80–90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

Factors associated with overactive bladder syndrome in the elderly community: a cross-sectional study

Abstract Objective: to identify risk factors related to overactive bladder syndrome. Method: a cross-sectional study was performed with elderly women (>60 years) from the community of Ceilândia, in the Distrito Federal, Brazil, with or without symptoms of OBS, who were evaluated through interviews and questionnaires. The clinical and sociodemographic variables analyzed were: age; body mass index (BMI); parity, schooling, previous abdominal and urogynecologic surgeries, physical activity, smoking, constipation, systemic arterial hypertension (SAH), diabetes mellitus; depression and anxiety. The questionnaires applied were the Overactive Bladder Awareness Tool (OAB-V8), the Geriatric Depression Scale and the Beck Anxiety Scale. Data were analyzed descriptively. Binary logistic regression was used to evaluate the significant associations between the independent variables and the outcome of interest. Risk ratios were calculated for each independent variable with 95% confidence intervals. Result: A total of 372 volunteers were recruited, 292 of whom were eligible. Of these, 172 were allocated to the case group (58.9%) and 120 (41.1%) were control subjects. The two groups were homogeneous between one another. There was a high prevalence of OBS in the study population and significant differences for the variables presence of SAH, abdominal surgery and pelvic surgery, with the case group presenting a higher frequency of these events. In multivariate analysis, it was observed that an active sexual life reduces the chance of having OBS by 70.8%, while urogynecologic surgeries increase this risk 3.098 times. Conclusion: In univariate logistic regression analysis, BMI, SAH, a previous history of abdominal and urogynecologic surgery, number of abortions and the presence of symptoms of depression and anxiety, were found to be factors associated with OBS.

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Zusammenfassung. Zusammenfassung: Eine Belastungsinkontinenz sollte immer zuerst konservativ behandelt werden. Schon eine Gewichtsreduktion, Hormonpräparate, Physiotherapie, Beckenbodentraining und/oder die Anwendung von Pessaren können zum Erfolg führen. Nach Ausschöpfen dieser Therapien werden heute Inkontinenzoperationen mit meist sehr guten Heilungschancen (ca. 80–90 %) angeboten. Der operative Goldstandard ist die suburethrale Schlingeneinlage. Die Pelvic-Floor-Sonografie liefert dazu sehr wichtige Hinweise zur Wahl der Operationstechnik und zur Behebung von Komplikationen. Ferner bildet die intra- oder paraurethrale Injektion von Bulking Agents eine vielversprechende, wenig invasive operative Alternative. In diesem Artikel werden Behandlungskonzepte, prä-, intra- und postoperative Untersuchungen, Wahl der Operationsmethode, operationstechnische Details für den Operationserfolg sowie Vorbeugung und Behandlung von Komplikationen diskutiert.

Long-term functional results after unilateral mid-urethral sling transection for voiding dysfunction

OBJECTIVE

To investigate the long-term outcomes of unilateral mid-urethral sling transection to treat voiding dysfunction after synthetic mid-urethral sling placement for stress urinary incontinence.

STUDY DESIGN

Twenty-three patients who underwent an unilateral sling transection were analyzed retrospectively. Patient records were analyzed for subjective outcome, and pre- and postoperative flow patterns were used as objective outcome parameters.

RESULTS

At the first postoperative follow-up, 77.3% of the patients remained dry. After a mean follow-up of 42 months, 73.9% of patients were continent. The flow pattern after lateral sling transection was significantly better than pre-operatively, with higher maximum flow rate (24.2ml/s, p=0.001), higher mean flow rate (10.4ml/s, p=0.001), higher voided volume (308.5ml, p=0.002) and lower residual volume (28.7ml, p=0.003). At final postoperative follow-up, eight patients (34.8%) reported urgency and six patients (26.1%) were incontinent; four of these patients (17.4%) mainly had urge incontinence.

CONCLUSIONS

Unilateral mid-urethral sling transection is a safe, effective technique to treat voiding symptoms with good preservation of continence. The technique repairs the obstructive flow effectively. Urgency and urge incontinence after mid-urethral sling placement are difficult to treat with transection alone.

A Valuable Option in the Management of Female Recurrent Stress Urinary Incontinence: Re-Adjustable Sling (Remeex Sling System)

INTRODUCTION

This study was conducted to evaluate the effectiveness and safety of adjustable slings in the treatment of recurrent stress urinary incontinence (SUI) after mid-urethral sling (MUS) failure.

MATERIALS AND METHODS

A prospective study was performed among women with recurrent SUI at the Urogynecology Division of Istanbul School of Medicine between February 2010 and March 2015. All women were preoperatively evaluated with detailed urogynecologic evaluations, which included pelvic examination, Q-tip test, pad test, urodynamic studies and a compilation of the Kings Health Questionnaire (KHQ). Postoperative follow-up was performed at 1, 6 and 12 months and annually thereafter. Our primary outcome was objective cure and patient's satisfaction with treatment. Secondary outcomes included perioperative complications and adverse events.

RESULTS

Nineteen women were included in the study. The patients' mean age was 55.3 ± 6.9 years (range 43-66 years). The median follow-up time was 20.7 ± 14.0 months (range 6-55 months). The overall cure and improvement rates were 84.2 and 10.5%, respectively. In the satisfaction questionnaire, 15 (79%) patients responded that they were very satisfied and 3 (15.7%) were moderately satisfied. Sling tension re-adjustment was needed during follow-up in 1 patient (5.3%), 13 months after the initial surgery. The preoperative mean KHQ score was 545.9 ± 243.0 and changed to 237.0 ± 217.5 (p < 0.05). Postoperative complications were slight and easily manageable.

CONCLUSIONS

Recurrent SUI is a challenging condition in urogynecology. The Regulation Mechanical External (Remeex) system has been found to be effective in the treatment of recurrent SUI after MUS failure with acceptable adverse effects. The Remeex system has the advantage of re-adjustment as a valuable option in the long-term management of patients.