The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome?

AIMS: The aims of our study were (1) to investigate subjective and objective outcomes after tension free vaginal tape (TVT) operations in mixed incontinent women, (2) to detect if preoperative subjective and objective variables predict the outcome, and (3) to evaluate whether the surgical outcome is different for women who preoperatively find stress incontinence, urge incontinence, or urge and stress incontinence equally the predominant bother. METHODS: A prospective cohort study was performed on 450 mixed incontinent women. A short-form disease-specific validated questionnaire, 24-hr pad test, standardized stress test, residual urine, and maximum urinary flow were used before and after a TVT operation. "Cure" was defined as a condition where the women were very satisfied with the TVT operation and had negative stress- and 24 hr pad tests. RESULTS: Preoperatively 69% had stress incontinence, 7% urge incontinence, and 24% urge and stress incontinence equally as the predominant bother. Cure rates were 80%, 52%, and 60%, respectively, in these groups. Postoperatively 43% of the women had no urge incontinence, while 49% were less, and only 8% were more bothered by urge incontinence. A higher preoperative urge incontinence index was correlated with significantly higher postoperative bother for all indices and leakage during 24-hr pad test. CONCLUSIONS: Mixed incontinent women with predominant stress incontinence had a better cure rate than those with predominant urge incontinence and those who were equally bothered by urge and stress incontinence. This point needs to be addressed when informing mixed incontinent women before a TVT operation.     

Which women develop urgency or urgency urinary incontinence following midurethral slings?

Introduction and hypothesis

De novo urgency has a negative impact on women after midurethral sling (MUS). We aimed to identify risk factors for de novo urgency (dU) and urgency urinary incontinence (dUUI) following MUS, using multivariate analysis.

Methods

We investigated 358 consecutive women with only stress urinary incontinence (SUI) [or urodynamic stress incontinence (USI)] and 598 women with both SUI (or USI) and urgency (but not UUI) who underwent MUS with a mean follow-up of 50 months. Women who developed dU or dUUI at long-term follow-up were compared to those who did not.

Results

dU occurred in 27.7 % (99/358) and dUUI occurred in 13.7 % (82/598) of women at long-term follow-up after midurethral sling. Intrinsic sphincter deficiency {odds ratio (OR) dU 3.94 [95 % confidence interval (CI) 1.50–10.38]; OR dUUI 2.5 (1.31–4.80)}, previous stress incontinence surgery [sling: OR dU 3.69 (1.45–9.37); colposuspension: OR dUUI 2.5 (1.23–5.07)], previous prolapse surgery [OR dU 2.45 (1.18–5.10)], preexisting detrusor overactivity [OR dU 1.99 (1.15–3.48); OR dUUI 1.85 (1.31–2.60)] increased the risk, whereas performing concomitant apical prolapse surgery [OR dU 0.5 (0.41–0.81); OR dUUI 0.29 (0.087–0.97)] significantly decreased the risk. Women are more likely to not recommend surgery when they experienced dU (18.2 vs 0.8 %, p?<?0.0001) or dUUI (20.7 vs 2.1 %, p?<?0.0001).

Conclusions

Urodynamic parameters, history of prior incontinence or prolapse surgery and concomitant apical prolapse operation were important predictors of dU or dUUI following MUS.     

Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

OBJECTIVE: We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI). METHODS: Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted. RESULTS: There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%). CONCLUSIONS: There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.     

Associated pelvic organ prolapse in women with stress urinary incontinence: when to operate?

PURPOSE OF REVIEW: This review discusses recently published data concerning the indications for pelvic organ prolapse (POP) surgery in women who present with stress urinary incontinence (SUI). RECENT FINDINGS: POP can functionally mask SUI. Surgery for POP may unmask occult SUI in many women. Clinically continent women undergoing POP surgery are at risk for developing symptomatic SUI postoperatively. Preoperative identification of occult (and overt) SUI will facilitate the use of an appropriate prophylactic anti-incontinence procedure at the time of prolapse repair. Numerous studies on the preoperative prediction of SUI following repair of POP have been conducted in an effort to determine whether concomitant prophylactic measures should be taken at the time of POP repair to prevent the postoperative unmasking of SUI in women who do not have SUI preoperatively (with or without prolapse reduction). Although the literary evidence available is not sufficient for POP with occult SUI, there is some information available to guide clinicians in deciding when to perform concurrent POP surgery in women who are undergoing primary surgery for SUI. SUMMARY: The intended goal of surgical correction of SUI and POP is durable restoration of normal anatomy and function, with symptomatic relief and avoidance of morbidity. Recommendations regarding when to surgically intervene for POP in women who present with SUI are based on the available literature although contemporary studies are few and include small numbers of patients with no controls. Long-term, randomized, controlled prospective studies of large numbers of patients are indicated.     

Do predictive parameters exist for therapy with duloxetine in women with stress urinary incontinence?

Introduction and hypothesis

To determine whether predictive parameters exist for successful duloxetine therapy in women with stress urinary incontinence (SUI).

Methods

Secondary analysis was performed of 1,714 women who received duloxetine in the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month longitudinal observational study to evaluate the results and direct costs of SUI treatment. Data of 1,087 women were analyzed. Univariate and multivariate analyses (stepwise forward logistic regression) were performed to investigate factors for discontinuation of treatment.

Results

Parameters that significantly reduced the probability of treatment termination were smoking and a body mass index (BMI) <20, while obesity (BMI >30) increased the probability in the univariate analysis. In the multivariate analysis significantly reduced likelihoods of duloxetine treatment discontinuation were found for an age >65 years, country, and 7 to 13 incontinence episodes per week. Co-medication, particularly anti-cholinergics, was significantly associated with therapy termination. Previous SUI surgery had no effect.

Conclusions

Identification of predictive parameters for successful therapy with duloxetine in women with SUI is desirable, and co-medications should be critically considered.     

What patients think: patient-reported outcomes of retropubic versus trans-obturator mid-urethral slings for urodynamic stress incontinence—a multi-centre randomised controlled trial

Introduction and hypothesis  

The purpose of this study is to determine if the trans-obturator tape (TOT; Monarc, American Medical Systems (AMS)), which has been claimed to have similar or improved outcomes to retropubic mid-urethral slings, was equivalent (but not inferior) to the trans-vaginal tape (TVT; Gynecare) by using patient-reported outcomes for the treatment of urodynamic stress incontinence.     

Surgical treatment for stress urinary incontinence with urethral hypermobility: what is the best approach?

A comparative study evaluating the results of three surgical procedures for stress urinary incontinence (SUI) with urethral hypermobility. This is a retrospective study of 189 patients, evaluating the outcomes of the percutaneous needle suspension using bone anchors (PNS), abdominal suspension (AS), and pubovaginal sling (PVS). The mean follow-up was 30.5 months. In our results, the patients were divided into three groups: PNS (49), AS (34), and PVS (106). No differences were found preoperatively. Intraoperatively, PNS had the shortest operative time and lowest estimated blood loss, and it is the only outpatient procedure. However, it had the highest complication rate. PNS had the lowest satisfactory rate (16.7%). This was followed by AS (78%), PVS with cadaveric fascia (90%), and PVS with autologous fascia (94%). In conclusion, PNS is a simple outpatient procedure, but the long-term results are disappointing. Both AS and PVS gave good results. PVS was superior to AS in shorter hospitalization, early recovery and overall patient satisfaction.     

Urinary incontinence in the elderly: what management for which patient?

THERAPEUTIC OPTIONS: Appropriate management of urinary incontinence in the elderly basically depends on the patient's medical status and degree of dependence and the type of incontinence. For outpatients, secondary effects of drugs limit their use, in favor of behavioral intervention and pelvic floor training, with good success. Recently proposed surgical approaches offer a promising alternative for the aged population. TEAM MANAGEMENT: Assessment and management of institutional urinary incontinence should be systematically elaborated by the medical care team. Potentially reversible conditions and precipitating factors may be causing or contributing to the incontinence. Their correction and bladder training are the principal items of the management scheme.     

Can urodynamic stress incontinence be diagnosed by ultrasound?

Introduction and hypothesis

Multichannel urodynamic testing is commonly used to diagnose urodynamic stress incontinence (USI). It has been claimed that USI may be diagnosed by imaging. In this study we determined the predictive value of ultrasound findings for USI.

Methods

This is an observational study utilising data obtained during urodynamic testing. Data sets were analysed in 209 patients in order to determine the predictive value of sonographic findings for the diagnosis of USI.

Results

Bladder neck descent and maximal urethral pressure were the only independent predictors of USI identified by multivariate logistic regression. The finding of a cystourethrocele with funnelling increased the odds of a diagnosis of USI by 2.5 (95 % confidence interval 1.17–5.4, p?=?0.018).

Conclusions

Translabial ultrasound can identify an anatomical configuration that is associated with USI. However, sonographic findings are insufficient to predict USI and can not replace urodynamic testing.     

Does urethral competence affect urodynamic voiding parameters in women with prolapse?

AIMS: To (1) compare voiding parameters and (2) correlate symptoms and urodynamic findings in women with pelvic organ prolapse (POP) and varying degrees of urethral competence. METHODS: We compared three groups of women with stages II-IV POP. Groups 1 and 2 were symptomatically stress continent women participating in the Colpopexy and Urinary Reduction Efforts (CARE) trial; during prolapse reduction before sacrocolpopexy, Group 1 (n = 67) did not have and Group 2 (n = 84) had urodynamic stress incontinence (USI) during prolapse reduction. Group 3 participants (n = 74), recruited specifically for this study, had stress urinary incontinence (SUI) symptoms and planned sacrocolpopexy. Participants completed standardized uroflowmetry, pressure voiding studies, and validated symptom questionnaires. RESULTS: Subjects' median age was 61 years, median parity 3 and 87% had stage III or IV POP. Fourteen percent of women in Group 3 demonstrated USI without, and 70% with, prolapse reduction. Women in Groups 2 and 3 had more detrusor overactivity (DO) than Group 1 (17 and 24% vs. 6%, P = 0.02) and detrusor overactivity incontinence (DOI) (15 and 8% vs. 0%, P = 0.004). Based on the Blaivis-Groutz nomogram, 60% of all women were obstructed. Post-void residual volume (PVR), peak flow rate, detrusor pressure at peak flow, voiding mechanisms, voiding patterns, obstruction and urinary retention did not differ among groups. Women in Group 3 had higher irritative and obstructive symptom scores than Group 1 or 2; neither score differed by presence of DO nor obstruction, respectively. CONCLUSION: Women with POP have significant rates of urodynamic obstruction and retention, independent of their continence status. Symptoms of obstruction and retention correlate poorly with urodynamic findings.     

How often does detrusor overactivity cause urinary leakage during a stress test in women with mixed urinary incontinence?

Introduction and hypothesis

The study examined how often detrusor overactivity (DO) causes leakage during a stress test in women with mixed urinary incontinence (MUI) and whether there are differences between those who do and those who do not have DO during the stress test.

Methods

A retrospective study was performed in 100 women who had an ambulatory urodynamic recording done where bladder, urethral, and vaginal pressures, and leakage were recorded. The stress test consisted of 20 jumping jacks and three forceful coughs.

Results

All the women leaked during the stress test: five due to simultaneous stress test and DO, 87 due to the stress test only, and eight during the stress test as well as due to DO before or after the stress test.

Conclusions

During the stress test, 5 % of women with MUI leaked due to the coughs and jumps and simultaneous DO. Women in whom DO was detected had significantly higher Urgency Incontinence Index and leakage during the 24-h pad test.