Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram

OBJECTIVE: To evaluate the outcome of surgery for stress urinary incontinence (SUI) in patients presenting with a combination of stress and sensory urge UI. PATIENTS AND METHODS: The study comprised 75 women presenting with mixed incontinence; the most important inclusion criterion was a negative cystometrogram for detrusor overactivity. Based on random selection, a third of the patients received a 6-month course of anticholinergic treatment (group 1) and 50 (group 2) had surgery for SUI. The surgical procedure depended on the Valsalva leak-point pressure (VLPP); those with a VLPP of > or = 90 cmH2O underwent Burch retropubic bladder neck suspension (group 2a, 24 patients) while 26 (group 2b) with a VLPP of < 90 cmH2O had pubovaginal sling (PVS) surgery. A further group of 20 patients with pure SUI (no urge UI) underwent surgery (PVS in 12 and Burch in eight) as a control group (group 3). After at least 6 months of follow-up (mean 9.3, sd 1.7), 68 patients were evaluable; they were assessed subjectively and objectively for dryness, and by a urodynamic evaluation and quantitative assessment using the SEAPI scoring system. RESULTS: In group 1 none of the patients became completely dry; there was persistent stress with and without urge UI in nine (43%) and 12 (57%) of the available 21 patients, respectively. Only three of those who had persistent SUI with no urge in the whole study group were satisfied and chose to continue anticholinergic therapy despite SUI. In this group the mean (sd) improvement in the subjective and objective SEAPI score was 3.4 (1.0) and 2.3 (3.8), respectively. In group 2a, 20 of the available 23 patients (87%) became completely dry (both stress and urge continent). The mean improvement in the SEAPI scores was 7.8 (0.9) and 7.8 (1.3), respectively. In group 2b, 20 of the 24 patients (83%) became completely dry, with mean improvements in SEAPI scores of 8.2 (0.4) and 7.9 (0.3), respectively. The improvement was statistically significant after surgery, vs anticholinergic therapy, for all variables (P < 0.05). The incidence of persistent urge UI was highest in group 1 (43%), being 13% in group 2 (13% and 12% in 2a and b, respectively). In group 3 there was de novo urge UI in four of the 20 patients, and not significantly different from that in group 2. CONCLUSION: Most patients with mixed stress and urge UI and a normal cystometrogram were cured of both symptoms by surgery. The incidence of residual urge in such patients was no higher than that of de novo urge after surgery in patients with genuine SUI.