Who has Stress Incontinence?
- Reported as 49% prevalence
- Index patient: otherwise healthy woman, interested in surgical therapy, SUI or stress-predominant MUI, no prior SUI surgery, low grade POP
- Non-Index Patient: POP stage 3-4, non-stress predominant SUI, incomplete emptying with elevated PVR, prior SUI surgery, mesh complications, high BMI, neurogenic LUTS, advanced age
Workup
History
- Inciting factors: cough, sneeze, lifting, walk/run (PPV 73-74%, NPV 66-86%)
- Degree of bother
- Assess characteristics: chronicity, frequency/severity, treatment expectations
- Pad usage
- UTI/LUTS: urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying
- Pelvic symptoms: pain, pressure, bulging, dyspareunia
- GI symptoms: constipation, diarrhea, splinting to defecate
- OB Hx: gravity, parity, delivery method, menopause status
- Prior SUI (non)surgical therapy
- PMHx, meds
- Fluid intake (water, alcohol, caffeine)
- Questionnaires: haven't been shown to be overall helpful
Physical
- Abdominal exam
- Pelvic exam w/ moderately full bladder: pelvic prolapse, vaginal atrophy, pelvic floor dysfunction
- Q-tip test: demonstrates urethral mobility, not predictive of SUI
- Focused neuro exam
Adjuncts
- Objective demonstration of SUI: positive stress test, involuntary urine loss while supine and/or standing
- 48hr pad test: PPV 81%, NPV 87%
- 1hr pad test: 94% sensitivity, 44% specificity, PPV 69%, 85% NPV
- Assess post-void residual: single elevated PVR is not reliable
- Urinalysis: check for infection/hematuria
Definitely needs further workup if...
Unclear diagnosis, unable to demonstrate SUI, concern for neurogenic LUTS, abnormal UA (hematuria/pyuria), urge predominant MUI, elevated PVR, high grade PVR (3-4), significant voiding dysfunction
May need further workup if...
OAB symptoms, prior failed surgery, prior prolapse surgery
Obtional Adjuncts:
- Cystoscopy: not required except for specific diagnoses, recommended if prior SUI surgery (especially if mesh used)
- UDS not required if SUI is obvious, but optional in non-index patients
Nonsurgical options
- Observation: not bothered, not interested, or too sick for surgery
- PFPT
- Inserts: urethral inserts, pessaries
Surgical Options
Midurethral Sling
- Uses synthetic mesh - FDA approved
- Retropubic: placed via suprapubic incision
- Transobturator: placed via lateral incision
- Goal is urethral support (loose sling), not urethral kinking (tight sling)
Pubovaginal sling
- Placed at bladder neck, not at midurethra
- Harvest autologous rectus or fascia lata
- Non-autologous sources are not recommended (worse outcomes)
Burch Colposuspension
- Useful if undergoing A/P surgery at the same time (hysterectomy etc)
- Avoids mesh and fascial harvest complications
Intraurethral bulking agents
- Inject material into submucosal space to coapt urethra
- Less invasive with shorter operative and recovery time
Non-Index Patients
- Intrinsic sphincteric deficiency (ISD): retropubic MUS, autologous PVS, and bulking agents - transobturator MUS does not provide adequate support with an immobile urethra
- Diverticulectomy, urethrovaginal fistula repair, or mesh excision: avoid mesh placement at same time (high risk for erosion), but staged procedure is okay
- History XRT, scarring, or poor tissue quality: avoid mesh placement (high risk for erosion)
- Pelvic prolapse repair: all options available, see nomogram for probability of needing concurrent SUI procedure
- NGB: factor in patient-specific risks/benefits
- Prepregnancy: high rate of SUI recurrence, consider waiting until completing childbirth, can use any option
- Diabetes: increased risk of mesh erosion, but can use any option
- Obesity: increased BMI decreases overall effectiveness, but can use any option
- Age > 65yrs: overall lower success rates
Risks/Complications
General Risks
- Pain: abdominal, pelvic, vaginal, groin, thigh, dyspareunia
- Bleeding
- Infection: UTI rates highest within first 3mo
- Intraop injury: do not place mesh sling if urethral injury
- Mesh: exposure, erosion, perforation
- LUTS: unmask or worsen OAB symptoms
Retropubic sling
- Vascular/visceral injuries
- Bladder/urethral perforation
- Voiding dysfunction
- Suprapubic pain
Transobturator sling
- Groin pain
- Repeat surgery
Pubovaginal Sling
- Factor in morbidity of fascial harvest
Burch Colposuspension
- 20% have wound complications
Bulking Agents
- Need for repeat injections
Jelovsek, J. Eric, et al. "A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery." Obstetrics and gynecology 123.2 0 1 (2014): 279.
Important Stress Incontinence Studies
CARE (Brubaker 2008): colposuspension at time of sacrocolpopexy leads to less postoperative SUI (without preoperative SUI)
OPUS (Wei 2009): anterior vaginal wall prolapse repair, postoperative SUI rates 27% if retropubic MUS performed (vs 43% for sham procedure), NNT 6.3 to see benefit of adding MUS
TOMUS (Kobashi 2017): at 5yrs, minimal difference in success between retropubic and transobturator midurethral slings
SISTEr (Albo 2007): PVS vs Burch, effectiveness (no SUI, no need for retreatment, negative stress test was 66% vs 49%, retreatment rates was 4% vs 13%
Sources
- Albo, Michael E., et al. "Burch colposuspension versus fascial sling to reduce urinary stress incontinence." New England Journal of Medicine 356.21 (2007): 2143-2155.
- Brubaker, Linda, et al. "Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence." Obstetrics and gynecology 112.1 (2008): 49.
- Jelovsek, J. Eric, et al. "A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery." Obstetrics and gynecology 123.2 0 1 (2014): 279.
- Kobashi, Kathleen C., et al. "Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline." The Journal of urology 198.4 (2017): 875-883.
- Richter, Holly E., et al. "Retropubic versus transobturator midurethral slings for stress incontinence." New England Journal of Medicine 362.22 (2010): 2066-2076.
- Wei, John, et al. "Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial—design and methods." Clinical Trials 6.2 (2009): 162-171.