Expert Opinions in Female Pelvic Medicine and Reconstructive Surgery Sandip P. Vasavada, Howard B. Goldman
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Stress urinary incontinence1

A 39-year-old woman, gravid 3, para 3, with no other major past medical history, presents for evaluation and management of symptomatic urinary incontinence. She describes her incontinence as predominantly stress incontinence with no overactive bladder symptoms at all. She has had these problems since the birth of her last child [vaginal delivery at term, baby's weight 7lbs 5 oz (3.3 kg)]. Her physical examination demonstrates a normal introitus and urethral hypermobility to the Q-tip test to 45°. She has demonstrable stress incontinence per urethra with coughing but no other focal abnormalities. She has no prolapse, her urinalysis is completely negative and her post-void residual is 20 mL. She states she is interested in curative therapy.
How would you proceed? Would you recommend urodynamics, and if so, why or in what scenario would you consider this? If she is leaning towards surgery, what procedure would you perform and why?
 
Expert's opinion
This patient is the ‘index patient’ described by the American Urologic Association (AUA) guidelines statement for the management of stress urinary incontinence. She denies overactive bladder symptoms, complains of straightforward stress incontinence symptoms and her physical examination demonstrates urethral hypermobility without pelvic organ prolapse. Involuntary loss of urine with increased abdominal pressure during cough is demonstrated, which confirms the diagnosis of stress urinary incontinence, and her post-void residual urine volume is acceptably low. I would proceed by asking her for more background about the nature and severity of her symptoms. Is she having incontinence episodes on a daily basis or more or less often? Does she wear pads to protect her underwear, and if so how many and what kind? Is her incontinence impacting her lifestyle or keeping her from doing things she wants to do? Finally, and most importantly, has she finished with child-bearing?
The answers to these questions help to guide my discussion with the patient regarding her treatment options. If she was thinking of having more children, then I would guide her towards non-surgical management with either pelvic floor physical therapy or a pessary trial. In patients with infrequent incontinence, not requiring pads, and for whom the incontinence does not impact their lifestyle negatively, then I would also encourage a course of pelvic floor physical therapy. For these patients I think that the risks of surgical intervention outweigh the potential quality of life improvement.
2Assuming that the patient does not wish to have any more children and the incontinence is negatively impacting her lifestyle such that she is abstaining from her normal activities, then I would discuss surgical options for her stress incontinence. For patients presenting with the symptoms of an ‘index patient’, the AUA guidelines suggest that no further investigation needs to be done prior to proceeding with surgical intervention. While I agree that urodynamic studies are not mandatory for this patient, I have found in my practice that the routine performance of urodynamics allows me to make more educated recommendations regarding surgical options, as well as more accurately counsel my patients as to the potential adverse outcomes of surgery. Anti-incontinence surgery is elective, quality of life surgery and as such our tolerance of adverse outcomes should be very low. Any information that I can obtain preoperatively to avoid these is beneficial. Using multichannel urodynamic studies, we are able to assess bladder capacity and compliance, uninhibited detrusor contractions during filling, the abdominal and Valsalva leak point pressures, as well as voiding parameters such as the detrusor pressure at maximum flow. I use the abdominal leak point pressure to help guide my choice of sling: for patients with lower leak point pressures I favor a retropubic approach over a transobturator approach. Patients who void with minimal increases in detrusor pressure but rather by Valsalva may have more problems with voiding dysfunction after an anti-incontinence procedure.
After the urodynamic study, I would have a discussion with the patient regarding the surgical options for her problem. For completeness, I would mention, but not recommend, urethral bulking agents to this young woman. Because of her urethral hypermobility and assuming that urodynamics do not uncover detrusor overactivity or dysfunctional voiding, I would discuss both autologous fascia pubovaginal slings and mesh mid-urethral slings. Both the lack of urethral hypermobility and an abdominal leak point pressure suggestive of intrinsic sphincter deficiency would push me to recommend a pubovaginal sling. If she were to choose a mesh sling, then I would recommend a retropubic approach. She does not have any contraindication to a trocar passage through the retropubic space and I find that the retropubic slings are much less likely to distort the vaginal anatomy and be palpable through the vaginal wall paraurethrally, leading to a lower risk of dyspareunia postoperatively.
We would have a lengthy discussion about the operative course and potential complications of both types of slings. For pubovaginal slings this is focused on the overnight hospital stay, second incision, longer recovery, potential for wound complications such as seroma, and the higher incidence of voiding dysfunction postoperatively. For mesh mid-urethral slings the discussion would be focused on the possible but rare complications of trocar passage such as vascular, bladder and bowel injury, the lower incidence of voiding dysfunction, and on the 3complications particular to the use of mesh. I inform patients that the longest follow-up data that we have on mesh slings is 13 years and that for a woman of only 39 years, we do not know how that mesh will behave when she is 50, 60, or 70 years old. I would discuss the minor complication of vaginal wall extrusion and the major complications of urethral and bladder erosion. In this litigious area of vaginal mesh implants, a careful and thoughtful informed consent process is critical. After reviewing her options, I would ask the patient to decide if she prefers to proceed with an autologous fascia pubovaginal sling or retropubic mesh mid-urethral sling.
Sarah E. McAchran MD
Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010; 183:1906–1914.
Nager C, et al. A randomized trial of urodynamic testing before stress- incontinence surgery. NEJM 2012; 366:1987–1997.