Q. What is the ICS definition of stress urinary incontinence (SUI)?
A. SUI is the involuntary leakage of urine on cough or straining or exertion and effort. The prevalence ranges from 12% to 52%. Of all incontinence cases approximately 50% have SUI, 11% urge urinary incontinence and 36% have mixed urinary incontinence. SUI is bothersome in 20% of patients with this problem.
Q. What is urodynamic stress incontinence (USI)?
A. USI is noted during urodynamic testing (filling cystometry) and is defined as the involuntary leakage of urine during increases in abdominal pressure in the absence of a detrusor contraction.
Q. A 52-year-old fit woman presents with worsening complaints of urinary leakage, when coughing and lifting heavy items. How would you assess her?
A. I would see this patient in a specialist clinic, with my continence nurse specialist present, and with the following completed prior to being seen - a validated symptom questionnaire such as the International Consultation on Incontinence Modular Questionnaire Short Form (ICIQ-SF) (as recommended by the European Association of Urology [EAU]), a representative bladder diary (frequency-volume chart) over 3 days, urinalysis and a post-void residual volume.
Then, I would take a detailed history. In the history I would establish the type of incontinence (stress, urge or mixed), severity of incontinence (ICIQ-SF outcome and use of pads - how many, what type and how wet they were), effect on quality of life, treatments (surgical and non-surgical) already tried and the desire for further treatment and the patient’s expectations. Furthermore, I would also enquire about associated voiding and bowel dysfunction (frequency, urgency, nocturia, dysuria, incomplete emptying, suprapubic pain, haematuria, UTIs, constipation and faecal leakage). A detailed gynaecological and obstetric history would be elicited including pregnancies (vaginal or caesarian section), menopausal status (including previous history of hysterectomy), use of Hormone Replacement tterapy (HRT) and the Oral Contraceptive Pill (OCP) and whether there was any dyspareunia, vaginal irritation or dryness. A past medical history of diabetes, neurological disease and previous pelvic cancer surgery or radiotherapy would be established. Finally, I would enquire about drug history (diuretics, anticholinergics) and whether the patient is a smoker.
Q. She has had three normal vaginal deliveries in the past and has not had a hysterectomy or any other abdominal or pelvic surgery. She does not complain of urinary infections or any other urinary symptoms. What will you look for on examination?
A. I will obtain verbal consent and examine her in the presence of a chaperone. I would perform a general examination first, as this may have a bearing on subsequent management, looking specifically for obesity (BMI). Then, in the supine position, I would perform an abdominal examination looking for a palpable bladder. I would then perform a pelvic examination in the supine position initially inspecting the tissue state of the introitus (well oestrogenised or atrophic). I would then ask my patient to cough or perform a Valsalva manoeuver to elicit the sign of stress incontinence. I would assess for pelvic floor tone using the Oxford grading system. I will then ask the patient to turn to the left lateral position, I would ask my chaperone to help lift the upper leg. A warmed lubricated Sim’s speculum would then be introduced and evaluation for cystocoele and rectocoele is performed. Finally, I check perineal sensation and assess anal tone to evaluate for any neurological abnormality. If present, lower limb neurological examination is also performed.
The Q-tip and Marshall tests which have been described to assess for urethral competence are not currently recommended by NICE.
Q. Clinical examination revealed no significant abnormalities. What investigations would you like to perform?
A. Initially, I would perform dipstick urinalysis to look for evidence of infection or nonvisible haematuria. If a UTI is present, I would treat this and then re-assess the patient. I routinely perform a flow rate and estimation of post-void residual volume, as well as review a representative bladder diary, with the patient. Pad tests can be used to objectively confirm incontinence. Further investigations depend on causative factors in the history. Specifically, if neurological features are present, a renal USS and creatinine are requested.
Q. How do you do a pad test?
A. The objective of a pad test is to try to quantify the volume of urine lost by weighing a perineal pad before and after provocation testing. Pad tests can either be short term (over 1 hour) or longer term (over a 24-hour period). In a 1-hour test, the patient is required to drink 500 mL of fluid (non-saline based) and then perform a set series of exercises over the next 1 hour.
The 24-hour test is a more physiological test where the patient is encouraged to perform the sort of normal daily activity which would cause her to leak urine. A weight gain of up to approximately 1.4 g for the 1-hour pad test and up to 8 g during the 24-hour pad test is considered normal (note that an increase in weight of the pad or pads of 1 g is considered equivalent to 1 mL of urine).
Pad testing is not recommended in the routine assessment of women with urinary incontinence (NICE).
Q. Would you perform urodynamics in a woman with pure stress urinary incontinence?
A. I do not perform urodynamics prior to starting conservative treatments for patients with urinary incontinence. I am aware that the NICE guidelines suggest that in the small group of women where pure SUI can be diagnosed on history and clinical examination alone that urodynamics are not necessary prior to considering invasive therapy. It is however my practice to perform urodynamics in all patients prior to surgery, for several reasons. First, there is evidence that 11%-16% of patients with history of stress incontinence also have detrusor overactivity on urodynamic testing and conversely, 22% of patients with a history of overactive bladder symptoms have demonstrable stress incontinence at urodynamics.
The NICE guidelines suggest that urodynamics should be undertaken if
There are symptoms of OAB leading to a clinical suspicion of detrusor overactivity.
Symptoms are suggestive of voiding dysfunction or anterior compartment prolapse.
There has been previous surgery for SUI.
I would also consider urodynamics if the clinical diagnosis as unclear prior to surgery or there are neurological clinical features.
Q. What are the indications for video-urodynamics?
A. In my practice, it is used in those patients with previous failed surgery, those with neurological features and in children. Furthermore, I am aware that in specialist centres, video-urodynamics are used more widely than in my practice, because of the perceived advantages such as allowing better evaluation of bladder neck descent and urethra as well as quantifying anterior wall prolapse better.
Q. How do you describe a urodynamic trace?
A. I use a systematic method to describe the trace as follows:
Establish which line is which on the trace (especially as the trace colours may be different to what you are used to normally)
Pves
Pabd
Pdet
Volume infused
Uroflowrate
Quality control
Are the baseline pressures correct?
Supine 5-20 cm H2O
Sitting 15-40 cm H2O
Standing 30-50 cm H2O
Subtracted Pdet 0-6 cm H2O
Coughing - does it lead to good subtraction and a biphasic waveform in Pdet?
Are there any artefacts that need to be looked at?
Filling phase
First desire
Normal desire
Strong desire
Cystometric capacity
Any detrusor overactivity?
Any stress incontinence?
Is quality control still OK? (see previous)
Standing
Do the pressures increase on standing?
Is quality control still OK? (see previous)
Provocative manoeuvres
Which have been used?
What are the effects of these?
Is quality control still OK? (see previous)
Voiding phase Pdet
Pdet at Qmax
Qmax
Volume voided
Is quality control still OK? (see previous)
Q. Do you know of any theories for development of SUI?
A. The first theory was proposed by Kelly, Bonney and Enhorning known as the urethral position theory. It suggested that the urethra should remain above the pelvic floor so that the pressure from the abdomen could be equally transmitted to the urethra closing it.
The intrinsic sphincter deficiency (ISD) theory was proposed by McGuire in the 1970s. It proposed that the abnormality was the weakness of the sphincter itself. He introduced the concept of Valsalva leak point pressure (VLPP) and maximum urethral pressure (MUP).
It was suggested that patients with VLPP <60 cm H2O had ISD, while those with VLPP of >90 cm H2O had an anatomical cause of SUI. The patients with pressures between 60 and 90 cm H2O had a combination of two problems.
Hammock theory: This was suggested by Delancey in 1994. He described the urethra as resting on a supportive layer of endopelvic fascia and anterior vaginal wall. This was reinforced by the lateral attachments of this fascia with arcus tendineus.
Integral theory: This was proposed by Petros and Ulmsten. This proposed that laxity of the anterior vaginal wall and pubourethral ligaments causes hypermobility of the bladder neck and dissipation of urethral pressure resulting in urinary incontinence.
Lately, a trampoline theory has been offered which incorporates all of the above theories. This is applied to the female pelvis as acting as the outer ring, the fabric is the pelvic musculature and ligaments are the springs. This proposes that SUI is a multifactorial problem and all of the above are compromised to some extent in its aetiology.
Q. In this 52-year-old woman, a diagnosis of stress incontinence is made. What treatment options are available?
A. The following options are available:
Non-surgical treatments
Lifestyle changes
Weight loss
Cessation of smoking
Modify high or low fluid intake
Supervised pelvic floor exercises
Bladder re-training
Oestrogen therapy if evidence of atrophy
Oral medical therapy in rare cases
Surgical treatments
Occlusive
Bulking agents
Compressive (artificial urinary sphincter)
Supportive
Mid-urethral sling
Colposuspension
Q. She wants to know more about the medical therapy and especially how it works. What information will you give to her?
A. The only agent with published data is duloxetine (Yentreve), which is a combined
norepinephrine and serotonin reuptake inhibitor at the spinal cord level (Onuf’s nucleus).
It increases the activity of the pudendal nerve and increases the urethral muscle tone. Its efficacy is about 20%-40%. However, it is limited by side effects and discontinuation rates are very high. The main adverse effects are nausea, dizziness, dry mouth, constipation, insomnia, somnolence and asthenia. Duloxetine is not recommended as a first-line treatment for women with predominant SUI, although it may be offered as second-line therapy if women prefer pharmacological therapy to surgery or who are not suitable for surgical treatment. In clinical practice, if duloxetine is prescribed, women should be counselled about its adverse effects, very carefully.
Q. Prior to offering this woman a surgical intervention or procedure is there anybody you would want to discuss your plans with?
A. Before offering invasive therapy for either OAB or SUI, each case should be discussed in a multidisciplinary team meeting (MDT) taking into account patient preference, past management, co-morbidities and treatment options.
Q. Who should be part of the MDT?
A. The MDT should comprise a urologist with a sub-specialist interest in female urology, a urogynaecologist, a specialist nurse, a specialist physiotherapist, a colorectal surgeon with a subspecialist interest in functional bowel problems for women with coexisting bowel problems and a member of the care of the elderly team for women with functional impairment [5].
Q. What are the indications for bulking agents?
A. The main indications will be symptomatic patients who are high risk for major surgery, elderly patients, previous multiple failed procedures and patient preference. I will offer this to patients with mild to moderate SUI with the understanding that although this is a minimally invasive technique, the success rate is between 50% and 70% but the effects are not long lasting. Women should be made aware that
Repeat injections may be needed to achieve efficacy.
Efficacy diminishes with time.
Efficacy is inferior to that of synthetic tapes or autologous rectus fascial slings.
Q. What types of bulking agents are you aware of?
A. I am aware of macroplastique (silicone), durasphere (carbon-coated zirconium beads), Zuidex (cross-linked dextranomer) and coaptite (calcium hydroxylapatite). I use macroplastique as it is permanent and there is no significant risk of migration due to the size of the particles.
Q. What materials are mid-urethral slings made of?
A. Mid-urethral slings can be classified into
Autologous
Rectus fascia
Fascia lata
Synthetic
Prolene (polypropylene)
Dacron (Mersilene)
Non-synthetic
Q. What is the efficacy of mid-urethral tension-free vaginal tape (TVT) slings?
A. Outcomes after TVT have shown that 90% of women were still objectively cured, from a study in which 11-year prospective follow-up data were available [6]. Similar data have been reported at 5- and 7-year follow-up [7].
Q. What are the complications of mid-urethral TVT slings?
A. These include
Complications at insertion
Bladder perforation (0%-12%)
Significant haemorrhage (1.9%)
Major vascular injury (<1%)
Urethral laceration
Bowel injury
Nerve injury
Material-related complication
Erosion (<1%)
UTI (4%-17%)
Post-operative symptoms
Post-operative voiding dysfunction (30%)
De novo urgency (3%-9%)
Urinary retention (2.5%-5%)
Dyspareunia/pelvic pain
There have been serious concerns about the use of mesh in vaginal implants for prolapse and stress incontinence surgery, in Scotland this led to the use of mesh implants being banned. The MHRA (Medicines and Healthcare Products Regulatory Agency) has reviewed the currently available information on the safety of vaginal mesh implants and concluded that from a regulatory perspective the benefits of the use of these devices outweigh the risks.
Important issues which should be undertaken by those using vaginal mesh implants include
1. Consent - Consent guidance, consent forms and patient information are available from the specialist societies, e.g. British Association of Urological Surgeons (BAUS).
2. Audit - NICE recommends that all procedures using mesh insertion should be part of regular audit on a recognised database, e.g. BAUS surgical database.
3. Adverse event reporting - Mesh inserted for pelvic organ prolapse or SUI is considered a medical device and There fore any adverse events should be reported to the MHRA.
4. Surgery for the removal of mesh - Surgery for the removal of tapes or prolapsed mesh, or repeat surgery for prolapse or incontinence should be performed in centres which can demonstrate relevant specialist expertise.
Q. How is erosion treated?
A. The tape has to be removed if there is a urethral or vaginal erosion. The urethral defect can be buttressed with a Martius fat pad if there is a significant defect. A rectus facial sling can be inserted later on if the patient remains incontinent after tape removal. A bladder perforation is more difficult to treat. It is difficult to endoscopically remove the tape from inside the bladder. Laser can be used with some success, although it may require more than one sitting to remove the tape. If there is a considerable erosion a cystotomy is required. It has been suggested that mesh erosions and complications should be treated at specialist centres with greater experience in the management of these complications.
Q. How does TVT compare with other pubovaginal slings?
A. In a recent systematic review and meta-analysis of five randomised controlled trials (RCTs) comparing TVT and other pubovaginal slings, a comparable cure rate between the two procedures was found [8].
Q. How does TVT compare with transobturator tape (TOT)?
A. The effectiveness and complications of TOTs were assessed in a recent systematic review of five RCTs that compared TVTO with TVT and six RCTs that compared TOT with TVT [7]. Both techniques had similar efficacy, with regards to subjective cure. However, the risk of bladder perforation (odds ratio 0.12) and voiding difficulties (odds ratio 0.55) with TOT was lower, whereas groin/thigh pain (odds ratio 8.28), vaginal injuries or erosion of mesh (odds ratio 1.96) were significantly more common after tape insertion by the transobturator route.
Long-term follow-up on TOT is limited.
Q. How does TVT compare with Burch colposuspension?
A. A recent systematic review and meta-analysis of nine RCTs comparing TVT and Burch colposuspension, in which 1170 patients were followed up for 3-24 months, concluded that TVT had a significantly higher efficacy in terms of overall cure rate than Burch colposuspension [8].
This was true for any definition of cure, namely, according to the presence of negative stress test (odds ratio 0.38) and according to the presence of negative pad test (odds ratio 0.59). Complication rates were similar after the two procedures, with the exclusion of bladder perforation, which was more common after TVT, and reoperation rate, which was significantly higher after Burch colposuspension.
In summary, TVT appears to be significantly more effective with similar complication rates if compared to Burch colposuspension.
Q. When will you offer colposuspension and what is its efficacy?
A. I will recommend this to patients with significant urethral hypermobility (TVT/TOT in these cases is likely to fail with the patient representing with SUI in the future). This procedure has the longest follow-up and the cure rate at >10 years is 69%.
I may consider offering a colposuspension to a young woman as an initial surgical treatment as there are currently concerns with the long-term complications of synthetic mesh and mesh erosions/complications.
Q. What are the principles of a colposuspension?
A. The surgical principle is the re-elevation of the bladder neck into the abdominal pressure zone so there is equal transmission of intra-abdominal pressure to the bladder neck, which closes off the urethra.
Q. What are the main complications after Burch colposuspension?
Immediate complications
Retropubic space haemorrhage (transfusion risk is approximately 0.5%)
Bladder trauma (2%-3%)
Long-term complications
Enterocele or rectocele (up to 20%)
Dyspareunia (4%)
Voiding dysfunction (up to 30% and need for CISC 0.5%)
De novo urgency (5%-15%)
Recurrent bacterial cystitis (1%-2%)
Q. What are the causes of failure of anti-incontinence surgery?
A. These include
Anatomical failure due to technical reasons
Functional failures due to poor tissue support
Inappropriate patient selection
Failure due to post-operative complications