For example, in a woman who requires a total abdominal hysterectomy for fibroids as well as an anti-incontinence procedure, I would do a Burch operation. For a woman who needed a vaginal hysterectomy, I probably would perform a sling procedure.
DAVILA: Ob/Gyns may be a bit unsure how to proceed at this point. For example, we formerly considered the Burch procedure the gold standard against which other procedures should be judged. Although I continue to view it as the standard, the Burch procedure increasingly is overlooked in favor of tension-free slings—due to increased marketing of the latter—for any form of stress incontinence. I think that has led us down a path that is not entirely beneficial for many of our patients.
In contrast to that approach, I use a basic evaluation of the patient to construct a treatment algorithm. In simple terms, 2 factors are taken into account: urethral sphincter function and bladder neck or urethral support. Using those 2 factors, I create a 2×2 table to select patients who do or don’t have urethral hypermobility and who do or don’t have sphincteric deficiency (TABLE).
For example, a patient with hypermobility and normal sphincter function has what we might consider “garden-variety” stress incontinence. Such patients do well with any form of treatment, whether it’s conservative therapy, a vaginal device, or a Burch procedure or tension-free sling.
I am more concerned when the patient has hypermobility with a significant degree of sphincteric deficiency. In recent years, the tendency has been to treat such patients with a tension-free sling. Although the literature is not absolutely clear, the success rate of tension-free slings in a patient with intrinsic sphincteric deficiency (ISD) is not as high as in a woman without ISD.1 So in these patients, I do a traditional sling.
Atrophy can cause significant urgency and nocturia symptoms.—Dr. Davila
The other 2 groups of patients have no hypermobility. I think most of us would agree that a woman with ISD and no hypermobility would best be treated with a bulking agent such as Contigen (C.R. Bard, Murray Hill, NJ) or Durasphere (Advanced Uroscience, St. Paul, Minn).
I have had good success rates with bulking agents. I do not think current data would support a tension-free sling in these patients.
Finally, there is the patient without hypermobility who has normal sphincter function. These patients do fairly well with conservative therapy, including pelvic floor exercises. They usually have mild forms of stress incontinence to begin with.
TABLE 1
Stress urinary incontinence treatment choices based on urethral support and urethral sphincteric function
| URETHRAL SUPPORT | URETHRAL SPHINCTERIC FUNCTION | |
|---|---|---|
| Bladder neck mobility (Q-tip test) | Normal urethral | Poor urethral function function |
| MUCP >20 cm H20 | LPP <20 cm H20 | |
| VLPP <60 cm H20 | VLPP >60 cm H20 | |
| Negative EBST | Positive EBST | |
| >30 degrees (hypermobility) | Kegel exercises | Traditional sling |
| Biofeedback | ||
| Vaginal device | ||
| Tension-free vaginal tape | ||
| Burch urethropexy | ||
| <30 degrees | Kegel exercises | Bulking agents |
| Biofeedback | ||
| Source: GW Davila, MD | ||
| EBST = empty bladder stress test; | ||
| MUCP = maximal urethral closure pressure; | ||
| VLPP = Valsalva leak point pressure | ||
| NOTE: Urethral plugs may function in all categories | ||
Simple method to assess sphincter function
DAVILA: This is the algorithm I tend to follow. It does entail evaluation of the urethral sphincter mechanism, but there are simpler ways to do that than with multi-channel urodynamics. For example, if the patient leaks with a Valsalva maneuver, after voiding, in a supine position, that suggests she has ISD and therefore is likely to have a low-pressure urethra or a low leak-point pressure. Multiple centers have reported on this.2,3
Role of urethral function in choice of treatment
LUBER: There seems to be 2 schools. The first dichotomizes urethral function to reasonable (“good” urethral function) versus unreasonable (“poor” urethral function or ISD) and selects the operation based on that. Thus, a Burch or supportive operation would be used for good urethral function with hypermobility, and a sling operation would be selected for poor urethral function or ISD.
More recently, some experts have preached an inclusive approach, whereby all patients undergo sling operations. That strategy evolved out of frustration over the difficulty of identifying which patients have poor urethral function. Unfortunately, we lack good long-term data on the potential downside of performing sling procedures on all patients with incontinence. Hopefully, over the next 3 years, the National Institutes of Health data will help clarify whether we need to dichotomize patients in terms of urethral function.
Meanwhile, at our center, we continue to consider urethral function the deciding factor as to whether patients will undergo a gold-standard Burch procedure or a sling. We steer toward a sling procedure when the patient clearly has poor urethral function or ISD. Of course in cases of the fixed immobile and poorly functioning urethra, we also make bulking agents available.