Additional factors in the choice of treatment
SAND: We throw 2 other things into the algorithm at our center: One is detrusor overactivity, which is very important when considering surgical treatment of stress urinary incontinence. The second is voiding function.
Activity level of the patient is an additional measure, as Dr. Myers commented on earlier. I’m not as concerned about age as I am about the patient’s physical activity and expectations for the operation over time. For example, for a woman who is relatively homebound and not physically active and has poor voiding function (underactive detrusor) and prolapse with normal intrinsic urethral function, a Kelly Kennedy procedure at the time of an anterior colporrhaphy may be more appropriate than a Burch procedure.
Detrusor overactivity is important because, in the trial that we performed, the Burch retropubic urethropexy had a 55% objective cure rate of concurrent detrusor overactivity and a 70% subjective cure rate of the symptom of urge urinary incontinence. In contrast, over the last 12 years, the sling procedure has had a resolution rate of between 20% and 28% for recurrent detrusor overactivity. Recent subjective data at 1 year for midurethral slings fall into the same range: 20% to 30% resolution of recurrent urge incontinence.
Another factor is de novo detrusor overactivity. The rate of de novo detrusor overactivity and urge incontinence in our sling patients seems consistently higher, compared with our retropubic urethropexy patients. We all know that the patient with urge incontinence is far more upset about her condition than the patient who has predictable stress incontinence, because urge incontinence can be far more destructive to quality of life. I try to encourage gynecologists to consider this factor.
Voiding function is less clear-cut. Basically, because intrinsic urethral function declines with age, it is not uncommon to see a woman in her 70s or 80s with ISD who also has absent detrusor contractions during voiding studies. The physician can assess this function by ultrasound or urodynamic testing, or by measuring the postvoid residual volume, which usually falls in the range of 100 to 200 mL, especially if no prolapse is present. Thus, even in cases in which I normally would want to do a sling for ISD, I opt against it if the patient has poor voiding function. That’s because the risk of permanent retention may rise as high as 15% to 20% in some of these patients.
Evaluation and treatment of mixed incontinence
DAVILA: I think we all agree that incontinence is easier to address than “hypercontinence” resulting from postoperative urethral obstruction, urinary retention, and irritative voiding symptoms. But what about patients with mixed incontinence? How do you evaluate them? Is there a role for surgical procedures in patients with primary urge incontinence?
I believe in offering all patients both nonsurgical and surgical options.—Dr. Sand
SAND: Many centers offer nonsurgical treatment of mixed incontinence, especially if urge incontinence predominates. But I believe in offering all patients both nonsurgical and surgical options. I end up triaging based on what patients select first, regardless of whether they have pure SUI or mixed symptoms, as long as they have been counseled appropriately about the expected outcomes of the various options.
MYERS: In my practice, I treat the urge symptoms first with anticholinergics or other medications. Then, if the stress incontinence continues, I offer a procedure.
This may be difficult in some cases, such as a patient with severe ISD. It is hard to treat detrusor overactivity when the urethral sphincter is weak, as the woman cannot hold increasing volumes of urine in the bladder.
Thus, I approach these cases by treating the stress incontinence first and then the urgency symptoms if intervention is still necessary—which is a 180-degree shift from my previous statement. In these cases, I treat the ISD first. Then, after the stress incontinence resolves, I offer medications for the urgency.
LUBER: I want to throw a little cold water on surgical treatment of overactive bladder. Clearly, this is an enormous issue. Probably 40% of women who come to my office complaining of urinary incontinence have mixed symptoms or mixed disease as determined by urodynamics. For the doctors out there caring for these patients daily, I think it is important to remember, as Dr. Sand mentioned, that in some cases, anti-incontinence operations can provoke detrusor overactivity in patients who were relatively asymptomatic previously. Dr. Myers’ suggestion that surgery may simply unmask the detrusor overactivity is also possible, of course.
Probably 40% of women who come to my office complaining of urinary incontinence have mixed symptoms.—Dr. Luber