Urogynecological Risk Assessment in Postmenopausal Women

Niladri Sengupta; Timothy Hillard

Disclosures

Expert Rev of Obstet Gynecol. 2013;8(6):625-637. 

In This Article

Pelvic Organ Prolapse

Although the etiology of pelvic organ prolapse (POP) is multi-factorial and poorly-defined, menopause is an independent risk factor and more than one-third of postmenopausal women have symptomatic prolapse.[1] About half of these patients have anterior vaginal wall prolapse (cystocele), a quarter have posterior vaginal wall prolapse (rectocele) and one-fifth have apical or vault prolapse.[2]

Ageing and menopause are considered to be decompensating factors contributing to the development of POP but the natural history of prolapse is not clearly understood. Change in the total collagen and collagen ratios (Type 1 to Type 3 ratio) with menopausal status have been postulated by different authors, but the results are conflicting.[3,4] Diminished expression of estrogen receptors has been found in patients with POP, but how exactly estrogen influences collagen metabolism in relation to POP is not clear. However, current opinion suggests that there is an active remodeling of the vagina and its connective tissues in response to different stimuli such as pregnancy and menopause and the metabolism of collagen and elastin is altered in women with POP.[3,4] In a study of postmenopausal women participating in the Women's Health Initiative (WHI) trial, it was observed that prolapse progresses and regresses with time and worsening prolapse is more common with age, multiparity and increased BMI.[5] In a group of post-menopausal women who were followed up for 4 years the incidence of new prolapse was 26% at 1 year and 40% at 3 years.[5]

Assessment

A history and general assessment of the patients is mandatory to exclude pathology and evaluate various factors which may influence choice and success of management. Evaluation of systems such as bowel, urinary and sexual function, coexistent morbidities, medical and surgical history, any physical or mental impairment and lifestyle are noticeably very important, particularly in the elderly. The patient's social circumstances and support systems, desire for treatment and expectations will have implications on the management options.[6]

A traditional clinical history taking in women presenting with prolapse should ideally be supplemented by a tool to assess the symptoms and impact of the POP on the patient's life. This lends some degree of objectivity to the preliminary assessment and can be compared with a post-intervention questionnaire to evaluate the efficacy of the intervention. The Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) and their shortened versions PFDI-20, PFIQ-7, are popular, reliable and validated quality of life questionnaires for women with pelvic floor disorders. This is especially useful as symptoms of bladder, bowel and sexual dysfunction often co-exist in prolapse patients and have poor correlation to the site and size of prolapse.[101]

Patient's expectations from treatment/intervention have also been used as a tool for measuring outcome. Patient-selected goals have therefore evolved as a recognized alternative way of assessing improvements in symptoms and quality of life (QoL).[7]

The size of a prolapse can change throughout the day, with it being more pronounced at the end of the day, especially after prolonged standing. Position of the patient during examination, straining, traction on prolapse and fullness of bladder are other variables which can influence the assessment of prolapse.[8] The morphological and clinical subdivision of the female pelvis and its functional supports are summarized in Table 1 & Table 2, respectively.

The gradation of severity of POP can be made using either the Baden-Walker Halfway Scoring System (Table 3)[9] or the International Continence Society (ICS) approved pelvic organ prolapse quantification (POP-Q) system (Figure 1 & Table 4).[10] The POP-Q system uses nine points measured in the vagina, with the hymen as the reference point and the prolapse is assessed in centimeters relative to the hymen. All measurements except total vaginal length are measured at maximum valsalva. It is an international standardized objective tool for clinical documentation and research purposes with proven inter- and intra-observer reliability.[10–12] However, in daily clinical practice, the Baden-Walker grading system of prolapse seems more convenient and popular among clinicians.

Figure 1.

Pelvic organ prolapse quantification (POP-Q) system.
Reproduced with permission from [10].

Management of Symptomatic Prolapse

Symptomatic prolapse can be managed either conservatively or surgically. It is important to remember that a prolapse rarely poses significant medical risks to the woman and the potential symptomatic benefit of any intervention has to be weighed up against the potential risks of that intervention on an individual basis.

Conservative Measures Conservative measures such as pelvic floor muscle exercises/training (PFMT) supplemented by lifestyle interventions such as weight loss, avoidance of straining (reducing lifting heavy weights, treatment of chronic cough and constipation) are recommended as first-line management. PFMT is aimed to increase the strength and endurance of the pelvic floor supports, prevent or delay worsening of prolapse and improve prolapse symptoms. PFMT can help women delay or avert the need for surgery and pre- and post-operatively have been found to improve outcomes after surgery.[13,14]

Reduction of Prolapse Reduction of prolapse by mechanical devices such as a pessary, supplemented by vaginal estrogen can be effective non-surgical measures for relieving prolapse symptoms. A pessary may be particularly suitable for the patients who are in poor surgical risks and those who want to avoid or delay in surgery. A trial of a pessary may also be helpful before deciding whether or not surgery would provide symptomatic improvement. There are a wide variety of pessaries such as ring, shelf, Hodge and Gellhorn which can be suited to different types of prolapse. They may be used on a long-term basis, but need to be replaced every 4–6 months and the vaginal mucosa checked for erosions. The commonest adverse effect is offensive vaginal discharge and bleeding from vaginal erosions. There are no randomized controlled trials to prove the efficacy of these mechanical devices but a recent prospective study noted similar improvement in symptoms and QoL with both pessary and surgical treatment of prolapse after 1 year.[15,16] Spontaneous regression of stage 1 prolapse is common[17] and symptomatic prolapse are mostly those where the bulge extends beyond the introitus (i.e., mostly stage 2 and all stage 3)[18] and hence conservative measures are appropriate in most cases of mild (stage 1) prolapse.

Surgical Treatment Surgical treatment of symptomatic prolapse aims to restore anatomy and function and is indicated when the woman is symptomatic and has either declined or failed to improve with conservative measures. Studies have shown that by the age of 80 years, around 12% (one in eight) of women will have undergone a single operation for prolapse or incontinence and up to 30% of women who undergo surgery for POP will require a second procedure (risk of repeat surgery being 8.8% for anterior compartment and 7.4% for posterior compartment).[19,20] The success rates for repeat procedures for recurrent prolapse is less than the primary procedure, hence careful choice of primary procedure is the most important thing.

A detailed review of the various surgical techniques is beyond the scope of this article but the discussion below gives a brief overview of the pertinent issues. Eighty one percent of all POP surgical repairs involve anterior vaginal wall repairs[19] with midline fascial plication being the most commonly performed anterior vaginal wall repair technique. There is a paucity of long-term data for different rectocele repair techniques, but fascial defect repair is currently the operation of choice as it appears to have fewer incidences of complications and better functional outcomes.[21,22] Both abdominal sacrocolpopexy (laparoscopic or open) and vaginal sacrospinous fixation are effective surgical options for apical or vault prolapse.[23]

The correction of a procidentia and large anterior compartment prolapse can sometimes unmask stress urinary incontinence (SUI). The incidence of new stress incontinence after prolapse surgery has been quoted as 15%. It is not known if the reduction testing can predict post-operative stress incontinence. The incidence of post-operative or de novo stress incontinence is not reduced by performing prophylactic concomitant incontinence surgery.[23] In approximately 50% cases, uterovaginal prolapse is associated with urinary incontinence (UI), mainly stress incontinence. The role of combining prolapse repair with an incontinence surgery has been much debated. Although small studies,[24,25] have not revealed any significant difference between the two strategies, a recent multicenter randomized controlled trial: outcomes following vaginal prolapse repair and midurethral sling (OPUS) trial concluded that concomitant prophylactic sling procedure done at the time of prolapse repair resulted in a lower rate of UI at 3 months (23.6 vs 49.4%) and 12 months (27.3 vs 43%), however the rate of bladder perforation, UTI, major bleeding complications and voiding difficulty were significantly higher in the group receiving prophylactic sling surgery.[26] While prophylactic incontinence surgery along with prolapse repair is usual practice in the USA, most surgeons in Europe prefer to perform anterior compartment repairs and incontinence procedures as interval procedures at separate sittings to minimize the above risks.

There is uncertainty about the benefits of performing a vaginal hysterectomy at the same time as a prolapse repair. Uterus-conserving surgery for uterovaginal prolapse with a hystero-sacropexy is gaining popularity as an alternative to the traditional vaginal hysterectomy and pelvic floor repair.[27]

In recurrent prolapse or where the quality of native tissue is sub-optimal, the use of vaginal grafts is becoming increasingly popular. Grafts can be biological (i.e., absorbable), synthetic absorbable or synthetic non-absorbable. At present synthetic non-absorbable type 1 polypropylene macroporous mesh appears to be the best choice. However while mesh gives good support and anatomical correction, there are significant complications with erosion rates as high as 15% being reported. Also, good anatomical repair has been superseded by good functional outcome as being the desirable goal of surgery. Thus the routine use of vaginal mesh is not recommended and further research is required to aid proper patient selection and minimize the adverse effects.[28] The US FDA (2011), and more recently the MHRA (2012) have highlighted the complications of mesh use in prolapse repair and have issued cautionary notes against their use in the vaginal prolapse repair.[29,30]

Obliterative surgery such as colpocleisis may be suitable for women who are unable to tolerate more extensive surgery and where women are no longer sexually active. It has a success rate of over 97% and has a short operating time and fewer complications. It can even be done under local anesthesia which may be particularly suitable for those who are poor anesthetic risk.[31]

In the presence of obstructed defecation or fecal incontinence with associated recto-enterocele, (as well as other complex cases) a multi-disciplinary approach is recommended with appropriate imaging (MRI/defecating proctogram), physiology studies where appropriate and discussed at a pelvic floor multidisciplinary team (MDT) meeting which comprises of physiotherapist, specialist urogynecology nurse, urogynecologist, colo-proctologist and radiologist.[32]

Transvaginal, transanal or laparoscopic repairs may all be considered depending on the underlying defect.

In general the choice between vaginal or abdominal approach will depend on multiple factors and the surgeon's preference. The vaginal approach is associated with less morbidity and less hospital stay compared to abdominal surgery; however the anatomical outcome and long-term effectiveness of an abdominal repair may be better especially for the apical compartment.[23] The increasing use of the laparoscopic approach rather than the traditional open abdominal approach may tilt the balance in favor of the abdominal approach but these procedures tend to be time consuming. Ultimately the surgeon's preference and expertise as well as patient's general health and choice should be the deciding factor.

Urinary Incontinence

Women are two times more susceptible towards development of UI as compared to men and the prevalence increases with advancing age. The prevalence of UI range increases with age from 17–55% in older women. Overactive bladder (OAB) syndrome is defined as urinary urgency, with or without urinary incontinence, usually with frequency and nocturia, in the absence of infection or other obvious pathology. OAB affects almost one out of eight women and the incidence as well as the disease is more severe in later life. Stress urinary incontinence (SUI) is the involuntary leakage of urine on effort or exertion, or on sneezing or coughing. SUI appears to peak peri-menopausally, whereas urge and mixed incontinence predominate in older women.[33–35]

SUI can be classified according to its pathophysiology into intrinsic sphincter deficiency (ISD) and urethral hypermobility. In majority of patients, these often co-exist, and there is no standardized test to differentiate between these two entities accurately.

Accurately diagnosing the underlying problem can be difficult on the basis of the history alone as there is a lot of overlap in symptoms and very variable reporting. Thus various tools such as bladder diary (frequency/volume charts), quality of life (QoL) questionnaires, number of pads used, pad testing and urodynamics are used to gain a better insight into the patient's problems with some degree of objectivity. The QOL questionnaires attempt to record and measure the subjective symptoms in an objective way. There are many different UI questionnaires which have been validated, some of which are gender-specific, or condition-specific, but the popular and recommended ones are International Consultation on Incontinence Modular questionnaire (ICIQ), Bristol Female Lower Urinary Tract Symptoms questionnaire – Short Form (BFLUTS-SF), King's Health questionnaire (KHQ), Urogenital Distress Inventory (UDI and UDI-6), Stress and Urge Incontinence and Quality of Life questionnaire (SUIQQ).[102]

A three-day bladder diary (frequency-volume chart) has been recommended by NICE as a reliable method of quantifying urinary frequency and UI, and is also useful for assessing the outcome of treatment. The bladder diary is a non-invasive, cost-effective method of assessing severity of incontinence in primary care compared with pad-testing and validated scales.[36] It also documents the timings, type and volume of fluid intake which can often be modified to improve the urinary symptoms and gives an idea of the functional bladder capacity. The frequency of night-time voiding has been shown to be the most important variable to discriminate between urge and stress incontinence.[37]

Urodynamic testing (UDS) is a laboratory based investigation to assess bladder function and diagnose the underlying condition which can be used to guide management decisions.[38] The commonest UDS is multichannel cystometry which records pressure-volume relationship during bladder filling and emptying.[39] Videocystometrography (videourodynamics) combines fluoroscopic screening with urodynamics and allows a combined anatomical and functional evaluation of lower urinary tract function. It is a useful tool for assessment of patients with neurogenic bladder (identification of vesico-ureteric reflux and detrusor sphincter dyssynergia). It also enables visualization of anatomic abnormalities such as bladder or urethral diverticulae or fistulae and bladder herniation. Conventional urodynamics (CMG) is a 'static' test and considered non-physiological test as it involves retrograde filling of the bladder in a hospital setting and may not always reproduce the symptoms reliably. In ambulatory urodynamics, bladder filling is natural and the patient is absolutely mobile and carrying out her daily activities, which may provoke symptoms. Hence it is useful in symptomatic patients where conventional UDS has failed to explain; it allows repeated measurement of pressure flows and helpful in assessment of neurogenic lower urinary tract dysfunction. However, videourodynamics and ambulatory urodynamics are complex, time-consuming and expensive investigations but are best suited to assess a limited subset of patients.

The place of UDS in current urogynecological assessment is where: the diagnosis is uncertain after initial history-taking and clinical examination; symptoms do not correlate with objective physical findings; there is failure to improve with treatment; surgical intervention is planned; there has been previous surgery for stress incontinence or anterior compartment prolapse; and there is suspicion of detrusor over activity, and in presence of clinical symptoms of voiding dysfunction.[38] However, there is no conclusive evidence that pre-operative UDS before surgery for stress incontinence has any actual impact on outcome. In addition, it is criticized as being an artificial set up which often fails to reproduce the patient's symptoms; it is expensive and operator dependent and can be interpreted differently by different investigators, most importantly patients find it unpleasant and the risk of infection (UTI) is about 20%.[40]

UDS should be used for the investigation of any new treatment modalities and to establish a diagnosis when the clinical diagnosis is in doubt. UDS is not necessary before pelvic floor muscle training, medical treatment of lower urinary tract symptoms (LUTS) or OAB or before the surgical treatment of primary female SUI or prolapse.[41] The Value of Urodynamic Evaluation (ValUE) trial,[42] concluded that routine pre-operative urodynamic investigation is not required in uncomplicated stress-predominant urinary incontinence with a positive office stress test, normal post-void residuals and normal urinalysis.

The results of the Value of Urodynamics Prior to Stress Incontinence Surgery 2 (VUSIS 2) trial in the Netherlands and the proposed INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect? (INVESTIGATE-2) trial in the UK, should define the further role of urodynamics.

UI is assessed in different ways depending on the clinical setting (i.e., primary care or secondary care) and Table 5 summarizes the accuracy of different methods when compared to urodynamics.[43]

Management of urge incontinence is often a challenging task and available modalities have to be tailored to suspected etiology (idiopathic, infection or inflammation, neurologic diseases such as multiple sclerosis, spinal cord injury, cerebrovascular disease or prior pelvic surgery). The options for managing urge incontinence are summarized in Table 6.

Lifestyle interventions such as a reduction in caffeine, alcohol or fizzy drink intake, modification of fluid intake, weight loss in obese patients, moderate physical activity and smoking cessation can have a positive impact on bladder function[34] and should always be a part of the initial strategy.

Behavioral Therapies

Bladder training/re-training which usually comprises of patient education, scheduled voiding and positive reinforcement should be offered for a minimum of 6 weeks as first-line treatment to women with urge or mixed UI.[36,44]

Physical Therapies

Pelvic Floor Muscle Training PFMT has been shown to be beneficial in all types of incontinence.[45]

Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) with electrodes placed over S2-S4 dermatomes has been shown to lead toward a subjective improvement in symptoms and is an option where pharmacotherapy is not tolerated.

Percutaneous Posterior Tibial Nerve Stimulation Percutaneous posterior tibial nerve stimulation (PTNS) which is a neuromodulation, based on the stimulation of peripheral nerves sharing the same S3 sacral root as the bladder, has reported success rates of about 60%, which is comparable to pharmacotherapy with anticholinergics and has the advantage of less side effects.[46]

Drug Therapies

Anticholinergics/Antimuscarinics Anticholinergics/antimuscarinics work by inhibiting detrusor muscle contraction that is under parasympathetic control via the M2 and M3 receptors. The Cochrane review of anticholinergic medication for OAB reported a statistically significant difference in outcome, compared to placebo, with those on active anticholinergic treatment having four less leakage episodes and five less voids per week.[47] A modest improvement in QoL was noted with anticholinergics, however, a significant placebo response was also noted (41% reporting cure or improvement in symptoms in the placebo groups). Anticholinergics are renowned for their side effects due to widespread action on the muscarinic receptors. Overall, dry mouth is the main side effect of the anticholinergics but other common side effects are constipation, drowsiness, leg cramps and blurring of vision. Discontinuation of treatment because of side effects often limits the efficacy of these agents. The incidence of dry mouth is almost three-times compared with placebo, but is also depends on polypharmacy which again is quite common in the elderly population.[48] Newer preparations are more specific to the M3 receptors which are predominantly found in the bladder and appear to be better tolerated with less side effects.[48]

Beta-three (β3) Adrenoceptor Agonist (Mirabegron) Beta-three (β3) adrenoceptor agonist (mirabegron) is a recently introduced class of drug which acts on the β3 receptors present in the bladder promoting detrusor relaxing and improving the bladder storage capacity, hence it is clinically effective as treatment option for overactive bladder. NICE recommends the use of mirabegron as a treatment alternative to anticholinergics for the patients of OAB who cannot have the anticholinergics (either because of contraindications or had to stop because of unacceptable side effects) or for whom they have been ineffective. Recommended dosage of mirabegron is 50 mg once daily (q.d.), and 25 mg once daily in the presence of hepatic or renal impairment. The common side effects noted in clinical studies were hypertension, nasopharyngitis, palpitations/tachycardia, UTI, headache and dyspepsia/gastritis. However, long-term adverse effects and pharmacokinetic interactions are yet to be evaluated.[49]

Estrogens Vaginal estrogens reverse urogenital atrophy in post-menopausal women and reduce symptoms of sensory urgency.[50] They are recommended as part of the treatment of OAB symptoms in post-menopausal women with vaginal atrophy.[36]

Desmopressin Desmopressin is a synthetic analogue of vasopressin and has a potent anti-diuretic action. It is an effective treatment for nocturia, whereby the number of voids as well as nocturnal voided volumes, are both reduced significantly. Side effects are mainly headache, nausea and hyponatremia (serum sodium should be measured within three days of treatment). The latter limits its use in the elderly.[51]

Tricyclic antidepressant, such as Imipramine, exerts anticholinergic and musculotropic effect, thereby increasing bladder outlet resistance, relaxing the detrusor and improving bladder storage. It has been used in conjunction with anticholinergics in treatment of OAB. However before prescribing to the elderly, the adverse effects on cardiovascular and cognitive function, as well as drug interactions should be kept in mind.[52]

Complementary Therapies

Complementary therapies such as hypnosis and acupuncture are no longer recommended for treatment of OAB.[36]

Surgical Therapies

Surgical therapies are reserved for those with debilitating symptoms who have not responded to medical and behavioral therapy.

Intravesical Injection of Botulinum Toxin A Intravesical injection of Botulinum toxin A provides rapid and significant improvement of symptoms of UI in patients with neurogenic detrusor overactivity. The Cochrane review of Botulinum toxin in OAB[53] noted that botulinum toxin is effective in idiopathic detrusor overactivity with a reported clinical response in 60% patients.[54] The duration of effect varies from 3–12 months depending on the dosage. Recent publication of the RELAX Study confirmed the safety and efficacy of Botulinum toxin A, in a dosage of 200 IU, in refractory detrusor overactivity with improvement in QoL scores. Continence was achieved in one-third of the patients but the incidence of UTI was 31% and voiding difficulty requiring catheterization was 16%.[55]

Sacral Nerve Modulation Sacral nerve modulation is a permanent implantable device (pulse generator) that provides continuous stimulation to S3 nerve roots. Insertion is an invasive procedure and life-long follow-up is required. A temporary device is implanted initially and if it is successful, a permanent device is implanted. Upto two-third of patient have significant improvement or achieve continence, and the beneficial effects may last for 3–5 years, at which point the battery needs replacing.[56] Pain at the implant site and lead migration are common complications, and cost of the device is a major limitation. Expertise in sacral and other forms of neuromodulation (PTNS and pudendal nerve stimulation) is picking up due to the growing popularity of these modalities for treatment of refractory OAB.

Augmentation Cystoplasty & Urinary Diversion by Ileal Conduit Augmentation cystoplasty and urinary diversion by ileal conduit are the last-line surgical options, discussion on which is beyond the scope of this article.

Management of Stress Incontinence

Pelvic Floor Muscle Training Management options for stress incontinence are listed in Table 7 . Pelvic floor muscle training (PRMT) NICE recommends supervised PFMT for at least 3 months' duration.[36] A Cochrane review of PFMT, concluded that pelvic floor exercises are beneficial in all forms of UI, however, the most noticeable effects are seen when women with stress incontinence who undergo supervised PFMT for 3 months or more (eight contractions performed at least three-times/day).[45]

Vaginal Cones Vaginal cones trying to retain or keep the cones inside the vagina, contracts the muscles and strengthen them. It has been superseded by PFMT as procedure of choice for conservative management of stress and mixed incontinence.

Drugs Duloxetine is a serotonin and noradrenaline reuptake inhibitor which acts on the sacral spinal cord and increases the pudendal nerve activity with resultant increase in urethral sphincter contraction and closure pressure. NICE recommends that duloxetine should only be considered if the patient prefers to take medications instead of surgery or if the patient is unsuitable for surgery, and in such circumstances the patient should be counseled about its adverse effects (nausea, dry mouth, vomiting, dizziness, fatigue, insomnia and increased sweating).[36] In the USA, duloxetine is yet to be approved for use in SUI.

Surgery

Bulking Agents Injection of bulking agents into the urethral sub-mucosa is performed to enhance the submucosal cushions to enable better urethral cooptation and increase the resistance to urinary flow in the face of increased abdominal pressure. It is a minimally invasive, day-case procedure, suitable for women who decline sling or colposuspension surgery, and in selected cases to assess if the patient's urinary symptoms are likely to improve after incontinence surgery. The procedure is usually performed transurethrally or periurethrally under local anesthesia with cystoscopic guidance and the injections made just distal to the bladder neck (or mid-urethrally). Various different preparations have been used with varying success.[57] Overall, the efficacy is inferior to colposuspension or sling procedures at 12 months, but has lesser morbidity. Complications include dysuria (47%), temporary urinary retention (usually short-term, in 6–17%), urinary urgency (12–25%) urinary infections and hematuria.[57] The main limitations are that the efficacy diminishes with time and the injections usually need to be repeated. Bulking agents are more expensive compared to sling surgery.[36]

Colposuspension Open abdominal retropubic urethropexy or Burch colposuspension was regarded as the gold-standard operation for stress incontinence before the advent of the mid-urethral slings, with cure rates of 85–90% after 1 year and 80% after 5 years.[58] Voiding dysfunction (short term), groin pain, de novo OAB and increase in post-operative prolapse (rectocele and enterocele) have been reported as complications.[59] In the hands of an experienced minimal access surgeon, laparoscopic colposuspension can be as effective as the open procedure, and has the advantage of a lesser morbidity and quicker recovery; however it has a longer operation time and is more expensive.[60] Although largely superseded by the mid urethral slings, colposuspension remains an option to consider in cases of failed mid-urethral tape.[61]

Slings

The Minimally Invasive Synthetic Sub-urethral Slings The minimally invasive synthetic sub-urethral slings such as Tension-free Vaginal Tape (TVT®) by the retropubic route, the outside-in Transobturator Tape (TOT®) and the inside-out Tension-free Vaginal Tape-Obturator (TVT-O) have now established themselves as the treatments of choice for stress incontinence. These tapes use monofilament type 1 polypropylene mesh that is positioned without tension under the mid-urethra by using needle passers/trocars to pass it through the retropubic space or obturator foramen. The TVTwas the first of its kind, has the longest follow-up data available[60,63] and is recommended by NICE as the first choice surgical treatment for stress incontinence.[37] In the Cochrane review superior objective cure rates for the retropubic tape (TVT) were reported compared to the transobturator tapes (TOT and TVT-O), however the subjective cure rates in both groups were similar.[62] Results from the National Incontinence Registry in Norway concluded that better objective and subjective outcomes were noted with TVT as compared to TOT and TVT-O.[63] However, adverse events such as bladder injury and voiding difficulties are higher with TVT, whereas groin pain, vaginal injury, mesh erosions and urethral injury were more common with TOT and TVT-O.[64] With reference to these observations, some surgeons prefer transobturator tapes as first choice in women with previous continence surgeries such as colposuspension, in significantly obese patients and also in women who are at higher risk of voiding problem (low to borderline flow rates).

Most tapes are performed as day cases under local or spinal anesthesia and the tension of the tape can be adjusted by using the 'cough test'.[65] However some surgeons prefer to do these sling procedures under general anesthetic. Although the sling operation was designed to treat stress incontinence, multiple researchers have noted encouraging results in mixed urinary incontinence patients where there has been significant improvement in symptoms of detrusor overactivity after a TVT.[66,67]

Mini-slings or single-incision midurethral slings were introduced in 2006 to avoid the potential complications of retropubic and transobturator passage of needles and was an attractive option which could be done quickly potentially as an office procedure under local anesthesia. However, short-term results were found to be inferior to the standard midurethral tapes with a higher re-operation rate.[68] Further studies are in progress.

Traditional Suburethral Sling These are open slings procedures, usually performed as a combined abdomino-vaginal approach, to support the bladder neck using autologous (rectus fascia, fascia lata) or synthetic materials (Gore-tex, Teflon, etc). Rectus fascial sling is the most widely evaluated biological sling that has been found to be as effective as open colposuspension and TVT, but it has higher rates of adverse effects (postoperative voiding dysfunction and OAB) and is not as cost-effective as the TVT.[69]

The effect of age on outcome of stress incontinence operations have been looked at by several authors. Pugsley et al. evaluated the outcome for women aged 70 years and more undergoing colposuspension and TVT and compared it with younger women.[70] Subjective cure or improvement for both procedures were the same in both groups, however the elderly patients were more at risk of post-operative and recurrent UTI, readmissions, voiding difficulty, self-catheterization and further surgery to divide the TVT.

Artificial urinary sphincter is an option in cases of recurrent severe stress incontinence where other surgeries have failed. It has been used in cases of neurogenic bladder, patients with previous pelvic trauma or pelvic irradiation.

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