Surgical Treatment of Female Stress Incontinence Flashcards
In the initial evaluation of patients with stress urinary incontinence desiring to undergo surgical intervention, physicians should include the following components:
History, including assessment of bother
Physical examination, including a pelvic examination
Objective demonstration of stress urinary incontinence with a comfortably full bladder (any method)
Assessment of post-void residual urine (any method)
Urinalysis
What would prompt further evaluation (other than just history, including assessment of bother, physical exam including pelvic examination, objective demonstration of stress urinary incontinence with a comfortably full bladder by any method, assessment of PVR by any method, and UA) for stress urinary incontience?
Physicians should perform additional evaluations in patients being considered for surgical intervention who have the following conditions:
Inability to make definitive diagnosis based on symptoms and initial evaluation
Inability to demonstrate stress urinary incontinence
Known or suspected neurogenic lower urinary tract dysfunction
Abnormal urinalysis, such as unexplained hematuria or pyuria
Urgency-predominant mixed urinary incontinence
Elevated post-void residual per clinician judgment
High grade pelvic organ prolapse (POP-Q stage 3 or higher) if stress urinary incontinence not demonstrated
with pelvic organ prolapse reduction
Evidence of significant voiding dysfunction
Physicians may perform additional evaluations in patients with the following conditions:
Concomitant overactive bladder symptoms
Failure of prior anti-incontinence surgery
Prior pelvic prolapse surgery
Should physicians perform cystoscopy for stress urinary incontinence?
Physicians should not perform cystoscopy in index patients for the evaluation of stress urinary incontinence unless there is a concern for urinary tract abnormalities.
Should physicians do urodynamics for stress urinary incontinence?
Physicians may omit urodynamic testing for the index patient desiring treatment when stress urinary incontinence is clearly demonstrated.
Physicians may perform urodynamic testing in non-index patients.
What important part of the history should influence if the patient should undergo surgery for stress urinary incontinence?
In patients wishing to undergo treatment for stress urinary incontinence, the degree of bother that their symptoms are causing them should be considered in their decision for therapy.
What are the treatment options (generally) for stress urinary incontinence or stress-predominant mixed urinary incontinence?
In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence who wish to undergo treatment, physicians should counsel regarding the availability of the following treatment options: (Clinical Principle)
• Observation
• Pelvic floor muscle training (± biofeedback)
• Other non-surgical options (e.g., continence pessary)
• Surgical intervention
Surgical treatment counseling
Physicians should counsel patients on potential complications specific to the treatment options.
Prior to selecting midurethral synthetic sling procedures for the surgical treatment of stress urinary incontinence in women, physicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.
What are non-surgical treatments for stress urinary incontinence or stress-predominant mixed urinary incontinence?
In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence, physicians may offer the following non-surgical treatment options:
Continence pessary
Vaginal inserts
Pelvic floor muscle exercises
What are surgical options for index patients considering surgery for stress urinary incontinence?
In index patients considering surgery for stress urinary incontinence, physicians may offer the following options:
Midurethral sling (synthetic)
Autologous fascia pubovaginal sling
Burch colposuspension
Bulking agents
What approaches can be used for index patients who choose midurethral sling surgery?
In index patients who select midurethral sling surgery, physicians may offer either the retropubic or transobturator midurethral sling.
What’s up with single-incision slings?
Physicians may offer single-incision slings to index patients undergoing midurethral sling surgery with the patient informed as to the immaturity of evidence regarding their efficacy and safety.
What should you do if the urethra is injured at the time of the planned midurethral sling?
Physicians should not place a mesh sling if the urethra is inadvertently injured at the time of planned midurethral sling procedure.
Should stem cell therapy be offered for stress incontinence?
Physicians should not offer stem cell therapy for stress incontinent patients outside of investigative protocols.
What happens if a patient has stress incontinence, and a FIXED, immobile urethra?
In patients with stress urinary incontinence and a fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’) who wish to undergo treatment, physicians should offer pubovaginal slings, retropubic midurethral slings, or urethral bulking agents.
What if a patient has stress urinary incontinence and intrinsic sphincter deficiency?
In patients with stress urinary incontinence and a fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’) who wish to undergo treatment, physicians should offer pubovaginal slings, retropubic midurethral slings, or urethral bulking agents.
When should a physician NOT use a synthetic mid urethral sling?
What factors would make them think against using a synthetic sling?
Physicians should not utilize a synthetic midurethral sling in patients undergoing concomitant urethral diverticulectomy, repair of urethrovaginal fistula, or urethral mesh excision and stress incontinence surgery.
Physicians should strongly consider avoiding the use of mesh in patients undergoing stress incontinence surgery who are at risk for poor wound healing (e.g., following radiation therapy, presence of significant scarring, poor tissue quality).
What should a physician do in patients undergoing concomitant pelvic prolapse or stress incontinence surgery?
In patients undergoing concomitant surgery for pelvic prolapse repair and stress urinary incontinence, physicians may perform any of the incontinence procedures (e.g., midurethral sling, pubovaginal sling, Burch colposuspension).
What should a clinician do for stress urinary incontinence and concomitant neurologic disease?
Physicians may offer patients with stress urinary incontinence and concomitant neurologic disease affecting lower urinary tract function (neurogenic bladder) surgical treatment of stress urinary incontinence after appropriate evaluation and counseling have been performed.
What patient populations need extra counseling to receive synthetic midurethral (actually any kind of) slings?
Physicians may offer synthetic midurethral slings, in addition to other sling types, to the following patient populations after appropriate evaluation and counseling have been performed:
Patients planning to bear children
Diabetes
Obesity
Geriatric
When should a patient be evaluated after a surgery for stress urinary incontinence?
SOON AFTER SURGERY
THEN WITHIN 6 MONTHS
Physicians or their designees should communicate with patients within the early postoperative period to assess if patients are having any significant voiding problems, pain, or other unanticipated events. If patients are experiencing any of these outcomes, they should be seen and examined.
Patients should be seen and examined by their physicians or designees within six months post-operatively. Patients with unfavorable outcomes may require additional follow-up.
What are the components of a post-operative appointment after a surgery for stress urinary incontinence?
When should a patient be evaluated after surgery?
Patients should be seen and examined by their physicians or designees within six months post-operatively. Patients with unfavorable outcomes may require additional follow-up.
The subjective outcome of surgery as perceived by the patient should be assessed and documented.
Patients should be asked about residual incontinence, ease of voiding/force of stream, recent urinary tract
infection, pain, sexual function and new onset or worsened overactive bladder symptoms.
A physical exam, including an examination of all surgical incision sites, should be performed to evaluate healing, tenderness, mesh extrusion (in the case of synthetic slings), and any other potential abnormalities.
A post-void residual should be obtained.
Q Tip Test
Holroyd-Leduc et al. included two studies with a total of 253 patients that evaluated the Q-tip test, with one study using a cutoff angle of 20° and the other 35°.
Both studies used urodynamic tests as the reference standard and the pooled positive LR was very small, suggesting that a positive test is unlikely to aid in the diagnosis of SUI.
Intuitively, this makes sense, since SUI may exist without urethral hypermobility and vice versa.
Thus, moderate strength evidence suggests that a positive Q-tip test has little value for diagnosis of SUI, and this test cannot be recommended by the panel to diagnose SUI.
However, it can provide some potentially useful information regarding the degree of urethral mobility.
What questions should be asked of a woman presenting with SUI?
Characterization of incontinence (stress, urgency, mixed, continuous, without sensory awareness)
Chronicity of symptoms
Frequency, bother, and severity of incontinence
episodes
Patient’s expectations of treatment (patient- centered goals)
Pad or protection use
Concomitant urinary tract symptoms (e.g., urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying)
Concomitant pelvic symptoms (e.g., pelvic pain, pressure, bulging, dyspareunia)
Concomitant gastrointestinal symptoms (e.g., constipation, diarrhea, splinting to defecate)
Obstetric history (e.g., gravity, parity, method of delivery)
Previous treatments for incontinence (e.g., behavioral therapy, Kegel exercises/pelvic floor muscle training, pharmacotherapy, surgery)
Previous pelvic surgeries
Past medical history (e.g., hypertension, diabetes,
history of pelvic radiation)
Current and past medications
Fluid, alcohol, and caffeine intake
Menopausal status
Options for management of SUI?
Mid urethral slings
Pubovaginal slings
Burch and retropubic suspensions
bulking agents
Options for management of SUI?
Mid urethral slings
Pubovaginal slings
Burch and retropubic suspensions
Bulking agents
Incontinence Pessary
Observation
Weight loss
PFME/PFPT
Contraindications to use of synthetic slings?
urethrovaginal fistula
urethral erosion
intraoperative urethral injury
urethral diverticulum
What are important questions to ask as part of history when assessing urinary leakage?
Frequency
Urgency (UUI)
Pads? How many?
Trouble urinating/incomplete emptying?
Hx of UTIs
Prior incontinence surgery
Bother of leakage
What are important for exam of SUI?
Abdominal masses/scars
POP
Hypermobility (Q-tip, visual inspection)
Urehtral/vaginal wall abonromaltieis
Atrophic Vaginitis
Objective leak (Valsalva, Leak; sitting, supine, stand)
PVR
What are risks to counsel patients on mid urethral slings?
Pain
Mesh infection
Dyspareunia
FDA Mesh notification (only vag. mesh, not sling)
General surgical risks (bleeding, infection)
Mesh extrusion, erosion
Obstruction (AUR)
De novo OAB
Bladder/urethral injury
Autologous: abdominal/thigh wound complications
What are some key principles of trochar passage? Common area of injury?
Make sure bladder drained
Evaluate vaginal wall to ensure no perforation/buttonholing
Cysto to ensure no trochar perforation of bladder/urethra
If bladder injury, can repass trochar
If urethral injury, abort, leave Foley
RP sling: dome
TOT: lateral walls
Treatment of intravesical mesh exposure?
Transabdominal mesh excision +/- tissue interposition
Transurethral laser ablation of exposed mesh or endoscopic excision
Transvaginal mesh excision, depending on how high along lateral bladder wall +/- tissue interposition
What do you do if there is a good deal of bleeding during sling placement?
Confirm patient hemodynamically stable
Finish sling placement
Pressure
Close and make sure no bleeding
Place packing if needed
What follow up questions do you ask post mid urethral sling?
Is she leaking?
Any new urgency
How is urinary flow
Pain with intercourse
UTIs
If patient complains of significant decrease in force of urine after sling, what should you consider?
Bladder outlet obstruction (sling incision/removal/urethrolysis)
Sling perforation
Cystoscopy
UDS (optional)
What are indications for UDS for patients with SUI?
Inability to make definitive diagnosis
Prior anti-incontinence surgery
Known or suspected NGB
Excessive PVR
Stage 3 or greater POP
Evidence of significant voiding dysfunction
Concomitant OAB
What is the prevalence of SUI?
A) Less than 10% of women are affected.
B) About 25% of women are affected.
C) As high as 49% of women are affected, depending on population and definition.
D) Only women over the age of 60 are affected.
Answer: C) As high as 49% of women are affected, depending on population and definition.
Explanation: The background states that the prevalence of SUI has been reported to be as high as 49% of women, depending on population and definition.
Who is considered the index patient for this guideline?
A) A male patient who has undergone previous SUI surgery.
B) An otherwise healthy female who is considering surgical therapy for pure stress and/or stress-predominant MUI and has not undergone previous SUI surgery.
C) A patient with high-grade pelvic organ prolapse.
D) Any patient who has undergone previous SUI surgery.
B) An otherwise healthy female who is considering surgical therapy for pure stress and/or stress-predominant MUI and has not undergone previous SUI surgery.
Explanation: The passage states that the index patient for this guideline, as in previous iterations of the SUI guidelines, is an otherwise healthy female who is considering surgical therapy for pure stress and/or stress-predominant MUI and has not undergone previous SUI surgery.
Which of the following is NOT a non-index patient that was reviewed in the analysis?
A) Women with SUI and pelvic prolapse (stage 3 or 4)
B) MUI (non-stress-predominant)
C) Incomplete emptying/elevated post-void residual (PVR) and/or other voiding dysfunction
D) Women with no history of SUI
D) Women with no history of SUI.
Explanation: The passage mentions several non-index patients that were reviewed in the analysis, including women with SUI and pelvic prolapse (stage 3 or 4), MUI (non-stress-predominant), incomplete emptying/elevated post-void residual (PVR) and/or other voiding dysfunction, prior surgical interventions for SUI, recurrent or persistent SUI, mesh complications, high body mass index (BMI), neurogenic lower urinary tract dysfunction and advanced age (geriatric).
Why did the Panel include studies of women who had undergone mesh procedures in their analysis?
A) To exclude mesh products from the surgical treatment of SUI.
B) To understand the literature regarding the safety of mesh products used in the surgical treatment of SUI.
C) To recommend mesh products for the surgical treatment of SUI.
D) To understand the literature regarding the efficacy of mesh products used in the surgical treatment of SUI.
B) To understand the literature regarding the safety of mesh products used in the surgical treatment of SUI.
Explanation: The passage states that the Panel felt it was important to more fully understand the literature regarding the safety of mesh products used in the surgical treatment of SUI, and therefore included studies of women who had undergone mesh procedures regardless of whether they were index or non-index patients.
Is there enough robust data to recommend a specific management approach for patients with persistent or recurrent SUI following any SUI treatment?
A) Yes, there is robust data to recommend a specific management approach.
B) No, there is not enough robust data to recommend a specific management approach.
C) The passage does not provide enough information to answer the question.
D) The Panel recommends against any specific management approach for these patients.
B) No, there is not enough robust data to recommend a specific management approach.
Explanation: The passage states that the Panel acknowledges that persistent or recurrent SUI following any SUI treatment is not uncommon, but that there is a lack of robust data to substantiate any recommendation from the Panel regarding the management of these patients. Therefore, there is not enough robust data to recommend a specific management approach.
What is SUI?
A) The symptom of urinary leakage that occurs in conjunction with the feeling of urgency and a sudden desire to urinate that cannot be deferred.
B) The symptom of urinary leakage due to increased abdominal pressure.
C) A leak point pressure of less than 60 cm H20 or a maximal urethral closure pressure of less than 20 cm H20.
D) A combination of SUI and UUI.
B) The symptom of urinary leakage due to increased abdominal pressure.
Explanation: The passage states that SUI is the symptom of urinary leakage due to increased abdominal pressure, which can be caused by activities such as sneezing, coughing, exercise, lifting, and position change.
How is intrinsic sphincter deficiency (ISD) often defined?
A) A combination of SUI and UUI.
B) The symptom of urinary leakage that occurs in conjunction with the feeling of urgency and a sudden desire to urinate that cannot be deferred.
C) A leak point pressure of less than 60 cm H20 or a maximal urethral closure pressure of less than 20 cm H20, often in the face of minimal urethral mobility.
D) The symptom of urinary leakage due to increased abdominal pressure.
C) A leak point pressure of less than 60 cm H20 or a maximal urethral closure pressure of less than 20 cm H20, often in the face of minimal urethral mobility.
Explanation: The passage states that ISD is often defined as a leak point pressure of less than 60 cm H20 or a maximal urethral closure pressure of less than 20 cm H20, often in the face of minimal urethral mobility.
What is mixed incontinence?
A) The symptom of urinary leakage that occurs in conjunction with the feeling of urgency and a sudden desire to urinate that cannot be deferred.
B) The symptom of urinary leakage due to increased abdominal pressure.
C) A combination of SUI and UUI.
D) A leak point pressure of less than 60 cm H20 or a maximal urethral closure pressure of less than 20 cm H20.
C) A combination of SUI and UUI.
Explanation: The passage states that mixed incontinence refers to a combination of SUI and UUI
What is leak point pressure?
Leak point pressure is the minimum pressure at which urine leakage occurs from the bladder during increased abdominal pressure, such as with coughing, sneezing, or other physical activities. It is used as a measure of urethral function in the assessment of urinary incontinence. A lower leak point pressure indicates weaker urethral sphincter function, which can be associated with stress urinary incontinence. However, the utility of urethral function assessment remains controversial and some clinicians utilize other measures such as urethral closure pressure.
What is urethral closure pressure?
Urethral closure pressure is a measure of the ability of the urethral sphincter to resist the flow of urine. It is usually determined by placing a pressure sensor in the urethra and measuring the pressure required to maintain continence. Urethral closure pressure can be measured at rest or during stress maneuvers, such as coughing or straining, to assess the function of the urethral sphincter in preventing urine leakage. A lower urethral closure pressure may indicate weaker sphincter function and can be associated with stress urinary incontinence. However, the utility of urethral function assessment remains controversial and there is no consensus on the most reliable measure of urethral function.
What components should be included in the initial evaluation of patients with stress urinary incontinence who desire surgical intervention, according to Guideline Statement 1?
A) Focused history, focused physical examination, and blood tests
B) Focused history, focused physical examination, and urinalysis
C) Focused history, focused physical examination, objective demonstration of stress urinary incontinence, assessment of post-void residual urine, and urinalysis
D) Focused physical examination, objective demonstration of stress urinary incontinence, and assessment of post-void residual urine
C) Focused history, focused physical examination, objective demonstration of stress urinary incontinence, assessment of post-void residual urine, and urinalysis.
Explanation: Guideline Statement 1 states that in the initial evaluation of patients with stress urinary incontinence who desire surgical intervention, physicians should include a focused history, including assessment of bother; a focused physical examination, including a pelvic examination; objective demonstration of stress urinary incontinence with a comfortably full bladder (any method); assessment of post-void residual urine (any method); and urinalysis.
Why is it important to include assessment of bother in the focused history of patients with stress urinary incontinence who desire surgical intervention?
A) To assess the patient’s financial resources for the surgery
B) To assess the patient’s knowledge of surgical interventions for stress urinary incontinence
C) To assess the impact of stress urinary incontinence on the patient’s quality of life
D) To assess the patient’s family and social support system
C) To assess the impact of stress urinary incontinence on the patient’s quality of life.
Explanation: Guideline Statement 1 states that in the initial evaluation of patients with stress urinary incontinence who desire surgical intervention, physicians should include a focused history, including assessment of bother. This is important to assess the impact of stress urinary incontinence on the patient’s quality of life, which is a critical consideration in the decision-making process for surgical intervention.
When should physicians perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence, according to Guideline Statement 2?
A) When the patient has a history of hypertension or diabetes
B) When the patient is over the age of 60
C) When the patient has a high grade pelvic organ prolapse (POP-Q stage 3 or higher) and stress urinary incontinence is not demonstrated by pelvic organ prolapse reduction
D) When the patient has a history of urinary tract infections
C) When the patient has a high grade pelvic organ prolapse (POP-Q stage 3 or higher) and stress urinary incontinence is not demonstrated by pelvic organ prolapse reduction.
Explanation: Guideline Statement 2 states that physicians should perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have certain conditions, including a high grade pelvic organ prolapse (POP-Q stage 3 or higher) if stress urinary incontinence is not demonstrated by pelvic organ prolapse reduction.
Why is it important to perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have abnormal urinalysis, such as unexplained hematuria or pyuria, according to Guideline Statement 2?
A) To assess the patient’s overall health before surgery
B) To evaluate for the presence of urinary retention
C) To rule out other causes of urinary symptoms
D) To determine the type of surgical intervention to be performed
C) To rule out other causes of urinary symptoms.
Explanation: Guideline Statement 2 states that physicians should perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have abnormal urinalysis, such as unexplained hematuria or pyuria. This is important to rule out other causes of urinary symptoms and ensure that the correct diagnosis is made before proceeding with surgical intervention.
Why is it important to perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have known or suspected neurogenic lower urinary tract dysfunction, according to Guideline Statement 2?
A) To assess the patient’s overall health before surgery
B) To evaluate for the presence of urinary retention
C) To rule out other causes of urinary symptoms
D) To ensure that the appropriate treatment is selected for the patient’s condition
D) To ensure that the appropriate treatment is selected for the patient’s condition.
Explanation: Guideline Statement 2 states that physicians should perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have known or suspected neurogenic lower urinary tract dysfunction. This is important to ensure that the appropriate treatment is selected for the patient’s condition, as surgical intervention may not be the best option for patients with neurogenic lower urinary tract dysfunction.
In which of the following conditions may physicians perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence, according to Guideline Statement 3?
A) History of smoking
B) History of diabetes
C) Concomitant overactive bladder symptoms
D) Elevated BMI
C) Concomitant overactive bladder symptoms.
Explanation: Guideline Statement 3 states that physicians may perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have concomitant overactive bladder symptoms.
Why may physicians perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have a history of failure of prior anti-incontinence surgery, according to Guideline Statement 3?
A) To assess the patient’s overall health before surgery
B) To evaluate for the presence of urinary retention
C) To rule out other causes of urinary symptoms
D) To determine the type of surgical intervention to be performed
D) To determine the type of surgical intervention to be performed.
Explanation: Guideline Statement 3 states that physicians may perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have a history of failure of prior anti-incontinence surgery. This is important to determine the type of surgical intervention to be performed, as previous surgery may impact the options available to the patient.
In which of the following conditions may physicians perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence, according to Guideline Statement 3?
A) Elevated blood pressure
B) Elevated cholesterol levels
C) Prior pelvic prolapse surgery
D) History of osteoporosis
C) Prior pelvic prolapse surgery.
Explanation: Guideline Statement 3 states that physicians may perform additional evaluations in patients being considered for surgical intervention for stress urinary incontinence who have prior pelvic prolapse surgery. This is important to assess the impact of the prior surgery on the patient’s anatomy and the potential impact on the success of the surgical intervention for stress urinary incontinence.
Which of the following has moderate strength evidence suggesting that it has little value for the diagnosis of SUI?
a. Pad test
b. Stress test
c. Q-tip test
d. None of the above
c. The Q-tip test has moderate strength evidence suggesting that a positive test has little value for the diagnosis of SUI.
What is the sine-qua-non for a definitive diagnosis of SUI?
a. A positive pad test
b. A positive Q-tip test
c. A positive stress test
d. Witnessing urine loss in the standing position
c. The sine-qua-non for a definitive diagnosis of SUI is a positive stress test or witnessing of involuntary urine loss from the urethral meatus coincident with increased abdominal pressure.
What details should physicians obtain from the history, bladder diary, questionnaires, and/or pad testing?
a. Menopausal status
b. Concomitant urinary tract symptoms
c. Fluid, alcohol, and caffeine intake
d. All of the above
d. Physicians should obtain details from the history, bladder diary, questionnaires, and/or pad testing including menopausal status, concomitant urinary tract symptoms, fluid, alcohol, and caffeine intake, among others.
What is the importance of assessing bother caused by SUI symptoms?
a) It can confirm the diagnosis of SUI
b) It can assess the differential diagnosis and comorbidities
c) It can help determine the patient’s expectations of treatment
d) It can determine the need for additional evaluation
c) It can help determine the patient’s expectations of treatment
Explanation: An assessment of bother caused by the symptoms is paramount to the decision to operate in the index patient, as treatment decisions should be closely linked to the ability to improve QOL. If bother is minimal, then strong consideration should be given to non-surgical management.
When should physicians perform cystoscopy in index patients for the evaluation of stress urinary incontinence (SUI)?
a) Always
b) Only when patients have normal urinalysis
c) Only when there is a concern for urinary tract abnormalities
d) Only when patients elect surgical therapy
c) Only when there is a concern for urinary tract abnormalities. According to Guideline Statement 4, physicians should not perform cystoscopy in index patients for the evaluation of SUI unless there is a concern for urinary tract abnormalities.
In which patients should cystoscopy be performed based on the guideline?
a) All patients with SUI
b) Patients with normal urinalysis
c) Patients suspected to have bladder pathology
d) Patients with normal lower urinary tract structure
c) Patients suspected to have bladder pathology. Cystoscopy should be performed in patients in whom bladder pathology is suspected based on history or concerning findings on physical exam or urinalysis. Additionally, it should be performed in patients with microhematuria on urinalysis and those with a history of prior anti-incontinence surgery or pelvic floor reconstruction, particularly if mesh or suture perforation is suspected.
According to Guideline Statement 5, when is urodynamic testing necessary in patients with uncomplicated SUI?
a) During initial patient evaluation
b) To determine outcomes after surgery
c) Both a and b
d) None of the above
d) None of the above. Guideline Statement 5 states that urodynamic testing is not necessary in otherwise healthy patients during initial patient evaluation or to determine outcomes after surgery.
What was the conclusion of the VALUE trial regarding the role of urodynamics in patients with uncomplicated SUI undergoing surgery?
a) Urodynamics in addition to office evaluation lead to better outcomes than office evaluation alone.
b) Urodynamics in addition to office evaluation do not lead to better outcomes than office evaluation alone.
c) There was no difference in outcomes between urodynamics in addition to office evaluation and office evaluation alone.
d) The VALUE trial did not evaluate the role of urodynamics in patients with uncomplicated SUI undergoing surgery.
c) There was no difference in outcomes between urodynamics in addition to office evaluation and office evaluation alone. The VALUE trial compared office evaluation alone to urodynamics in addition to office evaluation in 630 patients with uncomplicated SUI (pure SUI or stress-predominant MUI) undergoing surgery and showed no difference in outcomes as measured by clinical reduction in complaints measured by the Urinary Distress Inventory and the Patient Global Impression of Improvement (PGI-I).
In which patients should urodynamic testing be considered according to the guideline statement?
A) Index patients
B) Non-index patients
C) Patients with confirmed SUI
D) Patients with a negative stress test
B) Non-index patients.
Explanation: According to Guideline Statement 6, urodynamic testing may be performed at the urologist’s discretion in certain non-index patients to facilitate diagnosis, treatment planning, and counseling. These patients may include those with a history of prior anti-incontinence surgery or pelvic organ prolapse surgery, significant voiding dysfunction, significant urgency or overactive bladder, elevated post-void residual volume, unconfirmed SUI, and neurogenic lower urinary tract dysfunction. Index patients with confirmed SUI may not require urodynamic testing.
What should be considered when making treatment decisions for stress urinary incontinence (SUI)?
a) The patient’s age
b) The patient’s gender
c) The degree of bother caused by the patient’s symptoms
d) The patient’s socioeconomic status
c) The degree of bother caused by the patient’s symptoms should be considered when making treatment decisions for SUI.
Explanation: According to guideline statement 7, the degree of bother caused by the patient’s symptoms should be considered in their decision for therapy. Treatment decisions should be closely linked to the ability of any intervention to improve the bother caused to the patient by their symptoms. Patients should be counseled on the risks, benefits, and alternatives to any intervention they may choose in addition to the concept that the primary goal of treatment is to improve quality of life.
What treatment options should be discussed with patients with stress urinary incontinence or stress-predominant mixed urinary incontinence who wish to undergo treatment, according to the guideline?
a) Observation, surgical intervention
b) Pelvic floor muscle training, surgical intervention
c) Observation, pelvic floor muscle training, other non-surgical options, surgical intervention
d) Surgical intervention, incontinence pessary
c) Observation, pelvic floor muscle training, other non-surgical options, surgical intervention. According to the guideline statement, patients should be offered all of these options before a treatment decision is made.
Which treatment option may be appropriate for patients who are not bothered enough to pursue further therapy?
a) Pelvic floor muscle training
b) Incontinence pessary
c) Surgical intervention
d) Observation
d) Observation. The guideline states that observation may be appropriate for patients who are not bothered enough to pursue further therapy, not interested in further therapy, or who are not candidates for other forms of therapy.
Which surgical options may be used for the treatment of stress urinary incontinence or stress-predominant mixed urinary incontinence, according to the guideline?
a) Colposuspension
b) Incontinence pessary
c) Bulking agents
d) All of the above
d) All of the above. The guideline states that the primary categories of surgical options include bulking agents, colposuspension, and slings.
What is the significance of counseling patients on potential complications specific to the treatment options for SUI?
a. It is not necessary to inform patients about the risks of complications.
b. Patients can be informed about the risks of complications after the procedure.
c. The potential complications can affect the decision-making process of patients considering treatment for SUI.
d. Patients should not be informed about any risks of complications.
c. The potential complications related to a given intervention can play a significant role in the decision-making process for patients considering treatment for SUI. Accordingly, physicians need to educate and counsel patients regarding possible complications, some of which are non-specific and others that are unique to the various types of SUI surgery.
What are the potential intra-operative risks that can occur with surgery to correct SUI?
a. Dyspareunia and vaginal pain
b. Urinary tract infections and wound infection
c. Bladder injury, urethral injury, and bleeding
d. Pain associated with sexual activity and seroma formation
c. The potential intra-operative risks that can occur with surgery to correct SUI include but are not limited to bleeding, bladder injury, and urethral injury, as well as inherent risks of anesthesia, and of the procedure itself.
What are the risks associated with synthetic mesh sling placement?
a. De novo storage symptoms and worsening of baseline OAB symptoms
b. Abdominal, pelvic, vaginal, groin, and thigh pain
c. Mesh exposure into the vagina and/or perforation into the lower urinary tract
d. UTI and wound infection
c. In patients who are considering a synthetic mesh sling, counseling regarding the risk of transvaginal mesh placement is imperative. Risks include mesh exposure into the vagina and/or perforation into the lower urinary tract, either of which could require additional procedures for surgical removal of the involved mesh and, if necessary, repair of the lower urinary tract.
What is the focus of the discussion when counseling patients considering surgical intervention for SUI with midurethral synthetic sling procedures?
a) The superiority of MUS over alternative interventions
b) The efficacy of MUS in the long-term
c) The potential risks, benefits, and alternatives to MUS
d) The potential benefits of MUS in comparison to other interventions
c) The potential risks, benefits, and alternatives to MUS. The focus of the discussion should make clear to the patient the possible risks, benefits, and alternatives of MUS, and should not be on the superiority of one technique over another.
What are the potential intra-operative risks that can occur with surgery to correct SUI?
a. Dyspareunia and vaginal pain
b. Urinary tract infections and wound infection
c. Bladder injury, urethral injury, and bleeding
d. Pain associated with sexual activity and seroma formation
c. The potential intra-operative risks that can occur with surgery to correct SUI include but are not limited to bleeding, bladder injury, and urethral injury, as well as inherent risks of anesthesia, and of the procedure itself.
What are the risks associated with synthetic mesh sling placement?
a. De novo storage symptoms and worsening of baseline OAB symptoms
b. Abdominal, pelvic, vaginal, groin, and thigh pain
c. Mesh exposure into the vagina and/or perforation into the lower urinary tract
d. UTI and wound infection
c. In patients who are considering a synthetic mesh sling, counseling regarding the risk of transvaginal mesh placement is imperative. Risks include mesh exposure into the vagina and/or perforation into the lower urinary tract, either of which could require additional procedures for surgical removal of the involved mesh and, if necessary, repair of the lower urinary tract.
What is the prevalence of SUI among women, as stated in the AUA/SUFU guideline?
A) 10-20%
B) Up to 49%
C) 30-40%
D) 50-60%
B) Up to 49%
Explanation:
According to the AUA/SUFU guideline, the prevalence of SUI has been reported to be as high as 49%.
Memory Aid:
Think of a half-full glass of water. The glass isn’t 50% full; it’s just shy of half at 49%. This helps you remember the upper limit of SUI prevalence.
