Surgical Treatment of Female Stress Incontinence

Question 1

In the initial evaluation of patients with stress urinary incontinence desiring to undergo surgical intervention, physicians should include the following components:

Answer 1

 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

Question 2

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?

Answer 2

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

Question 3

Should physicians perform cystoscopy for stress urinary incontinence?

Answer 3

Physicians should not perform cystoscopy in index patients for the evaluation of stress urinary incontinence unless there is a concern for urinary tract abnormalities.

Question 4

Should physicians do urodynamics for stress urinary incontinence?

Answer 4

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.

Question 5

What important part of the history should influence if the patient should undergo surgery for stress urinary incontinence?

Answer 5

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.

Question 6

What are the treatment options (generally) for stress urinary incontinence or stress-predominant mixed urinary incontinence?

Answer 6

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

Question 7

Surgical treatment counseling

Answer 7

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.

Question 8

What are non-surgical treatments for stress urinary incontinence or stress-predominant mixed urinary incontinence?

Answer 8

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

Question 9

What are surgical options for index patients considering surgery for stress urinary incontinence?

Answer 9

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

Question 10

What approaches can be used for index patients who choose midurethral sling surgery?

Answer 10

In index patients who select midurethral sling surgery, physicians may offer either the retropubic or transobturator midurethral sling.

Question 11

What’s up with single-incision slings?

Answer 11

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.

Question 12

What should you do if the urethra is injured at the time of the planned midurethral sling?

Answer 12

Physicians should not place a mesh sling if the urethra is inadvertently injured at the time of planned midurethral sling procedure.

Question 13

Should stem cell therapy be offered for stress incontinence?

Answer 13

Physicians should not offer stem cell therapy for stress incontinent patients outside of investigative protocols.

Question 14

What happens if a patient has stress incontinence, and a FIXED, immobile urethra?

Answer 14

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.

Question 15

What if a patient has stress urinary incontinence and intrinsic sphincter deficiency?

Answer 15

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.

Question 16

When should a physician NOT use a synthetic mid urethral sling?
What factors would make them think against using a synthetic sling?

Answer 16

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).

Question 17

What should a physician do in patients undergoing concomitant pelvic prolapse or stress incontinence surgery?

Answer 17

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).

Question 18

What should a clinician do for stress urinary incontinence and concomitant neurologic disease?

Answer 18

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.

Question 19

What patient populations need extra counseling to receive synthetic midurethral (actually any kind of) slings?

Answer 19

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

Question 20

When should a patient be evaluated after a surgery for stress urinary incontinence?

Answer 20

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.

Question 21

What are the components of a post-operative appointment after a surgery for stress urinary incontinence?
When should a patient be evaluated after surgery?

Answer 21

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.

Question 22

Q Tip Test

Answer 22

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.

Question 23

What questions should be asked of a woman presenting with SUI?

Answer 23

 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

Question 24

Options for management of SUI?

Answer 24

Mid urethral slings
Pubovaginal slings
Burch and retropubic suspensions
bulking agents

Question 25

Options for management of SUI?

Answer 25

Mid urethral slings
Pubovaginal slings
Burch and retropubic suspensions
Bulking agents
Incontinence Pessary
Observation
Weight loss
PFME/PFPT

Question 26

Contraindications to use of synthetic slings?

Answer 26

urethrovaginal fistula
urethral erosion
intraoperative urethral injury
urethral diverticulum

Question 27

What are important questions to ask as part of history when assessing urinary leakage?

Answer 27

Frequency
Urgency (UUI)
Pads? How many?
Trouble urinating/incomplete emptying?
Hx of UTIs
Prior incontinence surgery
Bother of leakage

Question 28

What are important for exam of SUI?

Answer 28

Abdominal masses/scars
POP
Hypermobility (Q-tip, visual inspection)
Urehtral/vaginal wall abonromaltieis
Atrophic Vaginitis
Objective leak (Valsalva, Leak; sitting, supine, stand)
PVR

Question 29

What are risks to counsel patients on mid urethral slings?

Answer 29

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

Question 30

What are some key principles of trochar passage? Common area of injury?

Answer 30

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

Question 31

Treatment of intravesical mesh exposure?

Answer 31

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

Question 32

What do you do if there is a good deal of bleeding during sling placement?

Answer 32

Confirm patient hemodynamically stable
Finish sling placement
Pressure
Close and make sure no bleeding
Place packing if needed

Question 33

What follow up questions do you ask post mid urethral sling?

Answer 33

Is she leaking?
Any new urgency
How is urinary flow
Pain with intercourse
UTIs

Question 34

If patient complains of significant decrease in force of urine after sling, what should you consider?

Answer 34

Bladder outlet obstruction (sling incision/removal/urethrolysis)
Sling perforation

Cystoscopy
UDS (optional)

Question 35

What are indications for UDS for patients with SUI?

Answer 35

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