Stress Incontinence After Midurethral Sling: Now What?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: In the approximately 20% of patients not cured of incontinence by a midurethral sling, a pubovaginal sling or a repeat procedure using a minimally invasive synthetic midurethral sling appears to be appropriate.
Source: Walsh CA, Moore KH. Recurrent stress urinary incontinence after synthetic midurethral sling procedure. Obstet Gynecol 2010;115:1296-1301.
In this article, the authors address common questions related to management of those patients who have recurrent stress incontinence after already having a midurethral sling (MUS) using a synthetic mesh. They use the presentation of two cases as a starting point and the questions they pose are the common ones that we and our patients ask. Using the available data in the literature, useful answers are provided, thereby helping the reader move patient care in a positive direction.
Commentary
I love this article. It's relevant to our daily practice, but, more importantly, it verbalizes the same issues that both physicians and patients want clarified. It uses the data that are available to us (there isn't as much as we would like) and makes recommendations for care. What the reader will take away from the article is that large databases are lacking, but there is a reasonable way to approach these patients that can maximize success rates.
We all know that MUS with synthetic mesh is becoming/has become the standard first-line surgical management for stress incontinence (SUI). We also know, and, hopefully inform our patients, that the procedure is far from perfect, having about a 20% failure rate. How to approach these patients based on the data in print doesn't take us very far from what we already do for those patients with primary stress incontinence before their MUS. In a shortened version, here is what the authors offer (note that the answers to questions after MUS are very similar to the answers before MUS):
- Causes of incontinence after MUS: urinary tract infections (UTI), overactive bladder (OAB), overflow incontinence, urethral diverticulum, fistulae, and recurrent/persistent SUI (most common cause).
- Risk factors for MUS failure: low urethral resistance, advanced patient age, OAB symptoms. Data regarding body mass index (BMI) are conflicting.
- Assessment of patients with MUS failure: history, physical (including cough stress test, assessment of urethral mobility, mesh erosion, hypoestrogenism, pelvic floor strength and POP-Q), and culture, uroflowmetry (with post-void residual), and cystometry/cystoscopy.
- Non-surgical options: weight loss, pelvic floor training, pessary, and possibly duloxetine (although not FDA-approved for this indication).
- Surgical options:repeat MUS, pubovaginal sling with allograft or autograft, periurethral bulking, retropubic colposuspension, and artificial sphincter.
- Cures and complications after repeat MUS: complications are similar after the second procedure compared to the first. A repeat MUS appears to be comparable to pubovaginal sling, although data comparing the two procedures are lacking.
Since our patients deserve the best shot we can give them, be it the first or second procedure, this article provides us with a reminder that we should rely on the limited data available to us and make the best judgement we can for each patient. Relying on the basic principles that we all learned about stress incontinence and not taking shortcuts, we can offer the operation (or non-surgical treatment) that maximizes each patient's satisfaction with this challenging and sometimes frustrating situation.
I love this article. It's relevant to our daily practice, but, more importantly, it verbalizes the same issues that both physicians and patients want clarified.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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