Treatment Of Mixed Urinary Incontinence Research Articles

Results of surgical treatment of urinary incontinence in women with pelvic organ prolapse

Objective: long-term evaluation of the results of surgical treatment of mixed urinary incontinence in women with pelvic organ prolapse by the Kelly method in its own modification.Materials and methods: diagnosis and surgical treatment of pelvic organ prolapse and urinary incontinence were performed in 95 women aged 52–60 years. The patients underwent vaginal hysterectomy, anterior and posterior colporraphy, levatoroplasty, and perineoplasty. In order to optimize the surgical treatment of mixed urinary incontinence, urethral plastic surgery was performed using Kelly's method in its own modification. 3 years after the operation, the effectiveness of the operation was evaluated.Results: the performed surgical treatment improved the quality of life of the patients during the next 3 years of life, since there were no violations of the anatomy of the vagina and bladder. There were good forces of contraction of the pelvic floor muscles, women fully retained urine. The patients are completely satisfied with the results of the operation, are able-bodied and take an active life position.Conclusions: the proposed technique is a pathogenetically justified method of restoring adequate urination, reduces the number of relapses of the disease, and returns the main functions to the urethra: to retain urine in the bladder and ensure its release to the outside, which increases the effectiveness of surgical treatment and the duration of the positive effect.

Mixed Urinary Incontinence: Diagnosis and Management

The evaluation and treatment of mixed urinary incontinence receives relatively little attention as compared to other forms of incontinence. Mixed incontinence, however, defined as the combination of stress and urgency incontinence, accounts for the largest proportion of incontinence, with an increased incidence in older women. The condition can be very challenging to manage due to the coexistence of multiple pathologies. Treating either component can worsen the other, which means careful discussion of the risks and benefits, in addition to considerations of multimodal treatment approaches are required. In the older adult population, where this condition confers a significant impact on quality of life, there are many special considerations when evaluating and treating patients. Evaluation requires a careful assessment of the impact on QOL and goals of care and may need to involve caregivers and/or family members in the discussion, in addition to considerations of more advance evaluation on an individual basis prior to invasive treatments. Conservative treatments including behavioral and lifestyle modifications and pelvic floor physical therapy should be the mainstay of first-line treatment for older women with MUI, while taking into careful consideration how cognitive and/or physical limitations may impact treatment. Pharmacologic therapy should include a consideration of vaginal estrogen replacement, however oral medications for urgency and overactive bladder have increased risks in older women, which means more advanced treatments may want to be introduced sooner. There is really limited data on the use of third-line overactive bladder treatments in older women with mixed incontinence, however there may be some demonstrated benefits. Finally, when considering surgical interventions in this population, although the data demonstrate some benefit in mixed incontinence, providers may want to utilize a formalized assessment of frailty due to the increased morbidity associated with frailty in surgeries for incontinence.

Pelvic floor rehabilitation in the treatment of mixed urinary incontinence among women

BackgroundMixed urinary incontinence (MUI) is a common underreported problem among females; it has a major effect on patients’ quality of life. Treatment may be difficult since a single modality cannot be enough to alleviate both the urge and the stress symptoms. Biofeedback-assisted pelvic floor muscle training (PFMT) has a great role in strengthening the pelvic floor muscles especially when accompanied by electrical stimulation. Neuromodulation is another safe well-tolerated method that may improve symptoms of female voiding dysfunction. There are no previous studies that assessed the efficacy of biofeedback-assisted pelvic floor muscle training versus two different types of peripheral neuromodulation which are transcutaneous posterior tibial nerve stimulation (TPTNS) and anogenital neuromodulation in the treatment of mixed urinary incontinence among women. The aim of this work is to study the effectiveness of biofeedback-assisted pelvic floor muscle training with electrostimulation versus two different methods of peripheral neuromodulation techniques in the treatment of women with MUI. Patients were subjected to history taking, assessment questionnaires (Questionnaire for female Urinary Incontinence Diagnosis (QUID), Australian Pelvic Floor Questionnaire (PFQ), and International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF)), clinical examination, and manometric pressure assessment. The patients were allocated randomly into three groups. Group I received biofeedback-assisted pelvic floor muscle training and faradic electrical stimulation, group II received posterior tibial neuromodulation, and group III received anogenital neuromodulation.ResultsThe present study included 68 non-virgin female patients with mixed urinary incontinence. Significant improvement was noticed in the three studied groups on the subjective and objective levels. No statistically significant difference was reported between the studied groups following the different types of intervention.ConclusionsBiofeedback-assisted pelvic floor muscle training with electrostimulation is as effective as anogenital neuromodulation and posterior tibial neuromodulation in the treatment of mixed urinary incontinence among females.Trial registrationPACTR, PACTR202107816829078. Registered 29 July 2021 - Retrospectively registered.

Complicaciones intraoperatorias y posoperatorias de las cintas medio uretrales libres de tensión en incontinencia urinaria de esfuerzo

Antecedentes: La colocación de cintas medio uretral son actualmente el tratamiento de primera línea para la incontinencia urinaria de esfuerzo. El objetivo fue evaluar las complicaciones intra y posoperatorias de las cintas transobturadora y retropúbica; y los factores de riesgo asociados.
 Material y métodos: Estudio de cohorte retrospectivo en 105 mujeres durante el 2016 a 2018. Se dividió en dos grupos: TVT (n=28) y TOT (n=77). Se analizaron variables demográficas, factores de riesgo, complicaciones intra y posoperatorias. Se realizo estadística descriptiva y correlación de variables con programa SPSS v17.0, y p ≤ 0.05 estadísticamente significativo.
 Resultados: La edad promedio fue 56.7 ± 8.8 años; 31.4% (n=33) con incontinencia de esfuerzo, 65.7% (n=69) con incontinencia mixta (IUM) y 2.9% (n=3) con incontinencia oculta. La tasa de complicación global fue de 29.5% (n=31). La complicación intraoperatoria común fue la perforación vesical 3.8% en el grupo TVT asociada a obesidad (OR 12.9). Las complicaciones posoperatorias estuvieron relacionadas con la TOT (p=0.049), compuestas por infección de vías urinarias (11.4%), inguinodinea (7.6%) y otras (6.9%). El riesgo de infección urinaria posoperatorio estuvo asociado con incontinencia de esfuerzo (p=0.03), ausencia de tratamiento de incontinencia urinaria mixta (p=0.04); aumentado la tasa de incontinencia urinaria de urgencia de novo.
 Conclusiones: El enfoque transobturador tiene bajos índices de complicaciones transoperatorias en comparación con la retropúbica. La complicación más común en nuestra serie fue la infección urinaria por lo que se requieren estudios prospectivos aleatorizados.

PT235 - Exploration of litoxetine (LTX): A potential novel treatment for mixed urinary incontinence (MUI)

PT235 - Exploration of litoxetine (LTX): A potential novel treatment for mixed urinary incontinence (MUI)

Mixed urinary incontinence: a current view at the problem (review of clinical guidelines)

He purpose of the review - presentation of basic clinical scientific data based on current evidence on the management of patients with mixed urinary incontinence. Material and methods. A review of Russian and foreign sources on the prevalence, etiopathogenesis, diagnosis and treatment of mixed urinary incontinence in women. Results. The review presents terminology, data on etiopathogenesis, clinic, diagnosis, phasing and treatment methods of mixed urinary incontinence in women at different age periods.

Stress Urinary Incontinence Management in the Patient With Overactive Bladder

Mixed urinary incontinence is a common diagnosis that has significant impact on patient quality of life and can be more bothersome to patients compared to pure stress incontinence. Given the complexity of concomitant stress incontinence and overactive bladder symptoms, mixed urinary incontinence can often present as a clinically challenging scenario for treating physicians across different subspecialties and primary care medicine. In this review, we discuss the importance of a judicious evaluation and the utility of deciphering stress-predominant versus urge-predominant urinary incontinence in patients with concomitant symptoms. The temporal relationship between stress incontinence and urgency symptoms has been explored in recent literature. Although a common pathway has been alluded, characterization of the predominant symptom is essential in treating this difficult diagnosis. As suggested in recent guidelines, emphasis should be placed on setting appropriate patient goals of care and discussing treatment expectations in order to best optimize patient satisfaction and patient-reported treatment success. Risks, benefits, and alternatives for both stress urinary incontinence and overactive bladder treatment options should be reviewed, yet there is lack of a standardized approach in the literature. We outline a sequential algorithm to help guide patient counseling, management, and appropriate expectations for treatment of mixed urinary incontinence.

Mixed urinary incontinence- what should we treat first?

Mixed urinary incontinence (MUI) is defined as ‘the involuntary loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing’. It is highly prevalent, increases with age and affects women more than men. It has a significant negative impact on health-related quality of life (HRQL). Additionally, treatment of mixed urinary incontinence places a large financial burden on both individuals and the NHS. Optimal management of this common condition is contested – should we treat the urge urinary incontinence (UUI), stress urinary incontinence (SUI) or predominant symptom first? At the 2015 BAUS Section of Female, Neurological and Urodynamic Urology this subject was debated. Based on a common scenario, the authors of the debate present the arguments for treating the urge urinary incontinence component, stress urinary incontinence component or the predominant symptom of mixed urinary incontinence first, before making recommendations for current practice.

Change in urinary storage symptoms following treatment for female stress urinary incontinence.

Sling surgery is common for stress urinary incontinence (SUI). Yet many women have stress-predominant mixed urinary incontinence (MUI). The change in urgency/urge urinary incontinence (U/UUI) following treatment is not well documented. Our aim was to assess changes in U/UUI in women undergoing a sling placement for MUI and correlate this with improvement in quality of life (QOL). This was a retrospective review of women treated for SUI with either an autologous rectus fascia pubovaginal sling (AF-PVS) or synthetic retropubic midurethral sling (MUS). Validated questionnaires-Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), and visual analog scale (VAS) were obtained pre- and postoperatively. The independent association between change in storage symptoms and subjective cure-as defined by improved overall score on UDI-6, VAS score ≥ 7, or both -were assessed using multivariate logistic regression. Nine hundred and twenty-seven women were identified for inclusion; 718 (77.5%) had preoperative MUI, of whom 487 (67.8%) received an MUS and 231 (32.2%) an AF-PVS. Similar objective cure rates were noted following MUS vs. AF-PVS (78.2% vs. 71.9%, p = 0.315). Subjectively, women treated with MUS experienced greater improvement in U/UUI (72.8% vs. 57.6%, p = <0.001) than AF-PVS. Multivariate analysis showed MUS patients were more than twice as likely to show subjective improvement in UDI-6 and VAS scores than the AF-PVS cohort. Postoperatively, validated questionnaires were significantly associated with storage symptom outcome. Patients with U/UUI experience significant symptom improvement following treatment for MUI. QoL assessment following surgery is directly correlated with improvement in U/UUI.

Trends in surgical management and pre‐operative urodynamics in female medicare beneficiaries with mixed incontinence

We sought to examine the surgical trends and utilization of treatment for mixed urinary incontinence among female Medicare beneficiaries. Data was obtained from a 5% national random sample of outpatient and carrier claims from 2000 to 2011. Included were female patients 65 and older, diagnosed with mixed urinary incontinence, who underwent surgical treatment identified by Current Procedural Terminology, Fourth Edition (CPT-4) codes. Urodynamics (UDS) before initial and secondary procedure were also identified using CPT-4 codes. Procedural trends and utilization of UDS were analyzed. Utilization of UDS increased during the study period, from 38.4% to 74.0% prior to initial surgical intervention, and from 28.6% to 62.5% preceding re-intervention. Sling surgery (63.0%) and injectable bulking agents (28.0%) were the most common surgical treatments adopted, followed by sacral nerve stimulation (SNS) (4.8%) and Burch (4.0%) procedures. Re-intervention was performed in 4.0% of patients initially treated with sling procedures and 21.3% of patients treated with bulking agents, the majority of whom (51.7% and 76.3%, respectively) underwent injection of a bulking agent. Risk of re-intervention was not different among those who did or did not receive urodynamic tests prior to the initial procedure (8.5% vs. 9.3%) CONCLUSIONS: Sling and bulk agents are the most common treatment for MUI. Preoperative urodynamic testing was not related to risk of re-intervention following surgery for mixed urinary incontinence in this cohort. Neurourol. Urodynam. 36:422-425, 2017. © 2015 Wiley Periodicals, Inc.

Management of Urethral Stricture in Women

We describe the diagnosis and treatment of urethral strictures in women. We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Treatment of mixed urinary incontinence in women

Deciding on an optimal therapy for mixed urinary incontinence (MUI) is challenging, as a single-treatment modality may be inadequate for alleviating both the urge and stress component. A MEDLINE search was conducted regarding English-language literature pertaining to the treatment for MUI focusing on literature within the last 18 months. Behavioral therapy and lifestyle modification, such as moderate weight loss and caffeine reduction, should be considered first-line options for all women with MUI. The addition of pelvic floor muscle therapy may have an additional salutary effect. Treatment of the urge component with antimuscarinics is effective; however, the stress component is likely to persist after therapy. Treatment with vaginal estrogen cream may help in the short-term, but long-term benefits are unknown. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI; however, it appears that women with MUI may have lower cure rates compared to women with pure stress urinary incontinence. The optimum treatment of MUI may often require multiple treatment modalities. Although surgery may often have a positive impact on both components, its routine implementation should be approached with caution and patients should be carefully selected and counseled.

Surgical treatment of mixed urinary incontinence: effect of anterior colpoplasty

The aims of this study are to study the surgical outcomes in patients with stress-predominant mixed urinary incontinence (MUI) treated with tension-free vaginal tape, and to evaluate the effect of concomitant anterior colpoplasty. A total of 134 women with MUI clinical and urodynamic were assessed at 6 months and annually (maximum 9 years) after surgery. As a whole, a complete healing of 49-51% at 3 years is observed, which hence could result in a tax drop of 36.8% at 5-9 years. Nevertheless, the rate of healing or improvement (subjective) is 73.7% at long term (5-9 years). There were no significant differences between the two techniques used: TVT vs TVT-Obturator. On the other hand, we have found significant differences between association of anterior colpoplasty and not (complete healing rate 34.6% vs 64.6%, p = 0.014), at 2 years of monitoring. MUI with cystocele presents better surgical results for two components of incontinence, with its physiopathogenic implications.

Treatment of mixed urinary incontinence

IntroductionMixed urinary incontinence (MUI) is a prevalent condition and imposes a significant impact on a woman's quality of life. Treatment is often challenging, as a single modality may be inadequate for alleviating both the urge and stress component.Materials and methodsA MEDLINE search was conducted regarding English-language literature pertaining to the pathophysiology, diagnosis of, and treatment for MUI. Non-English language articles were considered if they could be translated into English using GOOGLE translator.ResultsThe identification of an ideal single treatment has also been made more challenging by the poor characterization of the pathophysiology of MUI. Behavioral and lifestyle modification, as well as pelvic floor muscle therapy, should be considered first-line options for all women with MUI. Treatment of the urge component with anti-muscarinics is effective; however the stress component is likely to persist after therapy. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI, with emerging evidence suggesting that transobturator MUS may be associated with lower rates of de novo and persistent urge component compared to other procedures. The presence of concomitant, preoperative detrusor overactivity has not been consistently associated with postoperative outcomes.ConclusionsThe optimum treatment of MUI may often require multiple treatment modalities. While surgery may have a positive impact on both the urge and stress component, its implementation should be approached with caution and patients should be carefully selected. Detailed informed consent in women with MUI cannot be overstated.

Overactive Bladder and Mixed Incontinence

Mixed urinary incontinence (MUI) is a complex problem and a difficult one to treat. Successful outcome associated with treatment depends on alleviation of not one, but two symptoms. This review addresses the definition, etiology, workup, and treatment of MUI. It encompasses conservative, pharmacological, and surgical therapies along with their outcomes in these complicated patients.

POS-01.03: Tension-free vaginal tape (TVT), suprapubic ARC (SPARC) sling and transobturator tape (TOT) in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling or transobturator tape (TOT) procedure in women with mixed urinary incontinence (UI), and identified factors predicting persistent UI in these patients.

POS-01.02: Efficacy analysis of trans-obturator tension-free vaginal tape (TVT-O) versus tension-free vaginal tape in the treatment of mixed urinary incontinence: a randomized study

POS-01.02: Efficacy analysis of trans-obturator tension-free vaginal tape (TVT-O) versus tension-free vaginal tape in the treatment of mixed urinary incontinence: a randomized study

Tension-free vaginal tape, suprapubic arc sling, and transobturator tape in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with mixed urinary incontinence and identified factors predicting the outcome in these patients. A total of 144 women, 29 to 77 years old (mean age 57.3), were included in the study; TVT (n = 72), SPARC (n = 22), and TOT (n = 50). The mean follow-up time was 10.9 months (range 6 to 52). There were no significant differences in the three groups in terms of the cure rate for stress urinary incontinence (SUI; TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; P = 0.625) and urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; P = 0.965). In the multivariate model, there is no influencing factor for treatment failure of SUI, while maximum urethral closure pressure (MUCP) and the diagnosis of uninhibited detrusor contraction during cystometry were independent risk factors for treatment failure of UUI. Decreasing MUCP was associated with an increased likelihood of treatment failure of UUI [odds ratio (OR), 0.974; 95% confidence interval (CI), 0.950-0.998; P = 0.034]. In the same model, uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI (OR, 3.351; 95% CI, 1.031-10.887; P = 0.044). Our findings suggest that low MUCP and the presence of uninhibited detrusor contraction during cystometry should be considered to be at high risk of treatment failure of UUI after surgery in these patients.

Efficacy Analysis of Trans-obturator Tension-free Vaginal Tape (TVT-O) Plus Modified Ingelman-Sundberg Procedure versus TVT-O Alone in the Treatment of Mixed Urinary Incontinence: A Randomized Study

ObjectiveThe treatment of women with mixed urinary incontinence still poses a great challenge. This study evaluated surgical outcomes of combined trans-obturator tension-free vaginal tape (TVT-O) and modified Ingelman-Sundberg (IS) procedure for the treatment of mixed urinary incontinence. MethodsA randomized controlled trial was conducted. Ninety-six women diagnosed with mixed incontinence were randomized, with 49 allocated to TVT-O plus IS and 47 to TVT-O alone. A baseline urodynamic study and evaluation of quality of life (QOL) was conducted. The primary outcome measure was objective assessment of surgical outcomes, and the secondary outcome measure was warning time. ResultsObjective surgical response rate was significantly higher in the TVT-O plus IS group than in the TVT-O alone group (84.8% vs. 62.8%; p=0.019). Furthermore, a significant increase in warning time was observed in the TVT-O plus IS group (from 3.9 to 9.4min; p=0.006), but the increase in warning time within the TVT-O alone group was not statistically significant (from 4.3 to 4.5min; p=0.695). Postoperative complications were similar in the two study groups with respect to pelvic hematoma, nerve injury, sepsis, mesh erosion, and fistula formation. However, fever occurred more frequently in the TVT-O plus IS group (30.4% vs. 20.9%; p=0.026). ConclusionsMixed urinary incontinence can potentially be treated with a one-step combined surgery using trans-obturator sling plus modified IS procedure. Although surgical time and blood loss were significantly increased in the TVT-O plus IS group, overall morbidity was not significantly increased.

Editorial Comment on: Prospective Clinical Trial Comparing Obtape® and DUPS to TVT: One-year Safety and Efficacy Results

Suburethral sling procedures are specifically designed to address both urethral hypermobility and intrinsic sphincteric deficiency components of stress urinary incontinence (SUI) in women. Although further studies are needed to establish their long-term efficacy and safety, these procedures seem more efficient than the ones adopted in the era before the development of tension-free vaginal tape (TVT). In their paper, Andonian et al [1] report the outcomes of three types of suburethral sling to treat female SUI. In a prospective, randomised, controlled, clinical trial Obtape and DUPS were compared to the original TVT procedure. The DUPS arm of the randomised clinical trial (RCT) was discontinued after 32 patients because they observed a high postoperative retention rate (18.8%) combined with suprapubic discomfort. This study demonstrates that, at 1-yr follow-up, no statistically significant differences in cure rates were evident, but Obtape, DUPS, and TVT were associated with postoperativecomplications in 14%, 28%, and 8% of patients, respectively (p 0.025). TVT was the only procedure associated with bladder perforation, and this complication was higher in patients who had undergone previous surgery [1]. The perivesical tissue hydrodissection due to local anaesthesia could reduce the risk of bladder perforation, but I agree with the authors that regional anaesthesia is better tolerated by patients. A recurrent SUI is reported in 23 patients (12.1%), but the outcome after retropubic and trans-obturator procedures is not available, so I suppose that the authors do not find any significant differences [1]. The International Consultation on Incontinence underlines that TVT procedure on recurrent SUI has shown promising results, whereas few data on this issue regarding the other type of suburethral slings efficacy are available in literature [2]. Urinary incontinence and pelvic organ prolapse (POP) commonly coexist [3]. SUI is observed in up to 60% of women with POP and prolapse in up to 40% of women presenting with SUI [3–5]. In this study a concomitant prolapse surgery (anterior and posterior colporrhaphy and vaginal hysterectomy) was performed in 29 patients (15.2%) and was associated with postoperative retention only in the Obtape group (38% vs. 4%) [1]. There are no data in the literature, obtained from comparative RCTs, that could clarify whether POP surgery and antiincontinence surgery have to be performed at the same or different times and which anti-incontinence procedure is better. The authors report no statistically significant differences among the three groups in terms of persistent or de novo urgency, but the overall rate of the persistent urgency ranges from 19% to 23% [1]. Recently, Costantini et al [6] reported on the efficacy of the retropubic or trans-obturator approach in the treatment of mixed urinary incontinence (MUI). They compared TVT and trans-obturator tape procedures and found that at a mean follow-up of 24 mo the outcome after TVT seems slightly worse in patients with MUI. ‘‘Urgency remains a postoperative problem especially in the TVT group’’ [6]. IbelievethatmulticentreRCTswithlongerfollowup are needed to establish which suburethral sling procedure in the treatment of MUI or recurrent SUI is better. In addition, comparative RCTs are needed to determine whether POP surgery and the retropubic or trans-obturator anti-incontinence procedure should be performed simultaneously or not.