Mixed urinary incontinence- sling or not sling

吳銘斌Ming-Ping Wu, M.D.,Ph.D. Director, Div. Urogynecology & Pelvic Floor Director, Div. Urogynecology & Pelvic Floor

Reconstruction, Chi Mei Foundation Hospital, Reconstruction, Chi Mei Foundation Hospital, Tainan, TaiwanTainan, Taiwan

Assistant Professor, College of Medicine, Taipei Assistant Professor, College of Medicine, Taipei Medical University, Taipei, TaiwanMedical University, Taipei, Taiwan

Definition: Lower urinary tract symptoms (LUTS)

Mixed urinary incontinence (MUI) is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing (Abrams P et al. 2002).

Definition: Urodynamic observations and conditions

Urodynamic stress incontinence (USI) is noted during filling cystometry, and is defined as the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction (Abrams P et al.2002).

Detrusor overactivity (DO) is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked.

Detrusor overactivity incontinence is incontinence due to an involuntary detrusor contraction (Abrams P et al. 2002).

MUI is the combination of the above conditions.

Epidemiologic study:2004 BJU: 17000 respondents (30000) women in households

high prevalence of incontinence increases with ageMixed picture symptoms dominant the spectrum

Hunskaar S: BJU Int 2004

Prevalence and impact of incontinence

GP practices in the UK are key places to discover the unmet needs of women with incontinence or urinary symptoms

3272 respondents to a questionnaire 21% stress incontinence symptoms21% with mixed symptoms3.5% with urge only9% suffered with severe symptomsonly 47% reported these symptoms to a healthcare professional.

Those who suffered from urgency and urge incontinence reported a greater impact on their daily lives than those with urgency but no incontinence.

Shaw C 2006 Fam Pract

Distribution of urinary incontinence by type in women

5204 adults data from the National Overactive Bladder Evaluation (NOBLE)

Chaliha C 2004 Urology

Prevalence according to different definitions

Mixed symptoms are very commonBetween 29% and 61% (most commonly 33%) of women will report a combination of urinary symptoms, but when investigated the actual figure of urodynamically proven mixed picture incontinence is lower at 14%.

(Dmochowski R and Staskin D 2005, Bump RC et al. 2003)

Demographic Characteristics of Women With USI and MUI

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Holmgren et al. 2005 Obstet Gynecol

Medical History of Women With USI and MUI

Holmgren et al. 2005 Obstet Gynecol

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The treatment modality.

There are a variety of treatments for USI, including physiotherapy, electrical stimulation, and continence surgery (Siegel SW et al. 1997).

Treatment of DO with/without incontinence is aimed at improving central control

using behavioral therapy or drugs that reduce the frequency and severity of detrusor contractility during filling (Chaliha C and Khullar V 2004).

ANTIMUSCARINIC AGENTSMixed Incontinence Effectiveness Research

Investigating Tolterodine (MERIT) trialdouble-blind, randomized, placebo controlled study

Khullar V 2002 Neurourol Urodyn;Chaliha C 2004 Urology

*P< 0.001

Duloxetine: serotonin-norepinephrine reuptake inhibitor

Chaliha C 2004 Urology

Duloxetine: serotonin-norepinephrine reuptake inhibitor

Chaliha C 2004 Urology

The challenges of MUI:the diagnosis

it may be difficult from the patients’ history to properly identify the two components of the disorder, i.e. urge and stress

An objective evaluation by urodynamic investigation is therefore recommended.

The stress component can easily be identified, whereas the urge component may consist of

either DO, urethral relaxation or an uninhibited premature micturition reflex (Rezapour M and Ulmsten U 2001).

other causes of the urge symptoms before treatment e.g. inflammatory diseases, infection, tumours and neurological disorders

MUI: detrusor overactivity (DO)

bladder

urethra

closure

Rezapour M and Ulmsten U 2001

MUI: DO vs urethral relaxation

Rezapour M and Ulmsten U 2001

MUI: uninhibited premature micturition reflex

Rezapour M and Ulmsten U 2001

bladder

urethra

closure

The challenges of MUI-the treatment

MUI more than 50% improvement in urge symptoms (Choe JH 2008)In general, surgery for mixed incontinence does not have an adequate success rate.

Persistence of the urge component De novo urge symptoms

Whether the presence of DO adversely affects the success of the mid urethral sling in treating SUI ??

INCONCLUSIVEINCONCLUSIVE

The surgical trend: from proximal urethra support to midurethral support

Dysfunctional urethral supportDysfunctional urethral sphincteric function

#Integral theory (1990)

#Hammock hypothesis (1994)

Integral Theory

(Petros and Ulmsten, 1990).

stress and urge symptoms both arise from the same anatomic defect, a lax vaginathe vagina has a dual role in transmitting voluntary and involuntary muscle contractions involved in bladder neck and urethral closure

supporting “hypothesized” stretch receptors in the proximal urethra and trigone.”

Based on this theory, it has been claimed that mid-urethral sling can cure “stress and urge”incontinence at the same time.

Similar cure rates in the 2 types of incontinence, USI vs MUI

Choe et al. the presence of preoperative DO did not significantly decrease the successful outcome of surgery in women with SUI

Subjective & objective cure rate for SUI 95.5% vs 93.2%(Choe 2008 J Urol)

Rezapour and Ulmsten reported a long term (mean follow-up was 4 years) cure rates of 85% in MUI patients (Rezapour M and Ulmsten U 2001).

Similar cure rates in the 2 types of incontinence, USI vs MUI

Nilsson and Kuuva reported cure rates of 81% and 88% cure rates, respectively (Nilsson CG and Kuuva N 2001).

Kulseng-Hansen reported an 81% cure rate of USI women, while also 81% of those with severe urgency reported a significant improvement postoperatively (Kulseng-Hanssen S 2003).

Jeffry et al. reported 89.3 % objective cure rates in both groups of patients

The subjective cure rate was 66% (Jeffry L et al. 2001).

subjective vs objective (sig). de novo urge symptoms was 37.9%.

Different results in the 2 types of incontinence

Laurikainen and Kiilholma reported a 97% cure rate among patients with stress, compared with 69%among those with urgency (Laurikainen E and Kiilholma P 2003).

Meschia et al. found a difference between cure rates of women with USI (90%) and women with concomitant urgency (about 50% “significant improvement” of urgency symptoms) (Meschia M et al. 2001)

Different results in the 2 types of incontinence

Paick et al. had a 96% cure rate in women with urinary stress incontinence, compared with 78% in those with mixed incontinence (Paick JS et al. 2004). Holmgren et al. reported cure rates for MUI were 20–25% lower than with USI (Holmgren C et al. 2005).

The controversy: to sling or not to sling?

The factors need to be considered when sling the women with MUI:

1. the long-term success rate: • esp. 4 years elapsed after surgery

2. the dominant bother, stress urinary incontinence, urge urinary incontinence

3. types of sling: • retropubic, transobturator

4. risk factor: • low maximal urethral pressure (MUP)

5. The presence of preoperative DO

Poor long-term success rate in MUI

Holmgren et al. 2005 Obstet Gynecol

Stress and urgency incontinence in MUI post-OP

Holmgren et al. 2005 Obstet Gynecol

Result according to predominant bother

PSI: predominant stress incontinence,SUIE: stress and urge incontinence equally, PUI: predominant urge incontinence

Kulseng-Hanssen S 2008 Int Urogyn J

7 months

Result according to predominant bother

PSI: predominant stress incontinence,SUIE: stress and urge incontinence equally, PUI: predominant urge incontinence

Kulseng-Hanssen S 2008 Int Urogyn J

38 months

The impact of TVT on OAB symptoms in women with SUI: significance of DO

All symptoms(36.8% vs. 18.1%)

Urgency(52.6% vs. 38.3%)

Frequency (28.9% vs. 32.6%)

Urge incontinence (68.9% vs. 53.7%)

The mean number of voids per 24 hours was decreased by 30.1% (from 11.8 ± 0.2 to 8.2 ± 0.5, p < 0.001) in the DO absent group and 24% (from 12.5 ±0.5 to 9.5 ± 0.5, p < 0.001) in the DO present group postoperatively.

OAB syndrome

Choe 2008 J Urol

Pre-op urodynamic parameters

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.

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.

Paick JS 2008 Int Urogyn J

Different types of slings in MUIOutcomes after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturatortape (TOT) procedure in women with MUITVT (n = 72), SPARC (n = 22), and TOT (n = 50). mean follow-up time was 10.9 months (6 to 52). There were no significant differences in the three groups in terms of the cure rate for SUI and UUI

SUI (TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; p= 0.625) urge urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; p= 0.965).

Paick JS 2008 Int Urogyn J

Disease of the detrusor dysfunction motor or sensory muscle and/or nerves

Etiology of MUI: Unknown

Pseudourge theory

Mixed symptoms may be a more severe form of stress predominant incontinence

Reported sudden loss of urine associated with urgency

SUI combined with waiting too long to void Pts adopt behavior of frequency as strategy to control SUI

Such patients theoretically would be cured at a greater rate after sling surgery than those with true severe UUI.

Chou 2003 J Urol

The proposed therapy algorithm

Dmochowski 2005 Curr Opin Urol

The proposed therapy algorithm

Modified from Dmochowski 2005 Curr Opin Urol

Mixed urinary incontinence

Subjective predominant bothersUrgency & urge incontinence stress incontinence

Treat predominant bother Treat predominant bother

relatively behavior or medication oriented relatively surgical oriented

Treat the other bother Treat the other bother

Discussion and unsolved problems

Lack of objectivity in diagnosis or inclusion criteria

Assessment tools : Multichannel urodynamic studyFrequency Volume Chart, validated questionnaire, patient perception of symptoms

Outcome evaluationthe overall affect of sling on urgency, frequency and urge incontinence by 3 different criteriaStrengthen the interpretation of the results

The pathophysiology of urgency component in MUI

Take home messageMUI is a heterogeneous groupTreatment targets to impact the individual’s most bothersome and preponderant symptomTreatment Modality (Dmchowski & Staskin 2005)

Medication 70% improved (not cure)Surgery 50-70%

Dependent upon quantification and definitionTo sling or not in MUI is still inconclusiveWhen sling the MUI patients several factors need to be considered

the low long-term success rate (esp. 4 years elapsed)The predominant bother, stressUrodynamic parameters:

presence of pre-op DO, low MUCP

Thank you

Bethesda Mission Hospital, Kalimantan, Indonesia