Researchers characterize post-sling incontinence

Shreveport, LA-Stress-incontinent women whose urinary urgency incontinence (UUI) worsens following a sling procedure are a heterogeneous group, according to research presented at the AUA annual meeting in San Diego.

Some women with urge symptoms following sling surgery for stress urinary incontinence (SUI) may not present for treatment of their urge symptoms until after a year or longer, requiring the need for long-term follow-up of these women, according to senior author Alex Gomelsky, MD.

Follow-up data from a single-center retrospective study of 1,184 women who had mixed urinary incontinence before undergoing sling procedures for the treatment of SUI revealed that 122 (10.3%) had their UUI worsen after surgery.

“This subset of women with worsening UUI after their sling procedure has been poorly characterized,” said Dr. Gomelsky, director of female urology, neurourology, and pelvic reconstructive surgery at Louisiana State University Health Sciences Center, Shreveport. “We wanted to gain a better understanding about what leads women to get worse urinary storage symptoms after their surgery.”

Of the 122 whose urgency incontinence worsened, 45.1% underwent a bladder neck sling, 35.2% underwent a retropubic midurethral sling, and 19.7% had a transobturator midurethral sling. The three sling groups were similar in age, body mass index, parity, and preoperative pad use. Mean follow-up was 47.9 months, with a minimum follow-up of 12 months.

“One of the theories proposed in the literature is that partial obstruction from excessive sling tension may be causing urinary storage symptoms after surgery,” Dr. Gomelsky told Urology Times. “But we found that was actually a fairly small amount of women.”

As presented by first author Joshua Holstead, MD, 36% of those who had worsening UUI had UUI only, whereas 41% had mixed urinary incontinence (MUI), 7% had symptoms of pelvic organ prolapse, and 16% had emptying symptoms.

Sling type not predictive of symptoms

“The type of sling was not predictive of postoperative symptoms,” Dr. Gomelsky said.

The mean time to presentation for management of urge symptoms ranged from 2.5 months in those with emptying symptoms to 15.4 months with UUI only and 17.9 months in those with MUI.

“We’re recommending vigilance in following these women long term because some of these symptoms may not manifest themselves immediately,” Dr. Gomelsky said.

Management differed based on symptom category. Most women with UUI were managed with antimuscarinics (70.5%), as were those with MUI (62%). Two-thirds of women with symptomatic pelvic organ prolapse were managed with surgery. Some 58% of women with obstructive symptoms were managed with antimuscarinics, 26% were managed with a surgical procedure, 16% with behavior modification only, and 16% with biofeedback-pelvic floor muscle training. (More than one treatment was applied to many women.)

About half (53%) of those with emptying symptoms improved after such treatment, compared with 62% with MUI, 77% with UUI only, and 78% with symptomatic pelvic organ prolapse. Significant improvement was often achieved only after repeat surgery for incontinence and pelvic organ prolapse, sling revision, and neuromodulation, according to Dr. Gomelsky.

“While conservative treatment options should be offered to all women, repeat surgical intervention may be necessary to ultimately improve UUI that worsens after sling surgery,” he concluded. “If you follow these women longitudinally and treat these adverse symptoms as they come up, you can improve your overall surgical results and patient satisfaction.”UT

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