Voiding complaints common in women having SUI surgery

Anaheim, CA-Urologists who believe that women electing surgery for stress urinary incontinence (SUI) are unlikely to have voiding problems should re-examine their conclusions. Baseline data from the largest randomized surgical trial of stress urinary incontinence in women shows that most women have voiding symptoms before surgery.

Baseline patient data analysis from the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) were presented in a poster at the AUA annual meeting here. Initial 2-year outcome data from the same trial were presented separately.

"It was really quite surprising to see how common voiding complaints were," said lead author Peggy Norton, MD, professor of obstetrics and gynecology at the University of Utah School of Medicine, Salt Lake City. "Women complained of having to press on their bladder or bend over to void, or that their stream was abnormal in some way. We had expected quite the opposite."

SISTEr was designed to compare the efficacy of the Burch colposuspension versus autologous fascia sling procedures for the treatment of SUI (see, "SUI: Sling shows higher overall success than Burch"). At baseline, all patients in the SISTEr study had an assessment of medical history and completed standardized measures of voiding and incontinence measures, the MESA symptom questionnaire, and the Urogenital Distress Inventory. In addition, all patients had a standardized physical examination and a non-instrumented uroflow study.

Characterizing patterns

More than four-fifths of the subjects reported some voiding problems, Dr. Norton said. Older women and women who had had prior incontinence surgery were somewhat more likely to voice voiding complaints. There were no statistically significant associations between voiding symptoms and higher degrees of pelvic organ prolapse or with the severity of stress or urge scores on the MESA. Investigators were all urogynecologists or urologists who specialize in female urology.

"We were interested in characterizing voiding patterns in women planning surgery," Dr. Norton said. "One such theory regarding these symptoms includes, for example, that women with stress incontinence may have a damaged urethral sphincter, thus having more rapid flow rates and few voiding complaints. We saw quite the opposite.

"These theories have remained un-proven because prior surgical trials lacked size or the use of validated instruments to provide this data."

The results of SISTEr leave clinicians in a quandary, Dr. Norton said. Physicians typically ask patients about voiding symptoms before surgery. If patients voice complaints, surgeons generally pursue further history about voiding and order uroflowmetry and other urodynamic testing to help guide surgical choices. These choices might in-clude a less obstructive procedure, or might even change the balance between risk and benefit of surgery.

SISTEr data suggest that those objective studies do not correlate with women's own perceptions of voiding symptoms. What is not clear is whether the problems lie in women's perceptions and expectations of voiding or in the current testing procedures.

"There isn't any single baseline test that one can do to help the surgeon and patient make a decision about how the surgery is going to be done," Dr. Norton said. "We really don't have a way to identify which patients are at increased risk for voiding symptoms, at least with our current testing. Further analysis of the SISTEr database will include voiding outcomes and whether any of these preoperative measures predict postoperative voiding dysfunction."