Mixed urinary incontinence - sling or not sling

Transcription

1 Mixed urinary incontinence - sling or not sling 吳 銘 斌 Ming-Ping Wu, M.D.,Ph.D. Director, Div. Urogynecology & Pelvic Floor Reconstruction, Chi Mei Foundation Hospital, Tainan, Taiwan Assistant Professor, College of Medicine, Taipei Medical University, Taipei, Taiwan

2 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).

3 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.

4 Epidemiologic study: 2004 BJU: respondents (30000) women in households high prevalence of incontinence increases with age Mixed picture symptoms dominant the spectrum Hunskaar S: BJU Int 2004

5 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 symptoms 21% with mixed symptoms 3.5% with urge only 9% suffered with severe symptoms only 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

6 Distribution of urinary incontinence by type in women 5204 adults data from the National Overactive Bladder Evaluation (NOBLE) Chaliha C 2004 Urology

7 Prevalence according to different definitions Mixed symptoms are very common Between 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)

8 Demographic Characteristics of Women With USI and MUI Holmgren et al Obstet Gynecol

9 Medical History of Women With USI and MUI Holmgren et al Obstet Gynecol

10 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).

11 ANTIMUSCARINIC AGENTS Mixed Incontinence Effectiveness Research Investigating Tolterodine (MERIT) trial double-blind, randomized, placebo controlled study *P< Khullar V 2002 Neurourol Urodyn;Chaliha C 2004 Urology

12 Duloxetine: serotoninnorepinephrine reuptake inhibitor Chaliha C 2004 Urology

13 Duloxetine: serotoninnorepinephrine reuptake inhibitor Chaliha C 2004 Urology

14 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

15 MUI: detrusor overactivity (DO) bladder urethra closure Rezapour M and Ulmsten U 2001

16 MUI: DO vs urethral relaxation Rezapour M and Ulmsten U 2001

17 MUI: uninhibited premature micturition reflex bladder urethra closure Rezapour M and Ulmsten U 2001

18 The challenges of MUIthe 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?? INCONCLUSIVE

19 The surgical trend: from proximal urethra support to midurethral support Dysfunctional urethral support Dysfunctional urethral sphincteric function #Integral theory (1990) #Hammock hypothesis (1994)

20 Integral Theory (Petros and Ulmsten, 1990). stress and urge symptoms both arise from the same anatomic defect, a lax vagina the 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.

21 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).

22 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%.

23 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)

24 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).

25 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

26 Poor long-term success rate in MUI Holmgren et al Obstet Gynecol

27 Stress and urgency incontinence in MUI post-op Holmgren et al Obstet Gynecol

28 Result according to predominant bother 7 months PSI: predominant stress incontinence, SUIE: stress and urge incontinence equally, PUI: predominant urge incontinence Kulseng-Hanssen S 2008 Int Urogyn J

29 Result according to predominant bother 38 months PSI: predominant stress incontinence, SUIE: stress and urge incontinence equally, PUI: predominant urge incontinence Kulseng-Hanssen S 2008 Int Urogyn J

30 The impact of TVT on OAB symptoms in women with SUI: significance of DO OAB syndrome All symptoms (36.8% vs. 18.1%) Urgency (52.6% vs. 38.3%) Frequency (28.9% vs. 32.6%) 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. Urge incontinence (68.9% vs. 53.7%) Choe 2008 J Urol

31 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), ; p = Uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI OR, 3.351; 95% CI, ; p = Paick JS 2008 Int Urogyn J

32 Different types of slings in MUI Outcomes after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with MUI TVT (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

33 Etiology of MUI: Unknown Disease of the detrusor dysfunction motor or sensory muscle and/or nerves

34 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

35 The proposed therapy algorithm Dmochowski 2005 Curr Opin Urol

36 The proposed therapy algorithm Mixed urinary incontinence Subjective predominant bothers Urgency & 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 Modified from Dmochowski 2005 Curr Opin Urol

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38 Discussion and unsolved problems Lack of objectivity in diagnosis or inclusion criteria Assessment tools : Multichannel urodynamic study Frequency Volume Chart, validated questionnaire, patient perception of symptoms Outcome evaluation the overall affect of sling on urgency, frequency and urge incontinence by 3 different criteria Strengthen the interpretation of the results The pathophysiology of urgency component in MUI

39 Take home message MUI is a heterogeneous group Treatment targets to impact the individual s most bothersome and preponderant symptom Treatment Modality (Dmchowski & Staskin 2005) Medication 70% improved (not cure) Surgery 50-70% Dependent upon quantification and definition To sling or not in MUI is still inconclusive When sling the MUI patients several factors need to be considered the low long-term success rate (esp. 4 years elapsed) The predominant bother, stress Urodynamic parameters: presence of pre-op DO, low MUCP

40 Thank you Bethesda Mission Hospital, Kalimantan, Indonesia