Paul K. Tulikangas, MD, FACOG, FACS
Kenton K, Richter H, Litman H, et al; Urinary Incontinence Treatment Network. Risk factors associated with urge incontinence after continence surgery. J Urol. 2009;182(6):2805-2809.
The symptoms of urinary urgency, frequency, and urge urinary incontinence (UUI) are characteristic of overactive bladder. New-onset or worsening overactive bladder symptoms following surgery for stress urinary incontinence is distressing for patients. This study is an analysis of data from the SISTEr trial (Stress Incontinence Surgical Treatment Efficacy), which compared the safety and efficacy of Burch colposuspension and autologous rectus fascial pubovaginal sling in women with stress urinary incontinence. In their analysis, Kenton et al evaluated factors associated with postoperative UUI following these surgeries.
655 women with predominant stress urinary incontinence participated the SISTEr trial (randomized, multicenter trial comparing Burch colposuspension to autologous fascial pubovaginal sling). The primary outcome of the trial was overall treatment success for urinary incontinence measures. Women underwent preoperative urodynamic testing and completed voiding diaries and questionnaires on stress and urge urinary incontinence. Follow-up after surgery (24 months) included repeat questionnaires, physical examination, and repeat urodynamic studies.
For the current analysis:
- Preoperative UUI at baseline was defined as prior antimuscarinic treatment and/or detrusor overactivity
- Postoperative UUI was defined in two ways:
- Primary analysis: requiring anticholinergic treatment for UUI at least 6 weeks following surgery
- Secondary analysis: symptom-based definition (an answer of ‘moderately’ or ‘greatly bothered’ to the Urogenital Distress Inventory question, “Do you currently experience urine leakage related to the feeling of urgency” 24 months after surgery)
- 408 women were not considered to have preoperative UUI. Of these, 18% in the sling group developed postoperative UUI compared with 9% in the Burch group (P = 0.009)
- In women who did have symptoms of urgency and urge incontinence prior to surgery, more women in the sling group had postoperative urge incontinence (41% vs. 29%; P = 0.07)
- Overall, 21% of women underwent treatment for UUI at least 6 weeks after surgery
- The odds ratio for postoperative treatment of UUI was higher in women who had sling surgery compared with those who received Burch procedures (OR 1.72, 95% CI 1.16-2.54, P = 0.007).
- According to multivariate analysis, factors independently associated with postoperative treatment for UUI included:
- Preoperative urge symptoms based on MESA urge score (OR 1.97, 95% CI 1.13-3.41; P = 0.016)
- Detrusor overactivity (OR 2.41, 95% CI 1.25-4.63; P = 0.008)
- History of anticholinergic medication use (OR 2.41, 95% CI 1.51-3.85; P < 0.001)
- In secondary analysis, bothersome UUI symptoms were not different between the surgical groups postoperatively
Women who undergo surgery for stress urinary incontinence may be bothered by urinary urgency and urge incontinence after surgery. In this analysis, treatment for UUI was more common after autologous fascial sling surgery than Burch colposuspension. This information may be helpful in selecting a surgery for stress urinary incontinence, particularly in patients with risk factors for post-operative UUI. Unfortunately, the most popular surgery for stress incontinence in the United States now is a mid-urethral sling, which was not part of this study.
This study emphasizes the need to have discussions with patients about the potential for postoperative urgency and UUI after stress urinary incontinence surgery. Even those with no urge incontinence symptoms preoperatively may develop urgency and urge incontinence after surgery.