Surgical Treatment of Female Stress Incontinence Flashcards
In the initial evaluation of patients with stress urinary incontinence desiring to undergo surgical intervention, physicians should include the following components:
History, including assessment of bother
Physical examination, including a pelvic examination
Objective demonstration of stress urinary incontinence with a comfortably full bladder (any method)
Assessment of post-void residual urine (any method)
Urinalysis
What would prompt further evaluation (other than just history, including assessment of bother, physical exam including pelvic examination, objective demonstration of stress urinary incontinence with a comfortably full bladder by any method, assessment of PVR by any method, and UA) for stress urinary incontience?
Physicians should perform additional evaluations in patients being considered for surgical intervention who have the following conditions:
Inability to make definitive diagnosis based on symptoms and initial evaluation
Inability to demonstrate stress urinary incontinence
Known or suspected neurogenic lower urinary tract dysfunction
Abnormal urinalysis, such as unexplained hematuria or pyuria
Urgency-predominant mixed urinary incontinence
Elevated post-void residual per clinician judgment
High grade pelvic organ prolapse (POP-Q stage 3 or higher) if stress urinary incontinence not demonstrated
with pelvic organ prolapse reduction
Evidence of significant voiding dysfunction
Physicians may perform additional evaluations in patients with the following conditions:
Concomitant overactive bladder symptoms
Failure of prior anti-incontinence surgery
Prior pelvic prolapse surgery
Should physicians perform cystoscopy for stress urinary incontinence?
Physicians should not perform cystoscopy in index patients for the evaluation of stress urinary incontinence unless there is a concern for urinary tract abnormalities.
Should physicians do urodynamics for stress urinary incontinence?
Physicians may omit urodynamic testing for the index patient desiring treatment when stress urinary incontinence is clearly demonstrated.
Physicians may perform urodynamic testing in non-index patients.
What important part of the history should influence if the patient should undergo surgery for stress urinary incontinence?
In patients wishing to undergo treatment for stress urinary incontinence, the degree of bother that their symptoms are causing them should be considered in their decision for therapy.
What are the treatment options (generally) for stress urinary incontinence or stress-predominant mixed urinary incontinence?
In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence who wish to undergo treatment, physicians should counsel regarding the availability of the following treatment options: (Clinical Principle)
• Observation
• Pelvic floor muscle training (± biofeedback)
• Other non-surgical options (e.g., continence pessary)
• Surgical intervention
Surgical treatment counseling
Physicians should counsel patients on potential complications specific to the treatment options.
Prior to selecting midurethral synthetic sling procedures for the surgical treatment of stress urinary incontinence in women, physicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.
What are non-surgical treatments for stress urinary incontinence or stress-predominant mixed urinary incontinence?
In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence, physicians may offer the following non-surgical treatment options:
Continence pessary
Vaginal inserts
Pelvic floor muscle exercises
What are surgical options for index patients considering surgery for stress urinary incontinence?
In index patients considering surgery for stress urinary incontinence, physicians may offer the following options:
Midurethral sling (synthetic)
Autologous fascia pubovaginal sling
Burch colposuspension
Bulking agents
What approaches can be used for index patients who choose midurethral sling surgery?
In index patients who select midurethral sling surgery, physicians may offer either the retropubic or transobturator midurethral sling.
What’s up with single-incision slings?
Physicians may offer single-incision slings to index patients undergoing midurethral sling surgery with the patient informed as to the immaturity of evidence regarding their efficacy and safety.
What should you do if the urethra is injured at the time of the planned midurethral sling?
Physicians should not place a mesh sling if the urethra is inadvertently injured at the time of planned midurethral sling procedure.
Should stem cell therapy be offered for stress incontinence?
Physicians should not offer stem cell therapy for stress incontinent patients outside of investigative protocols.
What happens if a patient has stress incontinence, and a FIXED, immobile urethra?
In patients with stress urinary incontinence and a fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’) who wish to undergo treatment, physicians should offer pubovaginal slings, retropubic midurethral slings, or urethral bulking agents.
What if a patient has stress urinary incontinence and intrinsic sphincter deficiency?
In patients with stress urinary incontinence and a fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’) who wish to undergo treatment, physicians should offer pubovaginal slings, retropubic midurethral slings, or urethral bulking agents.