Treatment options for stress incontinence Flashcards
What lifestyle measures can be implemented for stress incontinence?
1) Weight loss BMI>30
2) Appropriate fluid intake 1-1.5L per day
3) Trial without alcohol, caffeine, fizzy drinks
4) Smoking reduction and cessation
5) Constipation management
What is the first line treatment for stress incontinence?
Supervised pelvic floor exercise
1) vaginal examination to assess pelvic floor tone
2) 3 months supervised PFE
3) 8x exercise x3 times per day
4) If effective continue
What are the surgical options according to NICE guidance for stress incontinence?
1) colposuspension
2) Autologus Rectus fascial sling
3) Retropubic mid-urethral mesh sling
Describe the procedure of colposuspension (open)
Indication: surgical treatment for stress incontinence
1) Transverse suprapubic incision
2) Dissect the bladder base and proximal urethra medially off the paravaginal fascia
3) 4 sutures bilaterally in the paravaginal fascia attach to the ipsilateral iliopectineal ligament
4) This elevates the bladder neck and base
5) a drain is inserted into the retropubic space and a suprapubic catheter is inserted temporarily post procedure
Describe the procedure of autologus rectus fascial sling
Indication: surgical treatment for stress incontinence
1) Transverse suprapubic incision
2) Excision of a strip of rectus sheath
3) Incision into the anterior vagina
4) sling formed around bladder neck and proximal urethra up to the rectus abdominus muscle
Describe the procedure for retropubic mesh sling
Indication: surgical treatment for stress incontinence
1) Bilateral supraupic incisions
2) Anterior vaginal mucosa incised
3) Tape inserted using trocars lateral to the urethra on both sides and up through the suprapubic incisions
4) Appropriate tension is created
5) the vaginal wall is sutured closed and the mesh ends at the suprapubic incision sites are trimmed and steri-strips are applied
General risks of surgical treatment for stress incontinence
Bleeding requiring a blood transfusion 1 in 100
Damage to the bladder 1-10 in 100
Damage to the bowel 1-10 in 100
Urinary retention 1-10 in 100
Urgency (de novo detrusor overactivity) 1-30 in 100
Urinary infection 30 in 100
Persistent pain abdomen/ pelvis/sex 1-10 in 100
What postoperative complication is specifically associated with colposuspension compared to the other 2 procedures?
25 in 100 develop rectovaginal prolapse
What proportion of patients experienced symptomatic benefit from surgical treatment of stress incontinence (per procedure) at 1-5 years?
colposuspension - 70%
Rectopubic mesh sling- 75%
Rectus fascial pubovaginal sling - 75%
If surgical treatment is not appropriate or acceptable to a patient, what other minimally invasive treatment option might be available for stress incontinence?
Intramural bulking agent
What are the risks of inserting a intramural bulking agent for stress incontinence?
Abscess formation at site of injection Urinary tract infection Incomplete bladder emptying Urgency Less effective than the other operations and effects wear off over time, may require repeat injection
What are specific risks of retropubic mesh sling procedure do patients need consider?
Mesh erosion into vagina/bladder
Pain (abdominal/pelvic/leg/intercourse)
Recurrent UTIs
Permanent implant and it may not be possible to remove the entire mesh or correct the complications by mesh removal
What kind of material is permissible for midurethral mesh sling?
type 1 polypropelene mesh
What medical management is available for stress incontinence?
Duloxetine is the only medication that is licenced for use as a treatment for stress incontinence. However NICE does not recommend its use as first or second line treatment. Only if surgical treatment is not possible or acceptable
What is the mechanism of action for duloxetine?
Serotonin and noradrenaline reuptake inhibitor
