PROF. Rosita Aniuliene LITHUANIAN UNIVERSITY OF HEALTH SCIENCES President of Lithuanian Association of Urogynecology

 Definition ◦ Stress incontinence is involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Stress incontinence predominantly affects women, and can cause social and hygiene problems. A confirmed diagnosis of urodynamic stress incontinence is particularly important before surgical treatment, given that the symptoms of stress incontinence can occur in people with detrusor overactivity, which is confirmed by the demonstration of uninhibited bladder contractions. Joseph L. Onwude. Stress incontinence. Women’s health. Clin Evid 2006; 15; 1-3. P

 Incidence/prevalence ◦ Stress incontinence is a common problem. Prevalence has been estimated at 17-45% of adult woman in the setting of high income country. One cross-sectional study (15308 woman in Norway < 65 years) found that the prevalence of stress incontinence was 4,7% in woman who have not borne a child, 6,9% in women who had caesarean deliveries only, and 12,2% in woman who had vaginal deliveries only. Joseph L. Onwude. Stress incontinence. Women’s health. Clin Evid 2006; 15; 1-3. P

 Aetiology/risk factors ◦ Aetiological factors include pregnancy, vaginal or caesarean delivery, cigarette smoking and obesity. Joseph L. Onwude. Stress incontinence. Women’s health. Clin Evid 2006; 15; 1-3. P

 Prognosis ◦ Untreated stress incontinence is believed to be persistent, lifelong condition.  Aim of intervention ◦ To improve quality of life and social function, to reduce embarrassment, and to reduce frequency and volume of involuntary urine leakage with minimal adverse effects. Joseph L. Onwude. Stress incontinence. Women’s health. Clin Evid 2006; 15; 1-3. P

 Serotonin reuptake inhibitors (Duloxetine)  Pelvic floor electrical stimulation  Pelvic floor muscle exercises  Vaginal cones  Oestrogen supplements  Adrenergic agonists

 One systematic review found that duloxetine at doses of 80mg or above daily improved the frequency of incontinence episodes, the proportion of people who had improved at the end of treatment, rates of subjective cure or improvement, and quality of life outcomes compared with placebo. Duloxetine was associated with more adverse effects, including nausea, diarrhoea, headache, dizziness, fatigue, and dry mouth, compared with placebo.

 One systematic review found no significant in cure or improvement rates at 12 months between pelvic muscle electrical stimulation and pelvic floor muscle exercises. Another systematic review found no significant difference between pelvic floor electrical stimulation and vaginal cones in self reported cure or improvement rates, or in urinary leakage over 4 to 12 months, but it may have lacked power to detect a clinically important difference. A third systematic review found no significant difference in cure or improvement rates between pelvic floor electrical stimulation and oestrogen supplements.

 One systematic review found that pelvic floor muscle exercises increased cure or improvement rates and reduced the number of daily leakages over 3-6 months compared with no treatment or placebo. It found that pelvic floor muscle exercises reduced the number of daily leakage episodes at 6 months compared with vaginal cones, but there was no significant difference between treatments in cure or improvement rates at 12 months. One systematic review found that pelvic floor muscle exercises increased cure or improvement rates compared with oestrogen supplements at 9 months.

 RCTs found no significant difference between vaginal cones and pelvic floor muscle exercises in self reported cure or improvement rates over 12 months. It found that vaginal cones were less effective than pelvic floor muscle exercises in reducing the number of leakage episodes over 6 months. One RCT found no significant difference between vaginal cones and combined pelvic floor electrical stimulation and biofeedback in subjective and objective improvement rates after 6 weeks. The most common adverse effect associated with vaginal cones was difficulty maintaining motivation for use, but a small number of more serious events such as vaginitis and abdominal pain were reported.

 One systematic review found that short term treatment with oestrogen supplements improves cure or improvement rates compared with placebo. The review found lower rates of cure or improvement with oestrogen supplements compared with pelvic floor muscle exercises at 9 months. It found no significant difference in rates of cure or improvement between pelvic floor electrical stimulation and short term treatment with oestrogen supplements, but it may have lacked the power of clinically important difference.One RCT found that oral oestrogen supplements increased the risk of strokes in postmenopausal women without a uterus at 6 years. There is limited evidence that unopposed oestrogen is associated with an increased risk of endometrial cancer in women with a uterus.

 Pooled results from two small RCTs suggested that phenylpropanolamine increased subjective cure or improvement rates compared with placebo, although this difference was not significant. One RCT found that phenylpropanolamine increased subjective cure or improvement rates compared with pelvic floor muscle exercises. A second RCT found no significant difference between clenbuterol and pelvic floor muscle exercises. Phenylpropanolamine has been withdrawn from the US market because of an increased reisk of haemorrhagic stroke.

 Laparoscopic colposuspension  Open retropubic colposuspension  Suburethral slings  Tension free vaginal tape  Transobturator foramen tape  Anterior vaginal repair (anterior colporraphy)  Needle suspension

 It wasn’t found RCTs comparing laparoscopic colposuspension versus no treatment, non-surgical treatment, anterior vaginal repair, suburethral slings, or needle suspension. One systematic review found that open retropubic colposuspension improved objective cure rates at 1 year compared with laparoscopic colposuspension. One systematic review found that laparoscopic colposuspension was less effective than open retropubic colposuspension at improving objective cure rates at 1 year.

 One systematic review found that open retropubic colposuspension increased cure rates at 1-5 years compared with non-surgical treatment, anterior vaginal repair, or needle suspension. It found that open retropubic colposuspension improved objective cure rates at 1 year compared with laparoscopic colposuspension. It also found no significant difference in cure rates at 1 year between open retropubic colposuspension and suburethral slings. One systematic review found no significant difference in cure rate between tension free vaginal tape and open retropubic colposuspension at up to 2 years. RCTs included in the review found that open retropubic colposuspension was associated with a lower incidence of bladder perforation than tension free vaginal tape, but a higher incidence of postoperative fever.

 Five RCTs identified by a systematic review found no significant difference in cure rates at up to 6 years between suburethral slings and open retropubic colposuspension, although the studies may have lacked the power to detect a clinically important difference. The RCT found that suburethral slings increased perioparative complications compared with needle suspension. Two RCTs found no significant difference in subjective cure rates between suburethral slings and tension free vaginal tape at 6-12 months.

 Two RCT s found no significant difference in cure rates between tension free vaginal tape and other types of suburethral slings at 6-12 months. One systematic review found no significant difference in cure rates between tension free vaginal tape and open retropubic colposuspension at up to 2 years. RCTs included in the review found that tension free vaginal tape associated with a higher incidence of bladder perforation than open retropubic colposuspension, but a lower incidence of postoperative fever.

Reference: Nilsson CG et al, Int Urogynecol J 2008: 19:

 One RCT found no significant difference in cure rates between transobturator foramen procedures and tension free vaginal tape at 15 months. No RCTs found comparing transobturator foramen procedures versus no treatment, sham treatment, non-surgical treatment, anterior vaginal repair, non-tension free vaginal tape, suburethral slings, open retropubic colpoosuspension, and needle suspension.

 No RCTs found comparing anterior vaginal repair versus no treatment, suburethral slings, laparoscopic colposuspension, or tension free vaginal tape. One RCT provided insufficient evidence to compare anterior vaginal repair versus non- surgical treatment. One systematic review found that anterior vaginal repair was less effective than open retropubic colposuspension at increasing cure rates at 12 months or 5 years, and found no significant difference in overall operative complications between the two procedures.

 No RCTs found comparing needle suspension versus no treatment, non-surgical treatment, tension free vaginal tape, or laparoscopic colposuspension. One systematic review found no significant difference in cure rates between needle suspension and anterior vaginal repair or suburethral slings, but found that needle suspension was associated with fewer perioperative complications than suburethral slings. Another systematic review found that open retropubic colposuspension improved cure rates and was associated with fewer surgical complications than needle suspension at 5 years.

 Stress incontinence, involving involuntary leaking of urine on effort, exertion, sneezing or coughing, affects up to 45% of adult women. Risk factors include pregnancy, especially with vaginal delivery, smoking, and obesity.  Pelvic floor muscle exercises may improve symptoms and reduce incontinence episodes compared with no treatment, and seem to be as effective as pelvic floor electrical stimulation or vaginal cones over 12 months.  Pelvic floor electrical stimulation can cause tenderness and vaginal bleeding, while vaginal cones can cause vaginitis and abdominal pain. Pelvic floor muscle exercises can cause discomfort.

 Oestrogen supplements increase cure rates compared with placebo, but there are risks associated with their long term use. They my be less effective at reducing incontinence compared with pelvic floor muscle exercises.  Serotonin reuptake inhibitors (duloxetine 80mg daily) reduce stress incontinence compared with placebo at 4-12 weeks, or compared with pelvic floor muscle exercises, but increase the risk of adverse effects such as headache and gastric problems.

 It wasn’t found whether adrenergic agonists improve incontinence compared with placebo or with other treatments, but they can cause insomnia, restlessness, and vasomotor stimulation. Phenylpropanolamine has been withdrawn from US market because of an increased risk of haemorrhagic stroke.

 Open retropubic colposuspension may be more likely to cure stress incontinence compared with anterior vaginal repair at 1-5 years. Complication rates are similar to those with other surgical procedures, but are higher than with non-surgical treatments.  Suburethral slings, tension free vaginal tape (TVT), transobturator foramen procedures (TOT, TVT-O), and needle suspension may be as effective as open retropubic colposuspension in curing stress incontinence over 5 years. Complications of tension free vaginal tape include bladder perforation.  Laparoscopic colposuspension seems to be as effective over 5 years as open retropubic colposuspension or tension free vaginal tape.

Results of tension free vaginal tape (TVT) versus tension free tape obturator (inside-outside TVT-O) in the surgical treatment of female stress urinary incontinence Assoc. prof. Rosita Aniuliene Kaunas University of Medicine

Patients characteristicsTVT (n=114)TVT-O (n=250) Age ± SD51 ± 10,149 ± 9,5 POP Q system: Stage 1 Stage Follow up period (months)12 BMI, kg/m 2 27,9 ± 4,028,2 ± 3,8 Number of birth2,6 ±1,12,5 ± 1,2 Birth weight > 3500g49 ± 1,261 ± 1,3 Menopause (1-30 years)4857 Irritated bladder symptoms66 Urinary incontinence period6,5 ± 3,17,5 ± 2,4 Hysterectomy in the past1541 Operated incontinence in the past1638

Register parametersTVT (n=114)TVT-O (n=250)P Effectiveness of procedure94,6% NS Duration of procedure27 ± 7,119 ± 5,6P<0,05 Hospital stay (days)4,0 ± 1,61,5 ± 0,5P<0,05 Anesthesia: Epidural13 (11,4%)0 Local2 (1,8%)0 Lumbar95 (83,3%)22 (8,8%) Intravenous4 (3,5%)228 (91,2%) Bladder drainage: interrupted catheterization 18 (15,8%)7 (2,8%)P<0,05

ComplicationsTVT (n=114)TVT-O (n=250)P No81 (71,0%)235 (94,0%)P<0,05 Suprapubic hematoma1 (0,8%)0NS Wound bleeding in vagina2 (1,8%)3 (1,2%)NS Bladder perforation1 (0,8%)0NS Postoperative urinary retention18 (15,8%)7 (2,8%)P<0,05 Symptoms of irritated bladder6 (5,3%)7 (2,8%)NS Infection of urinary tract5 (4,4%)1 (0,4%)NS Temperature >38 0 C01 (0,4%)NS

 TVT and TVT-O operations are very effective procedures while curing female stress incontinence after 12 months of follow-up.  TVT-O procedure has a shorter operation time and hospital stay.  TVT-O had lower complication rate that TVT procedure.