Overview of Stress Urinary Incontinence & Minimally Invasive Slings Ken Maslow, M.D. Urogynecology and Reconstructive Pelvic Surgery Assistant Professor Department of Obstetrics & Gynecology University of Manitoba

Etiologies of UI SUI – Stress UI UUI – Urge UI (OAB) Mixed UI Functional UI (DIAPPERS) Overflow UI Other Fistula, ectopic ureter, urethral diverticula Uncategorised Incontinence SUI- symp: leakage of urine on effort or exertion, or on sneezing & coughing sign: observation of involuntary leakage from the urethra synchronously w exertional effort/cough/sneeze Dx/condition: Urodynamic SUI=Genuine SUI- at CMG as involuntary leakage urine during increased abd pressure in the absence of a detrusor contraction.

ICS SUI Definitions Symptom Sign Diagnosis Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Sign Observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing Diagnosis Urodynamic SUI: involuntary leakage of urine during CMG with increased abdominal pressure, in the absence of a detrusor contraction Sympt:ICS considers SUI to be unsatisfactory b/c of mental connotations: Effort incontinence preferred Sign: must be synchronous as cough induced detrusor contraction Urodynamic SUI=Genuine SUI

SUI: Mechanism Hypermobility (theory as to mechanism of SUI) Hammock theory – pressure applied to anterior urethra it is compressed against well supported posterior urethra which occludes the lumen Pressure transmission theory – with mobility the pressure transmitted to the urethra is less than to the bladder, can be measured with dynamic UPP as PTRs (pressure transmission ratio)= Δ Pure/Δ vesical Intrinsic urethral function of: collagen, smooth muscle, venous endothelium, neuro ISD: No Standard Definition for Dx (Diagnosis based on) Causes ISD: 1. Clinical severity of incontinence congenital 2. Positive supine empty stress test trauma 3. MUCP <20 cm H2O prev sergery (antiincontinence surgery, extensive pelvic) 4. Valsalva LPP <60 cm H2O post radiation 5. Endoscopic evaluation of bladder neck spinal cord disease 6. FIXED elevated position estrogen deficiency-luminal water tight seal dependant on epithelium, submucosal vasculature & collagenous matrix Assessment of bladder neck: 1. Clinical observation 2. Q tip test 3. Cystoscopy 4. Straining cystogram 5. Ultrasound 6. Video UDS

SUI Treatment Non surgical Behavorial Surgical Lose weight (Level 1) Timed toileting/↓ intake (1a) Treat constipation Stop smoking (cough) Avoiding high impact activities/heavy lifting Kegels (Level 1) ± biofeedback Non surgical Pessary (Level II-III) Meds Imipramine Not very effective Duloxetine Not available Surgical w/t loss Level I: Subak 2005 J of Urology Decreasing fluid intake Level I: Swithinbank 2005 J of Urology Biofeedback – perineometer or vaginal electrical activity Kegels- 5-10 sec squeeze, 10-20 cont/3-4 x per day (done correctly, Pt did better in intense program) Non surgical extra and intra urethral occluding devices Pt needs to learn to insert Irritation, discomfort Bleeding Infection Migration Imipramine (TCA)- α agonist & anticholinergic (25 mg po tid) Duloxetine (SNRIs)- potent inhibitor of the neuronal reuptake of serotonin and noradrenaline (SNRI) an indirectly acting agonist of serotonin and noradrenaline receptors serotonergic agonists generally suppress parasympathetic activity and enhance sympathetic and somatic activity Specifically increase to sacral spinal cord (Onuf’s nucleus) which via peudendal nerve stimulates striated sphincter Level 1 evidence (3-phase 3 trials) sign better than placebo for reduction in incont episodes Estrogen: Cochrane Review 2003 Estrogen vs placebo SUI subjective (46/107, 43% versus 29/109, 27%; RR 1.62, 95% CI: 1.15 to 2.28) Meta-analysis 2003 Drutz 4 placebo controlled RCT No sig. difference for SUI WHI 2005 Placebo vs oral HRT RCT Sig. worsening of symptoms of SUI in baseline symptomatic & asymptomatic women

Kegels / PFMT Level 1 evidence effective for SUI Tx Ensure Pt contracting correct muscles No one program recommended 3-5 sec squeeze, 10-20 cont/3-5 x per day Addition of biofeedback, vag cones, or electrical stimulation no benefit However in Pt who do not isolate correct muscles, may be benefit of biofeedback devices Pelvic floor physiotherapist NB: incorrect pelvic floor muscle contractions can make the incontinence worse! Pelvic tilt, gluteals, valsalva manuver most common mistakes

Vaginal Pessaries Intravaginal devices (Continence pessaries) Support the bladder neck Occlusive devices External to meatus (Miniguard, FemAssist) Ineffective & local irritation Intraurethral (Femsoft) Effective Discomfort, UTI, hematuria, migration Advantage Instant symptom control Non invasive Reversible with no long term sequela (vs surgery) Situational use (sports) No major comp Disadvantage Fitting & refitting required Maintenance Problem with pessary:infection, erosion, etc

Surgical Tx SUI Anterior colporraphy Needle suspension procedures Kelly plication suture Needle suspension procedures Stamey, Raz, Pereyra, Gittes Retropubic urethropexy Burch, MMK Suburethral Sling procedures Traditional Slings, Minimally invasive midurethral slings Periurethral bulking procedures Artificial Sphincter Anterior repair & Needle suspension Did not prove to be as efficacious

Burch Procedure Retropubic urethropexy Significantly more effective than: Pelvic floor muscle training Anterior repair Needle suspensions Periurethral injections Burch better than MMK 2 RCT’s: less failure RR 0.38, 95% CI 0.18-0.76 Equivilant to Sling as primary procedure Burch controversial as repeat procedure or in ISD Pt

Midurethral Slings

Suprapubic Approach Variations/Surgical technique Traditional slings New midurethral slings (TVT, TOT) Differences b/t traditional vs new slings amount of dissection position – bl neck vs mid urethral anchoring sites tension

Obturator Approach Transobturator tape (TOT) Delorme 2001 To avoid retropubic space to decrease bladder, bowel, large vessel injuries TVT vs TOT: deTayrac R, Deffieux X, Droupy S, Chauveaud-Lambling A, Calvanese-Benamour L, Fernandez H A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. American Journal of Obstetrics & Gynecology. 190(3):602-8, 2004 Mar. Equal efficacy at one year Transobturator tape (TOT)

Midurethral Sling Day surgery 10-20 minute procedure IV Sedation & local freezing Requires 1-2 weeks off work Complications Rare Bleeding, infection, voiding dysfunction, mesh erosion, de novo/worsening UUI TVT: bladder/bowel/lg vessel injury TOT: vaginal perforation, leg/groin pain Efficacy 90% cure at one year Comparable to Burch at 2 yrs F/U (RCT: Ward 2004) Small RCT’s comparing TVT to TOT with up to 1 year F/U

“Mini – Sling” TVT SECUR System ? Less groin pain ? Less anesthetic ?Less dissection/injury/bleeding

Urogynecology & Reconstructive Pelvic Surgery Summary SUI is a common problem in women Conservative Tx Kegels, weight reduction, pessary, (meds) Surgical Tx Minimally invasive mid urethral slings Day surgery Quick recovery Little risk Good outcome Ken Maslow Urogynecology & Reconstructive Pelvic Surgery St. Boniface ACF Ph: 237-2713 Fax: 237-2284