Urogynaecology Current Evidence and Practice in Female Mixed Incontinence Gunnar Lose1 and Søren Brostrøm2 1. Professor; 2. Associate Professor, Department of Obstetrics and Gynaecology, Herlev Hospital, University of Copenhagen
Abstract
Mixed urinary incontinence (MUI) accounts for approximately one-third of incontinent women seen in everyday clinical practice. The management of these women remains a challenge since the two entities may compete. It remains unclear to what extent concurrent detrusor overactivity (DO) is secondary or primary. A growing body of evidence indicates that subdivision of MUI into those with predominant stress incontinence (SI), those with equal bothersome stress and urge incontinence (UI) or those with predominant urge incontinence may be helpful in choosing treatment strategies. The majority of patients with symptomatic MUI have predominant SI and urodynamic SI and thus should follow principles of SI treatment. If the urgency component is equal or predominant (groups II and III) invasive urodynamic testing is mandatory to obtain as much predictive information as possible in order to decide whether treatment should be directed primarily against the stress or the urge component. Increasing urgency severity correlates with the likelihood of surgical failure. However, providing fully informed surgery is appropriate in patients, with MUI, especially those with predominant SI. There is a need to refine the terminology of urgency and DO from qualitative to quantitative terminology.
Keywords Mixed urinary incontinence (MUI), symptom predominant types, treatment strategies, surgery
Disclosure: Gunnar Lose has been a consultant for Contura and has participated in trials for Contura and Pfizer. Søren Brostrøm has been a speaker for Pfizer. Received: 8 June 2010 Accepted: 5 July 2010 Citation: European Obstetrics & Gynaecology, 2010;5:61–4 Correspondence: Gunnar Lose, Professor, Department of Obstetrics and Gynaecology, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark. E:
gulo@heh.regionh.dk
Definition
Mixed urinary incontinence (MUI) is defined symptomatically by the International Urogynaecology Association (IUGA)/International Continence Society (ICS) as the “complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing”.1
This definition is used in everyday clinical
practice. MUI has also been described urodynamically as “the demonstration of urodynamic stress incontinence (SI) and detrusor overactivity (DO) with and without incontinence”.2
In clinical studies, the
definition (symptomatic and/or urodynamic) of MUI varies widely and as both symptomatic and urodynamic diagnoses are method-dependent, patient materials are heterogeneous and hence difficult to compare.
Prevalence
In incontinent women the prevalence of symptomatic MUI varies from 25 to 60%.3,4
However, only 33–50% of these women have urodynamic MUI. Thus, the majority of women with symptomatic MUI have urodynamic SI. MUI prevalence continues to increase with increasing age. Mixed symptoms tend to be more prevalent in clinical than in population-based epidemiological studies.3,4
Characteristics
Despite the heterogeneity of MUI populations, it is well documented that women with mixed symptoms tend to report greater incontinence bother than women with either pure stress or urgency incontinence.5,6 According to some authors, this is because incontinence severity seems to be the driver of MUI symptoms rather than the pathophysiological condition(s) causing the incontinence.5
© TOUCH BRIEFINGS 2010 Assessment
Optimal treatment of MUI depends on a thorough evaluation followed by treatment of all of the likely causes and contributing factors. The evaluation programme should follow international guidelines such as those indicated by the International Consultation on Incontinence (ICI).11
Pathophysiology
In women with MUI, DO may be a secondary manifestation of the same underlying pathophysiological condition as for SI, namely an incompetent bladderneck mechanism that allows the ingression of urine into the proximal urethra during physical activity, thus eliciting a (secondary) detrusor contraction reflex.
Support for this concept is found in animal studies7 investigations.8
as well as in human
in women with DO. It is unclear whether the subdivision of DO based on chronological sequence of bladder and urethral pressure changes may play a predictive role. Thus, it has been recommended that if urethral pressure decrease precedes the detrusor contraction (e.g. mimic, a normal micturition reflex), those patients can be treated successfully with conventional SI surgery, whereas if the detrusor contraction is the first event, treatment should be directed against DO (e.g. using an antimuscarinic drug).9
This concept is in accordance with the finding that patients with MUI may be cured of both SI and DO by a mid-urethral sling. It remains controversial to what extent DO may be primary (or secondary) in women with urodynamic MUI. Measurements of simultaneous bladder and urethral pressures have shown different patterns9,10
It has been recommended by many authors that symptomatic 61
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